Objectives. Scottish Mortality and Morbidity Review Programme Update and shape the next phase

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Cecily Joseph
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2 Dr Brian Robson

Objectives Scottish Mortality and Morbidity Review Programme Update and shape the next phase Best Practice Guide review Develop a collaborative network for shared learning and linking M&M with

3 Objectives Scottish Mortality and Morbidity Review Programme Update and shape the next phase Best Practice Guide review Develop a collaborative network for shared learning and linking M&M with organisational governance as well as other relevant national work streams Develop a Short Life Working Group to design and test a training programme to support a structured Mortality and Morbidity process across NHS Scotland

4 100 colleagues attending today 40 medics 29 Anaesthetists 14 MDs / managers 14 surgeons 3 nurses

5 11 / 14 NHS Boards represented

7 Dr Alex Stirling

9 Acknowledgements We would like to thank our colleagues for their input into this report. SMMP Operational Group Mr Manoj Kumar Scottish Mortality and Morbidity Programme Steering Group Lead and Consultant Surgeon, NHS Grampian Dr Andrew Longmate -Clinical Quality & Safety Lead, Scottish Government (until May 2016) Isobel Macleod Clinical Co-ordinator, NHS National Services Scotland (until Dec 2015) Dr Brian Robson-Executive Clinical Director, Healthcare Improvement Scotland Dr Alex Stirling, Consultant in Public Health Medicine, National Services Scotland Christine Watters- Clinical Co-ordinator, NHS National Services Scotland (from February 2016) NSS Scottish Healthcare Audits Stuart Baird, Service Manager, NHS National Services Scotland Hazel Dodds, Senior Nurse, NHS National Services Scotland Martin O Neil Principal Information Analyst, NHS National Services Scotland NHS Education for Scotland Paul Bowie Programme Director (Safety & Improvement), NHS Education for Scotland

10 Anecdotal evidence of variation in practice across Scotland Consultant grade Lime survey

11 Respondent characteristics Other Not recorded Tayside National Waiting Times Island Boards Lothian Lanarkshire Highland Greater Glasgow and Clyde Grampian Forth Valley Fife Dumfries and Galloway Borders Ayrshire and Arran ~18.4% did not record a response ~17.5% did not provide a health board 74% work with adult population Proportion of responses (%) Paediatric Adult No response

12 88.1% of respondents said their specialty had an M&M or similar peer review meeting for mortality and morbidity case discussion

13 Meeting characteristics 59% took place at least monthly Within mental health, 70% of respondents said meetings were 6 monthly or ad hoc. weekly meetings occurred most frequently in critical care only

14 Meeting structure 25% 7% 1% 2% 3% No structure 7% 11% 28% 9% 7% Pre-defined criteria PowerPoint Proforma esystem Pre-set questions Learning and action Care score Don'tknow Other The most commonly reported meeting structure: power point (28%), learning and action (25%) 7% of respondents reported no structure 35% reported using either predefined criteria, a proforma or pre-set questions Only 10% of respondents are currently using an e system.

15 Job planned activity: variation by specialty

16 Timeliness 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 9% of M&Ms are conducted within two weeks 9% reported that the M&M took place over 3 months after the death 11% were unsure of Within specialty reported timeliness of M&M the timing. Within 2 weeks > 3 months Critical Care (53%) Haematology (37.1%) General Surgery (18.8%) Mental Health (30%) Neurology (60%)

17 Learning - WHO Where learning points are shared they are done so frequently amongst consultant colleagues (79%) and nurses (52%).Learning is rarely shared with other hospitals or boards (4%).

18 Why we do it?

19 Timeliness 50% 45% 40% 35% 30% 9% of M&Ms are conducted within two 25% 20% weeks 15% 10% 5% 0% Within 2 weeks Approximately within 1 month Between 1-3 months Over 3 months Unsure Not recorded 9% reported that the M&M took place over 3 months after the death Within specialty reported timeliness of M&M Within 2 weeks > 3 months Critical Care (53%) Haematology (37.1%) 11% were unsure of the timing. General Surgery (18.8%) Mental Health (30%) Neurology (60%)

20 Sharing learning - HOW

21 Recommendations for the M & M 60% Programme 50% 40% 30% 20% 10% Rank 9 Rank 8 Rank 7 Rank 6 Rank 5 Rank 4 Rank 3 Rank 2 Rank 1 0% Provision of an electronic structured M&M system in NHS Scotland Assistance with quality improvement generated from M&M Analyses, reports and support with data provision A best practice statement M&M A case selection facilitator/chair screening tool training Link with adverse event framework programme A generic paper proforma for M&M in NHS Scotland Other characteristics

