Safety Improvement in Primary Care


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The development of a Patient Safety Programme for Primary Care is being informed by the learning from two ongoing primary care safety projects. This session highlights the approaches used, the early findings and describes how to sustain and spread the success of this work.

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  • Scotland - Tayside / Forth Valley 32 Volunteer Practices –structured selection over 2 years Clinical Effectiveness/Governance Services Medical Protection Society HS QIS: support & funded
  • Like most people here, I am a patient and, in my case, make good use of the NHS facilities. For this project, I am a Public Partner, not a patient representative because at present I don’t use Warfarin or DMARDS nor am I suffering from heart failure …yet. Because I don’t have a healthcare background, the work I am doing with Lothian Health Board is related to patient involvement. What is Patient Involvement?
  • The Scottish government have been keen to develop the concept of “mutual NHS” where patients are partners rather than merely recipients of care and have both rights and responsibilities towards the health service that they “own”. Most of the work on this public involvement has been including patients in many, many committees and organisations where healthcare workers may have to accommodate the outpourings of some ill-informed patient. In SIPC we are operating at a different level of Patient Involvement. We are working to help individual patients to become involved. The aim is to improve their health and to improve the service they receive. The Patient Rights (Scotland) Act 2011 an NHS based on mutually beneficial partnerships between patients, their families and those delivering healthcare services.
  • Involving patients doesn’t have to be difficult. Here is one example One practice frequently writes information leaflets. This time they did it differently. The nurse, in consultation with the rest of the team, wrote a leaflet with information about Warfarin. Once her colleagues had pulled it to pieces, it was handed over to several patients for their comments. One of these patients had been a proof reader so was ideally suited for this task. An example of how many patients have many experiences from life and work which you can use. Once the patients made their comments, the leaflet was edited and used for patient education. Other practices loved it and have made use of it too. Not difficult – and have produced good product that helps all patients and gives the involved patients a special stake in the leaflet, in the practice and in their health.
  • One of the aims was to improve resources for practices and patients but we had to find out what improvements were required. There fore we needed to find out how patients using Warfarin felt . No point gathering Information if nothing is done about it You said – we did One rather academic exercise was seeing how the patients’ views of the process of having their Warfarin monitored, varied with the practices’ views
  • Just to explain what is meant by process map. Haven’t a chance of reading it but it is a flow chart showing the process from the patient attending practice for a blood test to check INR. Seen like this it is interesting to see how many tasks (12) must be carried out by practice and lab compared with the 6 communications with the patient. The reason for showing this is that the patients identified situations where their actual experience did not meet the mapped process. Action was taken by the practice to remedy these problems.
  • The first thing was to find out what patients thought. Our assumption was that not many folk would be interested. Seven practices sent letters to all of their Warfarin users – 425 in all Of these, 136 patients wanted to be involved (32%) 80 turned up (19%) 2 sessions – tables of 8-12, facilitator/recorder. Facilitators not from practices but health board office staff. “feedback shows that having an independent facilitator puts both patients and practices at ease.” Tayside report at Steering Group 05.05.11 Answers to 3 questions at different stages in life with warfarin Themes raised were fed back to practices No action resulted other than a request to have local focus groups Repeated the exercise with individual practices The themes raised were similar but practices felt responsibility for these and were willing to consider alterations if necessary Happy Patients Key topics were – Main difficulties with lack of information or muddly information. Scary drug need reassurance. Like more GP contact. “ witchcraft” Little understanding of the side effects.
  • Just two comments that were made and the type of response that the practice offered. One covering the lack of information.
  • Answer our own questions . Realised that patients, particularly those who had been using Warfarin for many years didn’t have uptodate information about using Warfarin. The creation of the new leaflet was clear and easy for patients to understand. There is evidence that well informed patients have better outcomes. The themes raised in practice focus groups had a validity and relevance for each practice and staff worked to solve problems The “You said, We did” sheets made patients feel that their comments were listened to. Although the focus group was a meeting between patients and non-practice facilitators, twice practice staff joined the meeting later. One GP and nurse took the opportunity to have a group education session. This was so successful that there is enthusiasm to use the same technique with other patient groups eg those with diabetes. The surprise resulted in an improvement too – staff were dismayed when one patient revealed that she had been using a wide range herbal medicines for many years so she never responded to the question “Any changes to your medications?”. Now the question asked is “what medications are you using?”
  • Practices did not identify with the issues raised by the large focus group involving patients from all practices. All comments could be countered by “It isnae me”. The practice groups raised topics that could not be ignored and staff were quick to react. The large group was good as a learning exercise for facilitators but was not essential Only 3 of the 7 practices requested a focus group. These, together with the practice that created the leaflet, are tuned into patients’ concerns. We hope that the remaining practices will see the benefits arising from this exercise Patient reps are never representative patients.
