Delivering Quality in Primary Care“Design and implement a Patient Safety Programme in Primary Care” • Why ? • Who? • What ? • How?
PATIENT SAFETY IN PRIMARY CARE - WHY BOTHER?• High Volume• Increasingly complex• Real harm – adverse events in primary care cause: – 12% of Admissions to hospital Quality and Safety in Healthcare April 2007 – 5.5% of Deaths in hospital To Err is Human, 1999• 76% of incidents in primary care are preventable Med Journal Australia ; 169 ; 73-6)
How Safe are we?• Consultations 98% safe• Adverse Event rate1- 2% Consultations• More with frail elderly• 300 million consultations in UK pa“Absolute number of those harmed may be just as large or greater than secondary care” Health Foundation 2011
Statistics- Commission• 11% prescriptions contain errors• In a care home - 50% chance of ADE• High risk prescribing
Omission Lack of reliable care• Methotrexate – 12% not monitored• Mix of strengths 30%• Prescribed daily
Causes of harm• Drug adverse events• Medication errors• Delayed diagnosis• Clinical error• Administration errors – Results – Med rec• Communication
6048 prescriptions• 95% Prescriptions are safe• 1 in 20 have an error• 1 in 550 serious error• 9 out of 11 from Warfarin• Processing errors not knowledge• Human factors
Why?- Human Factors• Time pressures• Frequent distractions and interruptions• Blood monitoring errors• Little training• Team communication• IT Issues• Interface communication
Not a new agenda…….
Development and TestingSafety Improvement in Primary Care 1
Aims• To enable 50 Primary Care teams to:1. Identify and reduce harm to patients2. Improve reliability of care for patientsOn High Risk MedicationsWith Heart Failure3.Develop safety Culture4.Involve Patients in QI
Knowledge • Topics • Tools • What to spread? • How to spread?
Reliable Care - Care Bundles4 or 5 elements of careEvidence basedAcross Patients JourneyCreates teamworkDone reliablyAll or nothingSmall frequent samples
DMARDSFull 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?
Warfarin - BundleWarfarin dosing followed current local guidance?Patient informed of the warfarin dose and date of nexttestPatient been taking the advised dose since last bloodtest?INR is taken within 7 days of planned repeat INR?Face to face education recorded every 12 months?5 patients per fortnightAll or nothing measure
Warfarin Bundle Compliance Overall Warfarin Bundle Compliance (Wave 1)100%80%60%40%20% 0% 28th 14th 28th 11th 25th 9th 23rd 6th 20th 4th 18th 1st 15th 29th 12th 26th 10th 24th 7th 21st 5th 19th 2nd Feb Mar Mar Apr April May May June June July July Aug Aug Aug Sept Sept Oct Oct Nov Nov Dec Dec Jan
Heart Failure Bundle
“The care bundle was useful because it identified gaps” “You can see week by week, month bymonth, whether or not you areshowing any improvement, we seem to be improving and that’s good”
Improvements• Optimised care• Guidance/ Templates• Blood monitoring /Recalls• Reduced variation• Patient Education and Self management• More efficient• Less Stress!
Greater efficiency & confidence in practice procedures“shortly after starting there seemed to be these patients in my messaging system all the time and that now seems much more manageable”
Less Stress for some staff in their job• “Staff member X who manages the register and the recall for these patients, it caused her an enormous amount of stress prior to the programme”“ Now that the programme is much more streamlined and she feels more confident and has taken much more clinical responsibility”
Staff time-saving - patients being more proactive“staff member X doesn’t have to continually phone people up every month, that is quite a time saver for her, patients are now more coming in cause they understand the consequences potentially of the side effects of the potential toxic drugs”.
Reduction in tests per patient Tests per Patient2.5 21.5 10.5 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
The Trigger Tool and GPDetecting Harm in Primary Care Where is all this harm?What are we going to do about it? Dr Gordon Cameron GP / Patient Safety Advisor
Not In My Back Yard? 11% of maintenance logs show significant errors which could jeopardize safety Around 2% of worker shifts end with the potential for a significant adverse event In the satellite workshop setting there is a 50% chance of a safety log containing a significant deviation from protocol More than 60,000 visitors a year spend time in the “high risk zone” of this facility
But This IS Our Back Yard … 5% of UK GP prescriptions contain the potential to harm the patient Around 2% of consultations end with the potential for a significant adverse event In the care home setting there is a 50% chance of a Kardex containing a significant drug interaction More than 60,000 patients in Scotland each year receive a “high risk prescription” – methotrexate, warfarin etc
Prescribing targets Interruptio Email ns EmergenciesMeetings Personal StressPhone calls Personal Health Fatigue
If pilots had the same working day as GP’s … …….. Would you get on a plane ?
