Identifying Problems Care and Service Delivery Problems (CDPs + SDPs) Concept of care and service delivery problems - Vincent and Adams (1999)

The RCA Process Getting Started Gathering Information & Mapping the Incident Identifying Care & Service Delivery Problems Analysing Problems & Identifying CFs and RCs Generating Solutions & Recommendations Identify Care + Service delivery problems – Compare what should have happened against what actually happened. i.e identify what happened that shouldn’t have, or what didn’t happen that should have. (BUT DON’T STOP THERE) Implementing Solutions Writing the Report

What are Care/Service Delivery Problems (CDP/SDPs)? Every point where: Something happened that shouldn’t have OR Something that should have happened, didn’t. CDP/SDPs

Care Delivery Problem (CDP) Problems that arise in the process of care… …usually actions or omissions by staff Care Delivery Problem (CDP) care deviated beyond safe limits of practice and ii the deviation had a direct or indirect effect on the eventual adverse outcome for the patient Failure to monitor, observe or act Incorrect decision or action Not seeking help when necessary

Service Delivery Problem (SDP) Acts or omissions identified during the analysis of the incident, but not associated with direct care provision. Service Delivery Problem (SDP) …These are generally associated with decisions, procedures and systems that are part of the whole process of service delivery. Fail to undertake environmental risk assessment System for ensuring all new telephones have an emergency number for switchboard on them

How to identify CDPs and SDPs Some will jump out immediately Others emerge, particularly when the clinical team involved is invited to contribute ... Never assume your organisation / team is doing what you (or even they!) think they’re doing Peter Pronovost - 2009 You are now at the point where you have mapped the incident fully and it may even have been at that point where you start thinking about what the real problems are in this incident? Actually, you want to get the stakeholders to come and take a look at your tabular timeline - Do give people the opportunity to contribute at various points in the RCA process. The next main task for you as an RCA Investigation Team is start thinking about what are the care and service delivery problems? Some of these will jump out at you immediately!! Other results emerge much more slowly particularly if you are having a multi-professional review team involved in the investigation.

To determine CDPs and SDPs Consider holding an Multi Disciplinary Team meeting This approach is valuable to:- Clarify your ‘map’ of the incident Identify CDPs + SDPs and contributory factors Invite those involved or interested to take part and learn from the process Gain help finding workable solutions Share the report and debrief staff on the learning It can also work well therapeutically Especially where ‘perceived’ blame issues need to be worked through! (NB: Wherever reckless, malicious or criminal activity is ‘actually suspected’, these issues are transferred to other experts for action)

But… So… And… Tensions may be running high It may be difficult to get everyone together So… Consider seeing people in smaller groups And… Practise with a low-harm incidents first

Hierarchies - the need for skilled facilitation When RCA meetings are attended by both medical and nursing staff, they are often dominated by doctors. Nurses feel uneasy about challenging the practice of Doctors Discussion during RCA meetings is often dominated by consultants. Junior Doctors remain silent and hardly challenge Senior Doctors. Clinical Governance teams struggle to get responses from clinical personnel to attend meetings. Incidents surface differences between clinical practices and conflicts between clinical departments. Warwick University Research - 2009

Tips on Preparing the meeting Choose a facilitator who enjoys respect and can respectfully challenge clinicians Be clear about the purpose of the meeting /review Ensure the right people attend Send out proper invitations (date, time, venue, agenda) Find out as much background info. as possible – know your group! Plan the agenda, tools, techniques, flipchart etc Decide how to record information and outcomes Welcome attendees and provide refreshments Develop contingency plans in case things go wrong Prepare yourself to facilitate a successful outcome

Key Points – Facilitating an MDT Research shows that this aspect can have a huge bearing on the effectiveness of the whole investigation Consider gaining advanced training or enlisting the help of an in-house expert

RCA tools to help identify CDPs & SPDs Change analysis Nominal group technique

Change analysis – the process Describe the “map” of your incident. Compare this with normal acceptable practice (based on national and local policy/guidance) List the changes. Did the changes contribute to the incident? Agree the main problems (CDP/SDPs). Carefully assess the differences and identify possible underlying causes. Describe how these affected the event. Did each difference change or explain the result?