  • Action occurs when experiences directly relate to practices Gathering a group of people that share similar health situations results in a sharing of experience and learning. Good opportunity to ensure that correct information is given, not rumour. Hard to reach groups are a challenge which our resources have not allowed us to meet. Tell more folk about it – so I hope you’ll tell others of our work What I wouldn’t change is seeing how practices now involve patients in a new way and are more open to their comments. Make use of your patients please!
  • Three main tasks Search for triggers, Search for harm Describe the characteristics of detected harm Five questions Are triggers present Did harm occur? How serious was the harm incident? Where did the incident of harm originate? Was the harm incident preventable? The focus is harm, not error . Ask yourself: ‘Would I have wanted this to happen to me or my family?’ Only review the specific period in the record (three months). Choose full calendar months to facilitate the review. The maximum spend on reviewing any record should be twenty minutes . The objective is to detect ‘obvious’ problems, rather than every single episode. If there is reasonable doubt whether harm occurred, the incident should not be recorded.
  • Systematic – start in one section and work way through. Selective / focused May have to ‘read up’ a specific time in another section Hospital admission – any that is overnight, including elective Clinical read codes vary according to the type of software that you use – GPASS, VISION, EMIS
  • Various Complementary Different indications Specific strengths and weaknesses Varying degrees of evidence Select according to context, cost, aims, criteria Varying degrees of evidence of each method’s reliability, validity, acceptability (usability), feasibility, transferability
  • Specific changes made in response to things picked up during reviews: New protocol for recording adverse drug reactions Minimum annual FBC checks for all Warfarin patients Minimum annual Digoxin levels check Better systems for highlighting possible drug interactions when deciding the next dose of Warfarin Much better at coding relevant read codes Checking that locums are familiar with practice systems for Warfarin patients
  • The survey measures perceptions – not reality. A ‘positive’ score does not necessarily mean that things are safe – only that staff thinks it is safe!
  • It is the shared perceptions of safety policies, procedures and practices held by a group. (Flin et al, 2006) ‘ Culture’ and ‘climate’ are often used interchangeably. ‘… The measurable features of safety culture…’ Factors (domains) are specific characteristics of climate Leadership Communication Workload Safety Systems Team work
  • Various instruments: Qualitative (dimensional) or Quantitative (typological) USA, industry, secondary care BUT … few for Scottish primary care Specifically developed for intended users, geography and organisation Undergo psychometric testing Relevant factors: communication, team work Written feedback (78) and interviews (46) with various staff groups. Endorsed by UK patient safety ‘expert’ group. Content validity index (CVI) 0.94. Psychometrically tested to a gold standard - 49 practices, 563 team members High validity and reliability of 30 items and 5 factors
  • What factor is most positive? Which factor is least positive? What is the difference between most and least positive and the overall safety climate? (relativeness) What proof is there for these perceptions?
  • Are there any differences between the two groups? (The size of variation is more important than what group is right!) Are there any similarities? What does that mean? (Increases the reliability of the finding) Does any of the findings change when you now consider clinical vs non-clinical? Is there additional variation? How does this fit with the first section? Practice x = about 12-14% variation vs. Practice Y = about 3-4%
  • Scores may not be numerical
  • Remember the cautions The results are yours - only you and your team can make sense of it. Statistical significance vs. practical significance Consider what evidence (if any) there are for the reported perceptions Involve as many team members as possible Keep an open mind !! High Reliability organisations (oil / aviation industries) Improved safety outcomes Improved safety behaviour Health care Emerging evidence of an association between safety climate and clinical outcomes in secondary care (but not yet primary care): shorter hospital stays, fewer medication errors, reduced rates of ventilator associated pneumonia, fewer patient falls, reduced bloodstream infection rates, increased adoption of safe work practices.
  • Safety Improvement in Primary Care

    1. 1. Improving Patient Safety in Primary Care in NHS Scotland
    2. 2. NHS Scotland Quality Strategy 2010 “ Design and Implement a Patient Safety Programme in Primary Care” New Agenda? Who? What? How?
