Development of the 'People-Processes-Paradigm' critical analysis tool for mortality and morbidity reviews: improving understanding of systems factors.

Abstract

The impact of systems problems and human factors on delivering safe, high-quality patient care is well recognized. In the surgical setting, mortality and morbidity reviews (MMRs) are the key forum for reviewing and analysing adverse events in patient care yet there is a paucity of simple tools for undertaking such analyses. The aim of this study was to develop and pilot a new tool for analysing mortality and morbidity cases incorporating human factors and systems analysis. The published literature, professional standards, guidelines and existing audit tools for MMRs were reviewed. The 'People-Processes-Paradigm' tool was developed and pilot testing was undertaken and stakeholder feedback was obtained. Models found for undertaking systems-based analysis of adverse surgical events included the 3D model, SEIPS and the Queensland Health human error and patient safety (HEAPS) Incident Management Tool. Guidelines for standards in MMRs are provided by the Royal Australasian College of Surgeons, New South Wales Clinical Excellence Commission and Australia and New Zealand audit of surgical mortality (ANZASM). The People-Processes-Paradigm model incorporates these standards and evidence-based systems analysis tools into a single effective tool. The pilot study evaluating the use of this tool demonstrated it to be practical and easily applicable to regular use by clinicians, with the ability to be tailored to individual health service use. Improvements such as electronic format and clarification of case selection processes were recommended by users. The People-Processes-Paradigm tool has been developed for surgeons by surgeons incorporating current professional, legal and regulatory requirements in Australasia, easily transferrable to electronic platforms. This model requires further testing for validation.