Quality News

Could the management of Clinical Audit processes have helped Mid Staffordshire NHS Trust?

2010-03-12T12:41:00Z

The situation at Mid Staffordshire NHS Trust has been one of the most highly publicised management failings within the NHS in recent years.

The Robert Francis Inquiry report was published last month, and the conclusions and recommendations of the final report identify a number of factors - the most prominent being that the hospital failed to deliver acceptable standards of care over a sustained period of time.

Although Mid Staffordshire is an extreme example of what happens when leadership - managerial and clinical - fails to focus on the things that really matter to patients, there is a lot more that can be highlighted from the report.

It’s interesting to note the analysis of the failings on Clinical Audit, as the failure here was not restricted to the Trust Board and Senior Management. The report states, ‘clinicians abrogated responsibility with regard to the need for each clinician to audit his or her practice'. Whatever the responsibilities of the Trust Board and Senior Management to oversee and drive quality improvement and measurement processes such as Clinical Audit, it is also a clinician's responsibility to audit their work.

According to Recommendation 5 from the report: The Board should institute a programme of improving the arrangements for audit in all clinical departments and make participation in audit processes, in accordance with contemporary standards of practice, a requirement for all relevant staff. The Board should review audit processes and outcomes on a regular basis.

Clinicians are required to take responsibility for ensuring they have the skills and commitment to use Clinical Audit as a quality improvement process. Just as the Department of Health makes it clear that Clinical Audit is a ‘significant way in which the quality of clinical care can be measured and improved’, the report also makes it clear that Clinical Audit is essential if these kinds of problems are to be avoided. The publication of this final report provides Trust Boards and Senior Clinicians with a real opportunity to review their systems and processes for reporting and discussing Clinical Audit at all levels throughout the Trust.

Let us know what you think – are you involved with Clinical Audit? Do you have any major obstacles in performing Clinical Audit? How does your Trust identify and address any failings in your Clinical Audit processes? How do you monitor and improve these processes?

Should Surgical Checklists be Used? It depends on who’s under the knife

2010-02-24T13:12:00Z

Dr Atul Gawande and a team of researchers studied what happened when surgeons involved in the WHO Surgical Safety Checklist research project were asked if they would continue to use the checklist after the research project was complete. Eighty percent (80%) said it was so beneficial that they would continue to use it in their practice.

Twenty percent said “No” - they didn’t need it.

The follow up question asked, “If you were the patient, would you want your surgeon to use the WHO Safety Checklist?” This time, a lot of the surgeon’s resistance melted away. Ninety-four percent (94%) said in effect, “Yes, my surgeon should use the checklist if operating on me.”

I wonder what their patients would say if they knew their surgeon was one of the ones who didn’t want to use the checklist personally, but wanted their own physician to use it when operating on them. I think the question might go something like this, “If using the checklist is good for you when you are a patient, why isn’t it good for me when I am your patient?”

Data like this demonstrates a truism that I have stumbled onto in my work helping hospitals implement effective checklists…

Human beings, even physicians, make their decisions to do something on an emotional basis and then seek data to support the decision they have made.

The survey results from the surgeons’ involved in the WHO study show all of us that logic and data don’t always carry the day in convincing others to support our change initiative. Think about it, these are surgeons involved in a hugely successful world-wide study producing peer-reviewed data showing a 35% decline in complications and deaths. The data is near conclusive. (As Al Gore would say, “The science is settled.”) Yet, 20% of the physicians involved said they wouldn’t continue to use the checklist.

These results reveal that we should never forget the power of the personal and emotional factors needed to motivate others to change.

When recruiting support for your change initiative - whatever the project may be - never forget to answer the age old question for your colleague, “What’s in it for me?” (WIIFM) Make sure that answer is something that affects them personally and on an emotional level.

This concept is one we devote quite a bit of time to in our Leadership Development training when implementing LifeWings in a hospital. The ability to communicate your project goals in a meaningful, and ultimately successful way by simultaneously combining data, logic, and emotions in your appeal is a critical leadership skill.

If you don’t have that level of communications skill, or ignore the power of the emotions in your project communications, you cripple the chances of success for your initiative.

See you at EASS in Lisbon…

2010-02-23T10:30:00Z

As committed members of the Flight Safety Foundation, we will be attending the forthcoming European Aviation Safety Seminar (EASS) which will this year be hosted in the Portuguese capital, Lisbon on March 15th-17th.

Consisting of a series of seminars, workshops and exhibitions, EASS brings together leading figures within the aviation industry to discuss safety issues and share best practice experiences with each other.

