Lynda Williams MSc (econ) RGN NDN
Meryl Wiltshire BSc RSCN RGN Dip Health Manag
Former Clinical Governance Manager
Moti Patel MBBS DPD
Kurt Burkhardt MBBch MSc MRCGP DRCOG DPD
GP/Clinical Governance Chair
Sarah Bradley BA (hons)
Primary Care Development ManagerRhondda Cynon Taff Local Health Board, Wales, UK
Peggy Edwards RGN MSc Dip Op Pract
Patient Safety Manager (South East Wales), National Patient Safety Agency, Wales UK
*Meryl Wiltshire now works for Pontypridd and Rhondda NHS Trust, Wales UK
Received date: 09 October 2006; Accepted date: 16 January 2007
Since its inception in April 2003, to March 2005, Rhondda Cynon Taff Local Health Board had only received six incident reports from practitioners. This significant under-reporting raised concerns and identified a need to consider how incident reporting could be improved.
Staff from the clinical governance directorate and primary care team at Rhondda Cynon Taff Local Health Board therefore joined forces with the National Patient Safety Agency to participate in the Welsh Assembly Government’s RAID programme (Review, Agree, Implement, Demonstrate) to undertake a project to improve incident reporting across Rhondda Cynon Taff.
The purpose ofthe RAID programme has been to offer practical support to NHS organisations in Wales in their implementation ofclin ical governance. The aim ofthe programme is to lead to sustainable improvements in services to patients by providing an environment for teams to challenge and question current situations and so consider changes for the future. The 18-month programme involves attending five residential workshops which facilitated ‘team time’ to develop and improve their projects. The programme was based upon the Modernisation Agency’s work in England.
The RAID model, the design used for the project, has been described in detail elsewhere,2 but basically involves:
• reviewing the current reality
flagreeing what changes need to be made
• implementing those changes
• demonstrating improvement.
The team named the project IRIS; ‘Incident Reporting Improves Safety’. The aim of the project was ‘to develop a system to encourage primary care contractors to report incidents/near misses and to promote the key message that reporting can improve patient safety’.
The National Patient Safety Agency (NPSA) was set up in 2001 as part ofthe drive to improve the quality of care in the NHS by establishing and managing a national reporting and learning system for adverse events or near misses. Every day, more than a million people are treated safely and successfully within NHSfunded primary care. However, given the diversity and complexity ofthe sector, things will and do go wrong, no matter how dedicated and professional staff are.
Despite Rhondda Cynon Taff Local Health Board being an ‘early adopter’ ofthe NPSA’s National Reporting and Learning System (NRLS) and ensuring that every GP practice had electronic access to the system, reporting levels remained low; little information was shared with the local health board, and consequently lessons could not be shared across the primary care community.
The IRIS team therefore decided that a more effective methodology for involving primary care in reporting and learning from patient safety incidents was required.
The following benefits of the project were envisaged:
• by identifying near misses and minor problems at an early stage, major patient safety incidents would be reduced, thus providing safer and more effective care for patients, carers and their families
• staff would learn from incidents in a supportive environment
• the organisation would improve the quality ofcare by sharing lessons learned across practices in Rhondda Cynon Taff, thus meeting its own core objectives and values, as well as contributing towards national learning.
The key objectives ofthe project were to:
• promote an open and fair culture across the local health board
• raise awareness ofthe need for reporting incidents
• improve the reporting ofpati ent safety incidents
flensure that lessons learnt from patient safety incidents are shared across the local health board area.
The review ofthe current position was multifaceted and is described below.
A limited literature review was undertaken, particularly looking at publications from the NPSA and data already collated in-house from significant event audits. Adverse events in the NHS are thought to cost more than £3 billion oflimited resources every year. The publication, Building a Safer NHS for Patients – implementing an organisation with a memory points out that there are few, if any, quick fixes to this problem, and successful clinical incident reporting and learning from errors and adverse events is the way forward. An extensive literature search was not completed, as expertise from the NPSA formed part of the project team.
Figure 1 highlights the potential correlation between improved incident reporting and the number ofhigh -risk air safety reports over a 10-year period. While some ofthe improvement may be due to other factors, such as technology improvements, the correlation demonstrated is nevertheless felt to be highly significant.
The deployment flow chart (see Figure 2) indicated the existing situation in the process ofincident reporting. It highlights that the process is complex, with many areas where decisions may be made not to report. This complexity is in itselfcon founded by the data collected on the number oforganisa tions involved with reporting incidents ofdi fferent natures.
The team also undertook an Ishikawa analysis (see Figure 3). The main finding was the large number of factors that may contribute to non-reporting to the local health board in all areas ofthe ‘fishbone’. These included issues with regard to people, the environment, and the methods and means ofreporti ng incidents.
