The Challenges of applying the International Classification for Patient Safety

Transcription

1 The Challenges of applying the International Classification for Patient Safety Alison J McMillan Director Quality Safety and Patient Experience Department of Health Victoria

2 Victorian Health Incident Management System (VHIMS) Background Victorian Auditor Generals Report (2005 & 2008): there is no state-wide picture of the nature and number of adverse events and near misses in Victorian hospitals. While sentinel events are reported to DHS they are only a small fraction of all clinical incidents. As a result, their value in identifying emerging issues, and for trend analysis, is limited. Large scale collection is required to characterise events that occur rarely at a system level Wide variation in tools and classification methodologies used for incident reporting at a local level (survey July 2006) Victoria was the only Australian jurisdiction not collecting state-wide clinical incident data

3 VHIMS: Data Set Specification VHIMS Data Set Specification is based on the International Classification for Patient Safety (WHO) and provides a state-wide methodology for the management and reporting of: Clinical incidents Occupational health and safety incidents Consumer feedback VHIMS Data Set Specification includes a set of standardised definitions for: Clinical incident Adverse event Near miss Hazard VHIMS Data Set Specification includes severity rating methodology based on consequence (outcome assessment) to minimise subjectivity

4 VHIMS: Scope All publicly funded health services in Victoria: 88 public health services 39 stand alone community health services Ambulance Victoria 14 bush nursing services Royal District Nursing Service Forensicare 5 incorporated public residential aged care services

5 Standard clinical terminology, together with standard data specifications can provide data with consistent meaning context NEHTA Architecture overview clinical registries 2008 Every system is perfectly designed to get the results its gets Donald Berwick, MD MPP, FRCP, President & CEO Institute for Healthcare Improvement

6 VHIMS: WHO ICPS conceptual framework Influences Contributing factors/hazards Informs Patient characteristics Incident type Incident characteristics Actions taken to reduce risk Influences Influences Detection Mitigating factors Informs Informs Actions taken to reduce risk Informs Patient outcomes Organisational outcomes Informs Influences Ameliorating actions Informs System resilience proactive and reactive risk assessment World Health Organisation Clinically meaningful, recoognisable categories for incident identification and retrieval Descriptive information

7 VHIMS: Data Set Specification VHIMS Data Set Specification supports a primary classification for Event Type/Event Characteristics/Patient Characteristics based on World Health Organisation (WHO) International Classification for Patient Safety (ICPS) Provides a consistent model for classifying: types or primary and related incidents issues (related to consumer feedback) contributing/preventative factors based on code sets Will be applied to clinical / staff / non-clinical incidents and consumer feedback

8 VHIMS: data set components Streamlining DH incident reporting requirements: Sentinel Event Reporting Radiation Safety Reporting Serious Transfusion Incident Reporting Allegations of physical and/or sexual assault in residential aged care Occupational violence Pressure ulcer clinical indicators

9 VHIMS: Business requirements Department of Human Services Statewide Quality Branch Regional offices Public Health Branch Aged Care Branch Nurse Policy Branch VMIA WorkSafe Victoria Health Services Commissioner All clinical and nonclinical incidents including sentinel events (Sentinel Event Program) and serious transfusion incidents (BeST program) (all services) Category 1 and 2 incidents that occur in stand alone community health services, RDNS and Ballarat DNHC Incidents involving radiation exposure, theft/ loss or damage or radiation source (hospitals only) Allegations of physical and/or sexual assault (residential aged care only) Occupational violence towards nurses (all services) All clinical and nonclinical incidents (all insured services) Notifiable incidents only (legislated) (all services) All complaints (all services) Health Service Incident Data Clinical (patient) incidents OH&S (staff, visitor, contractor) incidents Consumer feedback (including complaints) VHIMS Standardised Data Set and Methodology A complaint may lead to a clinical incident report being lodged and reviewed/ managed (source of an incident record)

10 VHIMS: Health Services requirements Health services (and agencies) had 2 options in considering the BEST model for moving to VHIMS. Health service hosted RiskMan.NET/VHIMS system If an existing RiskMan.NET user, health services received an upgrade with VHIMS integration (cost included in DH contract) Health service will retain their bespoke risk and quality modules that may already exist in RiskMan.NET Central hosted VHIMS.NET system DH hold statewide licence for a central hosted RiskMan.NET system that includes the VHIMS data specification System hosted, maintained and supported centrally (at no cost to the health service or agency) for the term of 5 year contract Accessed via web portal from health service desktop computer Limited local configuration options Provides health service with incident and consumer feedback systems, reporting functionality and some data analysis

11 VHIMS context diagram Health Service s local incident management system Health Service Line Manager Health Service Staff Reports incidents Classifies & approves incident Sends incident data HealthSMART Client Management System (TrackHealth) Patient data DHS VHIMS User Views & manages incidents, reports & notifications Patient data HealthSMART Patient Administration System (ipatientmaster) Notifies / Escalates incidents Manages access & configuration Victorian Health Incident Management System (VHIMS) Creates & schedules operational reports Sends analytical & archival data VHIMS Report Designer Health service sends data Health service sends data Health service sends data Sends analytic reports Data repository VHIMS Administrator VMIA Health Services Commissioner WorkSafe Victoria

12 VHIMS: Overview architecture

13 VHIMS: Is the chosen methodology sound?

14 VHIMS: What will it achieve for Victoria long-term? Better understanding of type, frequency and severity of incidents that are occurring within Victoria health services, via an ability to pool data across the state The ability to use this information to measure the effectiveness of various quality improvement projects that aim to reduce the prevalence of particular incidents The ability to use this information to provide justification for new quality improvement initiatives, targeted toward commonly problematic areas. An opportunity to streamline currently independent systems/reporting requirements thereby removing duplication of effort for health services A reduction in the rate of adverse events, through appropriately targeted quality improvement initiatives Opportunities to allocate resources normally consumed by adverse events toward other areas of patient care where resources are required Better, safer care for recipients of healthcare

15 VHIMS: For more information Additional information on the VHIMS project can be accessed via the DH website link

16 Questions