Ideas to improve the National Reportable Events Policy ... · simplifying reporting processes and tools : Strengthen the focus on consumers . ... The main audience for this report

Ideas to improve the

National Reportable Events Policy:

Internal report on stakeholder consultation

June 2016

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Contents Summary .............................................................................................................................. 4

Findings from this consultation .......................................................................................... 4

Potential policy changes that most participants supported ................................................. 4

Policy questions that require further work .......................................................................... 5

Topics with polarised views ............................................................................................... 6

Introduction ........................................................................................................................... 6

Context for this consultation .............................................................................................. 6

Audience for this report ..................................................................................................... 7

Aim of this consultation ...................................................................................................... 7

Consultation process ......................................................................................................... 7

Consultation findings ......................................................................................................... 9

Strengths and weaknesses of the current policy ................................................................... 9

What do people suggest to improve our current policy? ...................................................... 11

1. Stronger focus on learning and action ...................................................................... 12

2. More centred on consumers ..................................................................................... 19

3. More attention to the whole system .......................................................................... 23

4. Consider prioritising what is reported nationally ........................................................ 28

5. Clearer purpose statement ....................................................................................... 32

6. Easier ways to report and learn ................................................................................ 35

Simplify the SAC tool format ............................................................................................ 36

Simplify the reporting process ......................................................................................... 36

Conclusion and next steps .................................................................................................. 39

List of tables Table 1: Potential policy changes that most participants supported ....................................... 5

Table 2: Policy questions that require further consultation .................................................... 5

Table 3: Summary of participants .......................................................................................... 8

Table 4: Strengths of the current National Reportable Events Policy ................................... 10

Table 5: Weaknesses of the current National Reportable Events Policy ............................. 10

Table 6: Suggested options for ‘closing the feedback loop’ (translating recommendations into

action) locally ...................................................................................................................... 13

Table 7: Participants’ views on reporting Part Bs in the Commission’s annual report .......... 14

Table 8: Some suggestions for sharing learning .................................................................. 15

Table 9: Participants’ views on the idea of new aggregated reporting model ....................... 16

Table 10: Participants’ recommendations for changes to templates and policy guidance .... 18

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Table 11: What consumers need from incident reporting and management processes ....... 19

Table 12: Possible expectations for involving consumers in incident reporting and review .. 22

Table 13: Participants’ views on whole-sector coverage ..................................................... 23

Table 14: Summary of current requirements for and barriers to reporting in primary care,

aged care and disability sectors .......................................................................................... 24

Table 15: Participants’ views on the option of reporting falls differently ............................... 30

Table 16: Participants’ suggestions for ways to prioritise what is reported nationally........... 31

Table 17: Participants’ views on an always report (never events) list .................................. 32

Table 18: Participants’ suggestions for improving the aims and objectives of National

Reportable Events Policy .................................................................................................... 33

Table 19: Participants’ suggestions for clarifying roles and expectations of the Commission

and local organisations ....................................................................................................... 34

Table 20: Participants’ views on mandatory versus voluntary reporting ............................... 35

Table 21: Participants’ suggestions for simplifying the reporting process ............................ 37

Table 22: Suggested changes to the severity classification ................................................. 38

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Summary This report presents the findings of the Health Quality & Safety Commission’s (the Commission’s) interviews with providers and consumers on the National Reportable Events Policy. It summarises their views and ideas for change.

Our consultation identified a wide range of ideas for policy change, as well as strengths and weaknesses of the current national reporting system.

Findings from this consultation Providers and consumers agreed that the purpose of reporting should be to learn from incidents and to make changes that improve safety for consumers. They said the policy needs to focus more strongly on organisational learning and action. In their view, the failure to follow up the recommendations from adverse event reviews is a major gap in the current system at both local and national levels.

Our consultation drew out three broad themes for potential policy change.

1. Strengthen the focus on learning by supporting providers to improve the quality of reviews and recommendations, and by changing what we report nationally.

2. Strengthen the policy’s focus on consumers by adding a new section on consumers and setting out our expectations for involving consumers in reporting and reviewing incidents.

3. Move towards reporting and learning across the system as a whole. One possible way to do this is to expand the system in stages to include the wider sector, particularly primary care.

Potential policy changes that most participants supported A wide range of participants in the consultation supported a set of key potential policy changes, which may not require further consultation. Table 1 lists these changes.

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Table 1: Potential policy changes that most participants supported

Potential direction

Potential policy change

Strengthen the focus on learning

Provide new guidance for carrying out high-quality reviews and recommendations

Give more flexibility to use various review methods (not only root cause analysis)

Clearly state the purpose of the policy, spelling out national and local expectations and roles, and the benefits of reporting for local organisations

Make it easier for organisations to report and learn from incidents, for example, by moving to an electronic reporting system and by simplifying reporting processes and tools

Strengthen the focus on consumers

Introduce a new section in the policy on consumers and families/whānau – which signals the policy is prioritising consumer safety and sees incidents in a wider context of consumer safety

Provide a set of expectations (minimum standards) for involving consumers and families/whānau in reporting

Strengthen the focus on the whole sector

Ensure the policy is inclusive of and relevant to the whole health and disability sector, giving examples from across the sector and using shared terms and definitions

Provide guidance for multi-organisation reviews

Policy questions that require further work Our consultation also raised various policy questions that would require additional work and further consultation to assess whether they are feasible and acceptable. The consultation found either a moderate level of support, or mixed views, for each of these issues. Table 2 sets out these questions, along with the indicative level of support for each one.

Table 2: Policy questions that require further consultation

Policy question Indicative level of support

How can the policy encourage and support other parts of the sector, particularly primary care, to report nationally?

Strong support

Should the policy introduce (require or encourage) a national list of ‘always report’ (never) events?

Moderate support

Should the policy encourage near-miss reporting of incidents at a national level (for incidents with shared learning)?

Moderate support

How can the policy encourage a greater focus on the patient journey through the care system (rather than on single incidents or adverse events)?

Moderate support

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Should the Commission report annually on the number of Part Bs (reviews) that it receives – as a way of strengthening the focus on reviewing and learning?

Moderate support

Should the policy cover all incidents, including mental health incidents, which a separate policy covers currently?

Moderate support

Should the Commission initiate the development of an expert advice service, which would be available to help local organisations with reviews by providing specialised advice, mentoring and support?

Moderate support

Should the policy further prioritise which incidents organisations should report nationally (for example, in terms of their preventability or severity, by using an agreed set of national priorities, or by excluding some common incidents)?

Mixed views

Should the chief executive have to account for ‘closing the feedback loop’ locally by reporting to the Commission on how their organisation has implemented the recommendations and what impact this has had?

Mixed views

A minority of participants suggested and discussed two other key ideas that we could also consider further. They are options to:

• encourage organisations to develop systems to enable consumers and family/whānau members to report incidents (a pilot)

• use the triage and review process in the current mental health policy for general (non-mental health) incidents – that is, allow flexibility to decide on various levels of review depending on the circumstances.

Topics with polarised views Participants’ views were polarised on two topics: 1. whether to have mandatory or voluntary reporting (particularly in relation to primary care

reporting) 2. how to prioritise national reporting (particularly the idea of removing falls from national

reporting).

Introduction

Context for this consultation This consultation is part of a wider review of the National Reportable Events Policy of the Health Quality & Safety Commission (the Commission). Other components include a literature scan of national patient safety reporting systems and an earlier survey of stakeholders.

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Through this consultation, we wanted to hear views and ideas from key stakeholders to inform the policy review and to complement the literature scan and the survey.

Alongside this other work, the consultation will inform the development of potential policy options for a revised national policy. We will consult with a wider group of stakeholders on these options, with the aim of releasing a new policy in 2017.

Audience for this report The main audience for this report is the adverse events EAG and the Commission. This year’s annual report will include a summary of the findings, along with proposed policy options.

Aim of this consultation Our aim was to consult with consumers and providers in the health and disability sector to identify:

1. strengths and weaknesses of the current national reporting process 2. ideas for improving the policy.

Consultation process We held the consultation over five weeks in May and June 2016. It involved 48 meetings with around 140 individuals from various health and disability organisations.

