open access protocol patient reporting of safety ... · 1faculty of health & life sciences,...

Patient Reporting of Safety experiencesin Organisational Care Transfers(PRoSOCT): a feasibility study ofa patient reporting tool as a proactiveapproach to identifying latentconditions within healthcare systems

Jason Scott,1 Justin Waring,2 Emily Heavey,1 Pamela Dawson1

To cite: Scott J, Waring J,Heavey E, et al. PatientReporting of Safetyexperiences in OrganisationalCare Transfers (PRoSOCT): afeasibility study of a patientreporting tool as a proactiveapproach to identifying latentconditions within healthcaresystems. BMJ Open 2014;4:e005416. doi:10.1136/bmjopen-2014-005416

▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2014-005416).

Received 7 April 2014Accepted 17 April 2014

1Faculty of Health & LifeSciences, York St JohnUniversity, York, UK2Centre for Health Innovation,Leadership and Learning,Nottingham UniversityBusiness School,Nottingham,Nottinghamshire, UK

Correspondence toDr Jason Scott;[email protected]

ABSTRACTBackground: It is increasingly recognised thatpatients can play a role in reporting safety incidents.Studies have tended to focus on patients withinhospital settings, and on the reporting of patient safetyincidents as defined within a medical model of safety.This study aims to determine the feasibility of collectingand using patient experiences of safety as a proactiveapproach to identifying latent conditions of safety aspatients undergo organisational care transfers.Methods and analysis: The study comprises threecomponents: (1) patients’ experiences of safety relatingto a care transfer, (2) patients’ receptiveness toreporting experiences of safety, (3) quality improvementusing patient experiences of safety. (1) A safety surveyand evaluation form will be distributed to patientsdischarged from 15 wards across four clinical areas(cardiac, care of older people, orthopaedics and stroke)over 1 year. Healthcare professionals involved in thecare transfer will be provided with a regular summary ofpatient feedback. (2) Patients (n=36) who return anevaluation form will be sampled representatively basedon the four clinical areas and interviewed about theirexperiences of healthcare and safety and completing thesurvey. (3) Healthcare professionals (n=75) will beinvited to participate in semistructured interviews andfocus groups to discuss their experiences with andperceptions of receiving and using patient feedback.Data analysis will explore the relationship betweenpatient experiences of safety and other indicators andmeasures of quality and safety. Interview and focusgroup data will be thematically analysed and triangulatedwith all other data sources using a convergence codingmatrix.Ethics and dissemination: The study has beengranted National Health Service (NHS) Research EthicsCommittee approval. Patient experiences of safety willbe disseminated to healthcare teams for the purpose oforganisational development and quality improvement.Results will be disseminated to study participants aswell as through peer-reviewed outputs.

BACKGROUNDPatient safety has received much attentionsince the publications of An Organisation witha Memory1 in the UK and To Err is Human2 inthe USA at the turn of the century. Sincethen, there has been a particular emphasis onidentifying patient safety incidents, broadlydefined as an incident that harmed or had thepotential to harm a patient.3 The most prom-inent approach to identifying unsafe care isthe use of incident reporting, where health-care professionals are required to identify andreport on safety incidents.4 However, therehave been a number of criticisms of healthcareprofessional incident reporting, with health-care professionals not engaging with incidentreporting due to a myriad of cultural issues5

and subsequently under-reporting incidents.6 7

This is of particular importance to care trans-fers between organisations, which are acknowl-edged to be especially high in risk8–11 and areoften haphazard.12

Strengths and limitations of this study

▪ A strength is that the study will demonstratehow, or if, routinely collected data on patientexperiences of safety during an organisationalcare transfer is linked to other measures andindicators of quality and safety.

▪ A unique feature of the investigation will be howpatient feedback on safety promotes organisa-tional learning within multiple healthcare provi-ders when patients’ care crosses healthcareboundaries.

▪ Challenges include engaging patients to reporton their experiences of safety, and engaginghealthcare professionals to distribute surveysand use feedback for quality improvement.