    3. 3. SUB HEADING
    4. 4. Patient Safety in Primary Care - Why Bother? High Volume Increasingly complex Adverse Events cause: 1 in 8 Admissions to hospital 1 in 20 Deaths Largely preventable
    5. 5. Harm – Co-mission <ul><li>Level of harm unknown – NPSA </li></ul><ul><li>11% prescriptions contain errors </li></ul><ul><li>In a care home - 50% chance of ADE </li></ul><ul><li>60,000 patients - high risk prescription pa </li></ul>
    6. 10. Harm thro Omission Lack of reliable care Methotrexate – 12% not monitored Mix of strengths 30% Not prescribed weekly
    7. 11. ( un)Reliable Heart Failure Care ACE inhibitor 88% B Blocker 70% B blocker at target dose 28% Pneumococcal 71% NYHA 71% All 5 - 23 %
    8. 12. High Risks <ul><li>Warfarin </li></ul><ul><li>Methotrexate </li></ul><ul><li>Patients with complex conditions </li></ul><ul><li>Medication Reconciliation </li></ul><ul><li>Results </li></ul><ul><li>Communication </li></ul>
    9. 13. Safety Improvement in Primary Care 1 (SIPC 1)
    10. 14. Aims <ul><li>To enable 80 Primary Care teams to: </li></ul><ul><li>1. Identify and reduce harm to patients </li></ul><ul><li>2. Improve reliability of care for patients </li></ul><ul><ul><li>On High Risk Medications </li></ul></ul><ul><ul><li>With Heart Failure </li></ul></ul><ul><li>3. Develop safety Culture </li></ul><ul><li>4. Involve Patients in QI </li></ul>
    11. 15. The Tools <ul><li>Collaborative </li></ul><ul><li>Bundles </li></ul><ul><li>Patient Involvement </li></ul><ul><li>Trigger Tools </li></ul><ul><li>Safety Climate </li></ul>
    12. 16. Knowledge <ul><li>Topics </li></ul><ul><li>Tools </li></ul><ul><li>What to spread? </li></ul><ul><li>How to spread? </li></ul>
    13. 17. Reliable Care - Care Bundles 4 or 5 elements of care Evidence based Across Patients Journey Creates teamwork Done reliably All or nothing Small frequent samples
    14. 18. Heart Failure Bundle <ul><ul><li>1.Maximise medical therapy – </li></ul></ul><ul><ul><li>On a licensed B Blocker </li></ul></ul><ul><ul><li>B Blocker at max tolerated dose </li></ul></ul><ul><ul><li>2.Functional assessment - NYHA recorded in last year </li></ul></ul><ul><ul><li>3.Immunisation - pneumococcal vaccine ever </li></ul></ul><ul><ul><li>4.Self Management- information given to patient on recognition of deterioration </li></ul></ul>
    15. 19. DMARDS Full blood count in the past 6 weeks? Abnormal results acted on? Review of blood tests prior to issue of last prescription? Had pneumococcal vaccine? Asked re side effects last time blood was taken?
    16. 20. Bundles - Successes “ The care bundle was useful because it identified gaps” “ Not as reliable as we thought we were” Focus for improvement
    17. 21. 2 - Data
    18. 22. Seeing Improvement “ You can see week by week, month by month, whether or not you are showing any improvement, we seem to be improving and that’s good”
    19. 23. Tayside DMARD Compliance
    20. 24. NHS Forth Valley
    21. 25. Lothian - Warfarin Compliance
    22. 26. Outcome Data
    23. 27. Safety Improvement in Primary Care PATIENT INVOLVEMENT IN LOTHIAN Isobel Miller, Public Partner
    24. 28. Patient Involvement Scottish Health Council SIGN Public Partnership Forum Personal involvement in own healthcare with own healthcare workers Scottish Medicines Consortium Healthcare Environment Inspectorate
    25. 29. Active Patients <ul><li>Develop resources to help patients & practices </li></ul><ul><li>Health professionals at one practice write leaflet </li></ul><ul><li>Patients comment and suggest changes </li></ul><ul><li>Edited version adopted and adapted by other practices </li></ul>
    26. 30. Change and Improve <ul><li>Capture experience of patients on warfarin </li></ul><ul><li>Use that information to change and improve care </li></ul><ul><li>Compare patients’ experience with practice’s process map </li></ul>
    27. 31. Process Map
    28. 32. Methodology <ul><li>Focus group for warfarin patients from all seven practices involved in pilot project </li></ul><ul><li>What went well; what went not so well; what would you change? </li></ul><ul><li>Focus groups for individual practices </li></ul>
    29. 33. Results <ul><li>Patients were happy with most parts of process </li></ul><ul><li>Key topics identified </li></ul><ul><li>Practices considered all issues raised </li></ul><ul><li>Feedback to patients: You said - we did </li></ul>
    30. 34. Feedback You Said Our Response Only half of the patients attending the meeting had a ‘yellow pack’ (warfarin information) Some patients had heard about a new drug which might be taking over from warfarin When you attend for a blood test you will be asked if you have a yellow pack and this will be recorded in your notes so that we know that everyone has one who wants one There is no information on when this will be available but any news will be given out in the education session.
