Adverse Events Programme Board Learning from Adverse Events programme

AEPB/17/21

Adverse Events Programme Board

Learning from Adverse Events programme 2017–2020

Introduction

Healthcare Improvement Scotland has worked with key stakeholders and staff to reflect on its strategic direction and priorities and developed a draft strategic plan: Supporting Better Care in Scotland 2017–2020. The draft strategy sets out how we will deliver our

organisation’s core aim of making care better. Robbie Pearson, Chief Executive, describes our organisation’s vision for better health and social care in his May 2017 blog and invited input and views to help shape the strategy. The strategy was published on 24th _{August 2017.}

We have also been taking stock of the direction and priorities of the Learning from Adverse Events programme. At the March 2017 Programme Board meeting we discussed how we can refresh the programme to be an important partner in the developing national

collaborative approach to supporting Openness and Learning in health and social care. We began to consider ways to provide NHSScotland with support to implement the statutory organisational Duty of Candour, which will be implemented on 1 April 2018. To inform discussions at our June 2017 Programme Board meeting we set out how we will continue to build on the success of the programme to date in implementing, improving and quality assuring adverse events management systems. We describe how we will deliver the

programme aims through two work streams and key activities over the next 3 years to 2020.

Work streams

The Learning from Adverse Events programme has developed and supported the

implementation of the national framework for learning from adverse events (second edition of the framework published April 2015). The framework sets a national approach which enhances the safety of care systems in Scotland through supporting the development of an open learning culture learning where adverse events are reported and reviewed, learning is shared and informs continuous improvement. The framework provides: national definitions; guidance on reporting accountability, roles and responsibilities; approaches to sharing learning; and principles for an open, just and positive safety culture. The principles of the framework apply to all healthcare settings. All NHS boards’ adverse event policies are aligned with the national framework.

Building on the success of the programme to date, we will focus on two main work streams:  implementation and improvement support, including supporting the implementation of the

Duty of Candour.

 external quality assurance of adverse events management systems, as part of the Quality of Care Approach.

Implementation and improvement support

The programme has established mechanisms for providing implementation and improvement support, including:

 facilitating adverse events community of practice peer support networks

 providing guidance and tools to support local adverse event management system improvements (Adverse Events Toolkit and Suicide Review Learning and Development)  promoting a consistent approach to being open and communicating well with people

 promoting the sharing of learning points following adverse event reviews through learning summaries, our Community of Practice site, and the publication of a Learning and Improvement report featuring good practice and improvement examples

 disseminating Patient Safety Alerts, and

 facilitating topic specific adverse event national thematic analysis.

We will continue to support good practice through these implementation and improvement mechanisms, as detailed in the programme’s key activities.

Many of the key elements of good practice which the programme supports will be placed on a statutory footing when the new organisational Duty of Candour on health, care and social work services comes into effect on 1 April 2018. The overall purpose of the new duty is to ensure that organisations are open, honest and supportive when there is an unexpected or unintended incident resulting in death or harm. This duty requires organisations to follow a Duty of Candour procedure which will include: notifying the person affected; apologising and offering a meeting to give an account of what happened; reviewing the incident; and offering support to those affected.

The resources available for implementing and improving the management of adverse events will support organisations in carrying out the statutory Duty of Candour. We will:

 map the Duty of Candour procedure against the national framework and promote how existing adverse event management resources can support staff to understand and implement the organisation’s statutory Duty of Candour

 review how the national approach current resources (eg adverse events toolkit) can support the implementation of the Duty of Candour across different healthcare settings eg acute care, health and social care partnerships, primary care

 explore adverse event management governance structures across different healthcare settings to support the implementation of the duty of candour, and

 facilitate short life working groups to progress specific implementation support as required.

