The Measurement and Monitoring of Safety Framework Workshop 2 16 th - - PowerPoint PPT Presentation

The Measurement and Monitoring of Safety Framework Workshop 2

16th May 2017 Leeds

e: academy@yhahsn.nhs.uk / t: 01274 383966 www.improvementacademy.org

Housekeeping

Our # for the event

#howsafeisourcare

@improvementacademy

#howsafeisourcare

UK Improvement Alliance

• UKIA: howsafeisourcare

– http://www.howsafeisourcare.com/ – Monthly calls

• Wednesdays, 1-2pm.
• Sign up via Eventbrite.
• Next call: Wednesday 14th June 2017 at 1pm

Programme

Time Speakers 10:00 – 10:10 Introductions Debbie Clark 10:10 – 11:10 Group feedback Rachel Smith 11:10 – 11:30 Refreshments 11:30 – 12.00 Culture Survey

• Dr. Anna Winfield

12:00 – 13:30 Human Factors and the Measurement and Monitoring of Safety

• Prof. Rebecca Lawton

13:30 – 14:00 Lunch 14:00 – 15:30 Market Place Guest Speakers 15:30 – 16:00 Action planning Beverley Slater 15:50 – 16:00 Close

MMSF Market place

Mortality Review Programme

W2: Post session work

• Identify your top three harms
• Describe how the framework can help you to improve you

understanding of one of your top three harms.

• Consider which interventions may support you to achieve

this.

• Complete Bronze Quality Improvement Training

Workshop 3

• Quality Improvement
• Dr. John Bibby and Maureen McGeorge.
• Understanding and using data
• Prof. Mohammed Mohammed.

Feedback from workshop 1

Rachel Smith Improvement Academy

Feedback from workshop 1

Q1) Thinking about your current safety approach, what measures and monitoring activities actually help your teams to feel safe? Q2) What is your goal; at team level? at middle management level? at Board level? Q3) Can you identify gaps? Outline what you need to learn more about to understand how safe your care is?

Top three reported incidents

Lynn Pearl Safety, Risk & Resilience Manager

Incident System

• Each ward/service has unique top three
• Extract data from Datix/Safeguard
• Collate data set
• Analyse data set in detail e.g. different harms,

severity, times and locations

Integrated working

• Ask the team which are important to them
• Discuss with the team what the data tells you
• Check with team that they report all these types of

incidents

• Agree what will be measured and monitored
• How, frequency and by whom

Measures

• Days between (Safety Crosses?)
• Early warning triggers based on averages

(weekly) bespoke to team

• Visual monthly reports that summarise the

more detailed data which is also available

• Statistical Process Control Charts (SPCs)
• Automated reports
• Safety Huddles

Over to you...

• Start this conversation at a local level
• Identify the different types of harm that exist in

the setting

• Decide if there are three harms you want to

focus on

• Use a range of measures which are valid, reliable

and specific to help you understand if you are making a difference

• Create time and space to review the data you

collect as a team

Coffee

#howsafeisourcare

A systematic approach to measuring and addressing Safety Culture at the Frontline

Dr Anna Winfield Leeds Teaching Hospitals NHS Trust

Recap

Yorkshire Contributory factors framework

Recap: Safety Attitudes Questionnaire (SAQ)

• SAQ derived from Flight Management Attitude

Questionnaire – human factors survey to measure cockpit culture in commercial aviation

• FMAQ has been used for >20 years
• SAQ most commonly used tool for measuring

safety climate and culture in healthcare

• Can compare across the ward team i.e. doctors

with nurses and non-clinical staff

• 60 questions across 6 domains – we are using 2

(Safety and Teamwork climate)

Assessment of Safety Culture

• 28 questions in total
• Background information
• Confidential (includes

personal identifiers) data collection and anonymised reporting

• Additional Q:

“28. Please give your unit an

• verall grade on patient safety”

Principles

• This is an improvement intervention in itself and helps teams

realise their potential

• There is always some cause for celebration and sometimes

the results dispel myths about teams

• The majority of the elements are within the gift of the team

to address themselves

• The before and after measurement is helpful but need not be

the focus

• Behaviour Change Survey will help to understand more about

reasons for and issues behind attitudes

Principles

• Data belongs to teams not management. Free to use the

analysis as they wish

• Teams must have feedback and a “conversation”
• Point in time. Take at face value don’t need to over analyse,

interpret, justify or defend

• Team decides what to do. Have further support if they want

and Management listen

Teamwork and Safety Climate Survey St James’s University Hospital Ward XX March/April 2017