Consumers provided input in an earlier meeting with the Commission’s consumer network (March 2016) and three consumers took part in individual interviews. Providers included quality managers, other managers, clinical staff, primary health organisation (PHO) staff, professional organisations, the adverse events EAG, and advisors and managers in the Ministry of Health, the Accident Compensation Corporation (ACC) and the Commission.

The meetings were a combination of telephone interviews and face-to-face meetings with individuals and groups. Table 3 breaks down the participant groups.

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Table 3: Summary of participants

Sector or organisation Number of meetings

Number of participants

District health board 14 15

Primary care 11 34

Disability 4 5

Consumers 4 18

Ministry of Health 4 5

ACC 3 3

Private sector 2 6

The Commission 2 2

Aged care 1 1

Adverse events EAG 1 15

Chief medical officers 1 20

Regional quality and safety network

1 16

Total 48 140

Participant selection To identify potential participants, we started with a suggested list of key stakeholders from the Commission, and used the snowball technique to ask participants for further suggestions. For the consumer network, EAGs to the Commission, and regional safety alliances, we emailed an invitation to all members and asked people to volunteer to take part.

Consultation questions In a semi-structured interview schedule, we asked some standard questions but also had flexibility to develop other questions and seek new input from participants. Because the participants had many different roles in diverse sectors, interviews varied widely in their focus on particular topics. We developed several differing interview schedules for each sector, such as for consumers, primary care, disability support services, and aged care.

Analysis We wrote notes during the meetings, checking and adding to these soon after each meeting. Next, we analysed the consultation notes using qualitative content analysis to identify key themes and patterns in participants’ accounts. As new themes emerged, we built on this initial set of themes.

Strengths and weaknesses of this consultation Our consultation involved a large number of individuals and organisations, covering many professional roles and sectors. As many people were highly interested and willing to be involved, the recruitment process went smoothly.

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A key limitation was the broad and detailed nature of the topic, and breadth across sector organisations. This meant that we did not ask all questions in each meeting, and we can only estimate levels of support for key potential policy changes. Please treat these support estimates with caution, given that the consultation was exploratory and covered multiple topics. We anticipate that the next phase of (wider) consultation will be crucial to confirm which policy options have the most and least support.

Some of the topics discussed may be out of scope for the policy review; however, this report has taken an inclusive approach to reporting all of the topics covered to give a full picture.

Many who participated were in management or quality positions, with fewer in clinical roles. One meeting of PHO quality managers expressed concern about having only limited early consultation with general practices, in particular. Most of the primary care participants were from PHOs and the Royal New Zealand College of General Practitioners, although we did consult with several chief medical officers who were general practitioners, and a few general practitioners attended meetings such as the PHO and regional quality and safety network meetings. The PHO quality managers felt this gap needs to be addressed in the near future, before policy options are developed (that is, before the second phase of consultation).

Consultation findings Our findings are divided into two sections: current strengths and weaknesses of the policy, and suggestions to improve the current policy. The report focuses mostly on the ideas for improvement.

Strengths and weaknesses of the current policy On the whole, people said they saw the development of the national reporting system as an ongoing journey, which will need to evolve over time. Most didn’t suggest stopping national reporting, but assumed it would continue in some form.

A few exceptions said that national reporting had little value in its present form, because it wasn’t leading to much new learning or enough changes to improve patient safety. This minority questioned whether we should continue with a national reporting system.

Analysis of participants’ views highlighted a common set of strengths (Table 4) and weaknesses (Table 5) of the current policy.

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Table 4: Strengths of the current National Reportable Events Policy

Theme Example comments from participants

National learning and accountability

Opportunity for national learning Accountability to the public

Centralised, trusted system

The Commission is a respected central ‘home’ for the policy – and collaborates with the sector on incident reporting The system is seen as a non-punitive, safe process

Encouraging culture change

The Commission’s work has made a difference in developing more open organisational cultures – encouraging transparency, openness and open disclosure The system is important in collecting data to show that serious incidents do happen in New Zealand and can involve experienced clinicians

Open Books

We love the Open Books! We are distributing the Open Books and getting lots of good feedback

National provision of training

Having nationally provided adverse event training is helpful

Some people reported that our policy had been used as a guideline or basis to inform incident reporting policies at the local level – not only secondary care, but also primary care and disability sectors.

Table 5: Weaknesses of the current National Reportable Events Policy

Theme Example comments from participants Focus on reporting, not learning

Boxes are ticked but organisations are not really making enough improvements Lack of monitoring of recommendations, lack of quality assurance activities to support the process The Commission doesn’t require organisations to give evidence of work plans or improvement packages that have been developed after an adverse event Lack of dissemination of learning from the Commission to organisations

Poor-quality and delayed reviews and recommendations

Poor quality of reviews and recommendations; for example, human factors analysis is lacking and often have too many or unrealistic recommendations Delays in completing reviews and submitting Part Bs Mental health reviews are especially challenging because complex and time-consuming Reviews aren’t easy – need training, practice, coaching, support Lack of feedback from the Commission on the quality of reviews and recommendations Lack of standardisation – quality often depends on key individuals who drive the work

Lack of consequences

No consequences for failing to comply with the policy – for example, no consequence if don’t send in a Part B, or if it’s poor quality

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Theme Example comments from participants

Lack of consumer focus

Provider-focused system, not consumer-focused, for example, providers currently define an incident

Lack of integration

It is quite siloed, whereas national incident reporting and learning should happen in an integrated way across the whole system – Accident Compensation Corporation, Health and Disability Commissioner, Ministry of Health, Commission, mortality review committees, etc Duplication with other processes because have to report to multiple agencies on the same incident

Lack of guidance for incidents that involve more than one organisation

Current policy is not useful for complex care situations or dealing with the boundaries (transitions, handovers, discharges, etc) Lack of advice for how to deal with multiple providers when reviewing adverse events – that is, need guidance on how to do collaborative reviews – review the whole process not just part of it

Lack of guidance for reviewing lower-level events

At a national level we are losing learning from S[everity] A[ssessment] C[ode] 3 and 4 events Unusual or unexpected adverse events also have national learning potential and aren’t currently captured by our system

Lack of emphasis on staff

Little emphasis in the policy on supporting staff Lack of clinician engagement

Under-reporting

Under-reporting (for example, only 23 pressure injuries nationally) Hard to do good analysis with such a small national data set

The rest of this report addresses many of the identified weaknesses of the current system. It presents participants’ ideas about ways to improve how we report and learn from incidents.

What do people suggest to improve our current policy? Our analysis of the consultation notes identified six overarching themes. These summarise what many people wanted us to change in the current policy:

1. stronger focus on learning and action 2. more centred on consumers 3. more attention to the whole system 4. consider prioritising what is reported nationally 5. clearer purpose statement 6. easier ways to report and learn.

The findings for each of these themes are presented below.

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1. Stronger focus on learning and action

Provide guidance on the components of a quality review Our consultation identified a clear call for guidance on what a high-quality review – and recommendations – should look like, based on best-practice advice. Suggested models to use or adapt were Scotland’s checklist for quality reviews and the Queensland Quality Check tool.

In particular, participants advised it would be helpful to:

• acknowledge the importance of sharing the learning with frontline staff (in general and feeding back to staff directly involved in an incident)

• hold a structured debrief with the review team after an incident review.

Another idea was to add a new tool to the policy to help providers assess the likely effectiveness of recommendations, such as a Hierarchy of Effectiveness tool to rate actions from strong to weak. This kind of tool would help organisations to focus on developing strong actions that are more likely to improve safety.

Improving the quality of reviews and recommendations Providers said they want more feedback from the Commission about the quality of their reviews and recommendations – to help them to improve and learn from incidents. Other ideas to improve quality were to: • provide a human factors template with system-level prompts to help organisations

consider all potential contributing factors when reviewing incidents • encourage organisations to require the chief executive to check all serious adverse

event/incident review reports • design and introduce an indicator or measure to assess how effective an organisational

review is in preventing avoidable future harm.

