PHIRES is an incident investigation tool to review incidents sustained through patient handling.
The PHIRES Tool is based on a systems-thinking approach to preventing patient-handling injuries. It is designed to help employers:
- review, and if necessary revise, risk controls following a patient-handling injury
- focus on risk controls for the task, rather than the injured person
- consult with health and safety representatives (HSRs) and employees
- identify more effective risk controls
The following videos explain the PHIRES Tool and its use.
PHIRES, Patient Handling Incident Review of Systems is an incident investigation tool used to review incidents sustained through patient handling.
Workplace injuries present a significant burden on individuals, employers, community and society. The factors contributing to worker injuries are complex and multi-faceted.
To prevent the occurrence of future injuries in the workplace, it's essential that the tools used to investigate injuries are underpinned by an evidence base that will optimise learnings.
During an incident investigation, the model you choose will direct you to look at certain things and not at others.
The What-You-Look-For-Is-What-You-Find principle describes this phenomenon – essentially, the accident model you choose will determine what factors will be seen as the 'causes', and what other factors are ignored.
This means it is crucial that you choose the right type of model. The kind of accident causation model that you choose will determine the type of data collected, and the method used to analyse the data.
This is important as the outcome of the data analysis will ultimately inform the recommendations that will be proposed. This thinking extends the What-You-Look-For-Is-What-You-Find-Principle to What-You-Find-Is-What-You-Fix.
There are three types of models: Simple linear models, complex linear models, and systems thinking models.
Simple linear models view incidents like a set of dominoes. Social environment and ancestry generate fault or carelessness in a person, which in turn triggers an unsafe act, followed by an accident leading ultimately to the injury.
In this model, accident prevention sees frontline staff and equipment as the cause of workplace injury.
Prevention activities informed through simple linear models generally propose retraining staff and making repairs or upgrades to equipment as the only methods of accident prevention.
Complex linear models view incidents like 'Swiss' cheese. Each hole in the cheese illustrates a lapse in safety procedure and when multiple holes align it results in an adverse outcome.
Complex linear models go beyond simple linear models by proposing that there are usually many latent conditions within the organisation other than just frontline staff and equipment that act as the catalyst for accidents, but they still use a restrictive linear approach.
Prevention activities informed through complex linear models generally focus on increased supervision as well as revision to procedures and policies.
Systems thinking models, on the other hand, view incidents as results of a complex system of interacting work-related and societal factors, in addition to the physical risks typically associated with the work task.
System thinking models look at 'normal' conditions of work as contributors to injury, not just individual 'errors' or 'failures'. The purpose of the investigation is to understand why decisions and actions made sense at the time.
Prevention activities informed through systems thinking models go beyond simple 'find and fix' thinking and allow for complex analysis to take place and create system change. Let's take an example of a workplace injury from the health care sector and review it using the three different models.
A patient has fallen out of their hospital bed. A busy nurse hurries to lift them off the floor and, in the process, injures her back.
In the simple linear model, the dominoes would be: The nurse was ageing, the nurse rushed, a hoist was not used which caused an accident and subsequent injury. The solution presented by this model would be to retrain the nurse.
In the complex linear model, the holes in the 'Swiss' cheese would be: A gap in procedure, poor supervision from buddy nurse, perceived time pressure and, finally, the hoist not being used.
To prevent similar accidents, the complex linear model might suggest revising procedures as well as retraining both the nurse and her buddy.
In a systems thinking model, factors contributing to the incident are identified across all levels of the system. From Government, regulators, and external influences, to governance and administration,
to operations management, onto front-line staff, equipment and surroundings. In our example, legislation is identified as a factor that had an impact on patient ratios as well as budgeting at the administration and management level.
The impact of these factors flows on by contributing to a lack of supervision and support, which in turn, creates stress and the perception of time pressure.
This investigation also identified that the activity-based funding model for health services meant that the company had no specific budget for handling equipment, resulting in only two hoists being purchased per ward.
As a result, the patient did not have a hoist available in their room, which added to the nurse's perception of time pressure and contributed to the decision to lift the patient unsafely.
The recommendations for prevention activities using the systems thinking model have the potential of creating sustainable change in the prevention of future incidents.
For example, installing overhead tracking in every room or providing a dedicated hoist in each patient's room that requires mobility assistance would ensure that mechanical lifting aids are onsite.
Implementing a model of care on the ward where nurses work as a team to deliver patient care would make sure that help is readily available.
