Translating concepts into field reality

1. Translating concepts into field reality Rene Amalberti Haute Autorité de Santé Charles Vincent Department of Experimental Psychology, Nuffield Department of Surgical Sciences University of Oxford

2. Overview • Reconsidering AE definition and AE analysis • Educating ‘safe management of acceptable care’ • Applying patient safety to patients’ journey and home care

3. Focus on event journey Capture the story of the care Think in terms of risk control rather than causation Expand the analysis to recovery and mitigation Adapt solutions to the safety model Adverse-event analysis

4. Consequences for adverse event analysis (1/4)Focus on ‘events’ journey’ • Events’ journey : the sum of events positive (good care, recovery, mitigation from adverse events) and negative (poor care, adverse event) that make at end the care successful or catastrophic • Widen the window for consideration of the episode of care • Start throughpatient’s eyes, translate the patient’ vision on expected benefit of risk to conduct the analysis` (recovery, less suffering, more healthy life, more autonomy) • Consider a timeframe that makes sense for evaluating this expected benefit during the episode of care (could vary from a few days to a month) • List events positive and negative • Use a grid to assess causes and value of the risk control on these events

5. Consequences for adverse event analysis (2/4)an evolution of the grid

6. Consequences for adverse event analysis (3/4)an evolution of the grid • Patient factors • Task and technology factors • Individual (staff) factors • Team factors • Work environmental factors • Institutional context factors Full recovery Local recovery without global vision (stabilization, symptom oriented strategy) Global control. Treatment delayed because of competitive priority Mitigation creating room for further problems

7. Consequences for adverse event analysis (4/4)Develop safety interventions in accordance with the underlying safety model • Priority to Peer to Peer training (Ultra resilient) • Teach resilience to unstable conditions • Train small experts teams • Use simulation to emulate non standard conditions • Priority to Team Training (HRO) • Teach communication, coordination, sense making • Use simulation to emulate group work • Implement programs for ensuring that Human and Organizational Factors are considered in regulatory evaluations • Teach compensatory strategies and recovery to managers • Priority to Protocols (Ultra safe) • Teach prevention in priority and full compliance to protocols • Apply all value of small group dynamics • Define no go, Maintain knowledge in a ‘safe box’. No activity allowed outside the safe box • Develop external auditing and supervision

8. Why compensatory strategies instead of compliance? Who does what? Seven points for a successful control Risk controlCOMPENSAtory STRATEGIES

9. Three generic solutions for controlling risks and minimizing severe harm Estimated Applicability 85% • AMBITION / HOPE : Designing best practicesand making them known by professionals • COMPLIANCE : Complying with best practices • ‘Audit and search for ZERO default. • If you are not cleaning your hands anytime required, not prescribing exams as recommended, or if you have staff missing, please make corrections. • REALITY GAP : Leaving with non compliance • Compensating/mitigating local loss of Quality by active recovery and re-organization • betting on early recovery, early mitigation • betting on individual competences • betting on team and management • betting on continuous awareness on the occurrence of degraded conditions 50% 50%

10. The art of Managing risksManaging an instable compromise among four competitive fatal risks • A compromise is always required in the management of these four dimensions of care • Each of them is vital to the value of patients’ care • Each of them has an ideal roadmap never applicable as such … because • The optimization of any one is detrimental to the others • Importance of a consistent supervisory global control of trade-offs between these four dimensions (arbitration) • Loosing the market competition • Poor value of products, poor innovation • Unable to offer the last technology and knowledge • Poor technical image • Not able to produce in time, with best quality, at the right cost • Not able to offer access to care as expected • Poor quality, Poor maintenance • Poor social climate • Poor business plan, and business management • Cash management, debt management • Unable to buy equipment and hire people • Poor safety • Dramas, accidents • Denial of authorisations from authorities