Scott J, Waring J, Heavey E, et al. BMJ Open 2014;4:e005416. doi:10.1136/bmjopen-2014-005416 1

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When willing and able,13 patients are believed to havea role in improving their own safety during care trans-fers, which includes the identification and reporting oftheir own safety14 and increased involvement in thehandover process itself.15 Recent reports in the UK,such as the Francis Inquiry16 and the report by DonaldBerwick,17 indicate that patients should be involved atall levels in their own safety. This involvement falls intothree categories: informing a management plan, moni-toring and ensuring safe delivery of treatment andmaking systems safer,18 the latter of which includesreporting on experiences of safety.Patients differ from healthcare professionals in their

perceptions of safety,19–21 and these differences need tobe addressed. By involving patients in their own safety,healthcare professionals can encourage them to act asan extra safeguard within the healthcare system,14 inline with the systems approach to safety.4 Where the defi-nitions of safety differ between the patient and health-care professional, it is only the patient who can identifyand report on feeling unsafe in relation to their owndefinition of safety.As such, the aim of this study is to determine the feasi-

bility of implementing a patient safety survey which willmeasure patients’ experiences of their own safety relat-ing to care transfer, in particular the discharge, journeyand arrival stages of the transfer. In order to achieve thisaim, specific objectives include:1. Measurement of experiences of safety relating to a

care transfer following discharge from hospital,including a comparison of how these experiencesrelate to current measures and indicators of safety(readmission rates, length of stay, Datix reports onpatient experience and safety thermometer data).

2. Determining response rates and investigating thereceptiveness of patients to the reporting tool, includ-ing the applicability of the domains of safetymeasured.

3. Investigating the engagement and responsiveness ofhealthcare teams to the reporting tools and reportsof safety, and the promotion of organisationallearning.

METHODOLOGYAppreciative Inquiry (AI) is a methodological approachto research and organisational development that focuseson ‘what works well’ in an organisation, as opposed towhat does not work.22–24 It has been acknowledged thattrends in adverse events do not appear to be improv-ing,25 and there is an increasing emphasis, particularlyin proactive approaches to safety management, thateffective safety management requires identifying andmeasuring ‘safety’, as opposed to ‘unsafety’.26 Utilisingprinciples of AI provides a methodological basis for thefocus on ‘safe’, as opposed to ‘unsafe’ care. The involve-ment of patients in this proactive approach with anemphasis on safe care provides a radical alternative to

existing methods of measuring safety. By taking this posi-tive approach, AI has the ability to engage healthcareprofessionals by shifting the focus from problems tosolutions.27

METHODSThe study will investigate patient reports of safety follow-ing a care transfer, which will include the dischargeprocess, the journey and the arrival or admission process atthe following organisation. The safety surveys will be dis-tributed to patients discharged from wards in four clin-ical areas: cardiac, care of older people, orthopaedicsand stroke. These clinical areas were chosen in consult-ation with patient safety teams at the research sites so asto focus on clinical areas predominantly associated witholder patients who are at increased risk of safety inci-dents28 and are recognised as high priorities.29

Furthermore, the safety survey was originally developedbased on older patients’ perceptions of safety in caretransfers.14

Study designThe study will utilise a mixed methods approach, withqualitative and quantitative data collected across threecomponents of the study. The three components reflectthe objectives of the study, and include (1) patients’experiences of safety relating to a care transfer, (2)patients’ receptiveness to reporting experiences of safetyand (3) quality improvement using patient experiencesof safety (figure 1).Qualitative methods will supplement quantitative data

collected from the safety surveys, which will provide anunderstanding of the processes involved in learningfrom the patient feedback, potentially leading to qualityimprovement. The survey results will be made availableto clinicians, thus allowing them to take a proactiveapproach to safety. This will consist of implementing abi-weekly feedback loop between the research team andhealthcare professionals involved in the transfer ofpatients. The feedback will be provided bi-weekly in theform of a clinical dashboard collated from the safetysurveys representing three categories: patients withintheir own healthcare unit, patients within their clinicalarea and patients across the study (unidentifiableoutside of their healthcare unit; figure 2).