In another example, by recommending changes to minimum ratios and funding models, the systems thinking review could have the benefit of improving consultation across the system as well as mitigating against pressures --
such as time pressure on nurses -- at lower levels of the system. This recommendation shows that, if carried out, it would help prevent the same accident occurring not just to that nurse or in that hospital, but also in all other hospitals impacted by the same legislation and funding models.
From a systems thinking lens, accidents are not isolated events caused by single individuals but instead a result of complex interactions of multiple factors across many levels of hierarchy.
It looks to create a learning culture in which open collaboration can create tangible and far-reaching solutions.
A critical gap in current practice has been a toolkit that allows Occupational Health and Safety practitioners to use systems thinking to identify the complex system of factors that can inform incident prevention activities.
That’s why researchers in Australia have developed a standardised process for investigating injuries to staff. The unique contribution of this investigation toolkit is that it's underpinned by systems thinking principles.
The PHIRES Tool provides a systems thinking approach, which guides practitioners in identifying the factors that contribute to incidents and the relationships between these factors, and in generating actions to guide sustainable change in the system to prevent the recurrence of injuries.
PHIRES Step 1
PHIRES Step 1
Step one of the PHIRES Tool is focused on providing a summary of the incident. This step asks you to:
First: describe the flow of events on the day of the incident and any relevant events leading up to the incident.
Here is an example to illustrate a summary of the incident: 'An elderly patient fell out of their hospital bed. A nurse rushed to lift them off the floor and injured her back in the process.'
Second: describe the outcome for staff including any injuries or harm sustained by the staff member as a result of the incident. Based on the example incident, the outcome of the nurse assisting the fallen patient is an injury to her lower back.
It is also recommended that you describe the outcome for patients including any injuries or harm to patients as a result of the incident. In the example, this could be an injury to the patient's hip.
Third: list the risk control measures currently in place for the work at the time of the incident. Involve Health and Safety Representatives and the people who do the work. Make sure you list the controls that are used to reduce the risk.
For example hoist, manual handling procedures, and patient handling training and the systems that are in place to ensure that the risk control measures work and are reliable.
For example staff numbers and supervision.
The final piece of information at Step one of the PHIRES Tool asks you to describe the response to the incident prior to the review. In the example provided, the nurse's unit manager calls the nurse to ask if she is okay and when she is likely to return to work.
This information completes the first step of the PHIRES Tool.
PHIRES Step 2
PHIRES Step 2
Step 2 of the PHIRES Tool is about identifying relevant stakeholders to contribute to the review of the incident.
Under the OHS Act, employers must consult with workers and Health and Safety Representatives (HSRs):
- when making decisions on how to control risks
- when making decisions about employee welfare facilities such as dining facilities, change rooms, toilets or first aid
- when deciding on procedures to: resolve health and safety issues; consult with employees on health and safety; monitor workers’ health and workplace conditions; or provide information and training
- when deciding the membership of any health and safety committee in the workplace
- when proposing changes that may affect workers’ health or safety (such as changes to the workplace, plant, substances or other things used in the workplace, the work performed at the workplace)
- when doing anything else prescribed by the OHS Regulations.
To help you consult effectively, the toolkit includes a consultation framework to guide in identifying relevant stakeholders across the system including frontline staff, operations management, governance and administration, and external influences.
Consultation is critical to get the best outcomes from the incident review. Effective consultation will result in:
- Identifying a wider range of contributing factors
- More effective risk controls, as they will be based on the input and experience of a range of people in the organisation, including workers who have extensive knowledge of their own job
- Stronger commitment to implementing action plans, as workers and managers have been actively involved in reaching these decisions
- Greater co-operation and trust, as different parts of the organisation talk to each other, listen to each other and gain a better understanding of each of other's views.
These consultations are critical to optimising the success of the incident review. Meetings, group talks, conversations, emails and phone calls contribute to you gathering valuable insights into the system of factors that contributed to the incident.
Some tips for optimising your consultations…
Depending on your individual preference, your initial approach may be via phone, face-to-face or email. Some tips for using email in the initial approach include:
Introduce yourself and describe your work role and responsibilities in the review and revision of risk controls.
Be clear regarding your intentions in the review process. For example, you may say 'I am seeking your assistance in reviewing an incident that occurred last week, so that I can understand what contributed to
the incident and how we can prevent these types of incidents from happening again. Are you able to help me?'
