The Measurement and Monitoring of Safety Framework Workshop 2 16 th - PowerPoint PPT Presentation

The Measurement and Monitoring of Safety Framework Workshop 2 16 th May 2017 Leeds e: academy@yhahsn.nhs.uk / t: 01274 383966 www.improvementacademy.org

Housekeeping

Our # for the event #howsafeisourcare @improvementacademy

UK Improvement Alliance • UKIA: howsafeisourcare – http://www.howsafeisourcare.com/ – Monthly calls • Wednesdays, 1-2pm. • Sign up via Eventbrite. • Next call: Wednesday 14 th June 2017 at 1pm #howsafeisourcare

Programme Time Speakers 10:00 – 10:10 Introductions Debbie Clark 10:10 – 11:10 Group feedback Rachel Smith 11:10 – 11:30 Refreshments 11:30 – 12.00 Culture Survey Dr. Anna Winfield Human Factors and the Measurement 12:00 – 13:30 Prof. Rebecca Lawton and Monitoring of Safety 13:30 – 14:00 Lunch 14:00 – 15:30 Market Place Guest Speakers 15:30 – 16:00 Action planning Beverley Slater 15:50 – 16:00 Close

MMSF Market place Mortality Review Programme

W2: Post session work • Identify your top three harms • Describe how the framework can help you to improve you understanding of one of your top three harms. • Consider which interventions may support you to achieve this. • Complete Bronze Quality Improvement Training

Workshop 3 • Quality Improvement Dr. John Bibby and Maureen McGeorge. • Understanding and using data Prof. Mohammed Mohammed.

Feedback from workshop 1 Rachel Smith Improvement Academy

Feedback from workshop 1 Q1) Thinking about your current safety approach, what measures and monitoring activities actually help your teams to feel safe? Q2) What is your goal; at team level? at middle management level? at Board level? Q3) Can you identify gaps? Outline what you need to learn more about to understand how safe your care is?

Top three reported incidents Lynn Pearl Safety, Risk & Resilience Manager

Incident System • Each ward/service has unique top three • Extract data from Datix/Safeguard • Collate data set • Analyse data set in detail e.g. different harms, severity, times and locations

Integrated working • Ask the team which are important to them • Discuss with the team what the data tells you • Check with team that they report all these types of incidents • Agree what will be measured and monitored • How, frequency and by whom

Measures • Days between (Safety Crosses?) • Early warning triggers based on averages (weekly) bespoke to team • Visual monthly reports that summarise the more detailed data which is also available • Statistical Process Control Charts (SPCs) • Automated reports • Safety Huddles

Over to you... • Start this conversation at a local level • Identify the different types of harm that exist in the setting • Decide if there are three harms you want to focus on • Use a range of measures which are valid, reliable and specific to help you understand if you are making a difference • Create time and space to review the data you collect as a team

Coffee #howsafeisourcare

A systematic approach to measuring and addressing Safety Culture at the Frontline Dr Anna Winfield Leeds Teaching Hospitals NHS Trust

Recap Yorkshire Contributory factors framework

Recap: S afety A ttitudes Q uestionnaire (SAQ)  SAQ derived from Flight Management Attitude Questionnaire – human factors survey to measure cockpit culture in commercial aviation  FMAQ has been used for >20 years  SAQ most commonly used tool for measuring safety climate and culture in healthcare  Can compare across the ward team i.e. doctors with nurses and non-clinical staff  60 questions across 6 domains – we are using 2 (Safety and Teamwork climate)

Assessment of Safety Culture  28 questions in total  Background information  Confidential (includes personal identifiers) data collection and anonymised reporting  Additional Q: “ 28. Please give your unit an overall grade on patient safety”

Principles  This is an improvement intervention in itself and helps teams realise their potential  There is always some cause for celebration and sometimes the results dispel myths about teams  The majority of the elements are within the gift of the team to address themselves  The before and after measurement is helpful but need not be the focus  Behaviour Change Survey will help to understand more about reasons for and issues behind attitudes

