Research to Reform: Achieving Health System Change (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 14, 2009, Martin J. Hatlie made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (246 KB) (Plugin Software Help).


Slide 1

Slide 1. Research to Reform: Achieving Health System Change

AHRQ 2009 Annual Conference
Research to Reform: Achieving Health System Change
Bethesda, MD, September 14, 2009

Learning From the Patient's Experience: Opportunities to Improve Patient Safety
International Initiatives on Patient & Public Reporting of Adverse Events

Martin J. Hatlie, JD
President, Partnership for Patient Safety
Co-Founder, Consumers Advancing Patient Safety
CEO, Coalition for Quality & Patient Safety of Chicagoland.

Slide 2

Slide 2. Goal today is to share ideas about:

Goal today is to share ideas about:

  • Better understanding of risks of injury in healthcare that consumers see but providers/policymakers/ public health officials may not know.
  • How to encourage patient reporting.
  • Better understanding about ways consumers contribute to error, prevention, rescue & mitigation.
  • Advancing the transformation in attitude and culture toward systems-based safety/quality work.

Slide 3

Slide 3. International Classification for Patient Safety (ICPS)

International Classification for Patient Safety (ICPS)

  • 25% of things that go wrong are easy to understand.
  • 75% are infrequent and difficult to measure.
  • Hence, reporting events and deconstructing what happened is essential to understanding risk.

A pie graph showing 75%.

Slide 4

Slide 4. Patient/Public Roles re: Better Understanding Risk

Patient/Public Roles re Better Understanding Risk

Patients and their lay caregivers see things across the continuum of care.

    • Things caused by hospital care that do not manifest until later.
    • Things that "fall between the cracks" across transitions in care.
    • Things that multi-tasking healthcare workers just miss.
    • Things that are risky, but have become normalized.

Slide 5

Slide 5. Patient/Public Roles re: Better Understanding Risk

Patient/Public Roles re Better Understanding Risk

Perhaps in contrast to providers, patients appear to be very willing to report:

    • Patients and families who have experienced medical error have a high desire to see remedial actions (Vincent, Gallagher, Hickson, many more).
    • Patients frequently report when given a pathway to do so (Agoritsas & Perneger, Wasson).
      • 94% of patients answered safety questions; 51% reported one or more undesirable events.
    • 2009 focus groups done in UK and USA.

Slide 6

Slide 6. Patient/Public Roles re: Better Understanding Risk

Patient/Public Roles re Better Understanding Risk

Consumers (including patients and caregivers) have a unique expertise in relation to their own health and their perspective on how care is actually provided. Consumer complaints are therefore a unique source of information for health care services on how or why adverse events occur and how to prevent them. As well as reducing harm to patients, better management of complaints should restore trust and reduce risk of litigation, through open communication and a commitment to learn from the problem and prevent its recurrence.

Better Practice Guidelines on Complaints Management for Health Care Services (2004)
Australian Council on Safety & Quality of Health Care.

Slide 7

Slide 7. Research/Experience re: Impact of Patient Reporting

Research/Experience re Impact of Patient Reporting

Patient/Consumer reporting not well understood.

    • Most patient engagement activities are poorly tested, implemented & measured (Entwistle).
    • No human factors evidence to support patient action making things systemically safer (Lyons).
    • No highly successful patient reporting programs in healthcare to date.

Slide 8

Slide 8. Two Current Research Projects

Two Current Research Projects

  • National Patient Safety Agency (NPSA)
    • Evaluation of United Kingdom's (UK) patient & public reporting component of the National Reporting and Learning System (NRLS).
    • Project recognizes that patients are not reporting frequently and are not aware of the UK's reporting system.
    • Seven focus groups, Seven stakeholder interviews.
    • Will be completed in 2009.
  • Agency for Healthcare Research and Quality (AHRQ)
    • Project recognizes that consumers are an important source of information about health system safety.
    • Will be completed in 2010.

Slide 9

Slide 9. NPSA Patient and Public Reporting Notable Characteristics

NPSA Patient & Public Reporting Notable Characteristics

  • Implemented in 2005.
  • Meant to be used by:
    • Patient.
    • Relative, partner, friend or caregiver.
    • Someone else.
  • Never heavily promoted.
  • Has lost its own name (= Patient & Public Reporting).
  • Distinguishes reports from complaints
    • No investigation of reports.
    • Reports for learning purposes only.
  • No fields for capturing the names of the reporter or the providers involved.
  • Results of patient reports not integrated into quarterly NRLS reports.
  • Rarely used.