A fundamental principle of the Learning from Adverse Events programme is building an open, learning culture. We will continue to work collaboratively with national programmes which promote this principle and lead on creating the conditions for an integrated open learning system for health and social care in Scotland. We will:

 proactively contribute to Scottish Government’s openness and learning unit programme to develop an integrated system of learning.

 visibly align the national programmes for learning from adverse events and the

measuring and monitoring of safety, including testing the Measuring and Monitoring of Safety Framework as: an adverse events review methodology; an approach for adverse events governance reporting; and as a ‘shared language’ across different review

processes.



review where mortality and morbidity reviews and adverse event reviews fit into

organisations’ learning systems in partnership with the Scottish Mortality and Morbidity Programme to demonstrate the practical, mutual benefits of the different review

mechanisms for learning and improvement.



review where the learning from adverse events programme fits into developing national learning systems approaches and actively contribute to aligning priorities and

External quality assurance of adverse event management systems

We visited every patient-facing NHS board during 2012–2014 to review their processes for managing adverse events. The findings informed the development of the national framework for learning from adverse events.

Since 2014, the learning from adverse events programme has focussed on supporting the implementation of the framework to establish a consistent national approach to adverse event management. During this time, mechanisms for providing public assurance have been provided through a series of progress meetings with NHS boards, and engagement with NHS representatives through the community of practice network and short-life working groups.

The Suicide Review and Learning System (SRLS) is an established part of the Learning from Adverse Event programme. It provided external quality assurance of mental health services adverse events reviews of the care given to someone in touch with their service who completes suicide (suicide reviews). We have consulted with our partners and key stakeholders to consider the sustainability of the SRLS programme, assessing how the operational model can be redesigned to be more effective and efficient and focus on

improvements made following reviews. Building on feedback from the March 2017 redesign meeting we continue to work with partners to design and test an efficient, effective and sustainable operation model. The model will continue to be a part of the wider Learning from Adverse Events programme and provide an example of how other services/adverse events topics can be improved through external assurance, implementation and improvement support.

Towards the end of 2016, the Cabinet Secretary for Health and Sport asked Healthcare Improvement Scotland to undertake an independent review of the reporting and review of adverse events within the Maternity Unit at University Hospital Crosshouse, NHS Ayrshire & Arran. Findings from this review are available on the Healthcare Improvement Scotland website.

Scottish Government wrote to NHS boards in March 2017 to clarify expectations that there are assurance processes in place to demonstrate:

 the national framework is followed

 any learning from adverse events is shared, and

 that steps are taken to ensure improvements identified are implemented.

To support NHS boards to be able to provide assurance that the national framework is implemented across its organisation we will develop and test a model of external quality assurance as part of the Quality of Care Approach.

Quality of Care Approach

The new Quality of Care Approach is the way that Healthcare Improvement Scotland will deliver its external quality assurance function. This new approach represents a more robust and consistent methodology for the independent quality assurance of care provision across Scotland with a strong emphasis on outcomes and quality improvement. As well as

identifying local areas of good practice and areas for improvement, the outputs will link organisations as required to the tailored improvement support available through our ihub. The approach is underpinned by a quality framework which will form the basis of all of our external quality assurance activity going forward.

There will be a rolling programme of annual self-assessment against the quality framework at an organisational level. We will test using the annual self-assessment as a mechanism for organisations to demonstrate there are quality adverse event management systems in place. The Quality of Care Approach aims to shift organisational culture to one of local ownership

with routine and regular internal self-assessment against the quality framework to identify deficiencies and drive improvement activity. We will provide risk based external validation of this, including subsequent supportive conversations that will reflect contextual and system factors. This will help to proactively identify areas where organisations have improvement needs and support them to address those in a timely way. We will:

 develop and test external quality assurance mechanisms to support organisations to demonstrate implementation of the national framework for learning from adverse events, as part of the Quality of Care Approach.

 discuss with Scottish Government options to include Duty of Candour external quality assurance as part of the Quality of Care Approach.

 move from analysing completed suicide review reports to providing a risk-based,

proportionate external quality assurance model as part of the Quality of Care Approach, which can be applied across all adverse events.

Following agreement of the approach described in this paper at the June 2017 Programme Board meeting the programme team will update the programme work plan, outcomes chain (Outcome, Planning and Evaluation Framework) and measurement plan. We will promote the programme’s planned short, medium and long term impact with the Community of

Practice and key stakeholders and together deliver the programme aims through agreed key activities.