    31. 35. What went well? <ul><li>Better informed patients better outcomes </li></ul><ul><li>Practices more open to patients’ concerns </li></ul><ul><li>Patients felt listened to and practice staff had a few surprises </li></ul><ul><li>Improvements made </li></ul>
    32. 36. What went not so well? <ul><li>Practices did not engage with large focus group issues </li></ul><ul><li>Not all practices participated </li></ul><ul><li>Patients were not representative </li></ul>
    33. 37. What would we change? <ul><li>Practice specific focus groups </li></ul><ul><li>Increase educational aspect of focus group </li></ul><ul><li>Explore ways to involve hard to reach groups </li></ul><ul><li>Share the experience </li></ul>
    34. 38. Other Boards <ul><li>Patient Self Care </li></ul><ul><li>Board Groups </li></ul><ul><li>Practice groups </li></ul>
    35. 41. “ The main learning was that they appreciate being involved in their own care”
    36. 42. “ Barriers have just been ourselves” Need Resources Facilitators Expertise
    37. 43. The Trigger Tool and GP-SafeQuest Measuring – Learning – Improving Carl de Wet MBChB DRCOG MRCGP MMed (Fam) GP / Patient Safety Advisor
    38. 44. Overview <ul><li>The trigger tool (12 minutes) </li></ul><ul><li>What, why and how? </li></ul><ul><li>The story so far… </li></ul><ul><li>2. GP SafeQuest (8 minutes) </li></ul><ul><li>What, why and how? </li></ul><ul><li>The story so far… </li></ul>
    39. 46. SUB HEADING The trigger tool: Review of medical records Rapid, focused, structured, active Screen for undetected harm / error
    40. 47. SUB HEADING
    41. 48. SUB HEADING
    42. 49. SUB HEADING
    43. 50. 1. Plan and prepare 2. Review records 3. Reflection, further action Can triggers be detected? Did harm occur? Severity? Preventability? Origin? No. Continue to next trigger or record No Yes. Summarize the harm incident and judge three characteristics: Yes. For each detected trigger, consider: Review the next record Aim? Data ? Sampling: size and method? Individual and Team responsibilities? Triggers: number and type? Practitioner level Patient and medical records Practice team Primary-secondary care interface
    44. 52. Medical records and triggers Sections in GP records Triggers Clinical encounters (documented consultations) ≥ 3 consultations in 7 consecutive days  Medication-related (acute and chronic prescribing) Repeat medication item stopped  Clinical read codes High, medium, low, allergies New ‘high’ priority or allergy read code  Correspondence Section Secondary care, other providers <ul><li>OOH / A&E attendance / Hospital admission  </li></ul>I nvestigations Requests and results <ul><li>eGFR reduce <5 </li></ul>
    45. 53. Summarise your review
    46. 54. SUB HEADING Measure Learn Improve
    47. 56. Seemed a bit intimidating when we first had it presented to a large group … much easier to use in practice … it’s a remarkably effective tool for reflective analysis on patient safety and other clinical issues …has created a lot of interest from other doctors in the practice as a tool for professional development and for appraisals Doctor Gordon Cameron GP Edinburgh
    48. 58. Safety culture
    49. 59. Safety climate
    50. 63. Cautions <ul><li>Perceptions NOT reality </li></ul><ul><li>Results are NOT ‘right’ and ‘wrong’ and NOT ‘strong’ or ‘weak’ </li></ul><ul><li>Snapshot in time </li></ul><ul><li>Participation is key </li></ul>
    51. 64. Benefits of measuring safety climate <ul><li>Awareness </li></ul><ul><li>Identify perceived strengths and weaknesses </li></ul><ul><li>Starting point for reflection and change </li></ul><ul><li>Evaluate – serial measures </li></ul><ul><li>Encourage teamwork, participation and inclusion </li></ul><ul><li>Organisational benefits </li></ul>
    52. 65.