Translating recommendations into action Participants widely agreed that recommendations of adverse event reviews are not always followed up to see whether the corrective actions have:

• been implemented • helped to change systems or improve safety.

Participants reported the practice of ‘closing the feedback loop’ was inconsistent both locally and nationally. They saw it as a major problem with the current system.

Closing the feedback loop at the local level To close the feedback loop at the local level, people suggested various ways to encourage organisations to provide evidence that they have implemented recommendations and that those recommendations have had an impact (see Table 6).

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Table 6: Suggested options for ‘closing the feedback loop’ (translating recommendations into action) locally

Option Indicative support

Example comments from participants

Require the organisation’s chief executive to be accountable for following up on recommendations and ensuring the organisation monitors their impact and shares its learning Require the chief executive to report back to the Commission to say that recommendations have been completed

Mixed views Potential disincentive to good-quality reviews and recommendations Need to improve quality of recommendations first, because currently have too many ‘Big stick’ approach Potential duplication of the quality accounts

Change the Part B template to require organisations to provide follow-up evidence that they have completed recommendations and learned and shared lessons (or a new Part C)

Minority suggestion

Would make it harder to meet the Part B timeframe – longer delays

Require organisations to give information about reviews, and completion and impact of recommendations, as part of the annual quality accounts to the Commission

Minority suggestion

At least one organisation is already doing this voluntarily. Others said it would make sense to use the quality accounts to help close the feedback loop locally

Potential follow-up by HealthCERT: Some participants said that following up on recommendations was already the role of HealthCERT auditors, but others felt this either wasn’t happening or was insufficient. Several questioned whether the auditors were doing this adequately; they suggested the auditors need guidance on what to look for and on following up when a provider fails that part of the certification process.

One person suggested the Commission could provide example indicators for local providers to use to monitor their internal system, which the HealthCERT auditors could assess. A dashboard could show cases that are open, cases past the 70-day deadline, cases closed, and so on.

More sharing of learning is needed: Participants also discussed the need to share learning at the local level – in general, and especially between primary and secondary care. Some noted that learning from incidents in secondary care isn’t always communicated to primary care, even when it has direct implications for the primary care sector.

One idea was to have a forum for each district health board (DHB) to share learning across the organisation. For example, a joint primary–secondary clinical governance group could share what is learned more widely. Some DHBs are already taking this approach.

Closing the feedback loop at the national level While seeing Open Books as successful and useful, participants wanted more national-level exchange of learning and feedback to local organisations. In their view, identifying synthesised learning across the country is vital. Also, one participant questioned whether the

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learning from adverse event reviews is informing the development of programmes within – and across – the Commission.

People wanted us to be more proactive to ‘close the feedback loop’ nationally, such as by investigating and analysing clusters of events, and triangulating data from other sources (for example, accreditation data).

One suggestion was for the policy to include an expectation – for serious incidents – that organisations share the incident review report with the Commission on the day that it is published. Through this approach, more timely analysis and learning could take place nationally.

Strengthening the Commission’s annual reporting by reporting Part Bs: During the consultation, participants discussed an option that early interviews had identified: to start reporting the overall numbers of completed reviews (Part B summaries) in the Commission’s annual report. This idea would be a way to focus more on reviews and to provide an incentive to complete Part B.

Participants had mixed views on this idea (see Table 7). Some said they would generally prefer a more supportive approach, where the Commission follows up providers that miss the deadline for Part B – to ask what’s happening and how could they be supported to complete the review.

Table 7: Participants’ views on reporting Part Bs in the Commission’s annual report

Arguments for Arguments against

Would encourage organisations to complete more reviews

Could discourage good-quality reviews

The Commission has a responsibility to report it because it has that information

Prefer a supportive approach with proactive reminders and follow-up with delayed reviews

Focusing more on review and learning in the annual report would encourage the media to focus more on learning

Better to make it easier to do good-quality reviews

To implement this option, the Commission could use either:

• individualised information that identifies providers, or • aggregated, anonymised information – that is, report the percentage of Part As that are

followed by completed Part Bs.

Open Books: Participants also discussed whether providers should have to provide a case for an Open Book each year. Most preferred the option of encouraging Open Books as an expectation, rather than making it a requirement. This was because smaller organisations are unlikely to have an appropriate case each year; also, people tended to favour an encouraging, supportive approach (rather than a ‘big stick’).

Sharing of learning in other ways: Providers wanted the Commission to provide more regular progress reports, reflection and analysis about recent learning from serious incidents, and to allow rapid learning and changes to systems based on national learning. One person said that our annual reporting should include both summative analysis at the national level and process reporting to help services learn. This could include highlighting

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emerging patterns and the kinds of improvement programmes needed. Table 8 presents some other suggestions for sharing learning.

Table 8: Some suggestions for sharing learning

Method of sharing learning

Example comments for participants

Quality and safety markers

Develop a quality and safety marker for this policy (for example, number of reviews completed, number of actions taken – classified by strong, medium, weak) Develop quality and safety markers for high-risk incidents specifically, for example, medication errors, deteriorating patient

Targets Develop a set of agreed targets or benchmarks – so providers can see where they’re sitting and where opportunities are to improve

Thematic analysis nationally

Adapt the Part B template to enable thematic analysis at a national level, for example, poor transition management or poor communication

Publication of adverse event reviews on the Commission’s website

The Commission should put the detailed reviews (or Part Bs) that we receive on our website to help share the learning (without identifying the DHB)

Encourage local publication of adverse event reviews

Encourage local publication of adverse event reviews on DHB/local provider websites

Academic publication The Commission could publish national learning in academic journals

Potential for new model of aggregated reporting: In the early interviews, some participants suggested a new model. Instead of having individualised national reporting, local providers would be responsible for producing their own summaries of adverse events, trends, learning and corrective actions taken, which they would send to the Commission. We would then produce an annual report that draws together the aggregated data, identifying national trends and learning.

Following this suggestion, participants discussed this option throughout our consultation. People debated the best timeframe for providing summaries to the Commission under this model, varying in their level of support for annually, six-monthly and quarterly. Some suggested this approach could be integrated with our quality accounts.

Most either didn’t support this option, or saw it as aspirational, to move towards over time. Many felt the culture of reporting isn’t yet mature enough for this model. They said some organisational reporting could evolve into this, potentially, but moving immediately to this option wouldn’t help organisations that are weaker reporters at present. Table 9 summarises participants’ arguments for and against this model.

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Table 9: Participants’ views on the idea of new aggregated reporting model


Incentive for local providers to take more ownership of and responsibility for reporting and learning

More time-consuming for local providers

More efficient to report nationally in a more aggregated way – learning from clusters of events and providing summary information

Could duplicate information provided in the quality accounts

Would save time to not do Parts A and B and track them and do reconciliations – currently this is a lot of work

Want to use resources for improvement projects rather than reporting

May be feasible for large providers Loss of learning from reporting on an individual, ‘real-time’ basis

One said they would report more under this system because they learn so much from Severity Assessment Code 3s

Concern that some providers would under-report. Regular timelines are an incentive to report

One suggested change to the option was to continue to require Part A notifications of incidents so that the Commission could keep track of the numbers of incidents. One participant noted it would be helpful to have a national analysis of the quality accounts distributed to organisations.

Ideas for improving the training the Commission currently provides Our consultation questions didn’t focus on training specifically, but some themes related to it emerged nonetheless. On the whole, people in the consultation who had participated in the training gave positive feedback about it. One person from the primary care sector, however, stated that the content wasn’t relevant enough to primary care. Others noted that they, or people they knew, had tried to register for the training, but had missed out because it was oversubscribed.

A major theme in this consultation was that many lacked the capacity and capability to carry out high-quality reviews. Participants recognised a strong need for more widespread and relevant training, as well as coaching, mentoring and support.

Several participants suggested that our training should focus more on how to do a review (the ‘ABCs’ of doing a root cause analysis, for example). In their view, developing these skills is a top priority. They said the current training includes other contextual information, which leaves less time for the practical skills of applying the review methodology.

Another need participants identified was for our programme to provide advanced review training for more experienced practitioners.