Appendix 1: Key activities

We will deliver the aims of the Learning from Adverse Events programme through the following key activities.

Patient safety alerts

 Active member of the National Safety Alerts Oversight Group are improving current systems for disseminating safety alerts to support improvements in care.

 Disseminate patient safety alerts generated by NHS England to NHSScotland, providing the Scottish context where appropriate.

 Develop and disseminate a joint MHRA/HIS patient safety alert in a format that this relevant to NHSScotland’s infrastructures and drives the necessary actions for safety and improvement. Take forward in collaboration with MHRA, Scottish Government, Healthcare Improvement Scotland medicines team, Scottish Patient Safety Programme, and the Area Drug and Therapeutics Collaborative.

Design and test thematic analysis: local reporting for national learning

 Produce Safer Systems for the Use of Medicines interim learning report (Appendix 4):

progress on designing and testing an approach to thematically analysing local medicines adverse event data (oxycodone).

 Share and integrate the learning from the thematic analysis into the design and planning of safer systems for the use of medicines and move towards shifting the focus from the absence of harm to the presence of safety.

 Review and revise the thematic analysis model for transferability to other adverse event topics/categories to support the use of local reporting for national learning.

 Apply the revised thematic analysis model to a high frequency/impact adverse events (eg falls/suicides), share learning and resultant improvements.

External quality assurance

 Develop and test the Quality of Care Approach annual self-assessment as a mechanism for providing external assurance that organisations are implementing the national

framework for learning from adverse events.

 Discuss with Scottish Government options to include Duty of Candour external quality assurance as part of the Quality of Care Approach.

 Develop an adverse events thematic self-assessment and supporting validation tools against the quality framework to provide a more detailed assessment of adverse event management systems in response to identified need from shared intelligence. The self-assessment will include specific adverse event management systems measures, quality assurance questions and examples of evidence.

 Identify adverse event management systems best practice and required improvement areas through the Quality of Care Approach to promote excellence and inform the programme’s implementation and improvement support activities.

 Move from the current approach of providing external quality assurance of suicide reviews to testing the adverse events thematic self-assessment and validation tools to identify any deficiencies in suicide review processes and drive improvement activity.

Duty of Candour

 Map the Duty of Candour procedure to the adverse event management processes set out in the national framework and facilitate mapping to organisations’ adverse event management policies and procedures

 Review how the national approach to managing adverse events current resources (adverse events toolkit including resources on Being Open and effective communication, human factors, staff/family/carer support, multi-agency reviews, review process

templates, sharing learning) can support implementation of the Duty of Candour procedure across different healthcare settings, making agreed revisions.

 Explore adverse event management governance structures across different healthcare settings to support the implementation of the Duty of Candour.

 Facilitate short life working groups to progress specific NHSScotland Duty of Candour implementation support, eg a multi-agency group to consider a collaborative approach to consistent reporting of harms and supporting decision making.

 Provide a shared space on the community of practice website for organisations to share implementation approaches and support a consistent NHSScotland approach.

 Progress options to include Duty of Candour external quality assurance as part of the Quality of Care annual self-assessment and review methodology.

Education and training

 Compare the draft adverse events education framework to existing/developing education and training resources (eg SPSO/NES complaints eLearning modules, Duty of Candour eLearning module, healthcare organisations adverse event training packages) to

consider in collaboration with key partners where the framework adds value, identifying any gaps and duplication.

 Finalise the adverse events education framework and consider options for translating into an eLearning module or train the trainer resource to fit with and add value to existing resources.

 Ask healthcare organisations for examples of how adverse event training has improved the quality of review reports to inform education and training options.

 Ask healthcare organisations for examples of how learning from adverse event reviews has informed education and training.

 In partnership with NHS Education for Scotland, propose and develop the preferred education and training option to develop in collaboration with the adverse events community of practice.

Networks and community of practice

 Refresh, maintain and promote two community of practice websites: Adverse Events, and Suicide Reviews. Provide a one-stop online learning and development portal for adverse events management processes and sharing learning on improved outcomes (eg learning summaries).

