In 2013, Charles Vincent, Susan Burnett and I published The Measurement and Monitoring of Safety Framework (Vincent, Burnett and Carthey, 2013; The Health Foundation, 2014). Given that a second wave of COVID-19 is a real possibility, I have adapted the Framework and applied its Five Lenses of Safety, (past harm, reliability, sensitivity to operations, anticipation and preparedness and integration & learning), to illustrate some of the safety data, metrics and soft intelligence, health and social care organisations must seek out and integrate when planning for future outbreaks:
Looking through the past harm lens, (our rear view mirror), we need to reflect and learn from what we now know about the types of harms suffered by patients and staff, and what we can learn from them. Questions health and social care organisations might ask when looking through the past harm lens are: How many hospital or care home acquired COVID-19 cases did we have? What gaps in our systems and processes contributed to them? What can we learn from incident reporting, complaints, and claims data? What is our excess mortality rate? What worked well to prevent or recover harms (i.e. Safety II learning including administering dexamethasone to ventilated patients)?
Past harm is not just about learning from physical harm to patients, staff, residents, and those receiving treatment in their own home, for example, from hospital or care home acquired COVID-19. It is also about reflecting on other types of harm including, for example, dehumanisation and psychological harm: COVID-19 patients who are hospitalised are (necessarily) separated from their loved ones to reduce the spread of infection. What can we learn about how we supported patients, their loved ones, and staff through that enforced separation? Did we maximise the use of IT technologies and social media to ensure contact was maintained? What did we do well to support both patients, their loved ones, and staff? How did we adapt our ways of working to prevent dehumanisation and psychological harm to both patients and staff (i.e. Safety II learning)?
The reliability lens enables us to reflect on how reliably our clinical and non-clinical systems, processes and pathways worked. Looking through the reliability lens, are there lessons from how we reconfigured services to manage the pandemic which had unintended consequences for patient and staff experience, and efficiency? Is there a better way to manage service reconfigurations in the future? Are staff support services working reliably, i.e. what are the waiting times for staff to access support and counselling services? How well is the PPE supply chain working? Are there inefficiencies in the turnaround times for test results to become available and if so, how might we resolve these? How might we improve the reliability of both clinical and non-clinical systems based as we plan for a second wave?
Observing, listening, and perceiving (sensitivity to operations)
The third lens of safety, sensitivity to operations, is simply how health and social care organisations tune into safety risks by observing, listening, and perceiving. Are staff wearing PPE wearing it for long periods of time and if so, how has that affected their performance? Have staff fed back that they or their colleagues get dehydrated whilst working in PPE? Do observations of behaviour in communal areas, during rest breaks and in hospital lifts highlight environmental and points during a shift where it is more challenging to follow social distancing rules? Are our conversations with frontline staff giving us warning signs that staff are burnt out, tired, stressed, and traumatised? Is PPE readily available, including for non-clinical staff like cleaners, receptionists, catering staff etc.? The value of soft safety intelligence from what one sees, hears and perceives cannot be under-estimated: It is often the best indicator of how behaviour and practice in the ‘real world’ has drifted from the ‘world as imagined’ in policies, procedures and guidelines. As such, it must be at the heart of second wave planning.
Anticipation & preparedness
The ‘anticipation and preparedness’ lens involves asking the question, ‘Will care be safe in the future?’ From a COVID-19 perspective, the challenge for health and social care organisations are that much of the data which supports anticipation and preparedness is not generated by the organisation itself: Keeping abreast of media and social media reports, and research articles (both nationally and internationally) is vital. For COVID-19, media and social media are useful tools which may provide early warning signs that the general public’s behaviour could be increasing risk. For example, mass gatherings in the local community or social media reports describing public non-compliance with social distancing rules in supermarkets, at work etc. Tuning into public behaviour in the local community is especially important. So, is knowing your local business demographic, for example, what businesses exist in your local community where following social distancing is challenging for the workforce? What risks does your local business demographic introduce?
Anticipation and preparedness also involve asking different questions of existing data sets. For example, do annual leave rates indicate staff who are integral to the organisation’s response to COVID-19 (both frontline and non-clinical staff) have not taken their allocated leave? Has staff turnover increased and, if so, what are the implications of increased vacancy rates on the safe provision of future care? What does our occupational health and staff support services data tell us about how our workforce is feeling and coping? Are risk assessment and burnout tools being used and if so, what is that data telling us? Are we maximising the value of staff risk assessment data or has it turned into a ‘tick box’ exercise?
Integration & Learning
Finally, second wave planning involves integrating and learning from the plethora of hard data and soft safety intelligence health and social care organisations have gathered across the other four lenses (past harm, reliability, sensitivity to operations and anticipation & preparedness). The complexity of the integration challenge for COVID-19 is exacerbated because the world is still on a learning curve. Health and social care organisations are also working in a context where guidelines and policies change in line with new research evidence, and where new causes of risk are still being identified. What is important for both integration and learning is to look beyond our own organisational or health economy boundaries, and to seek out what has worked well and what has not (both nationally and internationally). We also need rapid feedback mechanisms in place to ensure lessons are shared effectively. Finally, it is vitally important to give equal weight to soft safety intelligence gathered from what we see, hear and perceive, and to integrate staff, relative and patient experience data alongside hard metrics (i.e. dashboard data on infection rates, mortality and morbidity rates etc..).