It is helpful to provide a brief explanation of the PHIRES Tool and its benefits. This will help the interviewee to understand the purpose of the consultation and what you are trying to achieve.
For example, you may say 'I am using a review process that helps guide me in identifying factors contributing to the incidents for the purpose of eliminating or mitigating future incidents.'
It is always helpful to provide some questions in preparation for the meeting. This will help provide clarity on the information you are wanting to gather, and allow them time to reflect.
Be clear on the amount of time required. It is suggested that you also make an appointment at a convenient time and ask if they have any questions prior to the meeting.
Other useful tips to consider….
Acknowledge the expertise of the people providing information and that you understand they are best placed to assist you in the review of the incident.
Acknowledge that with their help, you can generate solutions that will make a difference in creating systemic change that will reduce workplace injuries.
PHIRES Step 3
PHIRES Step 3: Identifying factors for review
Step three of the phase tool focuses
on identifying the factors that contributed to the incident under review.
Why the risk controls were ineffective.
With a bit of practice, risk controls are available.
This video will describe each of these components of Step 3.
The first component asks you to identify contributing factors.
It is critical in the review process that you gather as much detail as possible,
about the circumstances leading up to, during, and after the incident.
Talking to the right people and asking the right questions will
help you to understand the system of factors contributing to the incident.
A checklist of contributing factors and a prompt question sheet has been
provided to guide you in the process of collecting information from the
stakeholders identified in Step 2.
When identifying contributing factors, be as inclusive as possible,
you should have a very good reason to discard something,
even if you think a factor is beyond the control of your workplace.
For example, unclear regulations or guidance material.
Don't be afraid to seek further information.
For example, is there a stakeholder that could provide an additional piece of the puzzle?
For example, talking to the procurement manager
to understand why there was a change in equipment.
Avoid focusing just on the behavior of workers, equipment and the environment
you need to identify factors in a broader system that create the
conditions for injuries to workers.
Don't be deterred if many contributing factors have been identified.
The focus is on understanding the system of factors and the
relationship between factors, not trying to pinpoint a root slash
primary cause you will see the vice tool that the contributing factors
have been categorized using the systems thinking framework describing
the five levels of the health care system.
As a reminder, the five levels of the framework represented in the PHIRES tool include.
One equipment in surrounding this level includes factors relating to
the physical work environment and the equipment that was used prior, to or during the incident.
Two frontline. This level includes factors relating to work design,
staff, patients and consumers, carers and family and external care
providers such as GPS and ambulance.
Three operations management.
This level includes factors relating to supervisors,
patient management and work scheduling for governance and administration.
This level includes factors.
Relating to management systems, resources and leadership.
5 government regulators and external influences.
This level includes factors relating to suppliers,
unions and employer associations and government and regulators.
The second component of step 3 asks you to consider why the risk controls were ineffective.
Identifying the contributing factors should lead to some conclusions
about why the risk controls were ineffective for preventing the incident.
A risk control is used to eliminate or reduce the risk.
However, work systems need to have.
Supporting processes in place to ensure controls are implemented.
For example, providing buffers built into schedules to make sure that enough
time is available to use assistive equipment or ensuring there are
enough staff rostered on shift to use the assistive equipment effectively.
Identifying why risk controls are ineffective will help you identify the actions
required to prevent future incidents.
The third component of step three asks you to identify better practice risk controls.
The fire still prompts you to consider where the better practice risk controls are available.
Bit of practice means a risk control that would further reduce or eliminate
the risk and maybe higher order risk controls or a combination of different types of risk controls,
which work together to reduce the risk associated with the work.
For example, using a bed mover rather than manually pushing a patient bed,
combined with ensuring staff have the appropriate training and procedures in place to access and use that equipment.
This component also provides an opportunity to consult with and document
suggestions from staff to improve the effectiveness of the risk controls.
A simple example is starting shifts 15 minutes earlier to provide protected time for hand over at the bedside.
This completes step three of the PHIRES tool.
PHIRES Step 4
PHIRES Step 4
Step 4 of the PHIRES tool involves development of an Accimap, which is short for Accident Map.
An Accimap is used to represent the factors identified that contributed to the incident
under review, and the relationship between them.
The Accimap describes the five levels of the healthcare system which include:
1) Equipment and surrounding - this level includes factors relating to the physical
work environment and the equipment that was used prior to or during the incident.
