16 May Eva: A change is gonna come to serious incident investigation practices
Verita, one of the founding companies of Eva, has carried out hundreds of investigations in healthcare over the last 17 years. From Leeds paediatric cardiac surgery to Myles Bradbury to the death of Elizabeth Rourke at Jersey General Hospital. We have also undertaken numerous serious incident investigations or supported healthcare organisations to carry out their own. These have addressed incidents in hospitals, the community and specialist mental health services, as well as independent hospitals and the NHS.
When bad things happen
Patient safety incident investigations started in earnest in the early 2000s, prompted in part by the learnings from adverse events report by an expert body chaired by Sir Liam Donaldson, the government’s then chief medical officer. An Organisation with a Memory set out to understand what was known about the scale and nature of serious failures in the NHS, examine how the NHS might learn from those failures, and recommend methods to minimise future failures. The report gave rise to the National Patient Safety Agency (NPSA) and the emergence of investigating.
The NPSA provided the framework and approach to investigating in its promotion of root cause analysis. They also provided training for the task. The requirement to investigate and learn lessons is now a regulatory expectation. To improve patient safety and service delivery we first need to understand the facts when something goes wrong – hence the need for a quality investigation. CQC routinely inspects healthcare organisations for their ability to carry out this important function and to learn and improve. The regulator is quick to comment if it finds the organisation is deficient.
Not bad but could be better
In recent years many healthcare organisations have found themselves with little or no external support for investigations. Some have done extremely well, as is evidenced in CQC inspection reports. Others have found it much more challenging.
CQC’s assessment of an organisation’s investigative capabilities forms part of the ‘Are they safe?’ category.
The table below shows CQC’s scoring of 10 trusts across five inspection areas. Patient safety is included in the ‘Are they safe?’ category. None of the 10 trusts scored outstanding, with 70 per cent scoring inadequate or requires improvement. For these 10 trusts, the ‘Are they safe?’ category is the worst of their scores across the five inspection areas. Only 30 per cent were meeting the expectations of the regulator.
CQC believes that the likely explanation for this performance is the prevailing culture of the organisation or lack of training. They say one of the 10 “had not always managed patient safety incidents well. This was because serious incidents had not always been reported and investigated in line with the NHS England Serious Incident Framework” (CQC, Wirral University Teaching Hospital at NHS Foundation Trust: Inspection Report, 2018). In multi-site organisations, CQC found that the strength of the incident reporting culture differed between sites, particularly where there was no overall framework guiding practice. Patient safety remains a significant challenge for these organisations. We think that Eva would help trusts like these to strengthen the quality of their investigating and thereby contribute to the improvement of their ‘Are they safe?’ score.
CQC Scoring Across 10 Healthcare Trusts
Average Score of Trusts within each CQC Evaluation Category
Outstanding = 14%
Good = 44%
Requires Improvement = 38%
Inadequate = 4%
Don’t just stand there, help me
In 2016 over a thousand NHS staff went through Verita’s CPD-accredited systematic incident investigation programme. The Verita training team has gathered telling insights during the delivery of this programme including about the difficulties that frontline staff encounter in the investigation process. Typical feedback from frontline healthcare staff is:
‘I can’t find anyone to help me with the investigation’
‘I don’t understand the investigative process
‘I have forgotten what I learnt in my investigation training’
‘I haven’t had any training’
‘I don’t get down to the real reasons as to why something has gone wrong’
‘I am not sure where to store my evidence’
‘Someone higher up the organisation changes what I have written in the report and I don’t know who’
‘I find it hard to deal with families or patients who are so upset’
Not surprisingly, many frontline staff find investigating a major challenge. Their responses above reflect this. The saying goes that ‘a workman should never blame his tools’. However, we can make an exception when it comes to investigating patient safety incidents. The truth is that the tools for this task remain poor and unsophisticated – some training and a Word template if you are lucky.
In our experience many organisations find the practical demands of investigating burdensome. It can be complex, difficult work and for most investigators it comes on top of the day job. And the requirements of investigating have increased. Caring for distressed families; dealing with media interest; making an appearance in the coroner’s court. Satisfying the executive team and the CCG is probably the least of an investigator’s worries. Little wonder some trusts now say they struggle to recruit people to investigate.
If we set these practical difficulties against the scale of the investigative challenges facing healthcare today, the need for a different approach becomes obvious. Here are some striking figures:
- 1.9 million incidents reported to the National Reporting & Learning System in 2016/17
- NHS Resolution paid out £1.6 billion for 17,000 legal claims – the latest bill was £2 billion (trusts pay £2.4 billion in premiums)
- 65,000 incidents qualified for investigation
- A large multi-site trust can expect to conduct 250 investigations each year
In 2019 most healthcare organisations invest significant effort investigating patient safety incidents. It has become an industry. But there is no standardised approach and therefore no way of easily aggregating data and extracting useful insights about safety and care. The opportunity to improve is therefore compromised.
A change is gonna come
Around 12 months ago at Verita we concluded that we needed to find a new way of supporting healthcare organisations to investigate. This was borne out of our experience training frontline staff and the rapidly changing requirements of our healthcare clients. These have included:
- Trusts turning to us for our independent expertise when families had lost confidence in the findings of an internal investigation
- Support to organisations facing serious incident backlogs
- Quality-assuring serious incident reports for trusts
- Consultancy to organisations facing criticism from CQC – for example, for failing to investigate thoroughly and learn from incidents
- Feedback from patients, families and lawyers (particularly those on the NHS Resolution panel) that some internal investigations are inadequate
This suggested to us that healthcare organisations find the investigative task difficult. Of course, some healthcare organisations investigate patient safety incidents well. They get to the heart of the matter and they learn from them. But they are probably in the minority.
A new approach to investigating
We have built Eva with Microsoft on web-based, world class technology. Eva is the brand and the investigation application is the first of many.
The investigation application provides a healthcare organisation with a standard way of investigating using the analytical tools provided in the National Patient Safety Agency root cause analysis toolkit. It is intuitive and brings structure and simplicity to a complex task. We plan to continue developing the first version of the software with, for example, the introduction of voice-to-text transcription later this year. Crucially, the technology allows for the gathering of structured data from investigations. This is a first.
We want to encourage organisations to share data so that collectively we can build a deeper understanding about the outcomes of investigations and share this with our community of users. We will use Microsoft’s artificial intelligence and machine learning capabilities to achieve this. And we will then work with organisations to use that information in a productive, practical way to improve patient care and the safety of services.
We plan to work with Microsoft partners and interested trusts to find novel and imaginative ways to get insights and information back to frontline services.
For example, a Microsoft partner Thoughtonomy has virtual worker robots who can extract insights from a database and match them to future planned clinical activity therefore ensuring that the information is available to clinical staff at the time needed. For example, on-screen prompts ITU staff about the management of patients with chest infections or reminders to theatre teams about swab retrieval in theatres.
We have worked with a range of healthcare organisations in developing this technology. Investigators and clinical governance teams have had trials of earlier versions. HSIB gave us their feedback. We have incorporated suggestions and ideas.
And by building Eva in Microsoft Dynamics – tried-and-tested technology – means that it readily integrates with other tech used by many healthcare organisations.
Let me finish with this thought.
Some healthcare organisations are stuck in an investigative cycle of sub-optimal outcomes. Breaking out of this requires a technological fix.
Other organisations investigate well and want more value from the enormous effort they put into this activity.
Eva can provide a helping hand to both.
We believe that Eva represents a unique opportunity to deliver better and safer care to patients by wringing maximum value from serious incident investigations.