Safety survey for organisational care transfersThe safety survey was developed by healthcare profes-sionals and expert patients. It provides a brief explan-ation of patient safety and captures patient reports ofsafety across three stages of the care transfer (discharge,journey and arrival or admission). The questions asked ineach stage of the care transfer are provided in table 1,and focus around six domains: communication, responsive-ness, waiting times, falls, medication and hygiene. Thesedomains are based on patient perceptions of safety.14

Patients or their carers are asked to report on three

2 Scott J, Waring J, Heavey E, et al. BMJ Open 2014;4:e005416. doi:10.1136/bmjopen-2014-005416

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levels of safety: safe (green), neutral (yellow) and unsafe(red), and to leave any non-applicable sections blank.The safety survey asks patients or carers the mode of

transport for the journey and the arrival destination.Respondents are also asked if there was another reasonthey felt safe or unsafe and if anything could have beendone to make the patient feel safer; the safety surveygives space to explain their answers to these questions.The survey also provides patients or carers with thecontact details of the lead researcher, so that patientscan ask questions about the survey.

Study settingSurveys will be distributed by ward staff in three hospitalsacross two National Health Service (NHS) trusts. Thefour clinical areas will be represented across 15 wards:cardiac (n=3), care of older people (n=4), orthopaedics(n=4) and stroke (n=4). Distribution of numberedsurveys by ward staff means that it is known where thepatient has been discharged from. During the course ofthe study, the safety surveys will be used to map howpatients are transported ( journey) and who their care ishanded over to (arrival or admission).

Component 1: patients’ experiences of safety relating to anorganisational care transferObjectiveMeasurement of experiences of safety relating to a caretransfer following discharge from hospital, including acomparison of how these experiences relate to currentmeasures and indicators of quality and safety.

MethodPatients will be provided with a safety survey on dis-charge from hospital. Surveys are a commonly usedmethod of capturing feedback from patients on a widenumber of healthcare topics. Of relevance to this studyare patient experience surveys and patient safety surveys,with the latter currently the most reported method ofcapturing patient reports of safety.13 30 Routinely col-lected data relating to measures and indicators of qualityand safety will also be collected.

Figure 2 Process of feedback to healthcare teams,

organisational learning and quality improvement.

Figure 1 Flowchart demonstrating how the components of the study interlink.


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SampleAll patients discharged from the included wards, ortheir carers, will be given a safety survey by ward staff.Owing to the nature of the wards, it is not anticipatedthat this sample will include any patients under the ageof 18. As all patients will be given the safety survey, nopower calculation was conducted; instead response rateswill be monitored to inform feasibility for the universalinvitation for patients to provide feedback on their safetyin the setting of care transfers. It is estimated, based ondischarge information from the sites, that the safetysurvey will be distributed to 14 000 patients over a12-month period. Routinely collected data will consist ofreadmission rates, length of stay, Datix reports onpatient experience and safety thermometer data foreach of the wards included in the study.

ProcedureThe safety survey will be given to patients by an appro-priate member of the clinical team or an administratorresponsible for compiling discharge information, forexample, discharge coordinator or ward clerk. Patientswill be given a letter of invitation to the study, the safetysurvey and an evaluation form. The evaluation form willinvite patients to evaluate aspects of the safety survey,including its relevance to their own experiences ofsafety, its ease of use and its helpfulness in educatingthem about patient safety. The forms will be used toguide the ongoing development of the safety survey.Patients will also be given a prepaid addressed envelope,a technique which has been shown to improve responserates to surveys.31 Those distributing the safety surveywill be asked to prompt the patient to complete andreturn the safety survey.Participants will opt-in on completion and return of

the safety survey and/or an evaluation form. The optionto return either is designed to reduce bias from thosewho evaluate the safety survey negatively or do not wishto complete it. Patients’ family members or carers willbe encouraged to assist the patients to complete thesurvey where applicable, or to complete it on theirbehalf.Each return envelope will have a unique identifying

number which will be used to identify the ward that the

patient was discharged from. Owing to the potentiallysensitive nature of the topic, patients will have theoption of returning the safety survey anonymously, andthe identifying number will not be able to be used toidentify individual patients.