2) frontline - this level includes factors relating to work design, staff, patients and
consumers, carers and family, and external care providers, such as GPs and Ambulance,
3) operations management - this level includes factors relating to supervisors, patient management and work scheduling.
4) governance and administration - this level includes factors relating to management systems, resources and leadership
5) government, regulators and external influencers
this level includes factors relating to suppliers, unions and employer associations,
and government and regulators.
The contributing factors identified in Step 3 of the PHIRES Tool are used to populate the Accimap.
These factors are then linked together based on relationships between them.
An interaction between two contributory factors is present when one factor influences the other by:
- Weakening it
Linking the factors together also helps you identify clusters of factors indicating key
issues that need to be addressed.
Several key issues can be identified on the Accimap and can best be illustrated using
colours which identify the cluster of factors that represent each key issue.
For example, at the Equipment level: Availability (or lack thereof) may cause problems with
Work design Handling/Lifting and Load.
Also at the Equipment level: Availability may be caused by Work systems such as Budgets,
which is influenced by Resources such as Funding.
In turn these factors are enabled by Government and regulators: through Funding and priorities.
Identifying these key issues will help inform your action plan in Step 5.
This concludes step 4 of the PHIRES Tool.
PHIRES Step 5
PHIRES Step 5: Developing action plans
The final step of the PHIRES tool relates to developing an action plan to prevent similar incidents occurring in the future.
The action plan should be developed based on the suggestions put forward
by staff during their review and through further consultation with staff
HSR's and the manager is responsible for implementing the actions.
This will ensure that you get the best outcomes from your reviews.
The actions should address the key issues identified in your acci map.
The Axiom app provides the evidence base for the actions lead to improvements
in the implementation of your current risk control measures and if required,
the implementation of new control measures.
But feasible and practicable for implementation.
When developing the actions, it is important to consider the systems thinking principles.
Shared responsibility for safety.
People across the system need to take steps to prioritize worker safety in their decision making.
Multiple interacting factors.
Effective actions address multiple factors at all levels of the system,
including leaders, management, supervision equipment and
the work environment, not just the behavior of staff.
Effective actions focus on improving the flow of information up and
down the levels of the system.
This means that leaders, managers, and supervisors regularly talked
to staff and health and safety representatives to understand what is happening in the work environment.
This information is then informs the development of policies and
procedures which are subsequently reflected in work practices.
Pressures in the system effective action is involved reducing pressures
on staff through work planning to ensure they can perform their work safely.
This includes pressures on managers, supervisors and frontline staff.
Erosion of risk controls.
Work systems need to have good processes in place for monitoring the
implementation of risk controls overtime.
This might include examples such as monitoring the buffers built
into work schedules to make sure that enough time is available to
perform their work as it changes overtime or auditing the ongoing
maintenance of equipment to ensure it is working as intended and the
maintenance schedule is appropriate.
Once you've developed your actions, use the hierarchy of controls to
identify controls that will eliminate or reduce the risks so far as reasonably
practicable as required by the HS Act.
A review that results in more training supervision.
Or changes to procedures is not likely to prevent future injuries.
The fire still prompts you to develop an action plan, including one the specific action required.
The action should be a specific action that will be implemented.
It should not be framed in terms of considering whether to do something.
If more research and business case or approvals are required,
they should be provided as specific actions in their own right.
Two person responsible for action the leader or manager responsible.
Implementing the action needs to be clearly defined that OHS team
should not be responsible for implementing all actions.
Three evaluation of success.
You need to identify measures which will tell you whether the action
has been implemented and successful in addressing the issue.
Don't rely on incident reports four.
Finally, it proposed close off date for implementing the action needs to be identified.
Defis tool also allows you to include recommendations for parties external to your organisation.
For example, equipment suppliers, regulators, or other government agencies.
These should be framed as providing feedback or raising issues with external actors.
The responsibility for communicating the information should be allocated to a specific person in your organisation.
For example, the HS team can provide feedback
to equipment suppliers about design problems with equipment.
They could also email Worksafe Victoria to provide feedback on
guidance your senior leaders can raise issues at relevant industry
forums with government agencies.
Although you do not have control over the external actors in the system,
it is critical to identify and communicate opportunities for equipment,
suppliers, regulators and government agencies to play a role in improving workplace safety.
In doing this, there exists a better chance of
creating systemic and sustainable improvements in workplace safety.
This concludes the final step of the PHIRES tool.
Download the PHIRES Tool
The PHIRES Tool is available in an interactive Portable Document Format for downloading and printing.