22 Is the learning used? 50% of respondents reported that learning from M&Ms is used routinely/most of the time or frequently in NHS. In contrast 31% thought it was used infrequently % perceived that it was never used Routinely/most of the time Frequently Infrequently Rarely Never No repsonse

23 Learning Meetings regularly attended by consultants and senior trainees learning points so frequently amongst consultant colleagues (79%) and nurses (52%) learning is rarely shared with other hospitals or boards (4%) 50% of respondents reported that learning from M&Ms is used routinely or frequently Culture For improvement For learning (Not as and end in itself) Variations in practice by board and speciality Opportunities to improve learning within meetings Opportunities to share learning outside meetings Within departments Within hospitals and organisations Across Specialties /organisations and disciplines

24 Recommendations for the M & M Programme 60% 50% 40% 30% 20% 10% Rank 9 Rank 8 Rank 7 Rank 6 Rank 5 Rank 4 Rank 3 Rank 2 Rank 1 0% Provision of an electronic structured M&M system in NHS Scotland Assistance with quality improvement generated from M&M Analyses, reports and support with data provision A best practice statement M&M A case selection facilitator/chair screening tool training Link with adverse event framework programme A generic paper proforma for M&M in NHS Scotland Other characteristics

25 Other recommendations with over 25% support included: M&M facilitator/chair training, A case selection screening tool Link with adverse event framework programme

26 Characteristics of a national electronic system

27 Benefits of a national approach (N=856) Improvements Shared learning from M&M Governance Quality of care Staff engagement Variation Reassurance No Benefits Don t know Other Not recorded

28 In summary 88.1% of respondents said their specialty had an M&M or similar peer review meeting for mortality and morbidity case discussion 59% said meetings took place at least monthly Variable methods used to structure, report and disseminate findings 58.4% of respondents said that their time to attend M&M was protected. Variation between specialties and boards for job planned activity

29 Prof Craig White

30 Duty of Candour Procedure Professor Craig White FRCP FBPsS Scottish

41 National Implementation Guidance Raise Awareness Section 22 Regulations Organisational Duty of Candour Support Leadership

42 Effectiveness is key

43 Keep focused on peoples needs Recognise pain & distress Listen & respond honestly Support with matters to them Communication of the learning and change

44 @craigwhitephd

45 Norma Shippin

46 Litigation A sign of the times? Norma A Shippin

47 NHS (Clinical Negligence and Other Risks Indemnity Scheme (Scotland) Regs 2000 The Scheme was launched on 1 April 2000 Membership - mandatory for Boards Expanded from 1 April 2015 to assist health and social care integration Clinical and non-clinical claims and risks

48 Clinical - CNORIS Medical and Dental including provision to prison service Nurses Midwives PAMs Ambulance and Laboratory staff Forensic service

49 Non-clinical - Employers liability CNORIS Public liability ( including directors) Product liability Professional indemnity Income generation (but only in respect of NHS to NHS activity)

50 Payments under the scheme TRENDS SCOTLAND 2009/ m 2010/ m 2011/ m 2012/13 35m 2013/ m 2014/15 42m 2015/16 52m

51 Claims Accident and Emergency General Surgery Obstetrics and Gynaecology Value of Claims in last 3 years 10,350,830 3,368,549 2,439,815 52,595,640 6,300,169 2,355,949 1,152,201 20,779, , ,421 1,207,435 Non-clinical Accident and Emergency Anaesthetics Clinical (unclassified) Gynaecology Healthcare Acquired Infection Medication Error (excl anaesthetics) Obstetrics Oncology (excl Radiology and Surgery) Radiological Investigation Surgery (excl obstetrics)

52 CNORIS Claims New clinical claims in Scotland - 1 April March (669) New non- clinical claims in same period 457 (495) (Figures in brackets are for 1 April March 2014)

53 NHS in Scotland Existing clinical claims /actions 1684 (1573)

54 Prescription of claims Normally 3 years from date of incident proposed change to 5 years Discretion of court Position of children/incapax

55 Voluntary pre Action protocol for PI cases based on clinical negligence Benefits Avoid need for litigation Speed up case handling Early and full disclosure of information Narrowing of issues in dispute Enables us to have a trial and see how it works in practice

56 Voluntary pre Action protocol for PI cases based on clinical negligence Challenges Time scales could be tight where information from Boards is not forthcoming New approach always takes time to establish

57 Questions?? Norma Shippin

58 Dr Andrew Gibson

59 National Mortality Case Record Review Programme Andrew Gibson June 2016

60 Retrospective case record review (RCRR): structured judgement review (SJR) SJR methodology Implementing SJR in hospitals SJR in action

61 SJR methodology Hutchinson A, et al. A structured judgement method to enhance mortality case note review: development and evaluation. BMJ Quality and Safety 2013 doi: /bmjqs Explicit judgements Phases of care Analysis

62 What is the purpose of SJR? It is not just about counting numbers. It is about gathering quantitative and qualitative information about what goes well, or not so well, in a care system. The review system can be used for individual cases (eg morbidity and mortality M&M ) and for groups of cases. The information allows units or organisations to ask why questions about things that happen, to enable learning and action where required.

