A System Engineering Initiative for Patient Safety
The Patient Safety Incident Response Framework (PSIRF) is the new NHS toolkit which promotes a range of system based approaches for learning. It represents the new standard in the way Risk Investigators and Executives are expected to respond to patient safety incidents, with a widened focus on evidencing a systematic approach in capturing and understanding the interactions between contributory factors that are leading up to incidents occurring.
This white paper provides a short review of the PSIRF and how you can use CEMBooks to comply with and respond to the challenges it poses to you and your trust.
As part of the preparation for implementing the new PSIRF, organisations are obliged to review how they collect and review information across the wide variety of processes that contribute to their operational risk burden. A full preparation guide is provided here: https://www.england.nhs.uk/ patient-safety/incident-response-framework/#who
All organisations must adopt the national system-based learning response toolkit and be able to evidence active exploration of the contributory factors surrounding every patient safety incident or cluster of incidents, and to show how this has informed improvement. This will pose unprepared trusts with a significant operational burden and corporate risk.
Whilst current incident reporting systems including Datix© still have a significant role in reporting and managing the process of incident reporting, the sheer volume of contributory factors that need to be explored in PSIRF requires a much more in-depth level of understanding with collated information and analysis. This must be multiplied by the number of not only near misses, but evidence of active management of these issues before an incident occurs.
CEMBooks captures all the information required for each component of the PSIRF framework. It was developed by Emergency Physicians as a means to describe and react to the socio-technical complexities inherent to their work system. The ‘web-based platform’ invites staff members to generate timed situation reports and logs of events in their areas as they occur in real-time.
Figure 1. Dr Peter Cutting, Risk Lead at Leeds Teaching Hospitals Emergency Department is an early adopter of the PSIRF system and uses CEMBooks to capture the contributory factors when investigating incidents. Click on this link to find out more.
Healthcare is a complex socio-technical system
Healthcare is complex because it is highly variable, uncertain, and dynamic. Healthcare is a socio-technical system because it is characterised by multiple interactions between various components, both human and technological. The challenge we face is how we combine both data and narrative surrounding an incident to truly make sense of what has happened.
What is the System Engineering Initiative for Patient Safety (SEIPS)?
SEIPS is a framework for understanding outcomes within complex socio-technical systems. Figure 2 provides an overview of the SEIPS framework. The figure 2 describes how a work system (or socio-technical system, left) can influence processes (work done, middle), which in turn shapes outcomes (right). The SEIPS framework acknowledges that work systems and processes constantly adapt (see arrows in figure 2).
Figure 2. Overview of the SEIPS framework
What are the different parts of the work system?
A ‘work system’ consists of six broad elements: external environment, organisation, internal environment, tools and technology, tasks and person(s). Figure 3 provides a brief overview of the different elements and potential contributory factors to consider during a learning response.
People cannot be separated from the work system; their deliberate placement at the centre emphasises that design should support – not replace or compensate for – people.
Using SEIPS to learn from patient safety incidents
SEIPS can be used as a general problem-solving tool (eg to guide how we learn and improve following a patient safety incident, to conduct a horizon scan, and to inform system design).
Figure 4 (the work system explorer) provides questions to help explore different work system elements. Patient safety incidents result from multiple interactions between work system factors. SEIPS prompts us to look for interactions rather than simple linear cause and effect of relationships. If a learning response can thoroughly examine the different work system components and their interactions then safety responses can focus on wider system issues, not just individuals.
Figure 3. Overview of the SEIPS work system
Figure 4. SEIPS work system explorer questions
Traditionally, the investigator is required to look across multiple IT systems, emails and then interview numerous members of staff in an attempt to ascertain what happened on a particular event that often occured many days or weeks previously. They then attempt to collate and extract information from these replies to describe the situational context where the incident took place. This is where CEMBooks can help.
What is CEMBooks?
CEMBooks is a human centric, web-based, operational reporting system designed to capture and mitigate against the complexities inherent to healthcare.
Figure 5 describes how CEMBooks overlaps with the SEIPS framework by inviting staff members to capture events impacting on their work system (left) in the form of Situation Reports (SitRep), Logs and Escalation Responses in real-time. Any processes (middle) can be analysed within CEMbooks to shape desired outcomes (right). CEMBooks adapts by identifying and allowing changes to the learning response (see arrows in figure 5).