People said they wanted a stronger focus on human factors in the training, because local organisations lack expertise in human factors analysis. Training in how to use the Severity Assessment Code (SAC) matrix to assess the severity of incidents was another training need people mentioned, which they felt would help to increase consistency.

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Encourage national and regional learning Two alternatives participants proposed to the current training model were: a national conference to share learning from incidents and increase capability to carry out high-quality reviews; and regional-level learning and collaboration.

Some noted an opportunity to strengthen regional learning and development such as by: • using the regional alliances to look regionally at what changes have happened as a

result of serious incident/adverse event reviews • increasing collaboration and open sharing within regions; for example, the Central region

is looking at collaborative learning from SAC 1 and 2 events • having one organisation peer review another’s serious incident review process and

outcomes.

Independent service to provide expert advice and support Some participants supported the idea of a new service to provide expert advice and support for reviewing incidents. In their view, this service would be especially helpful for small providers, but potentially useful for larger providers as well. Several participants commented that they had used expert advice occasionally and found it helpful.

Suggested roles for such a service included: • provide advisors to help organisations with the process of doing a review, for example, to

help with human factors analysis • provide independent reviewers when an organisation prefers to use external people to

lead or help with a review • help to standardise reviews and achieve national consistency.

Concerns about the idea of an expert advice service included its cost and the potential for external experts to ‘take over’, reducing local involvement in the review. Participants saw it as crucial to have local ownership of the actions following an incident review.

Centralising review expertise within organisations Several participants mentioned another approach that they were developing within their organisations. In this model, the organisation trains a centralised, internal team of staff and encourages them to develop expertise in adverse event reviewing. In some instances, the organisation supports this team by giving them time away from their usual jobs to do the review work.

This model could save considerable time and stress as the organisation would not have to arrange a new review team for each incident.

Near-miss reporting Participants made the following observations about reporting near misses.

• Support for more near-miss reporting locally: Those consulted strongly supported encouraging more reporting of near misses at the local level. Describing them as common, participants saw near misses as important for learning.

• Support for near-miss reporting nationally where there is learning potential: Some people also supported near-miss reporting to the Commission – but only for a subset of incidents that have national implications and/or potential for shared learning. They said

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such reporting should be voluntary. Some noted that some PHO reporting systems include reporting of near misses that are considered important for learning.

• Potential for harm needs more attention: Several participants said the focus on outcome (harm) in the SAC matrix was problematic. They argued that potential for harm is also important, and should be weighed equally with actual harm in the SAC process to ensure that the health and disability sector can learn from near misses.

• Challenges with defining and identifying near misses: One person identified a need to clarify the definition of near miss and suggested using a Canadian definition. Others said it could be difficult to identify near misses. Someone noted that the South Island Alliance prefers the term ‘good catch’ on the grounds that it has a clearer meaning and positive connotations.

• Concern about increased workloads: Several people expressed concern about the opportunity cost of increasing the workload – locally and nationally – by increasing near-miss reporting.

Possible changes to our templates and guidance – to increase learning Table 10 lists changes to the templates and/or guidance in the policy that participants recommended. Allowing the use of a wider range of review methods – not only root cause analysis – was a strong theme. Many commented that not all incidents required a comprehensive root cause analysis, so they would like to have the flexibility to use other similar approaches.

Table 10: Participants’ recommendations for changes to templates and policy guidance

Potential change

Explanation Other comments

Allow a wider range of review methods

A strong message was the need to allow organisations to use a wider mix of methods to review serious incidents. Many wanted a suite of tools to choose from, including root cause analysis but having others as well

Other methods mentioned were London Protocol, Fishbone, LEAN and clinical review

Expand the reportable event brief into a more structured template

The aim would be to gather better information for learning (tailored to the Commission’s requirements), for example, to help identify contributing factors, and to identify what is expected for the recommendations

Options suggested were to align our reportable event brief form to: • ACC’s treatment injury

feedback form • the Medication Error

Reporting Programme’s electronic reporting form

Encourage reporting of non-clinical events

The rationale was that there is much potential learning from non-clinical events (for example, privacy breaches, technology failures, administration errors, fires or floods)

People argued for including non-clinical events in the SAC matrix because they are relevant in primary care and disability sectors

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2. More centred on consumers

Consumer safety approach – focused on the patient journey Many participants said the policy should focus more strongly on consumers and families/whānau, and on their perspectives of adverse events. Key themes included the need to consider the patient’s health care journey and emotional harm – especially to review how incidents have affected consumers and families/whānau. Consumers who participated in the consultation, including the Commission’s consumer network, highlighted that consumers want incident reporting and management processes to consider the topics outlined in Table 11.

Table 11: What consumers need from incident reporting and management processes

Topic What consumers need the processes to do Consumers and providers differ in how they define an adverse event

Recognise and value consumers’ understanding of adverse events Be open to reviewing care over a longer period – because consumers generally take a longer-term perspective of the whole continuum of care (patient journey rather than one episodic event)

After an adverse event

Acknowledge the event and apologise (hear and validate the consumer) Reassure them that the organisation has taken action to change the system to prevent the harm from occurring again

Interactions and communication

Consider the interactions around the adverse event – which consumers often see as just as important as the event itself Promptly disclose what has happened Continue to communicate Be reachable, for example, consumers appreciated getting a direct phone number for the key clinician or contact person involved

Recognise and report emotional harm

Draw out not only what happened; but also how it has affected the person Reduce uncertainty for the consumer and family/whānau, for example, by explaining at the beginning how long the review might take

Ensure adequate support

Consider the support needs of the consumer and family/whānau members, for example, by referring them to social work or cultural support

Inform about the outcome of the review

Inform the consumer and family/whānau about the review’s outcome, which can help them to come to terms with what has happened

Evidence of change

Consumers who had been involved in adverse events said they felt powerless, and lacked confidence that things would change They recommended communicating in an ongoing and sustained way so that consumers can see evidence of change

Near-miss reporting

Report near misses as well as actual events

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Option of independent review of serious adverse events The Commission’s consumer network called for independent investigation of serious adverse events and monitoring of recommendations. These participants said they generally distrusted DHB investigations. Several other participants agreed with this option.

Many providers, though, took a different view. Several said it is crucial to have local people involved in and owning the review process and content. They felt an independent review service or organisation would jeopardise local ownership.

A related option emerged during the discussions: to introduce an expert advice service that could be available to support local organisations with reviews (see Section 1 above). This would also be an independent service, but would provide occasional expert advice and support, rather than doing reviews ‘for’ organisations.

Proactive – not reactive – approach to preventing harm In our consultation, consumers said they wanted the Commission and local organisations to consider ways to encourage more proactive action to prevent harm.

They recommended, for example, that organisations should be more proactive about patient safety – rather than only taking retrospective action after something has gone wrong. A proactive approach could involve identifying potential problems and introducing systems to prevent incidents and near misses.

Consumer participants said they wanted incident reporting and learning to be part of a wider, more integrated approach to consumer safety.

Focus on the patient journey or continuum of care Consumers emphasised that incidents can happen at any point in a person’s journey of care, such as during transition points (for example, discharge or referral), and may involve several provider organisations. They recommended that organisations should:

• see incidents and their effects (for example, harms) from a consumer perspective because it is broader than a clinical or provider perspective

• consider extending the incident review period to consider the patient’s journey through the system, including considering the cumulative effects of incidents or other problems with care.

New section on consumers and families/whānau Many participants noted that the current policy pays insufficient attention to consumers. They recommended adding a new section on the role and involvement of consumers and families/whānau in incident reporting. As they saw it, this section would set out the benefits of, and expectations for, involving consumers and families/whānau – see below for proposed expectations for involving consumers.

A common message, from both consumers and providers, was that the primary reason for reporting and learning from incidents should be to help the consumer and family/whānau affected. The priorities were to meet the needs of the consumer and family/whānau involved and support them throughout the process, as well as making the changes needed to prevent harm to other consumers in future. One participant noted that the way in which consumers are treated and involved in reporting and learning from incidents can help or hinder public confidence in health and disability services.

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Incidents involving Māori or Pacific consumers We asked most people whether they were aware of any approaches to reporting or reviewing incidents involving Māori or Pacific consumers. No one came up with any specific examples of cultural approaches.

