Framing and Measuring Patient Safety

1. Framing and Measuring Patient Safety Dr Jeanette Jackson (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 indicatorsfor risk factors and safety events as well as leading indicators for safety (including causes like cultural factors)

4. Objectives • To propose a causal framework for patient safety outcomes • 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: • ‘Swiss Cheese’ model of accident causation (Reason, 1997)

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

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

8. External Influences Organization Intervening Behaviours Outcomes Safety Culture Leadership HR Practices Safety Management Practices Safe Compliance Reporting Speaking Up Unsafe Risk taking Risk breaking Motivation Wellbeing Morale Knowledge National Culture Economic Regulator Government Targets Plant/ Worker Safety Patient Safety Framing Patient Safety Research • 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: • ‘Swiss Cheese’ model of accident causation (Reason, 1997) • Vincent et al. (2000): Reason’s model within the healthcare setting • Factors influencing safety behaviours and safety outcomes at different levels of analysis (Flin, in prep) • Threat and Error model (Helmreich, 2000)

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

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

13. Framing Patient Safety Research • Examples of Patient Safety Models: • Generic Reference Model (GRM, Runciman et al., 2006) • 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. ActionsTaken to Reduce Risk or Harm Informs Influences ContributingFactors/Hazards Patient Incident Incident Characteristics IncidentType Characteristics Influences Informs Detection Actions Taken to Reduce Risk or Harm Influences Informs Mitigating Factors Informs Informs Organizational Patient Outcomes Outcomes Informs Informs Ameliorating Actions System Resilience (Proactive & Reactive Risk Assessment) Clinically meaningful, recognizable categories for incident identification & retrieval Descriptive information

15. Framing Patient Safety Research • Examples of Patient Safety Models: • Generic Reference Model (GRM, Runciman et al., 2006) • 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) • Donabedian’s (1966) ‘triad’ of structure, process and outcome • Brown et al.’s (2008) adaptation of Donabedian’s ‘triad’

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

17. Organizational Factors Unit Management Worker Behaviours Outcomes Individual Differences Framing Patient Safety Research Multilevel Framework of Patient Safety Research (Jackson & Flin, in prep): • 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

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

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

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

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

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

28. Organizational Factors Unit Management Worker Behaviours Outcomes Individual Differences • 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