Response Rate 55.56%

Produced by Improvement Academy on 04/05/17

6 7 2

1 2 3 4 5 6 7 8 Clin Support Worker Nurse Other

Number of Staff by Staff Group

Culture Survey

• Key Information

Key Questions:

• In this clinical area, it is difficult

to speak up if I perceive a problem with patient care

• The doctors and nurses here

work together as a well- coordinated team

• I know the first and last names of

all the personnel I worked with during my last shift

• The levels of staffing in this

clinical area are sufficient to handle the number of patients

• I would feel safe being treated

here as a patient

• The culture in this clinical area

makes is easy to learn from the errors of others

• In this clinical area, it is difficult

to discuss errors

• 30%
• 20%
• 10%

0% 10% 20% 30%

Decision-making in this clinical area utilises input from relevant personnel It is easy for personnel here to ask questions when there is something that they do not understand I have the support I need from other personnel to care for patients I know the first and last names of all the personnel I worked with during my last shift Briefing personnel before the start of a shift (i.e. to plan for possible contingencies) is important for… Briefings are common in this clinical area I am satisfied with the quality of collaboration that I experience with nurses in this clinical area The culture in this clinical area makes is easy to learn from the errors of others I receive appropriate feedback about my performance I know the proper channels to direct questions regarding patient safety in this clinical area In this clinical area, it is difficult to speak up if I perceive a problem with patient care I am frequently unable to express disagreement with the medical staff here In this clinical area, it is difficult to discuss errors Nurse input is well received in this clinical area The doctors and nurses here work together as a well-coordinated team Disagreements in this clinical area are resolved appropriately I am encouraged by my colleagues to report any patient safety concerns I may have I am satisfied with the quality of collaboration that I experience with medical staff in this clinical area Medical errors are handled appropriately here Important issues are well communicated at shift changes I would feel safe being treated here as a patient Personnel frequently disregard rules or guidelines that are established for this clinical area Leadership is driving us to be a safety-centred organisation My suggestions about safety would be acted upon if I expressed them to management Hospital management does not knowingly compromise the safety of patients This organisation is doing more for patient safety now, than it did one year ago The levels of staffing in this clinical area are sufficient to handle the number of patients

Overall Comparison To Goal

Worse Then Goal Better Than Goal

16.9% 4.4% 7.0% 10.0% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% Clin Support Worker Nurse Other Overall

Worse Than Goal Better Than Goal

100% 86% 100% 93% 0% 20% 40% 60% 80% 100% Clin Support Worker Nurse Other Overall

Q01: Nurse input is well received in this clinical area

Agreeing Goal Danger 0% 14% 0% 7% 0% 20% 40% 60% 80% 100% Clin Support Worker Nurse Other Overall

Q02: In this clinical area, it is difficult to speak up if I perceive a problem with patient care

Agreeing Goal Danger 100% 100% 100% 100% 0% 20% 40% 60% 80% 100% Clin Support Worker Nurse Other Overall

Q03: Decision-making in this clinical area utilises input from relevant personnel

Agreeing Goal Danger 100% 100% 50% 93% 0% 20% 40% 60% 80% 100% Clin Support Worker Nurse Other Overall

Q04: The doctors and nurses here work together as a well- coordinated team

Agreeing Goal Danger

The Safety Huddle …igniting a spirit of learning

Certificate of Excellence Awarded'to'Staff'on'Ward'5'

Huddersfield)Royal)Infirmary)

for$ achieving$ 30$ days$ without$ a$ fall$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 4$ September$ 2014!

“Excellent achievement given the history of falls on this ward”

Clinical Director, Calderdale & Huddersfield NHS FT

Addressing Teamwork and Safety Culture Celebrating success Making measurement visible

A culture of safety

An environment, where everyone regardless of their title or grade, feels safe to speak up. No one is hesitant to voice a concern about a patient or the plan. When staff do speak up, they are treated with respect and have confidence that leadership will act upon their concerns; a cycle of trust.

