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International Forum on Quality & Safety in Healthcare 2014 ‘Alive & Clicking: Patients and Families sign on as Care Quality Experts’

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Presentation on theme: "International Forum on Quality & Safety in Healthcare 2014 ‘Alive & Clicking: Patients and Families sign on as Care Quality Experts’"— Presentation transcript:

1 International Forum on Quality & Safety in Healthcare 2014 ‘Alive & Clicking: Patients and Families sign on as Care Quality Experts’

2 Disclosures: This project was funded by The Health Foundation’s ‘SHINE 2012’ Programme

3 Families reporting critical incidents & near misses in a children’s hospital. Ms Charlotte Magness & Dr Henning Clausen Great Ormond Street Hospital for Children, London

4 Why?

5

6 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

7 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

8 What is safe care? How will families report? What will families tell us? Will it save lives?

9 Current Hospital Safety Structure

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11 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

12 Quality Improvement Method Plan Stud y Do Act Cycle What do we want to change and why? How will we know changes are improvement? What actions can we take to achieve improvement?

13 Families & patients report adverse events The first phase

14 The family e-questionnaire

15 Seeing with ‘Eagle Eyes’

16 Type of incidents reported Complications Medication Equipment Communication %

17 How many family reports overlapped with staff reports? 3 % 13 % 23 % 33 % 43 %

18 How many family reports overlapped with staff reports? 3 % 13 % 23 % 33 % 43 %

19 Influence on staff reporting… 2012 2013 p = 0.0314 1.29 reports per week 2.05 reports per week 59% increase

20

21 Managing Harm / Risk: DATIX® questionnaire Data accuracy ? Exclusion of some families ?

22 Back to the drawing board…

23 Families & patients report adverse events The second phase

24 Real-time measurement of safety concerns by patients & families Same ward setting as other phases 1 st 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

25 Capturing events in real-time …

26 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

27 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

28 Sustaining real-time reporting Test 2 Clinical nursing staff Test 1 Non-clinical project staff Next test Hospital volunteers Reports: / week: 2.58 Reports / week: 0 Reports / week: ?

29 ‘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

30 ‘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

31 Do families feel more empowered to report critical incidents? BEFORE AFTER Safety score 0-5 3.06 3.93

32 How do staff view patient safety? BEFORE AFTER Overall safety score 4-5 (Sexton tool) 76.9 % 89.5 %

33 Manchester Patient Safety Framework (MaPSaF) 20132014 Nursing staffJuniorSeniorJuniorSenior Team3.544.53.6 Organisation4.53.642.8

34 What is Safety? How do I manage risk?IDENTIFYINVESTIGATEACTION  Real–time  Proactive  Every patient  Every day  Situation awareness  Communication bridge  Debrief opportunity  Transparency  Disclosure  Mitigations  Cross-learning  Communication Strategy  QI projects

35 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

36 What is the ‘safety world’ at GOSH? Information Trust Hudson, Qual Saf Health Care 2003

37 Our journey to a generative GOSH? Information Trust Hudson, Qual Saf Health Care 2003

38 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

39 Thanks to a fantastic team

40 References 1.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%20s ummary.pdf [Accessed: 27/01/2014] http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20s ummary.pdf 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


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