Principles  Data belongs to teams not management. Free to use the analysis as they wish  Teams must have feedback and a “conversation”  Point in time. Take at face value don’t need to over analyse, interpret, justify or defend  Team decides what to do. Have further support if they want and Management listen

Teamwork and Safety Climate Survey St James’s University Hospital Ward XX March/April 2017 Response Rate 55.56% Produced by Improvement Academy on 04/05/17

Number of Staff by Staff Group 8 7 7 6 6 5 4 3 2 2 1 0 Clin Support Worker Nurse Other

Culture Survey - Key Information Key Questions:  In this clinical area, it is difficult to speak up if I perceive a problem with patient care  The doctors and nurses here work together as a well- coordinated team  I know the first and last names of all the personnel I worked with during my last shift  The levels of staffing in this clinical area are sufficient to handle the number of patients  I would feel safe being treated here as a patient  The culture in this clinical area makes is easy to learn from the errors of others  In this clinical area, it is difficult to discuss errors

Overall Comparison To Goal The levels of staffing in this clinical area are sufficient to handle the number of patients This organisation is doing more for patient safety now, than it did one year ago Hospital management does not knowingly compromise the safety of patients My suggestions about safety would be acted upon if I expressed them to management Leadership is driving us to be a safety-centred organisation Personnel frequently disregard rules or guidelines that are established for this clinical area I would feel safe being treated here as a patient Important issues are well communicated at shift changes Medical errors are handled appropriately here I am satisfied with the quality of collaboration that I experience with medical staff in this clinical area I am encouraged by my colleagues to report any patient safety concerns I may have Disagreements in this clinical area are resolved appropriately The doctors and nurses here work together as a well-coordinated team Nurse input is well received in this clinical area In this clinical area, it is difficult to discuss errors I am frequently unable to express disagreement with the medical staff here In this clinical area, it is difficult to speak up if I perceive a problem with patient care I know the proper channels to direct questions regarding patient safety in this clinical area I receive appropriate feedback about my performance The culture in this clinical area makes is easy to learn from the errors of others I am satisfied with the quality of collaboration that I experience with nurses in this clinical area Briefings are common in this clinical area Briefing personnel before the start of a shift (i.e. to plan for possible contingencies) is important for… I know the first and last names of all the personnel I worked with during my last shift I have the support I need from other personnel to care for patients It is easy for personnel here to ask questions when there is something that they do not understand Decision-making in this clinical area utilises input from relevant personnel -30% -20% -10% 0% 10% 20% 30% Worse Then Goal Better Than Goal

Worse Than Goal Better Than Goal 18% 16.9% 16% 14% 12% 10.0% 10% 8% 7.0% 6% 4.4% 4% 2% 0% Clin Support Worker Nurse Other Overall

Q01: Nurse input is well received in this clinical area Q02: In this clinical area, it is difficult to speak up if I perceive a problem with patient care Agreeing Goal Danger Agreeing Goal Danger 100% 100% 100% 100% 93% 86% 80% 80% 60% 60% 40% 40% 20% 20% 14% 7% 0% 0% 0% 0% Clin Support Worker Nurse Other Overall Clin Support Worker Nurse Other Overall Q03: Decision-making in this clinical area utilises input from Q04: The doctors and nurses here work together as a well- relevant personnel coordinated team Agreeing Goal Danger Agreeing Goal Danger 100% 100% 100% 100% 100% 100% 100% 100% 93% 80% 80% 60% 60% 50% 40% 40% 20% 20% 0% 0% Clin Support Worker Nurse Other Overall Clin Support Worker Nurse Other Overall

The Safety Huddle …igniting a spirit of learning Addressing Teamwork and Safety Culture Making measurement visible Celebrating success Part of the Yorkshire & Humber AHSN “Excellent achievement given the history of falls on this ward” Certificate of Excellence Clinical Director, Calderdale & Huddersfield NHS FT Awarded'to'Staff'on'Ward'5' Huddersfield)Royal)Infirmary) for$ achieving$ 30$ days$ without$ a$ fall$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 4$ September$ 2014 !