Gael will be represented at EASS by myself and Robin Telfer this year where we will be presenting some of the exciting developments of the last 12 months including;

Our offline reporting project with Finnair (view the Capturing Safety Data at Point of Origin case study)
Q-Pulse integration with other aviation software via APIs
Recent implementation of Q-Pulse within a number companies including Dubai Air Navigation Services, Avsec NZ and GCAA

If you are attending the event, please do stop and say hello. If you can’t make it, keep an eye out for our post event report.

Q-Pulse in Dubai Air Navigation Services

2010-02-22T11:01:00Z

Dubai Air Navigation Services have recently selected Q-Pulse to help manage their safety and quality system.

Q-Pulse was selected after a rigorous tender selection process and consolidates Gael Ltd's position as the leading Safety & Quality solution provider to aviation organisations in the United Arab Emirates.

Q-Pulse is already installed at the region's regulator, the GCAA. In addition, another 12 aviation companies in the UAE such as Emirates, FlyDubai, Presidential Flight and Abu Dhabi Airports Company are using Q-Pulse to leverage competitive advantage through their compliance management activities

Read the official press release.

Patient Safety and NHS Trusts – Does the future look bright?

2010-02-17T13:19:00Z

After the publication of a report on 16^th February by Action Against Medical Accidents (AvMA) - Adding Insult to Injury - NHS failure to implement patient safety alerts, there has been a lot of media attention in the last couple of days around this subject. The report investigates NHS bodies failure to implement patient safety alerts issued by the National Patient Safety Agency (NPSA) – (under the patient safety alert system, the NPSA can issue guidance to NHS organisations to tighten procedures by a set time).

Compliance with implementing the alerts within a given deadline is one of the top ‘core standards’ which all NHS trusts in England are supposed to meet, and the research reveals that there is no system in place for monitoring compliance. Key findings include:

Over 300 NHS trusts (around three quarters of all trusts in England) had not complied with the required actions in at least one patient safety alert for which the deadline had already passed.
There are 2,124 separate incidences of patient safety alerts not having been complied with by NHS trusts.
80 NHS trusts had not complied with 10 or more separate alerts. 35 of these trusts have Foundation Trust status.
There are over 200 incidences of NHS trusts who have not complied with alerts which are over five years old (issued before December 2004).

This report just adds further ‘fuel to the fire’ around how the NHS is managing patient safety incident statistics and error reporting in the NHS - only recently an article was written on the Community after a news item reporting on the numerous mistakes being made in a high number of drug treatments given to children in hospital.

As every Trust has to be registered with the Care Quality Commission from April 2010, it will be mandatory for NHS organisations to report serious patient safety incidents, to improve identification and monitoring of incidents. The AvMA stated that ‘robust compliance systems’ were lacking in many hospitals in England.

It now begs the question – What systems do Trusts actually have in place to efficiently and effectively not only manage, but improve, patient safety? Should it be at a Departmental level these processes should be in place, or a Trust wide level? What do you think? - is it the media yet again blowing this out of proportion? Does your Trust have a system in place for CQC registration in April?

Integration of SPC into Q-Pulse Quality Management System Software

2010-01-25T09:00:00Z

In the third quarter of 2009, Quality America released the latest versions of our SPC-PC IV Explorer and SPC Explorer RT software packages. These incorporate an easy to use interface for control charting of CA/PA (Corrective Action / Preventive Action) records stored in Q-Pulse. This integration will facilitate the on-going management and improvement of your Quality Systems through the following key benefits:

Analysis of key system response metrics, such as Response Time and Cost;
Dashboard display of key system parameters, with drill-down to process level data;
SPC analysis of Supplier batch records stored in Q-Pulse;
Reporting of internal and supplier data in standardized, customizable MS Word documents for internal or external use, such as Certificates of Analysis

Statistical process control (SPC) is an analytical statistical method (i.e. applied to processes rather than populations) of using past experience to predict how a process will vary in the future. An SPC control chart provides a means of differentiating between common causes of variation that are systemic in nature and those special causes of process variation that require immediate action to prevent process instabiliy. SPC has broad application to all processes and industries:

To Monitor Processes:
- To verify process stability;
- To verify customer requirements met;

To Estimate Process Potential:
- To baseline before Six Sigma project improvements / CAPA analysis;
- To estimate/verify results of improvement effort;

To Predict Performance:
- To budget resources to maintain commitments
- To Improve Processes
- To identify & remove special causes
- To identify & reduce common cause (DOE)

As such, our SPC software provides a critical link between operational data and functions and the reaction and support of these data and functions through the Q-Pulse QMS.