Psychological Safety

Changes in Question Scores between Culture Surveys

Changes Post Culture Survey

• Change in shift times for pharmacists
• “hellomynameis…..” badges
• Involvement of CSWs in safety huddles
• Feedback to results to senior leaders
• Celebration
• Reflection and discussion with team
• Local changes to daily routine

Contact Details

www.improvementacademy.org t: 01274 383966 e: academy@yhahsn.nhs.uk

@Improve_Academy @improvementacademy

Human Factors in Healthcare and the MMF

Rebecca Lawton Professor, Psychology of Healthcare University of Leeds AND Bradford Teaching Hospital Foundation Trust

Overview of the session

• What is human factors – on being human
• Task, Individual, Team, Organisation
• Pulling it together - models
• How does all this fit with MMF

What is Human Factors

• Very many definitions, all of them long winded
• Human factors refer to environmental, organizational and

job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety. A simple way to view human factors is to think about three aspects: the job, the individual and the

• rganization and how they impact people’s health and

safety-related behaviour." WHO, based on HSE, UK

• “Enhancing clinical performance through an understanding
• f the effects of teamwork, tasks, equipment, workspace,

culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings”. NHS England

The key ingredients

The core elements

On being human

• We are all emotional creatures
• We are all social creatures
• We are all responders to our environment
• We are all habit formers
• We are problem solvers and decision makers
• We are all learners
• We are all exceptional and flawed………

The task: not all tasks are equal

• Lots of ways of

conceptualising tasks: high/low workload; demanding or easy, technical or non- technical

• Most useful distinction is

between those that are automatic and and those that require the application of complex thought processes.

The task: not all experiences are equal

An example task

Tasks, experience and the nature of error

Why do errors happen? Some examples:

• Use the wrong size needle

for the lumbar puncture

• Fail to get the needle in

the right place

• Do a lumbar puncture

when there is no indication of meningitis

• In groups – why might

these errors occur. Pick 1 and ask why 5 times.

The individual

• What factors associated with the individual make

these errors more likely?

– Stress – Experience – Fatigue – Emotional wellbeing – Personality – Knowledge…

• TASK: Each table pick two of these factors and

think about how and why these might affect safety at work

Yes, but sometimes people choose to do the wrong thing

• Often organisations have rules or procedures

to make sure people know what it is they have to do in a reliable way

• People don’t always do these things
• Why?

Behaviour change and patient safety: a video

The Team

• Mental health clip
• Surgical ward clip

TASK What are the team related factors in operation here? Professional rivalry, hierarchies, leadership, psychological safety, communication of information and style, emotional contagion, personal relationships, situational awareness, roles and responsibilities, professional identities …………

The Organisation

TASK: Imagine that there is a new person joining your

• rganisation. Your job is to convince them that they are

joining a safe organisation. What three things would you tell them about:

• The structure and the environment in which they will be

working?

• The safety culture of the organisation?

How well do these align with the list in your packs?

The Yorkshire Contributory Factors Framework

Putting it all together: Systems Engineering Initiative for Patient Safety (SEIPS)

Ladbroke Grove train crash

Accident

Region of Hazards

Individuals Defenses Task/Environment Organization

Inadequate engineered safety devices, signalling procedures and sighting standards

Inadequate defences Conditions

Bright sunlight Complexity of Track layout Signal

• bstructions

Inappropriate SPAD response Training Poor local Communication about hazards

Unsafe Acts

Driver misread signal or signal aspect Signalers Expected the driver to stop and so did not act with haste

Processes

Organisational learning Poor management

• f

Training Planning and design of Paddington Layout

Human Factors and measurement and monitoring of safety

CASE STUDY A nurse was in charge of the night shift on a 29 bed, speciality surgical ward. The shift was incredibly busy due to the acute status

• f 4 patients and the high nursing care needs of 6 others. An agency nurse who was unfamiliar with the ward and speciality was
• n duty with her. At 05.00 hours a heparin infusion needed replacing. The nurse was tired, stressed and felt rushed to draw up the

infusion so she could return to the sicker patients with whose condition she was quite preoccupied. She quickly made the calculation and started to draw up the drug. Before she had completed this she had to attend to a patient so quickly finished drawing it up. As she left the desk, her colleague asked, “Can I set this up?” to which she replied “No, I need to check it again”. It was 45 minutes before she got back to the desk where she found it missing and was told that it was being administered to the

