1. Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by

2. Outline Introduction Objectives Framing Patient Safety Research 1. Examples of Industry Models for Safety Research 2. Examples of Patient Safety Models 3. Multilevel Framework of Patient Safety Research Measuring Patient Safety Research

3. Introduction Effective management of patient safety in healthcare requires: 1. an understanding of the causes of adverse events and related outcomes 2. a capacity to measure adverse events and their causes as well as related outcomes at different levels (individual, unit, organization, industry, national, international) Measurement of industry safety status is achieved by a range of methods based on key performance indicators for risk factors and safety events as well as leading indicators for safety (including causes like cultural factors)

4. Objectives 1.To propose a causal framework for patient safety outcomes 2.To review possible methods for the relevant variables in each component of the framework with particular reference to acute hospitals

5. Framing Patient Safety Research Examples of Industry Models for Safety Research: 1)‘Swiss Cheese’ model of accident causation (Reason, 1997)

6. Framing Patient Safety Research Examples of Industry Models for Safety Research: 1)‘Swiss Cheese’ model of accident causation (Reason, 1997) 2)Vincent et al. (2000): Reason’s model within the healthcare setting

7. Framing Patient Safety Research Examples of Industry Models for Safety Research: 1)‘Swiss Cheese’ model of accident causation (Reason, 1997) 2)Vincent et al. (2000): Reason’s model within the healthcare setting 3)Factors influencing safety behaviours and safety outcomes at different levels of analysis (Flin, in prep)

8. External Influences OrganizationInterveningBehavioursOutcomes National Culture Economic Regulator Government Targets Safety Culture Leadership HR Practices Safety Management Practices Motivation Wellbeing Morale Knowledge Safe Compliance Reporting Speaking Up Unsafe Risk taking Risk breaking Plant/ Worker Safety Patient Safety Framing Patient Safety Research 3)Factors influencing safety behaviours and safety outcomes at different levels of analysis (Flin, in prep)

9. Framing Patient Safety Research Examples of Industry Models for Safety Research: 1)‘Swiss Cheese’ model of accident causation (Reason, 1997) 2)Vincent et al. (2000): Reason’s model within the healthcare setting 3)Factors influencing safety behaviours and safety outcomes at different levels of analysis (Flin, in prep) 4)Threat and Error model (Helmreich, 2000)

10. Framing Patient Safety Research 4)Threat and Error model (Helmreich, 2000)

11. Framing Patient Safety Research Examples of Patient Safety Models: 1)Generic Reference Model (GRM, Runciman et al., 2006)

13. Framing Patient Safety Research Examples of Patient Safety Models: 1)Generic Reference Model (GRM, Runciman et al., 2006) 2)Conceptual Framework for the International Classification for Patient Safety (ICPS, WHO Drafting Group of the Project to Develop the International Classification for Patient Safety, 2008)

14. Contributing Factors/Hazards Patient Characteristics Ameliorating Actions System Resilience (Proactive & Reactive Risk Assessment) Clinically meaningful, recognizable categories for incident identification & retrieval Descriptive information Organizational Outcomes Detection Mitigating Factors Actions Taken to Reduce Risk or Harm Incident Characteristics Patient Outcomes Incident Incident Type Influences Informs Influences Informs

15. Framing Patient Safety Research Examples of Patient Safety Models: 1)Generic Reference Model (GRM, Runciman et al., 2006) 2)Conceptual Framework for the International Classification for Patient Safety (ICPS, WHO Drafting Group of the Project to Develop the International Classification for Patient Safety, 2008) 3)Donabedian’s (1966) ‘triad’ of structure, process and outcome 4)Brown et al.’s (2008) adaptation of Donabedian’s ‘triad’

16. Framing Patient Safety Research 4)Brown et al.’s (2008) adaptation of Donabedian’s ‘triad’ Structure Patient Outcomes Clinical Processes - Error Fidelity Management Processes Fidelity Intervening Variables e.g. morale, culture Generic Intervention Specific Intervention Throughput

17. Framing Patient Safety Research Multilevel Framework of Patient Safety Research (Jackson & Flin, in prep): Organizational Factors Unit Management Worker Behaviours Outcomes Individual Differences Based on the causal chain and different levels of analysis (i.e., individual, team, unit, and organisational) proposed by industrial and patient safety models Applies within an organisation even though external factors such as government and regulators responsibilities exist outside an organisation

18. Measuring Patient Safety Research Medical records Incident reporting systems Prospective analysis tools Questionnaires Direct observations and video techniques Interviews Simulations Claims and complaints Shift reporting Autopsy reports Checklists and audits

19. Measuring Patient Safety Research Method Component Organizational Factors Unit Management Worker Behaviours Individual Differences Outcomes Medical records Questionnaires Claims and Complaints

20. Measuring Patient Safety Research Medical records ‘Triggers’ to measure patient harm to identify adverse events in medical records (Rozich et al., 2003)

21. Measuring Patient Safety Research Method Component Organizational Factors Unit Management Worker Behaviours Individual Differences Outcomes Medical records x

22. Measuring Patient Safety Research Medical records ‘Triggers’ to measure patient harm to identify adverse events in medical records (Rozich et al., 2003) Questionnaires Provide information about people’s knowledge, beliefs, attitudes and behaviours Wide range of questionnaires including instruments measuring Safety Culture  Safety improvement requires a culture of the healthcare system that is not regarded as a potential risk factor threatening the patient

23. Measuring Patient Safety Research Method Component Organizational Factors Unit Management Worker Behaviours Individual Differences Outcomes Medical records x Questionnairesxxxxx

24. Measuring Patient Safety Research Medical records ‘Triggers’ to measure patient harm to identify adverse events in medical records (Rozich et al., 2003) Questionnaires Provide information about people’s knowledge, beliefs, attitudes and behaviours Wide range of questionnaires including instruments measuring Safety Culture  Safety improvement requires a culture of the healthcare system that is not regarded as a potential risk factor threatening the patient Claims and complaints Incidence data, experience with intervention programmes, starting point for reviews of patient safety data and activities

25. Measuring Patient Safety Research Method Component Organizational Factors Unit Management Worker Behaviours Individual Differences Outcomes Medical records x Questionnairesxxxxx Claims and Complaints xxx

26. Any Questions? Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by

27. Exercise Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by

28. Organizational Factors: include stressors on the system  Available resources (e.g., staffing, equipment)  Responsibilities of the senior management (e.g., setting standards and goals within the organisation) Unit Management:  Wide range of behaviours that influence outcomes (e.g., planning, delegating, scheduling, providing training and supervision, leadership, communication, decision making) Worker Behaviours:  Reporting at unit / team level  Safety participation / compliance at individual level  Non-technical skills (e.g., teamwork, speaking up) Outcomes:  Wide range of outcomes affecting the patient (e.g., infections, surgical incidents, adverse drug events) and the worker (e.g., injuries) Individual Differences: possible mediators  e.g., motivation, knowledge, fatigue, burnout Organizational Factors Unit Management Worker Behaviours Outcomes Individual Differences

29. Method Component Organizational Factors Unit Management Worker Behaviours Individual Differences Outcomes Incident reporting systems Prospective analysis tools Direct observations and video techniques Interviews Simulations Shift reporting Autopsy reports Checklists and audits

30. Method Component Organizational Factors Unit Management Worker Behaviours Individual Differences Outcomes Incident reporting systems xxx Prospective analysis tools xxxxx Direct observations and video techniques xxxxx Interviewsxxx Simulationsx Shift reportingx Autopsy reports x Checklists and audits x