1. PSSIG Scoping Session Chris Foye Information Architect National Patient Safety Agency, UK 28 th September 2004 Chris Foye Information Architect National Patient Safety Agency, UK 28 th September 2004

2. Overview San Antonio –Revisit PSSIGs scope –Decision tree Ensure efficient working of PSSIG –Set priorities Aim –Ensure paper is truly representative –Finalise paper San Antonio –Revisit PSSIGs scope –Decision tree Ensure efficient working of PSSIG –Set priorities Aim –Ensure paper is truly representative –Finalise paper

3. Agenda Assumptions Patient safety / patient safety incident definitions Principles Vision statement / mission statement WHOs International Patient Safety Alliance Reporting systems Prioritisation Decision tree Assumptions Patient safety / patient safety incident definitions Principles Vision statement / mission statement WHOs International Patient Safety Alliance Reporting systems Prioritisation Decision tree

4. Assumptions Derive PS messages which have universal applicability. Cannot operate disconnected from the realities of modern health care No consistent view of patient safety and what constitutes a PSI Goal – improve patient safety Financial, resourcing and time considerations out of scope

5. Patient safety & patient safety incident definitions Patient safety: The processes by which an organisation reduces the risk and occurrence of harm to patients as a result of their healthcare Any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving healthcare services Patient safety incident:

6. Principles Provide context Unearth assumptions about patient safety –Translate into modelling assumptions Identify potential work streams –Activities –Prioritisation Formulate vision statement –Mission statement –Scope Provide context Unearth assumptions about patient safety –Translate into modelling assumptions Identify potential work streams –Activities –Prioritisation Formulate vision statement –Mission statement –Scope

7. Messaging Assumptions Modelling Assumptions Clinicians Workflow Clinicians Workflow Research Programme Research Programme Implement Lessons Learnt Implement Lessons Learnt Localisation Post-Incident Investigation Post-Incident Investigation Single Reporting System Single Reporting System Patient Safety Centre Patient Safety Centre Leverage Information Sources Leverage Information Sources Observatory External Factors External Factors Principles

8. Vision statement Ensure patients receive the safest care possible Encourage a systemic view Establish a message model for capturing and transmitting PSI data Ensure complementary information is directed to the appropriate organisations: –Aid understanding –Provide context –Assist in the analysis and identification of areas of concern. Embed patient safety related clinical decision support systems to reduce overall system risk. Ensure patients receive the safest care possible Encourage a systemic view Establish a message model for capturing and transmitting PSI data Ensure complementary information is directed to the appropriate organisations: –Aid understanding –Provide context –Assist in the analysis and identification of areas of concern. Embed patient safety related clinical decision support systems to reduce overall system risk.

9. Mission statement Standard message model for patient safety –Facilitate reporting and investigation Work with other SIGs –Ensure messages do not adversely affect patient safety –Decision support mechanisms Complementary information Standard message model for patient safety –Facilitate reporting and investigation Work with other SIGs –Ensure messages do not adversely affect patient safety –Decision support mechanisms Complementary information

10. WHOs International Patient Safety Alliance Recognise need for international representation PSA recognises that …no single player has the expertise, funding or research and delivery capabilities to tackle the full range of patient safety issues on a worldwide scale. An international alliance would provide a mechanism to decrease duplication of investment and activities. PSSIG should work with the PSA to: –Raise awareness of the groups activities –Disseminate key deliverables for review –Seek guidance –Ensure the needs of the international community are catered for Recognise need for international representation PSA recognises that …no single player has the expertise, funding or research and delivery capabilities to tackle the full range of patient safety issues on a worldwide scale. An international alliance would provide a mechanism to decrease duplication of investment and activities. PSSIG should work with the PSA to: –Raise awareness of the groups activities –Disseminate key deliverables for review –Seek guidance –Ensure the needs of the international community are catered for

11. Reporting systems Review of Central Returns Committee (ROCR) –Over 97 different requests for non-financial information. –Year-on-year impact on the NHS of supplying non- financial data in 2000/2001 was an increase of 74 person years. Unnecessary burden on frontline staff –Double entry –Information silos Review of Central Returns Committee (ROCR) –Over 97 different requests for non-financial information. –Year-on-year impact on the NHS of supplying non- financial data in 2000/2001 was an increase of 74 person years. Unnecessary burden on frontline staff –Double entry –Information silos

12. SpecialtiesSpecialties SpecialtiesSpecialties InfectionsInfections InfectionsInfections Generic Patient Safety Report TransfusionsTransfusions TransfusionsTransfusions MedicationMedication MedicationMedication VaccinesVaccines VaccinesVaccines DevicesDevices DevicesDevices Entry point

13. Prioritisation 1.Individual Case Safety Report 2.Generic Patient Safety Report 3.Sub-Domain Development 4.Incident Investigation 5.Decision Support 6.Complementary Information 1.Individual Case Safety Report 2.Generic Patient Safety Report 3.Sub-Domain Development 4.Incident Investigation 5.Decision Support 6.Complementary Information

15. chris.foye@npsa.nhs.uk