The Yorkshire Contributory Factors Framework (YCFF) was developed from a systematic review of 85 empirical studies that reported on the factors contributing to patient safety incidents in an acute hospital setting. In addition to the framework which provides a way of thinking about the factors that contribute to patient safety incidents, we have also developed a check-list which is used by risk managers and clinicians to learn from patient safety incidents. These tools might also be used by researchers and by those designing incident reporting systems.
For further information about the YCFF and associated tools please click here.
With funding from the Health Innovation and Education Cluster (HIEC, 2012-2014) we developed and evaluated a method for supporting UK Hospital Trusts to implement national patient safety alerts. We applied the Theoretical Domains Framework of Behaviour change and worked with hospital teams to identify barriers to change and feasible strategies to encourage change in practice. This approach is reported in two publications.
- Taylor N, Lawton R, Moore S, et al. Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline. BMC Health Serv Res. 2014;14:648
- Taylor N, Lawton R, Slater B, Foy R. The demonstration of a theory-based approach to the design of localized patient safety interventions. Implement Sci. 2013;8:123
Since 2013 we have delivered 18 Achieving Behaviour Change (ABC) for patient safety workshops at regional and national level to support teams in adopting this approach in their own organisations. A toolkit of resources and further information are available here.
We have recently developed and trialled the ‘Patient Reporting and Action for a Safe Environment’ (PRASE) intervention. Click here for more details on the trial. The Yorkshire Quality and Safety Research Group and the Improvement Academy are conducting further work to explore how PRASE feedback can be collected on a regular basis, and how hospital teams can access and use the intervention. More information about these next steps for PRASE can be found here.
Central to the intervention are two tools for obtaining feedback from patients on the safety and quality of their care whilst in acute hospital settings. These are:
- The Patient Measure of Safety (PMOS) – a 44 item questionnaire designed to gain the patient perspective on their care, based on the content of the Yorkshire Contributory Factors Framework (YCFF). We have recently produced shortened versions of the questionnaire: PMOS-30 (30 items) and PMOS-10 (10 items). Work is currently underway to validate the shortened questionnaires.
- The Patient Incident Reporting Tool (PIRT) – a simple reporting proforma designed to be used in conjunction with PMOS, which allows patients to report detailed safety concerns and/or positive experiences.
Supporting references for these tools:
McEachan, R. R., Lawton, R. J., O’Hara, J. K., Armitage, G., Giles, S., Parveen, S., Watt, I. S., & Wright, J. (2013). Developing a reliable and valid patient measure of safety in hospitals (PMOS): a validation study. BMJ quality & safety, bmjqs-2013.
Giles, S. J., Lawton, R. J., Din, I., & McEachan, R. R. (2013). Developing a patient measure of safety (PMOS). BMJ quality & safety, 22(7), 554-562.
O’Hara, J.K., Armitage, G., Reynolds, C., Coulson, C., Thorp, L., Din, I., Watt, I., & Wright, J. (2016). How might health services capture patient-reported safety concerns in a hospital setting? An exploratory pilot study of three mechanisms. BMJ quality & safety. Advance online publication. 10.1136/bmjqs-2015-004260
Sheard, L., O’Hara, J., Armitage, G., Wright, J., Cocks, K., McEachan, R., … & Lawton, R. (2014). Evaluating the PRASE patient safety intervention-a multi-centre, cluster trial with a qualitative process evaluation: study protocol for a randomised controlled trial. Trials, 15(1), 420.
Ward, J. K., & Armitage, G. (2012). Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ quality & safety, 21(8), 685-699.
To request the tools or for more information please contact: Sally-Anne.Wilson@yhahsn.nhs.uk Tel: 01274 542200 (Switchboard)