    53. 66. Trigger Tool experience so far It has been overall very positive, it has been a fantastic tool
    54. 67. Causes of Harm <ul><ul><li>Adverse drug reactions - ADRs </li></ul></ul><ul><ul><li>Co – prescribing </li></ul></ul><ul><ul><li>Unrecorded ADR’s </li></ul></ul><ul><ul><li>Missing read codes </li></ul></ul><ul><ul><li>Lack of follow-up </li></ul></ul><ul><ul><li>Not Monitoring drugs </li></ul></ul>
    55. 68. Expectations <ul><li>Hard to do </li></ul><ul><li>Time Consuming </li></ul><ul><li>Would not find harm </li></ul><ul><li>Threatening </li></ul>
    56. 69. Experience <ul><li>Quick </li></ul><ul><li>Finding Harm </li></ul><ul><li>Cultural change </li></ul>
    57. 70. Challenges Improvement Logistics Training Variation ? For measurement
    58. 71. Safety Climate Survey
    59. 72. Insights “ Many of us in the practice staff hadn’t really made the link that us failing to communicate in was a threat to patient safety ….we had a lot of really good stuff came out of it, a lot of very open discussion”
    60. 73. Insights <ul><li>“ We weren’t as good as we thought we were” </li></ul><ul><li>Practices are interested </li></ul><ul><li>Acts as a catalyst </li></ul>
    61. 74. Challenges <ul><li>Who? </li></ul><ul><li>Better process and report </li></ul><ul><li>Need guidance and support </li></ul><ul><li>Understanding/using it </li></ul><ul><li>Anonymity </li></ul>
    62. 75. Collaborative <ul><li>A positive experience </li></ul><ul><li>Promotes teamwork </li></ul><ul><li>Stimulating and challenging </li></ul><ul><li>All share, all learn </li></ul><ul><li>Need training </li></ul><ul><li>Need support </li></ul><ul><li>Local vs national ? – PLT sessions </li></ul>
    63. 77. Challenges Boards and Practices <ul><li>Time </li></ul><ul><li>Competing Priorities </li></ul><ul><li>Engaging Team </li></ul><ul><li>Skills and knowledge - Tools </li></ul><ul><li>Culture </li></ul><ul><li>Leadership </li></ul>
    64. 78. Outcome Measures? <ul><li>In targeted group of patients: </li></ul><ul><li>20% reduction in INRS > 5 and < 1.5 </li></ul><ul><li>20% reduction in admissions </li></ul><ul><li>Improvement in safety culture - years </li></ul><ul><li>Reduce Harm - TT as a measure? </li></ul><ul><li>Timescale? </li></ul>
    65. 79. SIPC 2
    66. 80. “ Look at three areas of major clinical risk to patients as they move across the health system.”
    67. 81. Areas of Focus <ul><li>Medication Reconciliation </li></ul><ul><li>Managing results </li></ul><ul><li>Shared care and communication after out patients </li></ul>
    68. 82. Develop Knowledge <ul><li>What does the evidence say </li></ul><ul><li>Process mapping </li></ul><ul><li>Areas of risk </li></ul><ul><li>Key reliable processes </li></ul><ul><li>Patient involvement </li></ul><ul><li>Measures and Improvement </li></ul>
    69. 84. “ Design and implement a Patient Safety Programme in Primary Care” 2011- 13
    70. 85. SUB HEADING
    71. 86. Themes <ul><li>Safer medicines </li></ul><ul><li>High Risk Medicines </li></ul><ul><li>Co- prescribing </li></ul><ul><li>Improving safety across the interface (care pathways) </li></ul><ul><li>Reliable Results Handling </li></ul><ul><li>Medication Reconciliation </li></ul>
    72. 87. Themes Reliable care for Chronic diseases Healthcare Acquired Infection Antibiotic prescribing Hand washing Culture and Leadership Safety Climate Trigger Tool
    73. 88. Based on SIPC 1 and 2 Medication Reconciliation Co-prescribing Other work….
    74. 89. Process <ul><li>Feedback on Draft Plan </li></ul><ul><li>Scoping </li></ul><ul><li>Develop aims/measures/tools </li></ul><ul><li>Implementation strategy </li></ul><ul><li>Launch 2013 </li></ul>
    75. 90. Feedback <ul><li>Themes appropriate </li></ul><ul><li>Methodology OK </li></ul><ul><li>Barriers </li></ul><ul><li>Engagement </li></ul><ul><li>Knowledge </li></ul><ul><li>Time - Prioritise – PLT </li></ul><ul><li>Need secondary care involved </li></ul>
    76. 91. Implementation will need: <ul><li>Communication </li></ul><ul><li>IT Support </li></ul><ul><li>Linkage </li></ul><ul><li>Board Support and commitment </li></ul><ul><li>Prioritisation- narrow and deep </li></ul><ul><li>Contractual Levers </li></ul><ul><li>Appraisal/ Revalidation </li></ul>
    77. 92. Developing Patient Safety in Primary Care in NHS Scotland Questions? How do we sustain and spread this work? Volunteers? [email_address]