Mapping – the chronology of the incident What actually happened - Patient journey Xxx xxxxxxxx Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx

Mapping – accepted practice What should have happened - Policy / Clinical guidelines Xxx xxxxxxx xxx xxxxxx xxxxxx Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx What actually happened - Patient journey Xxx xxxxxxxx Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx

Change Analysis – to identify CDPS & SDPs B. What should have happened - Policy / Clinical guidelines Xxx xxxxxxx xxx xxxxxx xxxxxx Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx A. What actually happened - Patient journey Xxx xxxxxxxx Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx 1. Variations from acceptable practice - Care & service delivery problems Xxxx xxxxxxx xxxxxxxxxxx xxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxx xxxxxxxx xx xxxxxxxxx

Worked example Mr Smith, 48yrs – diabetic steel worker scheduled for Right below knee amputation due to circulatory problems. Also problems with Left leg requiring amputation at a later date. After surgery they discovered that the wrong leg had been amputated.

Change analysis Normal procedure Incident www.npsa.nhs.uk/rca Was there a change? Did change contribute to incident? Surgeon knew patient’s condition - both feet gangrenous No Theatre list correct & reviewed by surgeon after typing Theatre list changed and hand written by SHO (RIGHT leg not clearly identified) Yes Marking of site by surgeon prior to list using skin pencil, after checking with pt and notes Right calf marked by SHO using Biro when consent form signed. Patient crossed legs & mark transferred to left leg Preparation & draping carried out by surgeon Preparation & draping carried out by surgical assistant who did not know patient www.npsa.nhs.uk/rca

Changes (CDPs) leading to the incident SHO produced an unclear hand written theatre list SHO marked the site using a Biro Surgical assistant draped limb after reading theatre list and noting site - omitted to check medical records and consent form Draping not carried out by surgeon This is a summary of the changes that contributed to the incident.

What should your CDPs/SDPs look like? Specific not vague: Communication failure X Paramedic failed to inform A&E patient was confused  What happened not why: Not enough training on hand hygiene X Staff member did not wash or clean his hands 

Care should be taken to avoid:- Hindsight bias = Judging with the benefit of knowledge others did not have at the time of the incident. This leads people to make unfair assumptions about staff closest to the incident. Outcome bias = If an error causes no harm it is considered lucky. If the same error causes significant harm we are more likely to blame. This allows accountability to become inconsistent and unfair.

Group work Verify unconfirmed facts (Try questioning your presenter/facilitator) Identify CDPs and SDPs Define the failing not the cause (Use clear & specific phrasing)

Why are CDPs and SDPs so important? To break down the analysis into manageable chunks To provide a forum for raising / referring perceived blame issues To ensure that both clinical care + service delivery issues (unsafe acts & conditions) are considered equally as appropriate To provide a means of prioritising in line with capacity and resource limitations. NB: To provide a forum for raising / referring perceived blame issues. Important to avoid blame being discussed outside the investigation (ref: Warwick University research findings)

How to conduct an adapted NGT Participants... Generate a list of CDPs & SDPs using Change analysis (True NGT = Generating a list of ideas by brainstorming/brainwriting) Combine or eliminate duplicate ideas. Individually vote on CDPs/SDPs considered most influential Rank/prioritise CDPs & SDPs in line with votes cast

Group work (Cont) Combine similar issues into one CPD/SDP Prioritise CDPs and SDPs for further analysis

Key Points – CDPs and SDPs A really important bit! Concentrate on correct phrasing of CDPs + SDPs Allow carefully facilitated exploration of perceived blame issues - at this stage only