Adverse events community of practice network:

 Review membership to ensure representation from all relevant health and social care sectors/professions and partner agencies.

 Facilitate two network meetings each year to provide peer support, share knowledge and learning.

 Progress discrete implementation and improvement support work via short life working groups

Suicide review team network:

 Review membership to ensure representation from all relevant health and social care sectors/professions and partner agencies.

 Facilitate two network meetings each year to provide peer support, share knowledge and learning.

 Progress discrete implementation and improvement support work via short life working groups eg test approaches to thematic analysis and external quality assurance.

Small organisations peer support network:

 Review membership to ensure representation from smaller health and social care organisations that would benefit from an operationally focussed peer support network.  Progress discrete, short life implementation and improvement work to support translating

the national framework into practice.

Suicide Reporting and Learning System Redesign

Building on feedback from the March 2017 redesign meeting continue to work with partners to design and test an efficient, effective and sustainable operation model. The model will continue to be a part of the wider Learning from Adverse Events programme and provide an example of how other services/adverse events topics can be improved through external assurance, implementation and improvement support (for further information please see Appendix 2).

While continuing to provide external quality assurance through the wider adverse events management quality assurance model (under development), we will shift our implementation and improvement support focus from supporting the review of suicide reports to reviewing how learning is shared and improvements are made. As of 30 June 2017, the SRLS no longer accepted submitted suicide reports for review.

The Suicide Review Team Network has agreed key implementation and improvement support activities for the SRLS to take forward with the community of practice:

 improving family and carer engagement and valuing their contributions to review, learning and improvements

 observe teams using the Reducing suicide risk: mental health team discussion framework. Refresh the framework and develop cases studies and examples of how the framework is used to reflect on/improve mental health multidisciplinary team practice.

 engaging the suicide review team network in taking forward national improvement from local learning, and providing peer review of suicide review processes on request  testing collaborative approaches to national thematic analysis, eg suicide reviews

thematic framework

 providing tailored support to services either by request or in response to identifying improvement needs through external quality assurance processes

 working to better understand health and social care partnerships’ current suicide review processes and identify any improvement support requirements

 refreshing the Community of Practice website to include a description of local suicide review quality assurance/governance arrangements, mechanisms for sharing local

learning gathered through the quarterly returns, and guidance on both suicide review processes and reducing suicide risk, and

 working with the community of practice and partners to improve the local suicide prevention infrastructure by contributing to the development of consistent suicide reviews (including sharing of information) across the range of services that people at risk of suicide engage with.

Cross cutting programmes

 Test the measuring and monitoring of safety framework as an adverse events review methodology. Invite a healthcare organisation to work with the Measuring and Monitoring of Safety and Adverse Event teams to design, test and share learning from undertaking an adverse events review against the measuring and monitoring of safety framework.  Test the measuring and monitoring of safety framework as a mechanism for reporting

adverse events data to clinical governance committees. Invite a healthcare organisation to test this approach with support from the Measuring and Monitoring of Safety and Adverse Event teams.

 Consider using the Measuring and Monitoring of Safety Framework as a mechanism for providing a shared understanding and language across different review processes.  Review where mortality and morbidity reviews and adverse event reviews fit into

organisations’ learning systems. With the Scottish Mortality and Morbidity Programme team, meet with NHS boards taking forward mortality and morbidity review improvements to inform adverse events improvement support.

 Contribute to the development and delivery of Scottish Government’s Openness and Learning Unit programme.

 Work with Scottish Health Council to align Learning from Adverse Events aims with Listening and Learning: Feedback, Comments and Concerns.

 Work with Healthcare Improvement Scotland’s ihub to contribute to the development of national learning systems approaches, aligning priorities and deliverables.

