International Forum onQuality & Safety in Healthcare

2014

‘Alive & Clicking:Patients and Families sign on

as Care Quality Experts’

Disclosures:

This project was funded by

The Health Foundation’s

‘SHINE 2012’ Programme

Families reporting critical incidents

& near misses

in a children’s hospital.

Ms Charlotte Magness & Dr Henning ClausenGreat Ormond Street Hospital for Children, London

Why?

• In developed countries as many as 1 in 10 patients are harmed while receiving hospital care.

• The probability of patients being harmed in hospitals is higher than when ambulatory.

• Risk of healthcare associated infection in some developing countries is up to 20 times higher than in developed countries.

• These costs add up to approx $ 29,000,000 per year in the USA alone.

The Facts

• Health Professionals are at risk of making the same mistake as the Titanic.

• Patients and their families are the eyes & ears of the hospital

The problem

What is safe

care?

How will families report?

What will families tell us?

Will it save

lives?

Structure

Online feedback

Risk manager

Clinical Staff

Complaints Service

Current Hospital Safety Structure

Structure

Family report

Risk manager

Clinical Staff

Complaints Service

• Increase incident & near miss reporting by using patients & families as partners in care

• Better pattern recognition of errors & near misses should focus improvement efforts

• Comparing staff versus family reports should identify previously unrecognised problems

• If families report incidents & staff accept this as learning opportunity, change in staff attitude towards safety concerns should follow

Ambitions

Quality Improvement Method

Plan

Study

DoAct Cycle

What do we want to change and why?

How will we know changes are improvement?

What actions can we take to achieve improvement?

Families & patientsreport adverse events

The first phase

The family e-questionnaire

Seeing with ‘Eagle Eyes’

Type of incidents reported

Complic

ations

Medication

Equipm

entCom

municatio

n%

How many family reports overlapped with staff reports?

• 3 %• 13 %• 23 %• 33 %• 43 %

How many family reports overlapped with staff reports?

• 3 %• 13 %• 23 %• 33 %• 43 %

Influence on staff reporting…

STAFF0

5

10

15

20

25

30

35

402012 2013

p = 0.0314

1.29 reports per week

2.05 reports per week

59% increase

Managing Harm / Risk:DATIX® questionnaire

Data accuracy ?Exclusion of some families ?

Back to the drawing board…

Families & patientsreport adverse events

The second phase

Real-time measurement of safety concerns by patients & families

• Same ward setting as other phases• 1st real-time bedside tool (paper based)• Families comments are collected daily• Shared action plans are agreed with families • Reaching out to non-English speaking

families• Sustainability through daily nursing routine

Capturing events in real-time …

ANALYSIS OF DAILY PATIENT SAFETY ISSUES• Staff member to discuss the patient safety issue with family.• Staff member to review and tick the most appropriate categories (below) that describes the patient safety issue.• Ensure that the issue number listed by families is coordinated with the issue number listed on the category section.• Staff member to write a brief description of the actions taken to resolve patient safety issues raised.

Actions taken to resolve patient safety issues raised (to be completed by staff):

Issue 1) ……………………………………………………..................................................................................................................................................................................................

……………………………………………………………………………………………………………………………………………………………………………………………………………….

Issue 2) …………………………………………………………………………………………………………………….………………………………………………………………………….….

………………………………………………………………………………………………………………………………………………………………………………………………………………………………… .…..….

Issue 3) ………..…………………………………………………………………………………………………………………………………………………………………………………..……...

……………………………………………………………………………………………………………………………………………………………………………………………………………….

STAFF MEMBER TO COMPLETE THE BELOW

Objective Pathways for escalation & feedback

• All reports are added to a paper based management

sheet positioned in the Ward Sister office

• Reports are reviewed by Ward Sister / Practice Educator• All actions are recorded

Sustaining real-time reportingTest 2

Clinical

nursing staff

Test 1

Non-clinical

project staff

Next test

Hospital volunteers

Reports: / week: 2.58

Reports / week: 0

Reports / week: ?

‘You are really brave to do this. I haven’t come across a hospital where they are welcoming criticism actively and want us to open about bad things.’ (Parent)

‘Will this tool be available at my local hospital?’ (Parent)

‘ Much prefer this version of the tool.’ (Parent)

11-year-old patient understood and used the tool to document a delay to theatre which caused extended period of fastening (nil by mouth).

Family perception

‘A family voiced a concern to me and I thought I had reassured them, but when I saw that they had raised this concern on the tool, it made me think I probably hadn’t spent enough time discussing their concern so I went back and spoke to them in more detail’

‘ The family and patient safety reporting tool really helped me communicate and helped to open up this conversation’

‘We want this information.’

Staff Perception

Do families feel more empowered to report critical incidents?

BEFORE AFTER

Safety score 0-5

3.06

3.93

How do staff view patient safety?

BEFORE AFTER

Overall safety score 4-5

(Sexton tool)

76.9 %

89.5 %

Manchester Patient Safety Framework (MaPSaF)

2013 2014Nursing staff Junior Senior Junior SeniorTeam 3.5 4 4.5 3.6Organisation 4.5 3.6 4 2.8

What is Safety?How do I manage risk?

IDENTIFY INVESTIGATE ACTION

Real–timeProactive Every patientEvery day

Situation awareness

Communication bridge

Debrief opportunityTransparencyDisclosure

MitigationsCross-learningCommunication

StrategyQI projects

What this means for GOSH…

Foundation for next projects on

situational awareness, disclosure

& transparency

Understanding of how to improve partnership

with parents & their children

New understanding of patient safety

What is the ‘safety world’ at GOSH?

Pathological

Reactive

Calculative Proactive

Generative

Information

Trust

Hudson, Qual Saf Health Care 2003

Our journey to a generative GOSH?

Pathological

Reactive

Calculative Proactive

Generative

Information

Trust

Hudson, Qual Saf Health Care 2003

Hear the patient voice, at every level,

even when that voice is a

whisper…“A Promise to Learn – A Commitment to Act”

Berwick Report, UK Government 2013

Thanks to a fantastic team

References1. Jeremy P. Daniels MD BASc. “Identification by families of pediatric adverse

events and near misses overlooked by health care providers” www.cmaj.ca [November 21, 2011]

2. Francis, R. “Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry” http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf [Accessed: 27/01/2014]

3. Manchester Patient Safety Framework research team (2006) Manchester patient Safety Framework (Acute). National Patient Safety Agency

4. Sexton, J. (2002) Safety Climate Survey; Institute for Healthcare Improvement