Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan...

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Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant

Transcript of Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan...

Page 1: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

Baseline assessment: Key findings

Dr Jane CartheyHuman Factors and Patient Safety Consultant

Susan Burnett,Patient Safety Researcher & Consultant

Page 2: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

A framework for safety measurement and monitoring

Vincent, Burnett and Carthey, 2013

Page 3: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

Methodology

Document review Interviews Analysis Summary

Report

Page 4: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

FindingsVaried

awareness of the framework

Variation in methods used

High volume of information

Significant QI activity

CCG maturity on sensitivity to operations

Page 5: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

DiversityPast harm

– Some Boards interrogate divisional performance variability. Others do not.

– Too many measures in some sites?

Reliability– Some measures of reliability for care bundles– More to do to develop measures of reliability of clinical systems

Sensitivity to operations– ‘Tell us today’ ‘HospiCom’, junior doctors, student nurses, entry

and exit surveys in mental health etc

Page 6: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

Diversity

Anticipation and preparedness– Wide differences in measures across sites.– Generally, We are not there yet

Integration and learning– DATIX incidents with staffing levels, clinical audit

findings etc.– Big differences in maturity of dashboards – Generally, still a long way to go on this dimension of

the Framework

Page 7: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

Common goals

A whole health economy approach to understanding past harm & reliability

Sensitivity to operations: Need for more triangulation with other data sources at Trust level: How might we use soft intelligence intelligently?

Anticipation and preparedness: To increase our focus on this dimension, improve our foresight and ability to act before harm occurs.

Integration and learning: To improve feedback to frontline healthcare teams & to improve how we bring safety data from the other dimensions of the Framework in a coherent way. Spreading learning in how to measure for improvement

Page 8: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

Examples of good practicePast Harm - Christie: Mortality review process. CCG lead involvement in Trust serious incident review panels

Integration and learning Tameside: Review of 2 years safety data formed basis for whole organisational development plan

Anticipation and preparedness -Wigan: Staff training data used to anticipate erosions in safetySalford safety culture survey in operating theatres

Sensitivity to operations –Tameside: virtual safety radar screenEast Lancs CCG: GP reporting system

Reliability - Lancashire Teaching: ‘Guardianship’Chester CCG: review of AQuA reliability data on sepsis

Page 9: Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

Past Harm: How might we maximise the learning from past harm data (improving incident investigation, understanding human factors etc.)

Integration and learning: How might we triangulate and integrate data in a more meaningful way?

Anticipation and preparedness: How might we create more real time safety measurement and monitoring data that supports us to act before things go wrong?

Sensitivity to operations: How might we use soft intelligence in an intelligent way?

Reliability: How might we ensure we are applying reliability measures appropriately?(i.e. understanding the limitations, which measures matter?)


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