Award Title: Developing a co-designed systems-level response to safety issues for residents transitioning from hospital to care homes
Funder: Dunhill Medical Trust

Abstract: Background: Transition from hospital to care home is high in risk, with a third of transitions resulting in adverse events (Kapoor et al., 2019). Common problems include communication failures, (Richardson et al., 2019) medication errors, (Weir et al., 2019) and incorrect documentation (Hellesø et al., 2004). Identifying incidents is difficult; reports do not accurately reflect level of harm (Scott et al., 2019a), care home and hospital organisations have different priorities (Sutton et al., 2016), and health and social care sectors use different definitions of safety (Scott et al., 2017). Consequently integrated care is lacking, and opportunities for organisational, cross-sector learning can be missed (Scott et al., 2017). Moreover, there is a knowledge gap around how care homes collect incident reports.

Aims: Develop a better understanding of incident reporting in care homes and co-design a systems-level response to safety issues for patients transitioning from hospital to care home. 
 
Methods: Two Workstreams (W) will run in parallel. W1 will consist of a scoping review of types of existing systems for reporting incidents, including policies, technology and types of data captured. Representative stakeholders representing medium to large care home organisations will be involved, leading to the development of a taxonomy of incident reporting in care homes. The taxonomy will be developed using a standardised approach to taxonomy development (Nickerson et al., 2013). W2 will be structured in three Phases (P) with care home organisations. P1 will consist of ≤40 interviews with care home staff to develop a better understanding of their specific internal systems for reporting incidents. P2 will consist of a retrospective documentary analysis of care home data relating to resident transitions, using the knowledge of the systems gained in P1. Data size and sampling will be determined based on potential data size. A validated data extraction form (Scott et al., 2019) will be adapted and revalidated before use. Content analysis (Elo and Kyngäs, 2008) informed by the heuristic of systemic risk factors will be the primary mode of analysis, supported by thematic analysis for emerging themes (Braun and Clarke, 2006). P3 will consist of four validation and co-design workshops to develop a service specification using NHS Improvement's (2018) framework. This will then be mapped against existing systems and recommendations produced. 

Discussion: Commissioners, providers and regulators will be able to use the co-designed service specification to improve integrated care, leading to a positive impact on the health and care of older people.

Lay Abstract: When people move from hospital into a care home, it is quite common for something to go wrong with their care that does or could affect their safety. This is called a safety incident. Some examples include medicines being lost or delayed, or important documents containing mistakes or going missing. It is important to find out when and why safety incidents happen so that improvements can be made. Finding this out doesn’t happen enough because care homes and hospitals sometimes have different priorities other than the person’s care. They also have different understandings of what unsafe care means. Hospitals generally think of unsafe care as being a problem with the system that affects everyone, whereas care homes usually think of someone being unsafe because of problems with the care provided to just them. 

Because of these different approaches, it can be difficult for care homes, hospitals, or even organisations that oversee them, to learn from safety incidents. As such, this study aims to understand how care homes and care home staff report safety incidents when a person moves from hospital to a care home. Using this understanding, we aim to work with care homes and hospitals to jointly design a better way of reporting and learning from safety incidents.

The study will be split into two parts that run alongside each other. During the first part (workstream 1), we will review how care homes respond to safety incidents. This will include looking at what policies exist, what technology is used and how reports are captured. This review will be desk-based, combining internet searches, telephone interviews and academic papers. From this, we will create categories of the different systems being used. During the second part (workstream 2), we will work with two care home organisations, one in North East and one in South West England. Each will contain around 30-50 care homes, and will cover all different types of care homes (eg nursing, residential, dementia). We will begin by speaking with up to 40 care home staff to find out how they report incidents. Then we will review the information that the care homes hold, using a method that we have developed and used previously. We will use what we learn to jointly design a new system for learning from safety incidents by hosting four workshops. This new system will be compared with existing systems and recommendations will be made.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health Categories: GENERIC HEALTH RELEVANCE