Aquestionnaire was developed to assess what might be preventing practices from reporting and what might encourage them to report. A pilot was initially undertaken to ensure face validity. The questionnaire was then sent to all general practitioners (GPs), practice managers and nurses; practices were also asked to distribute the questionnaire to all other staff within their practice. As it was intended to also use focus groups, a second posting was not used. The results are shown in Table 1. Overall, 60 people responded out of a possible total of237; 26 GPs, 12 practice nurses, 16 practice managers and 6 unknown, who were sent questionnaires. Ofthese, 55 indicated that they did report incidents. Even though the return rate for the questionnaire was encouraging, very few respondents answered a majority ofthe questions (hence the low figures outlined).
The common trends that colleagues in the different practices identified as to why they had not reported in the past, or why they had only done so occasionally and what would have encouraged them to do so in the future were as follows:
• to avoid further problems and to eradicate them
fla clear guarantee ofconfiden tiality for all involved
• clear-cut guidelines for reporting.
Specific groups raised other issues. Administration staff wanted better safety policies for staff and the provision ofguid elines and instructions. GPs wanted a simple user-friendly process with clear definitions of the implications ofreporti ng. They also raised the issue ofa learning, positive culture which attached no blame to the incident under review. Protected time for the process ofincid ent review and investigation was another theme that GPs raised. Nurses however identified that the process should be inclusive for the whole team, so reducing the risk ofbad feeling within the practice when incidents were reported. They also highlighted the need to learn as a team, to improve the workplace and work style, and also to learn from others external to the practice.
In general, the main findings were that there was a lack ofknowledg e ofreporti ng incidents in general, and in particular ofw ho such incidents should be reported to. Fewer than five practices reported to the NPSA; all other practices demonstrated poor awareness ofthe NPSA and its process. The local health board itselfwas only likely to become aware of incidents via submission ofthe Quality and Outcomes Framework data.
Focus group visits were undertaken at eight randomly selected practices from each of the Rhondda Cynon Taff Valleys. Some focus group participants had responded to the questionnaire previously discussed.
The findings were similar to the responses to the questionnaire and provided confirmation ofthe responses. However, they also indicated the wide variation in attitude to reporting in practices.
• ‘We do not have incidents to report.’
• ‘Incidents are reported within practice.’
• ‘The practice manager deals with all forms.’
• ‘Not sure who incidents need to be reported to, it all sounds very complicated.’
• ‘Staff discuss incidents in practice meetings.’
A team workshop was held to review the findings and compare the available data. The qualitative responses to the questionnaires and focus groups were noted to be particularly helpful in looking at opportunities to improving incident reporting. These were identified into five main themes:
1 the knowledge ofthe need for and the benefits of incident reporting
2 confusion regarding the process
3 culture within practices
4 barriers to reporting
5 enablers to reporting.
It was agreed that themain requirement was to develop a simpler process, raise awareness and knowledge of incident reporting amongst practices, and share lessons learnt across Rhondda Cynon Taff to promote the value ofincid ent reporting in the long-term.
The themes were used by the team to develop an action plan. The action plan contained specific tasks set within time frames, and nominated individuals responsible for ensuring implementation. The main actions agreed by the team were:
• to develop a simpler system and process for reporting incidents
• to target key individuals who would be influential in ensuring implementation ofa reporting system, e.g. GPs and practice managers
• to produce clinical governance newsletters with regular updates ofexample s oflessons learnt
• to raise awareness during practice development visits and clinical governance visits
• to hold a workshop for all staff to attend in March 2006.
The team held a workshop in March 2006 for all primary care staff to demonstrate the process and outcomes ofthe project, highlighting the importance ofincid ent reporting and the sharing oflessons. Early results have indicated that there had been an increase in the number ofreporte d incidents; 80 by GPs, three from out-of-hours services and 17 from the local trust. There was also a wider range in the type ofincid ents (see Box 1) reported to the local health board; all those submitting reports received individual feedback as well as wider sharing ofthe lessons learnt through the clinical governance newsletter.
There has also been a shift in the culture associated with incident reporting. Whereas the interviews indicated that practitioners would rather have a guarantee ofconfidentiality, now practitioners are openly sharing experiences at continuing professional development events. There is an audit planned for later in the year, where the degree ofcomplianc e will be measured.
The opportunities provided by the RAID process naturally lent themselves to a project-based approach rather than a research study. This could be seen as a limitation to the work outlined above.However, itwas felt by the project team that the approach used allowed a less formal line of communication between the local health board and the practices in Rhondda Cynon Taff. This has led to a demonstrable change in attitude and interaction between the local health board and practices.
By having senior management and team commitment and using a structured process such as RAID, Rhondda Cynon Taff Local Health Board has not only developed the processes for incident reporting, they have changed the culture ofthe patch to actively discuss and share experiences ofincid ents. ‘Incident Reporting Improves Safety’ (IRIS) was the basis of this project. There is now a higher awareness ofsaf ety issues at local health board level, fed by the frontline practitioners. The local health board is now able to offer support and practical solutions to its contractors, which are driven by their own and their patients’ safety needs.
The IRIS team would like to acknowledge the contribution to the project Dr Mike Rejman made during the early part ofthe project.