Appendix 2: Suicide review team network update

Background

The Suicide Reporting and Learning System (SRLS) is an established programme which supports mental health services to improve adverse event reviews of the care and treatment provided to someone in touch with its service who completes suicide (suicide reviews). When a suicide takes place, NHS boards need to understand what happened and learn from any lessons identified. The lessons learnt are important to improve services and help staff recognise where risk exists. Suicide reviews are the way that services, analyse what

happened and recognise where anything can be done to make things safer for other people at risk. Mental health services carry out these reviews under their NHS board’s adverse event policy, and the SRLS forms part of our wider learning from adverse events

programme. The team are currently reviewing the SRLS programme and redesigning the operational model to be more effective and efficient.

Current position

The SRLS quality assures all suicide reviews of individuals who have been in contact with mental health services in the last 12 months of their life. The SRLS assists NHS boards to improve the way that suicide reviews are carried out and to help to reduce risk by improving the effectiveness of suicide reviews; publishing guidance and improvement tools; sharing lessons learnt nationally; promoting the sharing of experiences and peer support among mental health services; and ensuring the Mental Welfare Commission has been notified of relevant cases where further investigation may be required.

We analyse review reports to provide feedback on the effectiveness of the review process and aggregates mental health services national learning themes to drive improvement. Learning themes are currently shared through the Community of Practice website and through a 6-monthly briefing paper which makes recommendations for action on current service improvement issues.

An SRLS clinical advisor analyses suicide reviews and liaises with NHS boards regarding the quality of the review process. The previous clinical advisor (Jamie Malcolm) retired from post in April 2017. Arrangements have been made for a clinical advisor to back-fill this post until end of August 2017.

SRLS redesign meeting (29 March 2017)

In light of potential changes, we aim to look at methods of continuing to provide assurance that NHS boards have systems for assuring the quality of suicide reviews and translating the learning identified into improvements. The redesign meeting provided colleagues with the opportunity to discuss the future direction of the programme and contribute to the

programme redesign. The meeting was attended by the SRLS team, health and social care partners and colleagues from the Scottish Government. Discussions included:

 experience to date (current position) and suggestions for future direction  overview of learning outcomes and what these inform

 findings from testing the quality assurance questions  potential benefits of national qualitative analysis, and

 where the SRLS could add most value to organisational and national learning systems. As part of an interactive workshop session, colleagues were asked to consider specific questions, based on their own knowledge and experience of services, and provide their thoughts for moving forward. Below are some examples of the responses received from colleagues during the redesign meeting.

What currently works?

 Credibility of briefing papers for clinicians.

 Creditability of Healthcare Improvement Scotland – useful and helpful – need more.  Support NHS boards to provide their own assurance on reviews.

 Assist with having less variation in quality of the process.

 Seeking details of clinical and care leads who might want coaching, support to improve leadership changes.

 Cross agency communication – feel that information is easily shared when it’s a mental health suicide but not so much with the other 69% of suicides.

 Support improvement – quality of actions derived from reviews (best practice).

 Smaller NHS boards found the quality assurance questions helpful (What we are looking for in your reports).

What doesn’t work?

 Learning missed from near misses.

 More standardised approach of when not to review a suicide.

 Liked when NHS boards were being chased by Mental Welfare Commission (for example). External assurance meant senior management would get things done.

 Using view that ‘it is too difficult’ to carry out reviews of other deaths (the other 69% that are not in contact with mental health services).

What are your improvement support needs?

 Consider assurance assessment processes for the wider adverse events.

 Require protected time for staff to carry out reviews as not part of their clinical role.  SRLS to be a central repository for learning summaries and other useful tools.  More information on when to review/not to review – be more consistent nationally.  Healthcare Improvement Scotland visits to NHS boards regarding SRLS standardisation

would enable consistency of approach.

 Target key information/communication directly to chief officers as well as NHS boards’ chief executives.

 Need national training about doing reviews (reporting writing training as well as carrying out reviews).

 Evidence based actions that lead to improvements and support for clinical leadership and governance committees.

 A lot of training for other fields, such as theatre nurses, but not a lot specific to mental health services.

As the redesign meeting came to a close, there was limited time to discuss where we can add most value. As such, this question was circulated to those who attended the redesign meeting and members of the network for further comment. Below are some examples of the responses received from colleagues:

 Can help manage the different relationships between health and social care partnerships – different review processes and cultures.