However, participants did point to examples of seeking cultural advice for reviews, such as: • seeking advice as needed from their organisation’s Māori health department or Māori

liaison nurse • aiming to be culturally responsive, for example, by offering to meet in a family’s/whanau

member’s home, providing hospitality and involving the wider family/whānau • getting external cultural reviews of their adverse event review, at the request of the

family/whānau.

Several people recommended that our policy should provide advice on how to tailor reviews to better suit Māori and Pacific populations. Someone also noted the need to add a question on ethnicity to the reportable event brief template so that we can monitor reporting and learning by ethnicity.

Consumer-initiated reporting Some providers and consumers strongly recommended enabling consumers and families/whānau to report incidents themselves because they have different perspectives from providers. One suggestion was to introduce an electronic consumer portal as part of a web-based reporting system, so that consumers could easily log incidents.

Someone gave the example of the Medication Error Reporting Programme, which has a parallel process for receiving reports from, and reporting back to, consumers.

Some concerns about this idea were that it might duplicate the work of the Health and Disability Commissioner in dealing with consumers’ complaints, and it raised questions about how the resulting information would be used.

Expectations for involving consumers in incident reporting and review A strong theme was that our policy should state our expectations (or minimum standards) for consumer involvement. Table 12 sets out an initial set of possible expectations, developed from participants’ advice in this consultation.

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Table 12: Possible expectations for involving consumers in incident reporting and review

Expectation for consumer involvement

Example comments by participants

Open disclosure to consumer and/or family/whānau

This should happen as soon as possible (the earlier the better) Providers should advise how long the review is likely to take One organisation said it was developing a pamphlet for consumers to explain the incident reporting process and how they can be involved

Starting point of hearing consumer’s story

The review’s starting point should be to hear and capture the consumer’s and/or family’s/whānau’s story of what happened and how they feel about it – including how it has affected them

Ongoing, open communication

Reportable event brief forms should be copied to the consumer and/or family/whānau (and to the chief executive or delegated manager) Regular updates on progress with the review

Invite the consumer and/or family/whānau to be involved in the review, if they wish to

Comment on the terms of reference for review Be interviewed as part of the review

Invite the consumer and/or family/whānau to comment on the draft report and recommendations

The review report shouldn’t be finalised until the consumer and/or family/whānau have had an opportunity to check the report for accuracy and had an opportunity to air any concerns with the draft report Seek consumer input on outcome measures – to monitor the impacts of the recommendations

Discussion on the report and outcomes with the consumer and/or family/whānau

A review team member should go through the report with the consumer and/or family/whānau to make sure they understand it

Update on consumer and/or family/whānau outcomes

An update on consumer and/or family/whānau outcomes should be provided at the review’s completion – that is, how they are doing at the end of the review (organisations could report this to the Commission as part of Part B)

Concerns about involving consumers Though the consultation found a clear call to involve consumers and families/whānau more in reporting and learning from incidents, several participants expressed concern about the idea of increasing consumers’ involvement.

The concerns fell into two categories:

1. the situation is confidential and sensitive – and involves the need to protect the interests of staff as well as consumers

2. a perception that this area is difficult and depends on the situation.

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Mixed views on independent consumer representation on review teams People had mixed views on the option of including an independent consumer representative on review panels (that is, an independent consumer, not the consumer involved in the adverse event). One organisation routinely included a trained consumer representative on every review team for SAC 1 and 2 incidents, while several others said this was a routine practice only in review teams for mental health incidents.

A few individuals thought some organisations would not be ready to involve independent consumer representatives on all review teams, but such representation could be something for them to work towards. Another view was that involving consumers and families/whānau throughout the process was more important than having independent consumer representation.

Some specific concerns about this idea were: including a consumer representative may not add value; review discussions are often technical; and staff need a safe environment.

Overall, support for this practice was insufficient to set it as an expectation (or minimum standard) in the policy; however, the policy could include it as a recommended – voluntary – practice. 3. More attention to the whole system

Work towards coverage of the whole health and disability sector Participants universally agreed, in principle, to including the whole health and disability sector in our policy. They favoured doing so through a staged approach, with lead-in time. Views were diverse, though, on the details of this approach – especially the extent to which reporting of serious incidents should be required or voluntary.

The potential for duplication was a key concern, particularly in disability support services and aged care where providers are already reporting some incidents on a national basis (to the Ministry of Health, through HealthCERT). Significant concern about the current lack of capacity and capability to carry out incident reviews was also widespread. Table 13 summarises some other views for and against reporting by the whole sector.

Table 13: Participants’ views on whole-sector coverage

Arguments for Arguments against National overview of the whole sector would allow better analysis and learning across the sector

Major question about the Commission’s current lack of capacity to handle increased reporting across the sector

Consistent with the New Zealand Health Strategy and the shift in patient safety towards primary health care and the home – and a whole-of-system approach

Concerns about confidentiality and anonymity of individual providers and clients/consumers – especially in small primary care practices and small disability support organisations

Increases in long-term conditions and complex care needs mean that care is more often shared across providers and consumers are often dealing with more than one organisation

Potential for ‘individual blame’ approach – would need to keep a strong focus on system-level analysis

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Reporting in primary care, aged care and disability support services Table 14 shows the current reporting requirements and barriers, as participants see them, for each of the three sectors of primary care, aged care and disability support.

Table 14: Summary of current requirements for and barriers to reporting in primary care, aged care and disability sectors

Sector Current requirements for reporting Barriers to reporting

Primary care

All accredited practices must have an incident reporting system, but do not need to report nationally Some PHOs contractually require practices to report to the PHO

Time and money Independent business model Reluctant to share information with PHO Fragmentation and lack of communication between primary and secondary sectors

Aged care

Expected to report incidents to the Ministry of Health (HealthCERT) – perceived under-reporting

Time and resource constraints, particularly for small owner-operators Heavy workload at present – new assessments required Lack of understanding of systems approach and fear of consequences Independent business model

Sector Current requirements for reporting Barriers to reporting Disability support

Required contractually to report to the Ministry of Health – variety in current reporting levels (both under- and over-reporting) If the service is certified, then the provider sends the report to HealthCERT as well

Confidentiality concerns due to small size of care homes (often can’t name an organisation/provider without identifying an individual staff member) Different workforce composition in the disability sector so can’t make the same assumptions about training and education (need for more upskilling/professional development)

Agreement on including primary care – but questions about how best to do this People generally agreed the policy should be more relevant to primary care. Many said that it should encourage primary care to report all incidents at the local level, and to report serious incidents nationally.

Several said that very few SAC 1 and 2 events occur in primary care, but others strongly disagreed. One PHO with a contractually required reporting system, for example, received 43 incident reports from primary care practices in a six-month period (which included serious incidents with shared learning and near misses).

Many participants supported the advice that our policy should: • include primary care examples, and reduce content specific to secondary care • promote Open Books more to primary care, and develop Open Books focused on

primary care • encourage collaborative reviews between primary and secondary care • align with Cornerstone and Foundation Standard guidance for managing incidents

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• use common terms that primary care professionals (and those in other sectors) use and understand, for example, participants tended to prefer the term ‘incident’ over ‘adverse event’

• apply the same classification and review system in primary care, but with some adaptation

• offer training for primary care practitioners in how to do review methods – particularly in human factors analysis. Participants supported the idea of regional-level training through regional alliances.

Considerations for primary care reporting: As participants saw it, trust and relationships – between the Commission and practices, and also between PHOs and practices – are both critical for increasing reporting and learning from primary care incidents.

Primary care participants also noted that the cultural and organisational landscape in primary care differs vastly from the secondary care context. They felt this point is crucial to take into account in developing and consulting on a new National Reportable Events Policy.

Several participants said the SAC classification wasn’t relevant for primary care. Some noted that the current incident review methods and timeframes might not be practical in primary care.

Potential option of reporting through PHOs: Some suggested introducing national reporting through the PHOs (that is, the practice would report serious incidents to the PHO, which would then report these to the Commission). Others, in contrast, expressed strong misgivings about this option because of the variable quality of relationships and trust between practices and PHOs.