In the coming weeks and months I will provide details and examples of how this interface is designed and used by our customer base. I will also share our development plans for this interface, most notably the ability to create Q-Pulse CAPA records from within the SPC software as a result of a process anomoly (such as out of spec or out of control condition).

CQC’s new registration process - friend or foe?

2010-01-22T09:42:00Z

On the back of a news article in last week’s HSJ, the Care Quality Commission’s (CQC) Registration system for all English NHS Trusts to register by the 1^st April 2010 seems to be causing a bit of a furor.

The new registration system is essential for ensuring standards of quality and safety across all of the regulated activities NHS Trusts provide. Trusts have until 29 January to submit their registration applications to the CQC - they face restrictions on the services they can operate, fines, and even closure, if standards are not up to scratch.

With other recent news stories about mistakes being made in medicines being given to children, patient safety and quality standards within the NHS are now more important than ever, and with the run up to the general election, no doubt even more will be made of these issues.

How is your Trust coping with the registration process, and what strain is this putting on your departmental resources? Are you on track for 29^thJanuary? Let us know.

Reap the Rewards for improving Patient Safety Incident Stats?

2010-01-19T15:22:00Z

According to a news article on today’s BBC website, numerous mistakes are being made in a high number of drug treatments given to children in hospital. A study carried out by the University of London found some shocking stats on prescription errors.

So the Shadow Health Secretary Andrew Lansley says that the Conservatives would, ‘improve the data collection of errors in the NHS and incentivise year on year improvements in avoidable incidences’. Great! If the Conservative get in, let’s not report any more prescribing related issues and take the big cheque when they see the massive reduction in numbers.

Of course I am not being serious; the only way to reduce the numbers of incidents is to report, report, report, analyse what has been reported, find the root cause, and take action to reduce the risk that it might happen again - we all know this, it’s not rocket science.

If you look to other sectors that are seen to lead the way in safety, like Aviation, they operate in a manner that encourages their staff to report even seemingly innocuous issues, they take the view that their staff should tell them everything, and they will decide if it has further significance or not.

Radiotherapy is a good example of this same approach coming into effect in the NHS. The ‘Towards Safer Radiotherapy’ report recommends that all Radiotherapy incidents, regardless of their severity, should be reported to the NPSA, and through this, they should be able to improve National Learning and in turn provide a safer service.

The report from the University of London says that the Pharmacists found and corrected errors in 13% of almost 3,000 prescriptions, but a third were dosing errors. What would be interesting is where this stat came from. Did it come from the Trusts Clinical Incident Report system? Probably, in which case would the Trusts involved be 100% confident that that number matches exactly the number of errors that were actually found by the Pharmacists during this time?

You see the problem with error reporting is that it is time consuming, sometimes it’s a paper form filling activity that then needs to find it’s way into the right hands and not fall off a desk or get lost along the way, sometimes you need to find a computer, and even then, you need to have a Licence to use the Incident Reporting system - the obstacles soon start to mount up.

If I was a Pharmacist what would I consider the easiest way to report an error, and what tools would I have at my disposal to let me do this? Would I have a mobile phone that I can use on the ward and call in the issue, i.e. dictate it over the phone and have it raised without having to type/write up a report. Would I find it easier to fill out a form on my laptop there and then, and have it sync automatically with the Trust reporting system as soon as I come into range with a wireless network. As I tend to live in my Inbox, email would be my ideal scenario.

The reality is that the easier it can be made for the Pharmacist to report the error, or any near misses, then the better chance Trusts will have in reducing the number of errors that do result in harm.

If you work in Pharmacy I’d love to hear your thoughts on what your nirvana would be for reporting errors, what tools you have to hand when you do your rounds, or any other comments you have on the report.

What’s the best way to improve work processes?

2010-01-13T11:42:00Z

Creating and implementing checklists to fix flaws in work processes is the “buzz” in health care right now. Fuelled by the success of the WHO Surgical Safety Checklist in reducing post surgical infections and deaths, the mistaken view of checklists as the “magic bullet” for improvements in care is becoming more pervasive.

After 10 years of experience helping hospitals create and implement effective checklists, one thing we know at LifeWings is that checklists, if done right, have their place and can significantly contribute to improving performance and care, but they are definitely not a magic fix all.

One common myth that reduces the magic of checklists is the idea that it is easy to take a successful checklist produced in another facility and by other people and just “drop it in” to your situation in your hospital. That rarely, if ever, works. There is no buy in, no investment, and no customization to your unit’s particular needs and work flow. Even the WHO checklist says on the very bottom of the sheet that individual customization of the checklist is encouraged.

