1. Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant

2. A framework for safety measurement and monitoring Vincent, Burnett and Carthey, 2013

3. Methodology Document review InterviewsAnalysis Summary Report

4. Findings Varied awareness of the framework Variation in methods used High volume of information Significant QI activity CCG maturity on sensitivity to operations

5. Diversity Past harm – Some Boards interrogate divisional performance variability. Others do not. – Too many measures in some sites? Reliability – Some measures of reliability for care bundles – More to do to develop measures of reliability of clinical systems Sensitivity to operations – ‘Tell us today’ ‘HospiCom’, junior doctors, student nurses, entry and exit surveys in mental health etc

6. Diversity Anticipation and preparedness – Wide differences in measures across sites. – Generally, We are not there yet Integration and learning – DATIX incidents with staffing levels, clinical audit findings etc. – Big differences in maturity of dashboards – Generally, still a long way to go on this dimension of the Framework

7. Common goals A whole health economy approach to understanding past harm & reliability Sensitivity to operations: Need for more triangulation with other data sources at Trust level: How might we use soft intelligence intelligently? Anticipation and preparedness: To increase our focus on this dimension, improve our foresight and ability to act before harm occurs. Integration and learning: To improve feedback to frontline healthcare teams & to improve how we bring safety data from the other dimensions of the Framework in a coherent way. Spreading learning in how to measure for improvement

8. Examples of good practice Past Harm - Christie: Mortality review process. CCG lead involvement in Trust serious incident review panels Integration and learning Tameside: Review of 2 years safety data formed basis for whole organisational development plan Anticipation and preparedness - Wigan: Staff training data used to anticipate erosions in safety Salford safety culture survey in operating theatres Sensitivity to operations – Tameside: virtual safety radar screen East Lancs CCG: GP reporting system Reliability - Lancashire Teaching: ‘Guardianship’ Chester CCG: review of AQuA reliability data on sepsis

9. Past Harm: How might we maximise the learning from past harm data (improving incident investigation, understanding human factors etc.) Integration and learning: How might we triangulate and integrate data in a more meaningful way? Anticipation and preparedness: How might we create more real time safety measurement and monitoring data that supports us to act before things go wrong? Sensitivity to operations: How might we use soft intelligence in an intelligent way? Reliability: How might we ensure we are applying reliability measures appropriately? (i.e. understanding the limitations, which measures matter?)