Polarised views on whether to make primary care reporting mandatory or voluntary: Primary care participants were divided on whether the policy should require or encourage reporting. Some argued for a stronger contractual requirement to report SAC 1 and 2 events to PHOs in the back-to-back agreement (which PHOs would then report to the Commission). Current back-to-back agreements do make a broad statement about risk identification; however, some said this needs to be more specific – to clarify and define what to report locally and nationally.

Two arguments for a mandatory requirement were that: it would make sense to be consistent with the secondary care sector; and practices would be more likely to report if it was required.

Yet other participants raised significant concerns about the idea of introducing a mandatory requirement for primary care reporting. Some felt that this approach would be a major risk for relationships with the primary care sector, which might disengage from a mandatory reporting process.

Another concern was financial, as the primary care sector doesn’t receive any funding for incident reporting at present. Some primary care participants said any extension of our policy to primary care would need to be accompanied by funding for staff in practices to carry out incident reviews.

Reporting models in primary care: Some PHOs require practices to report and review serious incidents using our SAC classification, and to report the most serious incidents to the PHO (which sometimes reports these to us).

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Participants also described other reporting approaches presently used in primary care. One general practitioner, for instance, had a practice meeting each month to discuss learning and proposed practice changes based on all incidents, complaints and patient feedback from that month.

A PHO quality manager gave a recent example where they had heard about a serious incident in one of their practices, so they invited the practice to have a conversation with the PHO about the shared learning from this incident. They believed this discussion was useful because of the PHO’s approach.

In summary, key advice from primary care participants was to take into account the differing contexts of primary and secondary care. We will need to adapt our policy to better suit primary care. To develop potential policy options, we will need to consult further with the sector, particularly those at the frontline, and to explore whether reporting should be voluntary or required.

Slower staging recommended for the aged care sector This consultation included only one participant from the aged care sector; however, several others had expertise or oversight in aged care auditing and evaluation. The main advice was to start small in encouraging more reporting from aged care – and to take a staged approach. The reasons for this more gradual approach are that the sector faces heavy workloads and compliance requirements, and contains many providers (656 facilities), with many small owner-operators among them.

As participants proposed, two potential options are to start the move towards reporting with: 1. required reporting of one incident category (for example, falls that lead to death or

suicide), while indicating that this requirement will extend to other incidents over time

2. several of the largest providers to test reporting on one incident category such as falls (for example, Metlifecare, Christian Health Trust, Bupa).

Mixed views on potential involvement of disability support services Participants in the disability sector held mixed views on whether it was appropriate or feasible to involve disability support services in the Commission’s national reporting system. In general, they were reluctant to introduce any kind of dual reporting. They were, however, open to participating to a lesser degree such as by using Open Books and our templates and tools, taking part in training that is disability-specific, and accessing expert advice and support on how to do adverse event reviews.

One person suggested working with the disability sector to develop shared principles for reporting, but also expressed concerns, which others shared, that the models and care/support settings are too different. In particular, the health and disability sectors differ in their approaches to managing risk.

Similar to other parts of the wider health and disability sector, disability sector participants supported the idea of developing common terms and definitions for incident reporting. They pointed out that language is extremely important. One participant, for example, stressed that the terms ‘patient’ and ‘consumer’ would both be unacceptable to the disability sector.

Like the primary care participants, some expressed concern about the costs of any new reporting. Disability support services only receive funding for direct care provision – so any increased reporting wouldn’t be funded.

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One suggestion for a way forward was for the Ministry of Health to analyse the disability incident data that it receives for themes and national learning, which it could then report to the Commission.

Guidance for collaborating on joint reviews (multi-organisation) A growing need to collaboratively review incidents was a strong theme. People said that, increasingly, incidents involve consumers who are accessing two or more (sometimes many more) organisations. Incidents can often relate to complex care pathways and transitions between providers and sectors.

Participants recommended that our policy: • provides guidance for collaborating on reviews where two or more organisations are

involved • encourages shared commissioning of reviews, for example, between PHOs and DHBs • encourages DHBs to have a policy to engage with other relevant parties when the

incident involves more than one provider • encourages a system-of-care approach where organisations agree (at chief executive

level) to do joint work to look at the system of care, rather than the care that one service provides.

Include mental health incidents in the policy Most participants with expertise in mental health said that one policy should cover all incidents, replacing the current system of having a separate policy document for incidents involving users of mental health services.

As they reasoned, mental health should be seen as integral to health, and separating it out from physical health is undesirable. The policy could still give specific guidance for mental health incidents, for example, to recognise mental health reviews are complex and to use a separate process if appropriate.

A few participants disagreed with combining the two policies, because of the sensitive nature of mental health incidents.

A criticism from some participants was that the SAC matrix is too clinically focused and not relevant for mental health (or disability) incidents, which are mostly behavioural issues.

Some participants advocated that all incidents – not only mental health – have a similar triage process and, as noted above, that organisations have flexibility in the method they use to review them, to help create a more integrated policy.

Work towards a cross-agency approach with common definitions and classification Common terms and definitions: Many participants supported using consistent, shared terms for incidents and harm across agencies and sectors. Currently there is much diversity even within our policy. Differences are also evident between ACC, Office of the Health and Disability Commissioner and the Ministry of Health, and across sectors (primary care, secondary care, aged care and disability support services).

Participants tended to favour the term ‘incident’ over ‘adverse event’ because it is more widely used, for example, in primary care and disability support, and covers near misses as well as actual events. Some commented that ‘adverse event’ is a specialised term that many people do not use or understand.

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Common classification system: Some participants wanted the national-level agencies – such as the Commission, ACC, Office of the Health and Disability Commissioner and Ministry of Health – to work towards a common classification system and reporting templates for classifying severity and incidents to be nationally reported. They identified the Commission as having a national leadership role in encouraging a cross-sectoral approach.

Standardisation of data with a new organisation: An aspirational goal some mentioned was to agree on standardised data fields in all agencies’ templates so that data could be linked across the data sets of various agencies. A few participants suggested creating a new organisation for managing incidents and complaints. It would then hold all the data in one database, and different agencies would contract to it to access the data and analysis they needed for learning.

Greater sharing of information across agencies: One of the opportunities for more sharing of information that participants identified was to have two-way sharing between HealthCERT and the Commission. We could analyse national trends using HealthCERT’s information, and HealthCERT could do a spot audit where we identify a pattern of similar incidents in one provider.

Greater sharing of information within the Commission: A few people commented on perceived duplication of information, or lack of integration, within the Commission. One, for example, asked whether the policy could include the various reporting streams to the Commission (for example, providers notify the infection prevention and control team of incidents, which is distinct from our policy). Another called for more consistency and information-sharing across internal programmes within the Commission.

Crossover with health and safety: Some participants said that adverse events often have a health and safety component, and that our system only relates to clinical – not staff – incidents. Where the boundaries are between an adverse event and a health and safety incident caused some confusion. Some felt there was duplication in reporting to us and to WorkSafe.

Others, in contrast, felt keeping these incidents separate was appropriate.

Some suggested options for addressing this crossover were to:

• acknowledge in our policy that employee events (health and safety) happen in clinical settings – so can be hard to separate out from clinical adverse events

• align our policy with the new WorkSafe methodology for health and safety reporting – for example, draw on its reporting template and classification system.

4. Consider prioritising what is reported nationally

Tensions over having enough resource for reviewing incidents One consultation question focused on the tension between reporting a total number of incidents that is high enough to allow learning, and avoiding reporting more incidents than the available resources can cover (to adequately review and learn from the incidents). Acknowledging this tension, many participants saw it as difficult to resolve.

Participants generally agreed it wasn’t appropriate for the Commission to require any set level of resourcing for reviewing incidents, but that it should make clear its expectation that local organisations are to allocate adequate resources to this area.

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Some possible ways to reduce this tension are to:

• make greater use of prioritising to identify the incidents that need to be reported nationally (see below)

• limit in-depth reviews of serious incidents to 5–10 a year for each organisation – and ensure these are done well

• triage incidents more at the local level to strengthen the focus on priority areas where much can be learned, for example, deteriorating patient, failure to follow up results

• simplify the review process so it is less resource-intensive • simplify the whole process so it is easier to report and review, and to take actions • shift focus to locally review more SAC 3 and 4 events, and near misses, as a way to

prevent serious incidents in the future.

