Feedback from reporting systems - PowerPoint PPT Presentation

1 / 20
About This Presentation
Title:

Feedback from reporting systems

Description:

NHS does not actively learn from failures. Existing systems take a long time to feed back ... SUPRA- ORG. LEVEL. Incident reports. Integrate & support changes ... – PowerPoint PPT presentation

Number of Views:84
Avg rating:3.0/5.0
Slides: 21
Provided by: internatio77
Category:

less

Transcript and Presenter's Notes

Title: Feedback from reporting systems


1
Feedback from reporting systems
  • Insights from a scoping study of methods of
    providing feedback within an organisation in
    England and Wales- 2004-6
  • Wallace LM, Koutantji, M,BennJ, Spurgeon P,
    Vincent C
  • DH Patient Safety Research Programme

Applied Research Centre Health and Lifestyle
Interventions
2
Rationale for focus on feedback learning
  • UK Dept of Health report An Organisation with a
    Memory (2000)
  • NHS does not actively learn from failures
  • Existing systems take a long time to feed back
    information and recommendations
  • There is little or no systematic follow-up of
    recommendations
  • Recommended establishing reporting and learning
    systems at local and national level.

Applied Research Centre Health and Lifestyle
Interventions
3
Rationale for focus on feedback learning
  • National Audit Office survey1 Committee of
    Public Accounts2 A Safer Place for Patients
  • emphasis on reporting and counting, but not on
    analysis and learning
  • there is a need to improve sharing of solutions
    by all organisations
  • lessons learnt on a local level are not widely
    disseminated either within or between trusts
  • considerable complexity in reporting and feedback
    channels currently exists (multiple agencies
    responsible)

Applied Research Centre Health and Lifestyle
Interventions
4
PSRP Feedback Research Programme
Scoping review of feedback from safety
monitoring systems in health care and high risk
industries (Imperial College London)
  • Requirements for effective safety feedback with
    rationale
  • Model of feedback/control process for safety
    monitoring systems

2. Expert Panel Review
1. Literature Review
Empirical studies of feedback systems in 351
trusts and 3 in-depth case studies (Coventry
University)
Expert Review Workshop with health care
professionals and domain experts
OUTPUT Design for effective safety feedback
systems for health care
Applied Research Centre Health and Lifestyle
Interventions
5
Safety issue management process
1. Detect
1. Incident report monitoring
2. Capture
3. Classify
4. Analyse
Iterate in ongoing cycle
2. Safety issue analysis
5. Prioritise
6. Investigate
7. Formulate
3.Solutions development systems improvement
8. Implement
9. Monitor
6
Corrective action and safety information feedback
Improvements in the design of work systems
Identified system vulnerabilities
Safer Work Systems
SAFETY FEEDBACK Learning lessons from
operational experience
Information on operational risks
Increased awareness of front line staff
7
OPERATIONAL LEVEL
LOCAL ORGANISATIONAL LEVEL
SUPRA- ORG. LEVEL
SAFETY ISSUE PROCESS
Incident reports
High-level and external reporting requirements
All classified incidents
Incident repository
1. Incident report monitoring
Single incidents priority issues identified for
follow-up
Aggregated data from multiple incidents
Local clinical work systems
2. Safety issue analysis
Corrective action loop
Care providers patients
Root causes, contributory factors and key trends
Integrate support changes
3.Solutions development systems improvement
Local implementing agents leadership
Systems improvements
8
Reporting systems in expert panel
9
Example feedback mechanisms from review of 23
best case health care reporting systems
  • Staff bulletin board postings with safety issues
    raised and actions taken (Holzmueller et al.,
    2005 Lubomski et al., 2004)
  • Targeted staff training programmes (Takeda et
    al., 2003)
  • Development of manuals on error prevention
    (Wilf-Miron et al., 2003)
  • One-to-one telephone debriefings with reporters
    (Wilf-Miron et al., 2003)
  • Departmental presentations and quality meetings
    (Parke, 2003)