Every checklist or safety tool must be created by the people who actually do the work - and not by administrators or managers, or worst of all, by people at another institution who have no idea what goes on in yours.

Research by the Robert Wood Johnson Foundation and Plexus Institute on the concept of Positive Deviance supports this point. These entities funded a study on the work process improvement methodology called Positive Deviance (PD). PD is a concept of process improvement that solicits ideas for solving a problem from those who deal with that problem every day. It encourages the workers who actually do the work to think of a solution that might be considered “out of the box,” but nevertheless one that just might work.

This approach is the essence of Kaizen from the Toyota Manufacturing Process (Lean). It overcomes the natural human resistance to change by allowing frontline workers and their peers to solve their own work process problems. Thus, there is investment in their solution.

The concepts of Kaizen and PD are the key components of the methods LifeWings uses to help hospitals create and implement their own safety tools like checklists, communication scripts, handoff forms, and teamwork algorithms. We know from years of tough, hard-won experience that this approach works best of all.

So it’s not surprising the study from the R.W. Johnson Foundation reveals that using Positive Deviance to lower MRSA rates has succeeded. Their success with this approach was announced at the annual scientific meeting of the Society for Healthcare Epidemiology of America . The study began in 2006 and introduced the idea of Positive Deviance into three hospitals from different parts of the country.

A team from the Centers for Disease Control and Prevention analyzed the data from these facilities to show a reduction in MRSA rates between 26 and 62%.

Proof that the best way to improve work processes is to make sure the people who actually do the work create the tools that improve their work.

"Dirty Dozen" - 12 Challenges for Aviation Safety

2010-01-11T10:02:00Z

Years ago an industry panel developed the "Dirty Dozen" list that identified hazards in aviation, focused on mishaps that were occurring in air carrier operations. Take a look at the list and see which ones we've made some progress towards eliminating through introduction of new technology, training and operational procedures. Then consider which ones are still basically uncontrolled. The areas where we still need a lot of work are highlighted in bold.

1. Midair collision-TCAS

2. Inadequate terrain separation-Enhanced GPWS, use of minimum safe/vectoring altitudes

3. Unstabilized approach-? See # 5. SOPs, approach gates for configuration, airspeed, altitude. Visual and electronic glide paths. Wind and surface info.

4. Weather related damage or injury-? SOPs and personal mins for turbulence, icing, convective activity

5. Runway excursions-? See # 3.

6. Abort before 100 knots-SOP

7. Significant operational deviation-SOPs and personal minimums, CRM.

8. Runway Incursion-ASDE-X at a few airports, but what about widely used cockpit technologies?

9. Landing on wrong runway/airport-Precision nav (FMS). Approach brief. Backup with instrument approach procedure. Landing clearances.

10. Altitude deviation-Readback hearback. CRM. Use of autopilot as additional crew.

11. Navigation deviation-Use of precision nav sources, GPS, FMS.

12. Ground injury or damage-? Slow down and be familiar with airport surface ops.

We need to get a lot smarter and technologically advanced with regards to surface operations, because hazards will exponentialy compound as the number of operations increases. In some ways we are more exposed to hazards on the ground, because flight planning and ops support may not focus as much on these phases of "flight". We need to be very familiar with the winds, surface conditions, runway lengths, geometry and facility layouts, airport lighting and approach systems.

We also need to be aware that the priority guidance to "Aviate, Navigate and Communicate" is essentially reversed when we are on the ground. The focus on the ground is to "Communicate", to listen and build a mental model of where other aircraft and vehicles are. Keep in mind that vision is our primary sensory input, and now we are asking the brain to shift priority to listening.

The next priority is to "Navigate", we must know at a minimum where we are, in order to get to where we want to be. Charts and electronic moving maps assist in this area, but the key is to "Look outside".

Lastly, it is harder to "Aviate" on the ground, we are not "aircraft" in this regime but rather ground vehicles with limited visibility, reduced maneuverability and many of our warning systems have little or no functionality on the ground. Couple this with the fact that the areas we are maneuvering in are confined and many times unfamiliar, and the fact that the runways are areas where there is great potential for a high energy collision, then we certainly have challenges to manage.

What can be done to improve the system? The first step is to study the operational environment, and the next step is to identify hazards, so that we can avoid them and implement programs to eliminate them. One good way to do this is to put in a report via NASA ASRS, because folks who manage airspace systems need this information to improve the system. Another good investment is to participate in the Wings program, and dedicate ourselves to lifelong learning in our chosen craft. The best way we will learn is from each other.

Fly Smart,
Kent