pssig scoping session

PSSIG Scoping SessionPSSIG Scoping Session

Chris Foye

Information Architect

National Patient Safety Agency, UK

28th September 2004

Chris Foye

Information Architect

National Patient Safety Agency, UK

28th September 2004

OverviewOverview

• San Antonio– Revisit PSSIG’s scope

– Decision tree• Ensure efficient working of PSSIG

– Set priorities

• Aim– Ensure paper is truly representative– Finalise paper

• San Antonio– Revisit PSSIG’s scope

– Decision tree• Ensure efficient working of PSSIG

– Set priorities

• Aim– Ensure paper is truly representative– Finalise paper

IncidentReport?

IncidentInvestigation?

General Specific

GPSRDevelopment

I need my organisation’spatient safety related

information structured in HL7

I have specific requirementsabout a PSSIG message that

need addressing

I want to provideexpertise

I want this non-PSSIGmessage to take into

account patient safety

Is the message past theinitial stages ofdevelopment?

Yes No

Does it align with ourpriorities?

Yes No

Does the message poseany risks in terms of

patient safety?

Yes No

- veballot

Can decision supportmechanisms be intro.

to help PS?

Yes No

Reprioritise Scheduling

YesNo

Out ofscope

Out ofscope


Yes No

Scheduling

Incorporateinto current

activity

TechnicalPatient Safety

/ Domain

Assign torelevant

area

PSSIGinvolvement


activity

GPSR Sub-domain

GPSRDevelopment


Yes No

SchedulingIncorporateinto current

activity

Request Type

Does the informationconform with the definition

of patient safety?

IncidentReport?


General Specific

GPSRDevelopment




need addressing





Yes No


Yes No


patient safety?

Yes No

- veballot


to help PS?

Yes No


YesNo

Out ofscope

Out ofscope


Yes No

Scheduling


activity


/ Domain

Assign torelevant

area

PSSIGinvolvement


activity

GPSR Sub-domain

GPSRDevelopment


Yes No


activity

Request Type


of patient safety?

AgendaAgenda

• Assumptions• Patient safety / patient safety incident definitions• Principles• Vision statement / mission statement• WHO’s International Patient Safety Alliance• Reporting systems• Prioritisation• Decision tree

• Assumptions• Patient safety / patient safety incident definitions• Principles• Vision statement / mission statement• WHO’s International Patient Safety Alliance• Reporting systems• Prioritisation• Decision tree

AssumptionsAssumptions

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

Patient safety & patient safety incident definitions

Patient safety & patient safety incident definitions

Patient safety:Patient safety:

The processes by which an organisation reduces the risk and occurrence of harm to patients as a result of their healthcare

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

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:Patient safety incident:

PrinciplesPrinciples

• 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

Messaging AssumptionsModelling Assumptions

Clinician’sWorkflow

Clinician’sWorkflow Research

Programme

ResearchProgramme

ImplementLessons Learnt

ImplementLessons Learnt Localisation

Localisation Post-IncidentInvestigation

Post-IncidentInvestigation

Single Reporting System

Single Reporting System Patient Safety

Centre

Patient Safety Centre

LeverageInformation

Sources

LeverageInformation

Sources ObservatoryObservatory External

Factors

ExternalFactors

PrinciplesPrinciples

Vision statementVision 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.

Mission statementMission 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

WHO’s International Patient Safety Alliance

WHO’s 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 group’s 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 group’s activities– Disseminate key deliverables for review– Seek guidance – Ensure the needs of the international community are

catered for

Reporting systemsReporting 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

Specialties

Specialties

Infections

Infections

Generic Patient Safety ReportGeneric Patient Safety Report

Transfusions

Transfusions

Medication

Medication

Vaccines

Vaccines

Devices

Devices

Entry pointEntry point

PrioritisationPrioritisation

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

IncidentReport?


GPSRSub-

Domain

GPSRDevelopment




need addressing





Yes No


Yes No


patient safety?

Yes No

- veballot


to help PS?

Yes No


YesNo

Out ofscope

Out ofscope


Yes No

Scheduling


activity


/ Domain

Assign torelevant

area

PSSIGinvolvement


activity

GPSR Sub-domain

GPSRDevelopment


Yes No


activity

Request Type


of patient safety?

IncidentReport?


GPSRSub-

Domain

GPSRDevelopment




need addressing





Yes No


Yes No


patient safety?

Yes No

- veballot


to help PS?

Yes No


YesNo

Out ofscope

Out ofscope


Yes No

Scheduling


activity


/ Domain

Assign torelevant

area

PSSIGinvolvement


activity

GPSR Sub-domain

GPSRDevelopment


Yes No


activity

Request Type


of patient safety?

[email protected]@npsa.nhs.uk

pssig scoping session

Documents

terms of patient safety

definition of patient

patient safetytranslate

range of patient safety

patient safetyfinancial

nonpssig message

incident investigation

incident report