Slide 10

Slide 10. NPSA Patient and Public Reporting Notable Characteristics

NPSA Patient & Public Reporting Notable Characteristics

FAQ 2: Why can't the NPSA investigate my case?

We don't have official powers to investigate individual cases or deal with complaints about the NHS organization that provides your care. But there are other organizations that can help if you have a complaint or would like to request an investigation. See Q3 below.

We don't keep information identifying individuals because we want to help the NHS learn from its mistakes by looking at why things have gone wrong, rather than trying to blame or punish individuals. We don't keep the names of either patients or healthcare staff.

We hope this anonymity will encourage everyone to tell us when things go wrong.

Slide 11

Slide 11. NPSA Research Questions

NPSA Research Questions

  1. Evaluate public perception, satisfaction, and level of awareness of NPSA's patient and public reporting system to date.
  2. Understand who reports patient safety incidents and how and why patients want to report their incidents.
  3. Determine patient expectations and needs when reporting patient safety incidents.
  4. Determine why the NPSA has received a lower than expected volume of patient safety incidents from the public and patients. Identify barriers to reporting.
  5. Provide recommendations on what the NPSA should do to increase reporting, reduce barriers for patients and the public to report, and manage expectations of patients and the public.

Slide 12

Slide 12. 1. Evaluate public perception, satisfaction, and level of awareness

1. Evaluate public perception, satisfaction, and level of awareness

  • 90% of the participants not aware of patient and public reporting system.
  • One or two in each focus group panel were not aware that NPSA existed.
  • Among those that know of the NPSA, low satisfaction level with regards to NPSA being helpful to patients.
  • High perception that patient data is considered second rate by NPSA.
  • Frequent comments reflecting deep distrust in government systems and fear that any entity dedicated to the patient will eventually "get done away with."
  • Many knew or knew of Peter Mansell. Frequent perception that Mansell welcomed patients and listened to their stories, and that he is now gone.

Slide 13

Slide 13. 2. Understand who reports and how and why patients want to report

2. Understand who reports and how and why patients want to report

  • Potential reporters = patients, family, friends, solicitors, advocates, organization leaders, community leaders, and healthcare workers.
  • Unanimous desire to see reports used to avoid repeat error.
  • Significant confusion about where to report a patient safety event; current "maze" of reporting avenues = "chaos."
  • Should be multimodal mechanisms for patient reporting - walk-ins, phone (most cited), email, website, letter.
  • Anonymous reporting should be optional only; patients want to use their name and want feedback and ongoing contact.
  • Assurance that reports are confidential should be an option.
  • There is strong opinion that patients should name the trust or consultant in their reports. If not, how can follow-up on patient reports happen, trends of unsafe care in trusts be identified, or change occur?

Slide 14

Slide 14. 3. Determine patient expectations and needs when reporting

3. Determine patient expectations and needs when reporting

  • Unanimous: Acknowledgement of receipt of report with some feedback indicating action on the report is essential.
  • Specific expectations included:
    • Explanation and recognition on behalf of trust (provider) of responsibility.
    • Accountability.
    • Evidence of action/change such as changes in policies or protocols.
    • Use of reports in future planning.
    • Apology.
    • Reporting to/acknowledgment by a human being.
    • Reporting system to provide or lead to access of a mechanism for investigation of incidents.
  • Some participants also expect publicity about reports.

Slide 15

Slide 15. 4. Determine why lower than expected volume of reports and identify barriers

4. Determine why lower than expected volume of reports and identify barriers

  • 90% of the participants not aware. (Question 1).
  • Perception that information will go into a "black hole."
  • Reporting system provides no feedback.
  • Web page hard to navigate and patient reporting info hard to find.
  • Language not motivating: Says NPSA will listen, but not engage.
  • "Too much anonymity."
  • E-form produces perception that NPSA is a data collection agency only interested in statistics.
  • E-form takes too long.
  • E-form lacks questions about how event impacted patient's life.
  • E-form does not include space to suggest solutions.
  • Belief that the e-form could be improved with more patient input.

Slide 16

Slide 16. 4. Determine why lower than expected volume of reports and identify barriers (cont.)