AnalysisDescriptive and inferential statistical analysis will deter-mine if a relationship exists between patient experiencesof safety and the other indicators and measures ofquality and safety (Datix reports, safety thermometerdata, readmissions, length of stay). One-waybetween-group analysis of variance will be used tocompare response rates between sites. Non-parametrictests (in particular Kruskal-Wallis test and Spearman’s r)will be used to analyse differences and relationships inevaluation responses. Descriptive statistics will form amapping process of the journey and admissions stages ofthe transfer, which will be used in component 3.Evaluations of the safety survey will be used to modifythe reporting tool on a monthly basis to ensure it meetsthe needs of the patients.

Component 2: patients’ receptiveness to reportingexperiences of safetyObjectiveTo determine response rates and investigate the recep-tiveness of patients to the reporting tool, including theapplicability of the domains of safety measured.

MethodSemistructured interviews, incorporating appreciativeand cognitive interview components, will be conductedwith patients to investigate their experiences of safety incare transfers and their experiences of providing feed-back on their safety. Appreciative interviews will utilisethe discover and dream stages of AI32 to investigateexperiences of, and ideas about, safety. Cognitive inter-views will involve inviting interviewees to describe theirthought processes in response to survey questionnaires,in order to identify any potential misunderstandings orother problems with those questionnaires; such inter-views have proven useful in validating and improvingsurvey questionnaires in healthcare settings.33 The

Table 1 Questions asked in the safety survey about the different stages of the care transfer

Please tick which of the following affected how safe or unsafe you felt

Discharge Journey Arrival or admission

Communication from staff Communication from staff Communication from staff

Staff listening to you Staff listening to you Staff listening to you

Departure running to schedule Journey running to schedule Waiting times

Falling or potential falls Falling or potential falls Falling or potential falls

Medication problems or concerns Medication problems or concerns Medication problems or concerns

Hygiene Hygiene Hygiene

Please use this space to tell us if there was another reason why you felt safe or unsafe or to expand on your answers above.

What could we have done to make you feel safer during your transfer?


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interviews will be supplemented by data on responserates and evaluation forms.

Interviews sampleInterviews will be conducted with patients from eachward included in the study (n=36). A representative sam-pling framework will be used to identify patients whoreported a range of experiences of safety, were trans-ported by different means and arrived or were admittedto different organisations. The inclusion criteria forinterviews include:▸ Able to give informed consent▸ Aged 18 or above▸ Able to speak English

ProcedureThe interview questions will be structured into fourthemes: general health questions, general safety ques-tions, care transfer questions and safety survey questions.The general health questions will explore healthcareexperiences from the patients’ perspective and thegeneral safety questions will explore how safety is under-stood and their experiences of safety. The care transferquestions will allow for further discussion of the answersto the general safety questions, applied to care transfersspecifically. Finally, the safety survey questions willexplore the patients’ perspectives on the survey, includ-ing the applicability of the questions to their experiencesand why they chose their answers. The questions willalso focus on barriers and enablers to providing usefulfeedback on their own safety within care transfers. Thepatient interview schedule will be refined iterativelythroughout data collection.

AnalysisOnce each interview is complete it will be transcribedverbatim, then coded and analysed systematically usingqualitative analysis software. Thematic analysis will beused, which is flexible enough to allow for new themesto emerge.34 The patient interviews and healthcare pro-fessional interviews (discussed below) will be analysedindependently of each other. Response rates will becompared between wards, allowing for analysis of non-response bias. Planning for this before the data collec-tion commences is considered the best practicewhen conducting surveys within healthcare settings.35

Evaluation forms will be compared with responses onthe safety survey using non-parametric statistical testsand descriptive statistics, and feedback will be used toiteratively modify the safety surveys on a monthly basis.

Component 3: quality improvement using patientexperiences of safetyObjectiveInvestigate the engagement and responsiveness ofhealthcare teams to the reporting tools and reports ofsafety, and the promotion of organisational learning.

MethodSemistructured interviews will be conducted with health-care professionals who were involved in the transfer ofpatients or who received the patient feedback.

