Development of the Patient Safety Incident

Report
Development of the
Patient Safety
Incident
Management
System (DPSIMS):
stakeholder update
Domain 5 Patient
Safety
December 2014
www.england.nhs.uk
WHY: Patient Safety strategy 2014/15
Statutory Responsibilities
Mandate Objectives
Keogh Review Ambitions
Francis Response
Gaining a better
understanding of what goes
wrong in healthcare
• Improving completeness of reporting
to the National Reporting and
Learning System (NRLS)
• Developing a new national patient
safety incident management system
• Developing patient safety
thermometers
• Creating the first ever direct national
measures of patient safety using
retrospective case note review
• Developing patient safety data pages
on NHS Choices Website
www.england.nhs.uk
Enhancing the capability and
capacity of the NHS to deliver
patient safety improvement
• Establishing the Patient Safety
Collaborative programme
• Deliver programme to identify and
recognise Patient Safety Fellows
• Further developing the investigations
capability across the NHS
• Developing an improvement
programme, including change packages,
to tackle key clinical patient safety areas
and vulnerable groups
• Establishing Medication Safety and
Medical Device Safety Officer Network
across England
NHS Outcomes Framework
Berwick Report
Tackling key patient safety
priorities
• Specific work programmes to address:
Pressure Ulcers
Medication & Devices
Error
Failure to Monitor
children
Neonatal admissions
Anti-Microbial
Resistance Imp
Mental health
Learning disabilities
Deaths and restraint
whilst in custody
Acute Kidney Injury
Nutrition and Hydration
Primary Care (Increase
GP reporting)
Discharge
Falls
Older People
Offender Health
Never Events
Handover
Deterioration
Sepsis
VTE
HCAI
WHY: systems and culture
Patient Safety culture
Leadership
Individual interactions
Practice
Patients
IT systems
Processes
Staff
Ethos
www.england.nhs.uk
LRMS
NRLS
STEIS
WHY: the NRLS today
www.england.nhs.uk
WHY: Identified needs
Quality
Streamlining
Culture
User Experience
System Needs
Other
Focuses on learning
Single system
Supports just culture in
the NHS
Easier to use
Meets statutory
requirement
Builds on international
best practice
Facilitates improvement
Reduces duplication
Engages the user in
reporting-learning cycle
Accessible to patients
Supports transparency
Supports specialtyspecific learning
Supports
standardisation
Interoperable with other
systems
Supports Patient Safety
Culture
Produces useful,
accessible data
Supports functions of
other healthcare bodies
Supports local learning
Improves data quality
Provides risk
management
functionality
Supports research
agenda
Improves feedback
Fits current NHS
delivery models
Supports national
learning
Supports identification
of and reduction in
inequalities
Triangulates data from
other sources
Aids patient
involvement in care
Locally customisable
Secure, safe, robust
Works on modern
conceptualisations of
harm
Supports better analysis
and review
Supports helpful
analysis
Good governance,
processes, policy
Allows for measurable
and narrative reporting
Offers VFM
Flexible
Surveillance function
Supports reporting from
all healthcare settings
Achieves widespread
buy-in
Works with agile/remote
working practices
Future-proof
Utilises cutting-edge
technologies
www.england.nhs.uk
WHY: barriers to reporting
Fear of
negative
response
from coworkers
No faith it
will lead to
change
Whose
Workload
responsibility
to report?