4. Determine why lower than expected volume of reports and identify barriers (cont.)

  • Fear that care will be compromised and that those who report will be "black listed" or branded a "trouble maker".
    • Three research participants used pseudonyms in the project.
  • Belief that patients who report are not taken seriously.
  • Some did not perceive NPSA's inability to investigate as a barrier, but would want NPSA to advise where to file complaint (which it does).
  • Some patients are too emotionally affected or too harmed by their experiences to go through process of reporting.
  • Dismay and cynicism about sustainability and the high rate of turnover of structures for patients to report/complain/call for investigation.

Slide 17

Slide 17. 5. Make recommendations on what the NPSA should do to increase reporting, lower barriers and manage expectations

5. Make recommendations on what the NPSA should do to increase reporting, lower barriers & manage expectations

Recommendations will address:

    • General issues.
    • Operations.
    • Outreach.
    • Publicity.

Slide 18

Slide 18. ICPS: Understanding Patient Roles in Contributing/Rescue/Mitigation

ICPS → Understanding Patient Roles in Contributing/Rescue/Mitigation

  • ICPS framework will advance understanding of patient actions or omissions as:
    • Contributing factors.
    • Mitigating factors.
    • Ameliorating actions.

Diagram of the Conceptual Framework for the International Classification for Patient Safety.

Slide 19

Slide 19. ICPS: Better Understanding Impact of Adverse Events on Patients/Families

ICPS → Better Understanding Impact of Adverse Events on Patients/Families

ICPS classification framework will advance patient outcomes research:

    • Physical injuries.
    • Mental/behavioral outcomes.
    • Extent of disability.

Diagram of the patient outcomes:

Patient Outcomes

    • Type of Harm
      • Pathophysiology
        • Certain Infectious & Parasitic Diseases.
        • Neoplasms.
        • Diseases of the Blood & Blood Forming Organs/Disorders Involving Immune Mechanisms.
        • Endocrine, Nutritional & Metabolic Diseases.
        • Diseases of the Nervous System.
        • Diseases of the Eye & Adnexa.
        • Diseases of the Ear & Mastoid Process.
        • Diseases of the Circulatory System.
        • Diseases of the Respiratory System.
        • Diseases of the Digestive System.
        • Diseases of the Skin & Subcutaneous Tissue.
        • Diseases of the Musculoskeletal System & Connective Tissue.
        • Diseases of the Genitourinary System.
        • Pregnancy, Childbirth & Puerperium/Conditions Originating in the Perinatal Period.
        • Congenital Malformations, Deformations & Chromosomal Abnormalities.
        • Symptoms, Signs & Abnormal Clinical/Laboratory Findings Not Elsewhere Classified.
        • Mental & Behavioral Disorders.
        • Other Psychological Patient Outcomes Not Elsewhere Classified.
      • Injury
      • Other
    • Degree of Harm
      • None
      • Mild
      • Moderate
      • Severe
      • Death

Slide 20

Slide 20. Research about Patient Roles

Research about Patient Roles

Consumer Reporting Research Questions:

    • Do patients who report contribute to changed practice standards or better outcomes?
    • What is impact of patient reporting on litigation frequency or amount of compensation?
    • Do consumers have different reporting needs?
      • Phone intake? Narrative format?
    • Do consumers need feedback to sustain participation in reporting?

Slide 21

Slide 21. Impact of Patient Reporting Attitude and Culture Change

Impact of Patient Reporting Attitude & Culture Change

  • Providers currently reluctant to discuss inherent, emergent risks of healthcare with patients.
  • Patient reporting has potential to advance shared mental model about continuous challenges of managing complex risk.
  • Maybe: Patient engagement as reporters of adverse events creates trust?

Slide 22

Slide 22. The Power of Partnership: A Lesson from Aviation

The Power of Partnership: A Lesson from Aviation

"One reason that an incident reporting system worked in aviation...was that the entire aviation community -- essentially all of the stakeholders, including air passengers — were involved in the process from the beginning and became advocates for the reporting system (as well as severe, but constructive, critics)."

...Charles E. Billings, MD, Developer of the Aviation Safety Reporting System, Editorial Arch Pathol Lab Med 1998, 121:214-215

Slide 23

Slide 23. Patient Reporting of Adverse Events = an Issue at Every World Health Organization Patients for Patient Safety Workshop

Patient Reporting of Adverse Events = an Issue at Every World Health Organization Patients for Patient Safety Workshop

Images of 9 photographs of workshop groups.

Current as of December 2009
Internet Citation: Research to Reform: Achieving Health System Change (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/hatlie/index.html