SampleFour healthcare professionals from each of the includedwards, including the ward manager, patient safety lead(where in post), discharge coordinator (where in post)and other ward-based staff involved in care transfer(n=60), will be invited to participate in interviews orfocus groups during the period of study. These partici-pants will meet the following inclusion criteria:▸ Work on one of the included wards during the

period where safety surveys are distributed, where:– They are responsible for managing the ward, or– They have been involved in distributing the safety

survey, or– They have responsibility for discharging patients.Healthcare professionals (n=15) from other organisa-

tions (eg, ambulance services, nursing homes) involvedin the journey or arrival/admission process of the caretransfer, identified via the mapping process, will also beinterviewed. The inclusion criterion for these partici-pants is:▸ Have responsibility for the management of patients

or services relating to the transfer of the patient.

ProcedureThe interview questions will be structured into threethemes: general questions, general patient safety ques-tions and questions about safety survey feedback. Thegeneral questions will enquire about professional back-ground, current role and length of service in theircurrent role and healthcare setting. The general patientsafety questions will focus on understandings of patientsafety, their perceptions of patient involvement in safetyand the role of patients in reporting experiences ofsafety. The questions relating to the safety survey feed-back will investigate how much contact they had with thefeedback, how the feedback has been used in practice,including the relevance and appropriateness of informa-tion provided, and the barriers or enablers to using thefeedback to learn about patients’ perceptions of safetyand improve services. This section will also contain thecognitive interview component, where participants willbe asked how they interpret the domains of safety in thesurvey. The healthcare professional interview schedulewill be refined iteratively throughout data collection.

AnalysisOnce each interview is complete, it will be transcribedverbatim, then coded and analysed systematically usingqualitative analysis software. Thematic analysis will beused, which is flexible enough to allow for new themesto emerge.34


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Mixed methods analysisOnce data collection is complete across all objectives,mixed methods analysis will be conducted to provide aholistic meta-analysis. This analysis will consist of triangu-lating the findings in a convergence coding matrix,which displays findings from each component on thesame page.36 The matrix will allow for an analysis of(dis)agreements, partial (dis)agreements or silencesacross the different components of the study, resultingin meta-themes.This mixed methods analysis will provide a much

deeper understanding of patient reporting of safety incare transfers than would have been possible if analysingthe components in isolation. Case studies, underpinnedby AI and combining the data together, will be devel-oped to provide examples of best practice, relating tohow patients are currently made to feel safe, or how thefeedback has been used to improve safety and experi-ences of safety.

Study managementThe study was designed with input from patient repre-sentatives from the Patient, Carer and PublicEngagement network at the former North East StrategicHealth Authority. The Patient, Carer and PublicEngagement network was part of the Safer Care NorthEast programme of work, where the safety survey wasdeveloped. One member of the network, along with twoother patient representatives, will be part of an advisorygroup to provide direction and guidance throughoutthe study. Other members of the advisory group willinclude two healthcare professionals responsible forsafety and quality at the included NHS Trusts, independ-ent patient safety experts, the research team and seniorhealthcare professionals with expertise in healthcarepolicy.

ETHICS AND DISSEMINATIONPatient feedback received via the safety survey will be dis-seminated regularly to the healthcare teams and organi-sations involved in the study, in line with the qualityimprovement strategy, as stated in the study designsection. Respondents will have the opportunity torequest at the time of returning the survey a summary ofthe findings, which will be provided at the end of thestudy. The findings will also be published in peer-reviewed journals and at academic and health servicesconferences.