Possible ways of setting priorities Some participants supported the idea of giving priority for reporting and review to the areas with the greatest potential for improvement. They advocated national reporting for only an agreed set of events that are considered the most preventable, the most serious, or the highest-priority areas, such as deteriorating patient or treatment delays. A few people suggested changing the system to report only SAC 1 events nationally, because they felt local organisations need not report all SAC 2 events individually to the Commission. One said that local organisations could use various methods to review incidents that were SAC 2 or below, such as root cause analysis, the London Protocol or clinical review.

For those who supported prioritising, their reason was to reduce the volume of reporting so that local organisations had adequate time to conduct high-quality reviews and take appropriate action to prevent harm.

Report common incidents differently Many participants argued that organisations could report and review some common serious incidents – such as falls, pressure injuries and community suicides – in a different way to other serious incidents. Participants had sharply different views on this idea, however, particularly on the topic of falls, as Table 15 shows.

Table 16 lists options participants suggested for prioritising what is reported nationally.

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Table 15: Participants’ views on the option of reporting falls differently


Time-consuming to report all incidents individually

High level of harm and cost from falls so they still need to be counted nationally (one of the areas causing the most harm)

Limited new learning may come from common incidents like falls

Evidence indicates reductions in falls are linked with the national focus on falls prevention

Most DHBs now have falls review groups in place, so it is less relevant to report falls nationally

Risk of losing the good engagement and work that organisations have done on falls, if how they are reported changes

If a good falls programme is in place, then organisations shouldn’t need to review individual falls

Risk that people will see falls as less important if not required to report them nationally in the same way as other incidents

Duplication exists because the Commission’s Windows project also reports nationally on falls each year

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Table 16: Participants’ suggestions for ways to prioritise what is reported nationally

Theme Specific ideas

Report nationally on only a few defined events over a two-year timeframe

• Consider selecting a few clearly defined incidents on which to report nationally to the Commission over a specified timeframe (for example, two years). Use these reviews for a national thematic analysis and national learning

• Change the incidents for national reporting every two years

Change the classification of selected common events (for example, falls, suicides)

• Remove falls (and/or pressure injuries and community suicides) from SAC 2 and require or encourage organisations to review them locally

• Rather than reporting all falls as SAC 2, allow more leeway for moderate falls to be SAC 3

Report on selected common events in a different way

• Ask DHBs to report on the themes that emerge each year, instead of reporting all individual events – DHBs could do a large review of all falls

• Allow providers to report incidents such as falls in batches to the Commission instead of individually – monthly or quarterly

• Allow providers to review incidents such as falls locally and then give a summary to the Commission six-monthly or annually (numbers and summary of learning)

• Report falls nationally using the quality accounts

Apply the current mental health process to selected common events

• Apply the current mental health review process to falls and pressure injuries at a local level – because they share contributing factors and preventive strategies

• One provider, for example, takes these cases to an internal moderation group, which looks at the preliminary analysis and decides whether more needs to be done

Devolve responsibility to EAGs

• Consider devolving responsibility for reviewing and learning nationally from falls and medication errors to the EAGs that focus on these areas

List of always report (never) events Most participants favoured defining an ‘always report’ list of events that organisations must always report no matter what the outcome is. Of the 20 interviewed participants that discussed this topic, 15 supported having an always report/never events list, four disagreed and one participant was neutral, taking the view that such reporting is only valuable if evidence shows it is effective (see Table 17).

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Table 17: Participants’ views on an always report (never events) list


Helps to raise profile of these events Not necessary because the included events would be generally covered by the SAC matrix

Puts a stake in the ground Implies mistrust

More open and transparent Could be used punitively

Having a list makes the process simpler Could introduce confusion about whether to report events that aren’t on the list

Helps remove uncertainty and increase standardisation

One person questioned whether it would affect insurance (for remedial work after an incident on the list)

Acknowledges there are some things you have to report

Participants said the list shouldn’t be too long and should be reviewed regularly to keep it current and relevant.

Advice for what to include in a list covered: surgical site infections; pressure injuries; falls with fracture; blood composition given to wrong consumer; abduction of baby; retained instrument; and foreign body.

A suggested option was to encourage local providers to develop their own list on a voluntary basis, rather than requiring them to use a national list. 5. Clearer purpose statement Many participants said the policy should explain its purpose and rationale more clearly.

Its purpose statement should explain why national reporting and learning are important, why organisations should report and learn, and what the Commission expects to achieve from reporting and learning.

Review objectives and scope of our policy According to participants, our policy objectives and scope should include the areas listed in Table 18.

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Table 18: Participants’ suggestions for improving the aims and objectives of National Reportable Events Policy

Area of policy

Suggestions

Aim To prevent harm and increase consumer safety

Objectives • To drive local improvement actions • To create a national picture of serious incidents and learning, and to

share this learning nationally • To encourage learning from serious incidents, at both national and local

levels, as a quality improvement tool

Use of a diagram/ model

One participant suggested using a visual consumer safety diagram to show how reporting relates to consumer safety (example from Whanganui DHB) Another suggested using the model of reporting, reviewing, whole-system learning that the first Perioperative Mortality Review Committee report promoted

Audience Clearly state who the audience is – the policy needs to be relevant to consumers, providers, frontline staff, managers, board and other affected parties

Scope Clearly state the scope of the policy Question of whether to include or exclude health and safety (staff) incidents – and explain this decision

Participants thought our current policy principles were appropriate, particularly the principles of just culture, open communication and open disclosure.

Several said the policy should emphasise the need for organisations to develop just cultures, which look after the needs of staff who have been involved in a serious incident.

Another wanted the policy to distinguish between open communication and open disclosure, rather than defining them in the same way. They argued open communication has a broader and more proactive meaning.

Clarify roles and expectations nationally and locally A key finding was that people wanted the roles and expectations of both the Commission and local organisations to be clear.

Table 19 sets out the components and questions that participants suggested need to be clarified.

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Table 19: Participants’ suggestions for clarifying roles and expectations of the Commission and local organisations

Role and expectations of the Commission

Role and expectations of local organisations

National integration role: opportunity to integrate consumer safety and learning from incidents across agencies and sectors

Expectation that local organisations have ownership of reporting and learning

The Commission wants the policy to enable more learning from incidents – the new policy should signal it puts more emphasis on learning (and less on reporting)

Expectation that chief executive, board and clinical leaders are committed and involved For example, the Commission could clarify we encourage incident reporting information to routinely go to the board to consider and integrate with planning

The Commission wants providers to adopt this policy in a spirit of partnership – to agree to a common approach to classifying, reporting and learning from incidents

Clarify what is mandatory in the policy and for whom

The Commission will set out our expectations in this policy – for example, for timeliness of reporting and learning, consumer input, and components of a good review

Many said they wanted the Commission to clarify what it wants providers to do to implement this policy (linked to the purpose and aims)

The Commission will provide guidance on how to share learning, for example, across primary and secondary care

In this consultation, some providers said they expected to get feedback and guidance on SAC 1 and 2 events from the Commission – but they don’t get this currently. They wanted our:

• feedback on the quality of their review and recommendations • advice for other actions that they may not have considered • advice on sharing information about similar incidents in other services so that they can

share learning more directly and give each other peer support.

Benefits for providers in reporting and learning from incidents A common theme from participants was that the policy needs to explain why local organisations should report – in other words, why it is in providers’ interests to report and learn from incidents.

As participants saw it, incident reporting and learning can help providers by:

• providing information back to affected consumers and families/whānau • making providers accountable to the public • helping local providers to prioritise and make the best use of their resources – to decide

which incidents need a detailed review and which don’t • potentially saving time and costs with safer systems and fewer incidents. Some said the

potential to save money should be a key driver of this work.