 Provide data of the quality of reviews.

 Provide assurance versus sharing the learning – can the SRLS be the ‘policing arm’ and the learning/improvement support?

 Provide support on how mental health services source feedback from family members in order to improve (were families contacted at the right time, were they offered to meet in a location of their choice, was the report sufficient, etc).

 Sampling whole process rather than reports themselves. Internal assurance and SRLS can sample. Bundle approaches for quality assurance.

 Can SRLS do both, ask the hard questions of mental health services and review quality of reports?

 (NHS Grampian) – The SRLS has been highly influential in shaping a learning culture from reviews and stressing the importance and value of family involvement. The main challenge going forward will be being able to continue to support and develop this culture of learning in an ever integrated world in which other national bodies have an obviously different approach to suicide and other significant adverse events.

 (NHS Greater Glasgow and Clyde) – Don’t get a sense that there is a shared knowledge across Scotland of what good systems and good reports look like. What about collective learning sessions on a regular basis; hosted by individual boards, in rotation, to keep costs down.

 (NHS Greater Glasgow and Clyde) – Appreciate the ‘human, thoughtful’ nature of SRLS reports and recommendations; sense of real people thinking about practical problems, rather than experts or monitors telling others what to do from a distance.

Actions following the redesign meeting

The feedback provided by colleagues, and wider discussions with stakeholders and

partners, have informed the redesign of the SRLS model. The model will continue to be part of the wider Learning from Adverse Events programme and will provide an example of how other services/topics can be improved through external assurance, implementation and improvement support.

As of 30 June 2017, the redesign will focus on improving efficiency, effectiveness and sustainability by integrating the current operating model with the quality of care approach. The quality of care approach is currently being tested as the new way that Healthcare Improvement Scotland will deliver all its external quality assurance functions. The SRLS model will move from analysing completed suicide review reports to providing a risk-based, proportionate external quality assurance approach which can be applied across all adverse events. Suicide review team network members will be invited to work with us to design and test the suicide reviews external quality assurance model. To inform initial discussions at the network meeting on 29 May 2017, an introduction to the Quality of Care Approach will be included.

Moving forward, we will continue to provide implementation and improvement support to NHS boards. Below are a number of SRLS key priorities for consideration by the Network.

Suicide review development session

During discussions at the last suicide review team network meeting, it was decided that a development session would be useful to share current practice in undertaking suicide

reviews and taking forward recommended improvements. The session is proposed for chairs of suicide review teams and chairs of groups which quality assure suicide reviews to share and learn from each other. This will include discussions on chairing a suicide review, quality assuring a review, making improvements following a review, implementing suicide reviews in integrated services and supporting continued improvements in reviewing and learning from completed suicides. This session will be taking place on 27 June 2017.

Facilitating family and carer feedback

The SRLS has recently sought the views of mental health services on the most effective way of engaging family members and carers in the suicide review process. While there is some

variation of approach, there are common themes in how this is done. However, there is very limited information about the experiences and opinions of families who have had some form of involvement in suicide reviews. The Mental Health Foundation were commissioned to seek the views of family members and carers as a means to better understand the

experience and perspectives of families to support improvements in review processes. This information is essential in developing good practice and training for professional staff. The findings, although to date form a very small sample, highlight the need to provide families and carers an opportunity to give an account of their experience.

The findings also reiterate the need to use the learning gained from families and carers to improve the practice of suicide reviews. With this in mind we are working on a proposal to work with mental health services to offer family members and carers who are currently involved in suicide reviews, and those who become involved, the opportunity to participate in an interview with an independent researcher at an agreed stage of the review process. It is anticipated that this approach may result in building a representative sample of the range of experiences which can be used to inform learning and improvement.

Community of Practice website

The purpose of the Community of Practice (CoP) website is to provide mental health services staff with a shared space where they can find guidance on the process of suicide reviews. This includes what is needed when deciding whether or not to hold a suicide review to ensuring effective recommendations have been created to drive service improvement. The CoP contains vital resource information, training tools and guidance information for those carrying out suicide reviews. This resource will be updated to reflect the new model and will continue to be updated with relevant information to support mental health services.