63 SJR: unique selling points It examines both interventions and holistic care. Reviewers give written explicit judgements on safety and quality of phases of care much more readily than with other commonly used tools (eg GGT). Reviewers give overall care and phase of care scores to accompany judgements. the scores are Results show good care as well as poor care (and good care is much more frequent). It is an internal review process usually based on one reviewer, with a second stage where there is cause for concern.

64 Phases of care Admission and initial care first 24 hours approximately Care during a procedure Perioperative/procedure care Ongoing care up to end of life or discharge of the patient (this phase may cover a prolonged period) End-of-life care or discharge care Care overall

65 Scoring phases of care 1 Very poor care 2 Poor care 3 Adequate care 4 Good care 5 Excellent care

66 Case selection is your choice High case fatality disorders All end-of-life care All elective deaths All learning disability deaths All borders deaths A random sample of all deaths A directorate by directorate analysis

67 Low scores in phases of care All scores of 1 or 2 have second stage review Independent of first stage review 1 or 2 does not mean avoidable death

68 SJR: implementing in hospital setting Trained reviewers National case record review can support this Mature, robust and transparent governance structures Action on process failure Action on person failure Mechanisms for selecting case notes for review (eg national Hospital Standardised Mortality Ratio (HSMR) data for high case fatality disorders) Timeliness of reviews

69 SJR: the regional experience Study site / cohort (n) Percentage with scores <2 Sheffield Teaching Hospitals Foundation Trust (STHFT) cardiac arrest (80) 11% STHFT weekend data (80) 18% MYHNT (24) 16% Hogan et al 2016 Avoidable death ~3%

70 SJR in action: cardiac arrest as a harm event Admission 48 hours pre cardiac arrest During Post arrest

71 SJR: thematic analysis and PDSA cycles

72 SJR: second stage review of low scores

73 Summary SJR methodology is a validated tool to review mortality. SJR methodology includes robust governance. SJR methodology can reveal themes and poor or excellent practice.

74 Dr Paul Bowie

75 Enhancing Mortality and Morbidity Meetings: Incorporating Human Factors Principles and Approaches Paul Bowie PhD MIEHF FRCPE (Hon.) Programme Director (Safety & Improvement)

76 Content NES role in Scottish M&M Programme What is Human Factors? Correcting HF misunderstandings Incorporating key HF principles into M&M Taking a Systems Approach to enhancing M&M

77 What is Human Factors (or is it Ergonomics)?

79 Definition of Human Factors Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance... (IEA, 2000) The settled will of the international Human Factors community! In other words, ergonomics/human factors is designing for people.

80 Wide ranging discipline focused on the evaluation and improvement of all aspects of human work HF can benefit a diverse range of important healthcare problems where performance and wellbeing are often compromised e.g. the introduction of new information technology reducing work-related musculoskeletal disorders amongst clinicians decision-making to inform NHS procurement of products and services the design of physical care environments staff wellbeing e.g. addressing job stress, fatigue and burnout reflecting on and learning from the prevailing safety culture supporting the needs of the ageing clinical workforce the design and usability of medical equipment Patient safety and Quality improvement interventions ** Key differences between healthcare and other industries need to be appreciated to ensure HF Integration reflects care complexity and uncertainty

81 Twin Aims of Human Factors 1. To enhance the well-being of employees and consumers (patients and clients) 2. To enhance the well-being of the organisation. Individual wellbeing = personal health, safety, comfort, convenience, satisfaction, interest and enjoyment; Organisational wellbeing = performance (in terms of safety, productivity, efficiency, quality, flexibility, responsiveness) and competitiveness (where appropriate). Twin Aims not mutually exclusive but are interdependent known as joint optimisation (Atkinson, 2014)

82 HF System Components and Interactions - Onion Model (Grey, Wilson, 2003)

83 Human Factors Misunderstandings in Healthcare

88 Some Perspective and Understanding - The HF Profession Building HF capacity and capability QI model? Chartered profession in the UK highly specialist, 6-years of training Knowledge and evidence across: Anatomy, anthropometry and physiology in human activities; Environmental stressors (performance shaping factors), psychophysiology; Socio-technical systems; general and organisational psychology; Survey and research methods Expertise in principles, standards, legislation and methods NOT on how work is actually done, experienced and impacts on performance and wellbeing healthcare workforce, patients Some HF principles and approaches are transferable to frontline care professionals and staff group