DISCUSSIONThis paper has presented the background, methodologyand methods of a large scale, multisite research projectinvestigating the feasibility for patients to provide feed-back on their experiences of safety relating to their caretransfer. As identified earlier, there is an increasingemphasis on the need for patients to be involved intheir own safety,13 14 37 highlighted by the recent events

and subsequent enquiries at Mid-Staffordshire NHSFoundation Trust.16 17 This need can be addressedthrough patient reporting of safety concerns or inci-dents,30 so that organisations can learn from the patientperspective. This study will address that need in thecontext of care transfers.Surveys are the most common method of soliciting

patient reports of safety,13 30 although there has beenlittle research into how the results can lead to organisa-tional learning and quality and safety improvements. Insettings other than patient safety, it has been identifiedthat if used correctly, patient feedback can lead toimprovements in the quality of care delivered,38 39

although this does not occur as often as it should.40

This study will build on this knowledge base by closingthe gap between patients being involved in traditionalincident reporting and the universal invitation forpatients to provide feedback on their experiences ofsafety. This will also allow for the investigation of howpatient feedback on safety can instigate quality improve-ments within multiple healthcare providers whenpatients’ care crosses healthcare boundaries: a timewhen patients are at particularly high risk of experien-cing safety incidents.8 9 11 Depending on the outcomesof the study, such as whether patient feedback on theirexperiences of safety can lead to improvements and howthis feedback relates to other measures and indicators ofquality and safety, there is potential for this feedback tobecome routinely collected data.As with other studies on patient involvement in

safety,41 there are a number of risks to the study whichcan be broadly categorised into patient engagement andhealthcare professional engagement. While evidencesuggests that patients can be involved in their safetywhen willing and able,37 the majority of this researchhas been conducted within single healthcare settingssuch as a hospital, and transferability of findings to caretransfers is unknown. The distribution of the reportingtool during discharge, alongside other discharge docu-mentation, has the potential to result in informationoverload among patients, which may reduce responserates. This may be further complicated as older patientsoften do not understand discharge information.42

Proactive dialogue between the research team and health-care professionals can help to mitigate this by encouragingthe healthcare professionals to highlight the purpose ofthe survey to patients, thus encouraging dialogue arounddischarge information. The potential for reducedresponse rates will be further mitigated by distributing thesurvey universally, although this does not entirely removethe risk that data collected does not reflect the wholepopulation being surveyed, but only those who are ableand willing to respond. As with other patient involvementin safety research,43 the research team acknowledges thatultimate responsibility for patients’ safety remains with thehealthcare teams, and the safety feedback is meant to sup-plement rather than replace other measures and indica-tors of quality and safety.


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In a similar manner, the patient safety surveys are nota means to quality improvement alone, but instead arepart of a larger process of organisational learning andcontinuous quality improvement, which incorporatesfeedback loops and the constant analysis of data.Consequently, and as the research team will not beimposing themselves on the healthcare professionalsin the sense of active encouragement of team meet-ings or having a constant presence within their teams,it is possible that the feedback will be overlooked orignored. This risk can be mitigated by including pro-active dialogue between the research team, healthcareteams and the patient safety managers within theresearch sites outside of the feedback periods, discuss-ing inside and outside the interviews any issues thatarise. Understanding any barriers to engagement isalso important to uptake, and this dialogue shouldhelp to improve the ecological validity of the safetysurveys.38

The authors intend to demonstrate how, or if, rou-tinely collected data on patient experiences of safety islinked to other measures and indicators of quality andsafety, much like patient incident reporting shares somesimilarities with healthcare professional incident report-ing.19–21 The investigation of the processes involved inusing and learning from this feedback will provide agreater understanding of how improvements can bemade to quality and safety as a result of patient feed-back, within the context of care transfers.

Acknowledgements The research team would like to thank The HealthFoundation, an independent charity working to improve the quality ofhealthcare in the UK, for funding the study. We would also like to thank theNational Health Service (NHS) Trusts involved in the study for their ongoingsupport, and members of the advisory group who have helped to guide theproject. The research team also acknowledge the support of the NationalInstitute for Health Research, through the Comprehensive Clinical ResearchNetwork.

Contributors JS, JW and PD were involved in the conception and design ofthe study and preparation of the manuscript. EH was involved in preparationof the manuscript. All the authors read and approved the final manuscript.

Competing interests None.

Ethics approval The study has been granted ethical approval by Yorkshire &The Humber—Leeds West NHS Ethics Committee (13/YH/0372).

Provenance and peer review Not commissioned; peer reviewed for ethicaland funding approval prior to submission.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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