Figure 5. Overview of CEMBooks and framework
There is significant crossover between some of the factors highlighted in the SEIPS model and NHS operational models such as FOCUSED (see our paper and webinar on FOCUSED here: https://cembooks.com/ecist-webinar-on-cembooks-and-focused-site-operating-model/)
CEMBooks can capture all the elements within the SEIPS and Focused models. The level of detail found in CEMBooks will ensure that you can answer the following types of questions required within the new patient safety incident response framework including:
Situational factors
- Was there any failure of team function – were local internal professional standards followed?
- Were there conflicting team goals, poor delegation or issues between colleagues?
- Were there individual staff factors such as workload or lack of senior support highlighted – were these known about, were they documented and how often do they happen?
- Were there any task characteristics that made the incident more likely – what was the timeframe for tasks to be done in the department at that time e.g. transfers to CT or time for antibiotics to be delivered or bloods to be done – can this be accurately checked at any time-point and including time-points two months previous?
Local Working conditions
- Workload and staffing issues – was there a mismatch – how is this collated? The staffing Rota may show the planned staffing but do they include any subsequent staff movements between areas or sites, where is the current service demand captured both in terms of numbers and severity?
- Were there adequate senior decision makers available?
- Were there difficulties with obtaining correct medications, equipment or supplies – how are these issues recorded and managed within your department – are they paper based or IT solutions, are they searchable and date/time stamped?
- Is there evidence of staff/specialty interaction logs – capturing both positive interactions and areas for improvement?
Organisational factors
- Are there any physical factors influencing the ward at this time – maintenance work, overcrowding, additional bed spaces being used or non-designated bed spaces being used
- This there support or issues from other departments?
- Scheduling and bed management issues causing delays – What is the wait for a CT scan or report of a CT scan?
- How are prolonged admission times managed?
- Are there training and education – skillset shortages?
External Factors
- Is there a national policy that applies – are your guidelines and local applications of national guidelines easily accessible to staff working within your department and how do you ensure they’re kept up to date?
Communication and culture
- How are safety issues communicated within your department, how is handover performed and captured, how do you ensure jobs don’t slip through the net?
Learning
- How are learning events and improvements documented, disseminated and tested?
The level of information required to comply with the new PSIRF is much more granular and encompassing than previous incident investigations and reports. Many organisations have some degree of understanding found within existing trust data systems but nowhere is this information brought together in a single format. Neither are these systems rapidly searchable for retrospective analysis and improvement.
Furthermore, trust systems rarely capture a scripted narrative from staff members in departments of what is happening in their areas. It is this combined level of detail that makes CEMBooks unique and it also provides the functionality to add and change quality markers and escalations to test new improvement initiatives.
Engineering a system for patient safety and complying with PSIRF is less challenging with the right information. CEMBooks has been implemented in many organisations and is helping them move to outstanding.
Book a demo at www.CEMBooks.com
References
NHS England SEIPS, Quick reference guide and work system explorer, https:// www.england.nhs.uk/wp-content/uploads/2022/08/B1465-SEIPS-quick-reference-and-work- system-explorer-v1-FINAL.pdf
NHS England, Patient Safety Incident Response Framework, https://www.england.nhs.uk/patient-safety/incident-response-framework/#who
Lawton R, McEachan RRC, Giles SJ, et al Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review BMJ Quality & Safety 2012;21:369-380.
Holden, R.J., Carayon, P., Gurses, A.P., Hoonakker, P., Schoofs Hundt, A., Ozok, A.A. and Rivera-Rodriguez, A,J. (2013) SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11), 1669-1686.
Holden, R.J., Carayon, P. (2021). SEIPS 101 and seven simple SEIPS tools. BMJ Quality & Safety, 0, 1-10
Carayon P, Wooldridge A, Hoonakker P, Hundt AS, Kelly MM. SEIPS 3.0: Human-centered design of the patient journey for patient safety. Appl Ergon. 2020 Apr;84:103033. doi: 10.1016/j.apergo.2019.103033. Epub 2020 Jan 10. PMID: 31987516; PMCID: PMC7152782.