• patient. When she asked if the administering nurse had checked it the answer was, “No, you’ve already done it”. The nurse quickly

reperformed the calculation and discovered the dose was incorrect. The error was corrected and no harm came to the patient. When the Ward Sister arrived at 07.15 hours, the nurse discussed what had happened with her, what had gone wrong and the lessons learned. The nurse was upset and tearful. Once the nurse had left the ward she realised she had not completed an incident form. When she returned for a shift two days later she completed the form. The following day she received a call at home to say the senior nurse wanted to take the matter further, there would be an investigation and she was suspended from drug administration until a formal disciplinary hearing had taken place. She describes the next six weeks as the worst of her career. She felt humiliated having to constantly explain to colleagues why she could not have any involvement with drug administration as well as guilty for the impact on not only her own colleagues who had to do her medication rounds for her, but on nurses on the neighbouring ward and site practitioners who at times had to help administer intravenous drugs for many patients, multiple times per shift. She was fearful of what the outcome of the disciplinary would be and resentful that the action being taken against her seemed harsh and served little purpose – she had had already learned from her mistake. At the hearing she was reprimanded for failing to follow protocol by not immediately completing an incident form and, whilst being the nurse in charge of the shift, failing to better supervise the colleague who had administered the drug. She was given an oral warning to be kept on record for six months and required to be reassessed on drug administration. Afterwards, colleagues told her she was stupid for having reported the incident as no harm had come to the patient. One colleague told her: “If this is what happens then I’ll be keeping my mouth shut if that happens to me”. Five weeks later, the nurse resigned.

TASK

• Take the measurement and monitoring framework and

ask yourself five questions:

• Has care been safe in the past?
• Is this ward responding and improving?
• Will care be safe in the future?
• Is care safe today?
• Are the clinical processes and systems reliable?
• For each question – how do you know and if you don’t

how could you find out.

• What would you do to make care safer on this ward?

The measurement and monitoring of safety

Caution: Having protocols in place doesn’t mean the process is reliable

Caution: not just about how many and what type of staff and patients but how they work together and whether they have a shared mental model

Caution: having few reported incidents in the past doesn’t mean you are safe Caution: implementing recommendations from incident analyses doesn’t guarantee improvement Caution: We can become blind to the things that are wrong

Smart measuring and monitoring

• What one thing will you start to measure or monitor now that you

didn’t before?

• Safety culture
• Team-working skills
• Patient feedback on safety
• Usability of equipment
• Whether the recommendations from incident reports go beyond

reminding and disciplining

• Patients at risk
• The physical environment
• Whether there are opportunities for staff to flag concerns……..

An example of using human factors to think differently about measurement

Supporting resources

• Carayon, P., Hundt, A. S., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith,

M., & Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Health Care, 15(suppl 1), i50-i58.

• Lawton, R., McEachan, R. R., Giles, S. J., Sirriyeh, R., Watt, I. S., & Wright, J.

(2012). Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic

• review. BMJ quality & safety, bmjqs-2011.
• http://chfg.org/search-content/
• http://www.improvementacademy.org/documents/Projects/human_facto

rs/Human-Factors-How-to-Guide-v1.2.pdf

Lunch and Networking

#howsafeisourcare

Market place

#howsafeisourcare

Action Planning

20 minutes

Your Team’s Review of the Day

What are your top 3 harms?

• Do you know?
• As a team can you identify
• ne harm that is a priority?

Describe how the framework can help your teams to improve understanding

• f one of top three harms
• Which marketplace

interventions could help?

• What else do you need to

know?

Your Action Plan

10 minutes

Access via: http://qitraining.improvementacademy.org/

Our Bronze training provides free e-learning entry level Quality Improvement training for everyone who works in health and social care interested in supporting or delivering improvement

W2: Post session work

• Identify your top three harms
• Describe how the framework can help you to improve you

understanding of one of your top three harms.

• Consider which interventions may support you to achieve

this.

• Complete Bronze Quality Improvement Training

Questions?

#howsafeisourcare

Thank you for attending

Please complete the evaluation form in your pack,

and return your badges before leaving

#howsafeisourcare

Contact Details

Debbie Clark - deborah.clark@yhahsn.nhs.uk Rachel Smith - Rachel.Smith2@sth.nhs.uk Abimbola Olusoga - Abimbola.Olusoga@yhahsn.nhs.uk

academy@yhahsn.nhs.uk F: @ImprovementAcademy T: @Improve_Academy t: 01274 383966

www.improvementacademy.org