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Should the policy be mandatory or voluntary? Polarised views emerged on this issue throughout the discussions – sometimes in relation to specific sectors like primary care, but also more generally. People tended to agree that the policy should clearly state our stance and signal the type of culture it is encouraging (for example, a culture of local ownership and quality improvement, or a culture of reporting and compliance).

Table 20 summarises the contrasting arguments for mandatory and voluntary approaches, based on this consultation.

Table 20: Participants’ views on mandatory versus voluntary reporting

Arguments for a mandatory approach Arguments for a voluntary approach

Organisations should experience consequences for not complying with the policy – otherwise they don’t report all serious incidents and don’t provide all Part Bs

Reporting nationally should be an expectation that organisations voluntarily commit to – because they can see it is important for consumer safety and improving care

A mandatory requirement has ‘more teeth’

Many organisations feel under pressure already and have multiple compliance requirements – so don’t want to add to this

It is inconsistent to contractually require DHBs to report while allowing other organisations to report voluntarily (all organisations that provide health or disability services should be required to report serious incidents)

The policy should articulate the expected outcomes and provide guidance, and then leave it to local organisations to decide how to deliver the outcomes (the policy should be a code of practice, rather than a compliance document)

The WorkSafe model is useful to look at because, although it requires legal compliance, it also encourages wide engagement to develop safe workplaces for everyone – taking a constructive, not punitive, approach

Important to take an approach that is based on good relationships and developing good cultures – work together to develop safer cultures (as opposed to a ‘big stick’ approach)

6. Easier ways to report and learn

Electronic reporting Participants made a strong call for an online reporting template. They also wanted better use of technology to improve areas such as regional learning.

Many people criticised the current system for requiring local providers to email in reports that the Commission then manually processes. In their view, this approach is time-consuming and outdated. A common concern was that both national and local organisations are duplicating information and effort.

In supporting an online reporting template, many wanted a template that could be embedded into existing local electronic reporting systems, so that all information is in one system and can be easily linked. They commented that internal reporting systems (both DHB and other

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systems, such as some disability support service providers) have improved recently, yet organisations have to duplicate information from their internal system to send to us.

Some DHB participants said our policy should be consistent with the language and categories used in Safety First, Risk Man and other reporting systems DHBs are now using.

Specific ideas were to: • introduce a separate online ‘consumer portal’ so that consumers can enter an adverse

event into the system – as well as an ‘organisation portal’ for incidents the organisation enters

• allow the full range of staff in an organisation, including cleaners, to enter an incident.

Some participants said reporting increased significantly (for example, by 12–16 percent) after an organisation introduced electronic reporting. They thought the reasons for such increases were that the electronic format made reporting templates more visible and gave prompt feedback to staff once they had reported.

Make it easier for clinical staff to take part by back-filling clinicians A common theme was that staff had limited capacity to do detailed reviews of incidents. In particular, people talked about clinicians finding it difficult to take part in adverse event reviews, given their heavy workloads. One recommendation was to consider ways to fund organisations to free up clinicians to take part in reviews (that is, ‘back-filling’ clinicians).

Concise policy document with tools and templates attached There was a strong preference for a more concise policy document – 1-3 pages only – as people felt the current document was too long. They wanted the policy to be accompanied by a wider range of tools and templates, which could be attached as appendices or links when viewing the document online.

Simplify the SAC tool format Many people said the SAC matrix was too detailed and confusing. Southern Cross provided an example of how they have adapted our matrix into a one-page version, which they are open to the Commission using or adapting.

Simplify the reporting process Some people suggested changes to streamline the two-part reporting process (Part A and B). Others were satisfied with the existing two-part process. Suggestions are set out in the table below.

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Table 21: Participants’ suggestions for simplifying the reporting process

Option Indicative support

Remove the Part A notification altogether (because it is easier to report at the end only)

Some participants

Allow Part A to be submitted without chief executive sign-off (as this slows the process)

Minority suggestion

Change Part B to send in the whole review report, rather than summarising it (because it is time-consuming to summarise the report and the Commission should see the whole picture)

Some participants

Change Part B process to allow organisations to prioritise ‘easy’ actions (so that they can quickly act on easy recommendations and share learning with frontline staff promptly)

Minority suggestion

Simplify the classification of severity Consultation participants, on the whole, supported simplifying the classification of severity (see Table 22). Views differed widely on the best way to classify it, however. Some others favoured our current classification system, arguing that it is best to keep it for consistency and comparability.

In discussing the problems with the current approach, some said the SAC tool was too sensitive and produced inappropriate ratings at times. In particular, some were concerned about doing reviews of some incidents unnecessarily, as well as about situations where organisations inappropriately downgraded SAC 2 events to SAC 3 and therefore did not thoroughly investigate them.

Several spoke about classification coming down to the judgement of practitioners (for example, ‘knowing’ when an event is serious). One said that a way of making SAC assessment more consistent would be for staff to use and refer to the SAC tool when reporting an event, rather than relying on recall. Another felt the SAC tool wasn’t helpful with a cluster of incidents (for example, a cluster of SAC 3 events should become a SAC 2 event and be reviewed because they are likely to recur).

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Table 22: Suggested changes to the severity classification

Potential change

Options

Reduce the number of categories of severity

Reduce the current SAC 1–4 to only two categories – nationally reportable and non-reportable events (because all events are serious to a greater or lesser degree) Merge SAC 3 and 4 because a local review deals with both of them in the same way

Align the classification system with other relevant systems

Align with WorkSafe’s new severity classification system Reverse the order because other classification systems (for example, pressure injuries classification, Bupa critical incident reporting) have the most severe incidents classified as 5, not 1

Specific ideas on incidents to remove from the requirement to report nationally

Remove the need to report suicides in the community – because these shouldn’t be defined as an adverse event (more an undesired outcome of treatment), reporting feels punitive (mental health staff feel under more scrutiny) and exacerbates stigma, the suicide mortality review committee should capture this learning in any case, and some (others disagreed) felt little learning came from community suicides as they often did not involve system issues Participants who argued for removing community suicides from national reporting emphasised they should still be reported locally and learned from

Suggested changes to the likelihood classification Some said they were confused about the likelihood classification and argued that the decision could be based on consequence alone (without considering likelihood because people find it confusing and subjective). They recommended removing the likelihood table altogether. Others argued that both dimensions are needed to assess severity/harm and potential risk.

An alternative suggestion was to reduce the number of categories for assessing likelihood from five to three (almost certain, moderate, rare) – to make it easier to decide the likelihood.

Keep the current timeframes Participants generally agreed that the Part B timeframe was difficult to meet, particularly for mental health and other complex reviews. Most, though, favoured keeping the current timeframes as an aspirational goal, rather than extending them. As they saw it, timeliness is important for learning and for reporting back to consumers and/or families/whānau. Deadlines also give organisations an incentive to be efficient and reduce delays.

Several other participants, in contrast, suggested extending the Part B timeframe from 70 to 90 days.

Many participants favoured the current approach of seeing the timeframes as an expectation or guideline, rather than making it a requirement. Some said they would prefer the Commission to follow up when deadlines are extended too much, and to offer support to help to complete the review.

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Review the World Health Organization codes Finally, participants saw the current World Health Organization codes as too broad, and not relevant to primary care or disability support services. Some suggested breaking down Category 2, in particular, into various components. One recommended using the same codes (16 categories) as in the Safety First reporting system.

Conclusion and next steps Our consultation found strong agreement – among more than 100 diverse participants – on the need to reorient the National Reportable Events Policy to focus more on facilitating learning from incidents, so that organisations can make changes to improve consumer safety.

Consequently, people generally supported changing the policy to lift the quality of incident investigation and corrective actions, and to make reporting and learning easier.

The consultation provides important insights from key people with an interest in incident reporting – both providers and consumers – to help inform the next stage of our policy review. It will complement our literature scan on national patient safety reporting systems.

Despite the broad nature of the topic, the findings indicate which potential policy changes may be more or less acceptable to stakeholders. This consultation provides a basis to further consider and consult on the best ways for the National Reportable Events Policy to advance learning and take action to improve safety.

Documents

Ideas to improve the National Reportable Events Policy ... · simplifying reporting processes and tools : Strengthen the focus on consumers . ... The main audience for this report