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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
Does it align with ourpriorities?
Yes No
Scheduling
Incorporateinto current
activity
TechnicalPatient Safety
/ Domain
Assign torelevant
area
PSSIGinvolvement
Incorporateinto current
activity
GPSR Sub-domain
GPSRDevelopment
Does it align with ourpriorities?
Yes No
SchedulingIncorporateinto current
activity
Request Type
Does the informationconform with the definition
of patient safety?
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
Does it align with ourpriorities?
Yes No
Scheduling
Incorporateinto current
activity
TechnicalPatient Safety
/ Domain
Assign torelevant
area
PSSIGinvolvement
Incorporateinto current
activity
GPSR Sub-domain
GPSRDevelopment
Does it align with ourpriorities?
Yes No
SchedulingIncorporateinto current
activity
Request Type
Does the informationconform with the definition
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?
IncidentInvestigation?
GPSRSub-
Domain
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
Does it align with ourpriorities?
Yes No
Scheduling
Incorporateinto current
activity
TechnicalPatient Safety
/ Domain
Assign torelevant
area
PSSIGinvolvement
Incorporateinto current
activity
GPSR Sub-domain
GPSRDevelopment
Does it align with ourpriorities?
Yes No
SchedulingIncorporateinto current
activity
Request Type
Does the informationconform with the definition
of patient safety?
IncidentReport?
IncidentInvestigation?
GPSRSub-
Domain
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
Does it align with ourpriorities?
Yes No
Scheduling
Incorporateinto current
activity
TechnicalPatient Safety
/ Domain
Assign torelevant
area
PSSIGinvolvement
Incorporateinto current
activity
GPSR Sub-domain
GPSRDevelopment
Does it align with ourpriorities?
Yes No
SchedulingIncorporateinto current
activity
Request Type
Does the informationconform with the definition
of patient safety?
chris.foye@npsa.nhs.ukchris.foye@npsa.nhs.uk
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