Fear of
impact on
reputation
Incident
unlikely to
happen
again
Incident was
not
preventable
Cause
already
clear
Not a priority
Definitions
of what to
report are
unclear
Repeat
incident,
repeat
report
Fear of
punishment
Extra admin
Complex
processes
Lack of
feedback
Interrupts
work
process
Takes too
long
Fear of
disciplinary
action
No major
patient
impact
Not
confidential
www.england.nhs.uk
WHY: facilitators to reporting
Rewarded for
reporting
Value the
feedback
provided
Value
importance of
PS reporting
Simple
processes
Faith that
reporting leads
to change
Blame-free
organisational
culture
Can learn from
reporting
www.england.nhs.uk
Clear policies
and guidelines
for reporting
WHAT: The task
•
•
•
We need a reporting and learning system that will help improve the ability:
• of all healthcare-associated organisations to report more effectively (eg
non-acute settings, Independent Sector, devolved nations)
• to develop better learning that supports more improvement
• to provide greater transparency of patient safety data
• to reduce risks associated with:
• duplication and omission
• lack of standardisation
• the gap between the capabilities of the NRLS and the needs of the
NHS, patients, and other users
Therefore, seeking to develop a successor to the NRLS, building on its success
and making it fit for the future
And considering how best to do this in a context of uncertainty and possible
change
www.england.nhs.uk
WHAT: the story
Investigation
Results
Patient
Story
Locally
derived
learning
Acute
Route
PSI
Most
other
settings
Report
extracted for
NRLS
Clinical
Report in
LRMS
eForm
Report
Cleansing/
anonym’ion
Record of
incident in
NRLS
National
Clinical
Review
Nationally
derived
learning
KEY:
www.england.nhs.uk
Live file in STEIS
for action/
management
Report made to
STEIS (within
48hrs)
Incident
Data
Document
Process
Stored data
Neither the local nor
national learning
systems are perfect –
they both meet some
requirements, but
neither make best use
of the other as a
supporting resource or
channel
WHAT: the story
The patient story is often lost
from the incident, unless they
make a complaint - which is
then handled through separate
systems – or if the incident
goes to full investigation
Other learning frequently is developed,
but often sits outside of this system –
NRLS processes don’t fully integrate
with culture
Investigation
Results
Patient
Story
Locally
derived
learning
Subjective
classifications,
reports of
varying
quality/detail
Acute
Route
PSI
Most
other
settings
Time and resource
intensive;
frequently sits
outside local
processes,
requiring
duplication of
effort. Low
reporting rates.
www.england.nhs.uk
Live file in STEIS
for action/
management
Report made to
STEIS (within
48hrs)
Report
extracted for
NRLS
Clinical
Report in
LRMS
Cleansing/
anonym’ion
eForm
Report
Source of poor
standardisation,
as local
arrangements vary
KEY:
Incident
Data
Document
Process
Stored data
This separation of “live”
management files and
static NRLS records can
lead to “two versions of
the truth”
Loses benefits of more
evolved local
management systems
available to trusts with
LRMS
This step effectively
prevents any nongeneric feedback to
individuals making
reports
Record of
incident in
NRLS
The new Stage 1,2,3,
Alerts allow for locally
derived learning to be
disseminated, but only
on issues that make it
to national Alert level.
Benefit is lost when
local learning remains
local.
Only Serious
Harm or Death:
<1% of reports
National
Clinical
Review
Nationally
derived
learning
WHAT: the systems NRLS vs STEIS
NRLS
•
•
•
•
•
•
•
any Patient Safety incident
any degree of harm
voluntary
no deadline to report
for learning
access by agreement
operated by Imperial Trust
www.england.nhs.uk
STEIS
Patient
Safety
Serious
Incidents
(“Severe
Harm” or
“Death”)
•
•
•
•
•
•
•
Any category of Serious Incident
Serious Incidents only
mandatory
must be reported within 48 hrs
for management/investigation
commissioners have access
operated by DH
HOW: the building blocks
Data model
Data capture
Explore &
analyse
Share the
learning
www.england.nhs.uk
Investigate &
manage
Support
functions
HOW: the possible combinations
Data
model
Data
capture
Explore
and
analyse
Investigate
and
manage
Share the
learning
Support
functions
Current dataset
LRMS batch
upload
Web accessible
analytical tools
Incident workflow
and management
Summative
reports and
statistics
Guidance and
training
Expanded
dataset
eForms and web
interfaces
National
feedback and
clinical review
Collaborative
workgroups
Patient safety
alerting system
Helpdesk and
system support
Combined
datasets (NRLS
& STEIS)
LRMS
synchronisation
Free-text and
data mining
Schedule and
coordinate tasks
Web portal for
learning
resources
Standards and
guidelines
Re-engineered
dataset
Mobile devices
Thematic and
qualitative
analysis