11. Controlling risks and compromisesWho does what in the hospital? • CEOs: Strategic vision • Ask top managers of Finance Directorate, medical Directorate, nursing Directorate and Q&S Directorate • Every one comes with an ideal safety plan • And leaves with a compromise : less resources, delays… • He/she controls the space of negotiation : knowledge of NO GO, knowledge of risk transfer • He/she gets recurrent feedback from middle managers on the control of risks • Middle managers : Tactical vision • Manage contradictory production goals • Know margins and validate non compliance strategies • Manage the return to normal • Get support and listening from top managers on feasibility and controllability of non compliance • Front line managers : Instant vision • Know and Respect no go • Manage safety compromises • Follow non compliance and control • Get support and listen from the hierarchy Note that Middle and front line Managers are not safety managers Best safety practices is a matter of safety specialists Risk control is ultimately a matter of non specialists

12. Seven points for a successful safety control • Defining and respecting no go • Controlling / limiting the negotiation of margins and sacrifices in the ideal safety plan • Controlling time / duration of safety sacrifices and non compliance • Managing compensatory strategies : staffing, word demand, competences, style of management, etc. • Installing an alerting culture as a routine for all workers • Installing a collective and reflexive culture of analysis , not only of adverse events, but of risky behaviors • Sharing knowledge on risk (risk awareness)

13. A changing paradigm Patients enter home health care (HHC) ‘‘sicker and quicker,’’ often with complex health problems that require extensive intervention. A tentative application to home care and patients’ journey

14. Risks and challenges • Increasing burden on patients, families, relatives and Home Care Aids (HCI): in care and also in home environment changes • 53% managed to give a correct or partially correct answer on questions concerning medication administration (Axelson 2004). • Family members are tired ... if they didn’t look after their own health, they didn’t keep themselves safe • Increasing burden on medical system – resources may be considerable (which may increase burden on patients) • Transitions hospital <> Primary care<>Nurses becoming strategic • The client’s home is also a workplace, and it should not be a limiting factor to receiving services. • Definition of error change at home. New or increased errors by patients and new hazards in the home • Increasing reliance on integrity of relatives rather than professionals • New or increased errors by patients and new hazards in the home • Failure to recognise deterioration not captured by monitoring

15. A changing perception of safety • Clients, family members and caregivers speak with ease about home care but seem less sure about how to respond to questions specific to home care safety. • Terms such as concerns or challenges regarding home care may be more appropriate and meaningful when speaking with clients, family members and their caregivers. • Generally speaking, home is considered a haven or a safe place for these home care recipients. Even though they are able to describe examples of unsafe or risky experiences and situations, these participants do not think in terms of issues around home care safety. Home care recipients expect that those entering their home would get to know them, provide competent care and give them or arrange for them the necessary supportive care in a flexible and timely manner. • The providers, on the other hand, consider safety to mean completing resident assessments to determine risks (e.g., for falls), making sure clients received medications in blister pacs to minimize medication errors and ensuring clients used proper disposal containers for syringes and needles. These provider concerns were geared primarily toward the client and focused almost exclusively on physical safety. Lang , Macdonald, Storchet al HealthcareQuartely, 12, Special Issue, 2009, 97-101

16. The changing nature of patient safety • Reconsider the perimeter of patient safety • Moving to a view of safety along the whole pathway of care • Assessing benefits and risks over a longer time scale • Increasing shift to risk of slow deterioration/decay rather than ‘incidents’ • Good care is care that increases life, avoid re-hospitalization, and maintains stability, rather than ‘improvement’ • Increased focus on patient capacity for error

17. Implications and discussion • Patients. At the moment there is considerable ‘equality’ of treatment once in hospital in many systems, at least given equal access. This changes dramatically for home care. Home care for the rich will be very beneficial – space for separate ‘hospital’ accommodation, paid support, leisure, less disruption of family life. Higher probability of relatives who can ‘work’ as carers and be able to carry out tasks. Better nutrition etc. Quite different for family in small flat in block. • Accountability: shift from healthcare professional to patient. Difficulties with malpractice and insurance • Regulators. Systems currently struggling with monitoring hospitals (fixed structures). Much greater challenge for existing primary care, care homes. Completely new challenge for home care. • Researchers. Shift in nature of phenomena of safety, need for expanded measurement systems. • Clinicians. Rapidly changing role, more community based, more social care. • Evaluation of new systems. Needs to be much broader than currently envisaged in many papers. Multiple risks and benefits will need to be considered. Also, not clear that feasible to directly compare ‘old’ and ‘new’ systems as criteria for success different for each system. Same for future systematic reviews.