Development of the Patient Safety Incident Management System

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 Processes Staff Ethos www. england. nhs. uk IT systems 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 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 e. Form Report Cleansing/ anonym’ion Live file in STEIS for action/ management Record of incident in NRLS National Clinical Review Nationally derived learning KEY: www. england. nhs. uk Report made to STEIS (within 48 hrs) 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 Report made to STEIS (within 48 hrs) Report extracted for NRLS Clinical Report in LRMS Cleansing/ anonym’ion e. Form Report Source of poor standardisation, as local arrangements vary KEY: Incident Data Document Process Stored data Loses benefits of more evolved local management systems available to trusts with LRMS This step effectively prevents any nongeneric feedback to individuals making reports Live file in STEIS for action/ management 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. This separation of “live” management files and static NRLS records can lead to “two versions of the truth” 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 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 e. Forms 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 e. Forms 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 Carers Primary Care Community care Ulysses Department of Health Scottish Government NHS England Specialised Commis’ning NICE 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 Royal Colleges Imperial College London Patient Safety Domain (5) Team 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 lucie. mussett@nhs. net • 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