Suicide review team network

The suicide review team network was set up with a view to building a ‘community of practice’ in order to share knowledge across organisational boundaries and facilitate and enable of experiences, lessons, challenges and solutions. This is achieved by providing support, advice and guidance for suicide review teams, providing a forum for exchange of ideas and best practice and furthering the dissemination and implementation of evidence and best practice. The network will continue to meet twice a year and contribute to the design and delivery of the SRLS programme.

Reducing suicide risk: mental health discussion framework

The Reducing suicide risk: mental health team discussion framework was published by SRLS in 2015. The purpose of the framework is to help mental health multidisciplinary teams and managers develop a habit of coming together to think about risk and how to reduce it in the work that they do. The framework was designed to promote, and provide structure to, discussion between members of multidisciplinary teams, to make sure there is a common understanding of knowledge, practice and attitudes towards the way that individual patient care is organised and managed. Going forward, SRLS will arrange for review teams to observe these multidisciplinary team meetings using the discussion framework. This will inform a refresh of the framework and the development of case studies/examples of how the framework is being used to reflect on/improve mental health multidisciplinary team practice.

Test collaborative approached to national thematic analysis

The SRLS provides national thematic analysis through 6-monthly briefing papersand more recently a qualitative analysis report. The qualitative analysis report includes a suggested suicide reviews thematic analysis framework. Initial discussions at the SRLS redesign meeting began to consider how services could use the suicide reviews thematic analysis framework and if it could add value to local qualitative analysis. We will invite the suicide review network to work with us to continue to share and develop approaches to thematic

include testing an approach which is currently being designed and tested to thematically analyse local medicines adverse event data.

Health and social care partnership suicide reviews

In our June 2016 briefing paper, we focussed on the challenges and opportunities of suicide reviews in integrated services. At the SRLS redesign meeting, this was raised as an area where continued support would be welcome. Two mental health services have invited us to visit with them to better understand current suicide review practices within health and social care partnership and to discuss improvement support requirements. We will use the suicide review development session to explore this further and will invite the suicide review team network to work with us to define and design implementation and improvement support.

Providing tailored support to services

The SRLS provides tailored implementation and improvement support to services. We will continue to work with services either by request or in response to identifying improvement needs through external quality assurance processes. The Quality of Care external quality assurance approach has a strong emphasis on outcomes and quality improvement. Testing this approach to quality assure suicide reviews will support mental health services explore how suicide reviews improve the quality of care and promote a culture of continuous learning and improvement.

Appendix 3: Our approach to external quality assurance

The quality assurance directorate leads on providing assurance to the public about the quality of care. We do this by undertaking independent inspections and reviews of services across Scotland and reporting what we find.

From 2017, our new quality of care approach will be how we will deliver our external quality assurance function. This new approach represents a more robust and consistent

methodology for the independent quality assurance of care provision across Scotland with a strong emphasis on outcomes and quality improvement.

As well as identifying local areas of good practice and areas for improvement, the outputs of our assurance work will link organisations as required to the tailored improvement support available through our improvement hub (ihub). The outputs may also stimulate other work such as national improvement programmes or development of standards and/or guidance. The approach is underpinned by a Quality Framework which will form the basis of all of our external quality assurance activity going forward.

The new approach makes better use of available data and intelligence to allow us to focus our activity in a more risk-based way, including collecting data once and using it many times to help reduce the burden of assurance activity on services. The quality of care approach aims to shift organisational culture to one of local ownership with routine and regular internal self-assessment against the quality framework to identify deficiencies and drive improvement activity. We will provide risk based external validation of this.

Care providers will undertake a rolling programme of annual self-assessment against the quality framework at an organisational level. This will be supplemented with subsequent supportive conversations with Healthcare Improvement Scotland that will reflect contextual and system factors. This will help to proactively identify ‘amber flags’ and areas where organisations have improvement needs and support them to address those in a timely way.