Applied Research Centre Health and Lifestyle
Interventions
10
Modes of feedback from incident reporting
Safety Action and Information Feedback from
Incident Reporting (SAIFIR) framework
11
15 Requirements for effective feedback Examples
based on expert opinion
12
Framework for Safety Action and Information
Feedback from Incident Reporting (SAIFIR)
13
Survey of feedback learning in NHS trusts
  • 351 trusts responded (out of all 607 English and
    Welsh trusts contacted) 58 response rate
  • Administered between November 2005 and March 2006
  • Respondent Local risk management leads
  • Survey items
  • Development of an open, no-blame culture
  • Development and structure of local level
    reporting systems
  • Analysis and use of information from incident
    reports
  • Formulation and implementation of safety
    solutions
  • Feedback mechanisms and methods of dissemination

Applied Research Centre Health and Lifestyle
Interventions
14
Comments on the SAIFIR model applied to UK NHS
  • Not linear system-has to account for reporting by
    observers, not always those involved in
    incident, or can arise from other healthcare
    services in pathway- unclear to whom feedback is
    needed.
  • Filtering, and feedback occurs prior to
    reporting- (Mode A)
  • Non Healthcare systems are more mature- can short
    circuit some analysis by having standard
    responses to known incident types as causes known

Applied Research Centre Health and Lifestyle
Interventions
15
Mode A acknowledgement, clarification,
categorisation
  • UK NHS
  • Only a third trusts acknowledge and inform re
    incident handling.
  • Needs dialogue with reporter and affected staff-
    e systems show promise
  • Research-
  • Pre-categorisation of incidents- does it deter
    reporting/ lack detail?

Applied Research Centre Health and Lifestyle
Interventions
16
Mode B rapid response recovery prevention
actions
  • UK NHS
  • Little evidence of this occurring- and fear in
    NHS of premature formulation and harmful action.
  • Would require systems to identify known incident
    types and reliable actions.
  • Research
  • Experiments in rapid feedback are needed- using e
    mail and other targeted means- analogue and field
    experiments.

Applied Research Centre Health and Lifestyle
Interventions
17
Mode C Dissemination of learning
  • UK NHS
  • Limited effectiveness shown in survey reliance
    on one way communication known to be ineffective
    but most used.
  • Audit of newsletters- most use for alerts,
    national guidance, not targeted feedback.
  • Research
  • Identifying common incident scenarios with known
    causes- testing most effective methods of
    communicating required actions, and uptake- eg by
    requiring an implementation plan and triggers for
    action.

Applied Research Centre Health and Lifestyle
Interventions
18
MODE D Outcome of incident investigation
  • UK NHS
  • 68 trusts communicate some information to
    reports/ affected staff and these have only
    modest levels of impact.
  • Wider sharing of outcomes (esp. causes and
    solutions rather than incident types) required
    within services , across trusts, within regions
    and the national bodies (e.g. NPSA).
  • Research
  • Experiments on effective modes of feedback and
    impact on intentions and actions re future
    reporting and safety actions. Are vignettes more
    effective, tan data reports?

Applied Research Centre Health and Lifestyle
Interventions
19
MODE E Implementing actions to improve safety
  • UK NHS
  • One third of trusts do not produce effective
    guidelines as a result of incident reporting, and
    25/351 had no system for monitoring if this was
    implemented.
  • Recommended changes should be targeted,
    actionable, monitored, in double loop learning.
  • Research
  • Using known methods of improving adherence to
    guidance- test impact on safety behaviour and
    reporting.

Applied Research Centre Health and Lifestyle
Interventions
20
High level conclusions
  • Attention must be given to the use of information
    from incident reports to improve safety
  • There is a lack of evaluative evidence concerning
    effective modes of feedback
  • There is wide variation in trusts practice in
    terms of information and action feedback to front
    line work systems
  • Little evidence of capacity for rapid action in
    Trust systems
  • Little evaluation of impact of actions upon
    operational safety
  • Feedback should be timely and targeted to
    specific practitioners
  • Safety actions should be monitored and their
    effectiveness evaluated

Applied Research Centre Health and Lifestyle
Interventions
Write a Comment
User Comments (0)
About PowerShow.com