Define lessons
and action plans
Discover and join
ongoing projects
Communication
toolkits
RCA, SEA,
causal factors,
etc
Integration with
other info
systems
Risk analysis and
safety monitoring
Monitor and
assure
implementation
Share local
lessons and
improvements
Curate and edit
resources
User generated
tagging and
coding
Data sharing
agreements
Clinical and
specialist
analysis
Manage risk
register
Automated
feedback and
updates
User profiles and
permissions
www.england.nhs.uk
HOW: sample combinations
Data
model
Data
capture
Explore
and
analyse
Investigate
and
manage
Share the
learning
Support
functions
Current dataset
LRMS batch
upload
Web accessible
analytical tools
Incident workflow
and management
Summative
reports and
statistics
Guidance and
training
Expanded
dataset
eForms and web
interfaces
National
feedback and
clinical review
Collaborative
workgroups
Patient safety
alerting system
Helpdesk and
system support
Combined
datasets (NRLS
& STEIS)
LRMS
synchronisation
Free-text and
data mining
Schedule and
coordinate tasks
Web portal for
learning
resources
Standards and
guidelines
Re-engineered
dataset
Mobile devices
Thematic and
qualitative
analysis
Define lessons
and action plans
Discover and join
ongoing projects
Communication
toolkits
RCA, SEA,
causal factors,
etc
Integration with
other info
systems
Risk analysis and
safety monitoring
Monitor and
assure
implementation
Share local
lessons and
improvements
Curate and edit
resources
User generated
tagging and
coding
Data sharing
agreements
Clinical and
specialist
analysis
Manage risk
register
Automated
feedback and
updates
User profiles and
permissions
Example 1
www.england.nhs.uk
Example 2
Example 3
Domains 1-5
Director of
Patient
Safety
Datix
CQC
GMC
Independent
sector
MHRA
Clinical
Support
Units
Primary
Care
Ulysses
NICE
Department
of Health
Carers
Community
care
Scottish
Government
NHS
England
Specialised
Commis’ning
Monitor,
NHS TDA
Vantage
Repres’ive
orgs and
charities
LATs
www.england.nhs.uk
Northern
Ireland
Government
Others…
Medical
Protection
Society,
Medical
Defence
Union, (and
devolved
counterparts
)
Patient
Safety
Regional/
Area Teams
Other NHS
orgs:
estates,
SHOT,
Confed,
NHS BSA
Federation
of
Independent
Practitioner
Orgs
Lord Ara
Darzi
Operations
Commis’ing
Dvlpmnt
System
Leaders
Clinical
Advice and
Guidance
Team
NRLS
Oversight
Team
Comms
Centre for
Health
Policy, Inst.
of Global
Health
Innovation
Research
bodies
Comms
Longer-term
develp’t
NHS
Alliance
World Health
Org.
Senior
Leadership
Team
Short term
solutions
HEE
PHE
Other NHS
delivery
(prisons,
local
authorities
etc)
Corporate
ICT Team
Day to day
operations
International
Community
Patient Safety Domain
(5) Team
Royal
Colleges
Imperial College
London
Welsh
Assembly
Government
NHS England
NHS Arms’ Length
Bodies
Local Risk
Management System
Vendors
Devolved
Administrations
Government Sponsor
Clinical
Commis’ing
Groups
NRLS Operational
Team at Imperial
Patients
NHS
Litigation
Authority
Professional networks
NHS trusts
Health service
commiss’rs
Health
Service
providers
Health
Service
users
WHO: Stakeholders
Delivery
Mgmt
Domains 1-4
research
and develp’t
teams
Tech
companies
WHO: Stakeholder engagement…
Establishing the basics
•What is the current situation?
•Why does it need to change?
•Who has an interest?
Questionnaire
•Seeking to answer fundamental questions from users
•What should the core aim of the system be? What’s good about what we’ve
got? What’s bad? What else do users want?
•Over 600 responses from policy makers, users, ALBs, patients and carers
Focus Group
•Bringing together representatives of key stakeholders
•Validating the questionnaire findings
•Highlighting key risks and issues from across stakeholder perspectives,
agreeing core principles and aims
www.england.nhs.uk
WHO:…stakeholder engagement
The Patient and Carer Perspective
• A workshop for patients and carers only
• Identifying their needs and wants from the system
• Giving them a voice in what is largely considered to be a “clinical”
resource
User Workshops
• Presented through the lens of the stated patient perspective
• Addressing issues such as risks, barriers, ideals and supportive
actions
• Agreeing user needs in the light of the information gathered to date
Identification of requirements for the new system
www.england.nhs.uk
WHAT NEXT?
• If you have any comments or questions about this
presentation, please do not hesitate to contact
[email protected]
• Any feedback received will be incorporated into the
development of the longlist of options, currently
underway
• The options will be assessed against a Five Case
Model (strategic, economic, financial, commercial and
management) to identify a shortlist
• Information about this will be made available in due
course
www.england.nhs.uk

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