Figure 1 below shows how the range of our quality assurance activity fits within the quality

Figure 1: Quality of care approach

Designing and testing the assessment approach

Options for the methodology for quality of care reviews have been considered and different tools are being tested to determine how they can be used depending on the scale of reviews. There will be a rolling programme of annual self-assessment against the quality framework at an organisational level. The annual self-assessment will require organisations to demonstrate that there are systems in place to report, review and learn from adverse events.

 In addition to the rolling programme against the annual self-assessment, we are testing a thematic self-assessment (in CAMHS) and point of care self-assessment (HAI). In

collaboration with the adverse events community of practice, we will develop a thematic self assessment to assess the quality of adverse event management systems. The aim is to enable organisations to provide a more detailed assessment of adverse event management systems against the quality framework.

 We will work with the suicide review team network to test the adverse event

self-assessment as a means of identifying good practice and any deficiencies in suicide review processes to drive improvement activity. We will design and test approaches to validating the self-assessment findings (eg sampling complete sets of review

documentation/speaking with staff, patients, families and carers) and using the information to share learning nationally.

Appendix 4: Learning from adverse events – safer systems for the

use of medicines

Background

The aim of this project was to:

 test collection and sharing of existing local data relating to adverse events involving medicines at a national level starting with one high risk medicine, oxycodone  design and test an approach to thematically analyse this data nationally

 integrate the learning from the thematic analysis into the design and planning of safer systems for the use of medicines and move towards shifting the focus from the absence of harm to the presence of safety, and

 develop next steps for the work after the test of change.

Learning from initial analysis

We have tested the collection and sharing of existing local data relating to oxycodone at a national level. All 14 NHS boards provided us with data on all adverse events involving oxycodone between 1 January 2015 and 30 June 2016 as well as improvement work relating to oxycodone undertaken within the last 18 months.

The project has demonstrated that collection and analysis of local data at a national level is possible and has provided a richer data source to drive improvement in the safe use of oxycodone across Scotland. It has shown that there is value for collating and sharing this information for national learning and while there are differences in the way NHS boards code and categorise the information requested, this did not create a barrier to aggregating and analysing the data. However to optimise future and deeper analysis and learning, the

differences in the way data is collected and coded in health boards would benefit from being addressed.

A key finding from the improvement work carried out by NHS boards is that nine out of the fourteen territorial NHS boards have switched to only prescribing one brand for immediate release (Shortec®) and modified release (Longtec®) forms of oxycodone. This was done with the aim of reducing the number of adverse events involving confusion between immediate release and modified release forms of oxycodone.

An initial, high level, analysis of the data, within the subcategories of process, specialty, patient outcome and severity was carried out. Within the acute settings, the process with most incidences was administration. Surgery was the specialty with the highest rate of adverse events followed by care of older people/elderly medicine and then orthopaedics. The majority of incidents resulted in no harm to the patient; however, there were some incidences that resulted in harm.

We received primary care data from eight boards, from a range of sources, including, community pharmacy, GP practice, and community nursing. Although this was a small data set, it identified that the process with the most incidences in primary care was dispensing, followed by administration. The majority of incidents resulted in no harm to the patient; however, there were some incidences that resulted in harm.

Adverse events involving controlled drugs need to be reported to regulators, so we were also able to gather care home and independent healthcare data from the Care Inspectorate and Healthcare Improvement Scotland as regulators for these services. Within the care home data, administration had the highest rate of incidents, which was also the case with the independent healthcare data. Both data sets were analysed further, where it was identified that the highest type of administration error was an omitted dose, followed by wrong drug for care home data and wrong dose for independent healthcare.

Next steps

We will conduct further analysis on the stage in the process that the error occurred, with particular focus on administration errors, for example looking at:

 administration of a wrong or incorrect drug (for example errors with confusion between oxycodone and morphine)

 rates of omitted dose

 wrong dose (for example over and under)  wrong formulation

Breaking these points down further could allow an increase in the potential for learning. Please contact [email protected] for further information.