89 Distinguishing Features of Human Factors/Ergonomics (Dul et al, 2012) 1. It takes a systems approach (holistic) 2. It is design driven (to take account of human characteristics, needs and capabilities) 3. It focuses on two closely related outcomes: Performance and Well-being ( of people and organisations joint optimisation )

90 Integrating Human Factors Principles into the M&M Process

91 For example: Understand healthcare as a complex sociotechnical system Why things go wrong (and right) How to respond to when things go wrong Incorporating systems thinking Taking a participatory approach (i.e. speak to people who do the work and co-design) Simplification and standardisation (where judged appropriate)

92 Healthcare as a Complex System? A system characterised by multiple interactions between various components, both human and technological: Decisions often made with imprecise information Actions vary dependent on conditions to ensure successful and safe outcomes. Systems conditions are dynamic and can change rapidly - not always predictable. Demand may increase e.g. due to holidays or influx of emergency cases. Capacity can change e.g. due to staff absence or resource cuts Wishes and health of patients can change e.g. influencing our understanding and how we clinically manage

93 FIRST PRINCIPLE (No.1) Understanding Why Things go Wrong e.g. The Human Error problem (misnomer, not a cause ) System complexity and interactions (contributory factors) Goal conflicts (e.g. increase productivity Vs decreased resource) Trade-offs (e.g. safety Vs efficiency) Performance variability (e.g. adapting to context to get job done) Organisational constraints (e.g. resources, priorities, culture) Local rationality (e.g. makes sense based on available info/context) (Compensating for complexity and system deficiencies)

94 FIRST PRINCIPLE (No.2) Response to When Things go Wrong e.g. We don t got to work to do a bad job - axiomatic Blame (self and colleagues) psychological need and counterproductive to learning and improvement Human biases need to manage these esp. The Hindsight bias & Attribution bias Emotional impacts on staff 2 nd victim, frequent, inhibits openness, barrier to engagement and learning Professional Accountability report, apologise, commit to learn Organisational Accountability create and sustain the conditions Egregious or reckless behaviours/actions PM issue Openness, transparency, no-blame, learning, but accountability = Just Culture

95 Taking a Systems Approach (to understanding safety and implementing change) Characteristic of a safe and just culture Don t need to be an expert in systems thinking : key principles to consider: 1. Understand interactions and relationships between system components i.e. How these contributed to the problem or safety incident; Change is implemented by considering these interactions when improving overall system performance. 2. Multiple perspectives are necessary - How the system works appears different to different people as interactions change frequently. Speak to people who do the job, they re the experts in everyday work! 3. Define your boundaries - Systems are subjected to many influences and it is not possible to consider all of these, need to agree upon a boundary done on a case-by-case basis. 4. Anticipate what can go wrong - designing suitable defence or coping mechanisms to minimising the risks and impacts of error 5. Limitations of linear cause and effect methods

96 Standardise and Simplify? Problematic given the complexity and diversity of clinical needs/systems in healthcare Standardising common work procedures may make it easier (e.g. less mental effort, workload and stress) communication tools, checklists, etc Proposed M&M process e.g. data collection, documentation, use of tools, systems approach

97 Thank You! Any Questions?

98 Jenny Long

99 LEARNING FROM ADVERSE EVENTS: A national framework for Scotland Because human error is normal and, by definition, is unintended, well-intentioned people who make errors or are involved in systems that have failed around them need to be supported, not punished, so they will report their mistakes and the system defects they observe, such that all can learn from them. The best way to reduce harm is for the NHS to embrace wholeheartedly a culture of learning. A promise to learn a commitment to act, The National Advisory Group on the Safety of Patients in England, chaired by Don Berwick, August 2013 Jenny Long jennifer.long1@nhs.net hcis.adverseevents@nhs.net

Sharing learning for improvement As part of the learning from adverse events programme, a learning summary template has been developed as a way to ensure: a consistent approach for sharing key

This mechanism for sharing learning can be used for any form of learning, not just from adverse events and we would like to encourage the use of these across the organisation and all other care

100 Sharing learning for improvement As part of the learning from adverse events programme, a learning summary template has been developed as a way to ensure: a consistent approach for sharing key learning points to improve services, and we are open and transparent with findings from significant adverse event reviews with staff, patients, families and carers. This mechanism for sharing learning can be used for any form of learning, not just from adverse events and we would like to encourage the use of these across the organisation and all other care providers. Examples of the learning summaries can be found on the adverse events community of practice ( support can be provided by the team (hcis.adverseevents@nhs.net) Jan-15 Mar-15 Learning summaries shared May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 Total Cumulative total 0 Page views Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 Unique page views Baseline median page views

Using the structured judgement review method

National Mortality Case Record Review Programme Using the structured judgement review method A clinical governance guide to mortality case record reviews Supported by: Commissioned by: Dr Andrew Gibson