Experience so far…Generally received positively• “It has been overall very positive, it has been a fantastic tool”
“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 forreflective 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”
Experience• Quick – about 90mins to review 20 sets of notes• Finding harm not previously indentified – and that would not have been otherwise identified• Focus for Improvement• Cultural change• Need training and support• Not for measurement
Frequent Themes• Missing Read codes• Huge variation in what doctors thought the “allergy” or “adverse reaction” codes were for• Often the most valuable safety lessons were in patients who had no triggers found in their notes• It’s led to big changes in my practice
Trigger Tool or SEA• SEA • Trigger tool – Can only be used in – Can pick up near miss cases where harm has cases where no harm already occurred actually occurred – Needs a lot of writing – No formal writing up up needed – Very reliant on the – Less threatening clinician feeling able – A more powerful tool to share for changing individual – Can be threatening ways of working
That’s the good news• We know harm exists• We know what it looks like• We know how to find it• We’ve got a strategy to deal with it
But now for the bad news …
Culture Eats Strategy For Breakfast Safety Culture Safety Climate
Safety Climate Survey • On line • Practice report • Measurement • Diagnosis • Catalyst for change
Safety Climate Results • My own practice • Two years of results
Workload Average this year 4.5 Last year 5.0 Other practices average = 4.7 Leadership Average this year 5.8 Last year 5.8 Other practices average = 5.8 Teamwork Average this year 5.5 Last year 5.6 Other practices average = 5.4 Safety Systems and Learning Average this year 5.2 Last year 5.5 Other practices average = 5.6
Communication Category:Our average 2010 = 4.4 out of a possible 7.0Our average 2011 = 4.2 out of a possible 7.0Average for all other practices 2011 = 4.8
Doctors and managers Scored the communication category questions at 5.7
Doctors and managers Scored the communication category questions at 5.7 Non managers Scored the communication category questions at 3.5
Team members feel free to question the decisions of those with more authority Our score 0.6 less than the average Team members are comfortable expressing concerns to leadership about how things are done Our score 0.7 less than the average There is open communication between team members across all areas in the practice Our score 0.5 less than the average Team members are kept up to date about practice developments Our score 0.4 less than the average The practice leadership communicates its vision for practice development Our score 0.2 less than the average
Progress in Aviation
Team Resource Training Team members feel free to question the decisions of those with more authority Assertiveness Team members are comfortable expressing concerns to leadership about how things are done Assertiveness There is open communication between team members across all areas in the practice Communication Team members are kept up to date about practice developments Awareness The practice leadership communicates its vision for practice development Leadership
Development and TestingSafety Improvement in Primary Care 1
Overall Challenges• Understanding• Time Pressures• Competing priorities• Staff and IT changes• Team Involvement• Resources and remuneration• Practice environment - culture
Overall Successes• Increased Knowledge and skills• Improved Patient Care• Safer Systems• Improved Team-working• Real Patient Involvement• Less stress• Greater Efficiency and confidence
Overall• 82% say the programme has benefited their practice• 75% say the Programme has improved the safety culture of their practice• 81% say they plan to continue using SIPC tools/procedures
Safety Improvement in Primary Care 2
“Look at areas of major clinical risk to patients as they move across the health system.” • Medication Reconciliation • Results handling • Communication after outpatients
Experience so far…• Literature review• Process mapping• Areas of risk• (un)Reliable processes• Measures• Improvement in practices and interface
Current Activity SpreadSIPC • Greater Glasgow &C• Lothian- LES • Dumfries and• Forth Valley- LES Galloway - LES• Tayside • Ayrshire and Arran• Grampian • Lanarkshire - LES• Borders • GP training• Highland • Appraisal • Pharmacy – Climate Survey
Innovation Adoption Curve.
“Design and implement a Patient Safety Programme in Primary Care”Start with GP Practices, Community Nurses and Pharmacy
Patient Safety in Primary Care Programme - 3 Workstreams• Safer Medicines• Safe and reliable patient care across the interface and at home• Safety Culture and Leadership
Safer medicines• Safe and reliable prescribing, monitoring and administration of high alert medications e.g.DMARDs Warfarin Insulin Lithium• Reducing high risk prescribing – data/alerts• Reliable Medication Reconciliation
Safe and Reliable Patient Care across the Interface and at homeReliable:• Medication Reconciliation• Management of test results• Communication at point of referral• Handling written communication
Identify risk and reduce harm for vulnerable frail adults in the home care settingReducing harm from:• Falls• Pressure ulcers• Catheter associated UTIs
3. Safety Culture and leadershipEnsuring:A culture of safety and learninge.g. Trigger tools, climate surveys safety walk roundsOrganisational learning from SEAsCapacity and capability to support the programmePatients become partners in making care safer
Patient Safety in Primary Care Programme - 3 Workstreams• Not all at once• Menu• Build over time• Boards and practices prioritise
Implementation Plan• Communication• Engagement• Capacity Building• Measurement• Method ??• Central support• Linkage – Prescribing - RTC• System changes – IT – Pharmacy• Reporting and Evaluation
Successful implementation needs..• To Build on the professionalism of front line staff• Prioritised within existing and adapted GMS contract• Alignment with GP Appraisal and Revalidation• Commitment of boards
Boards need…• Executive buy in and championing• To Prioritise this programme• Dedicated clinical leadership, QI and pharmacy support• Build knowledge and skills• PLT
In Return …• Fewer adverse events• Fewer Admissions• Fewer Falls/ UTIs/Pressure ulcers• Improved Interface working – SPSP• Engage with Primary care
How can we make sure the Boards are facing the right way …?
How might the current GP Contract support patient safety?Patient safety is a core responsibility of all staffBUTEnsure key high risk processes are done safe and reliablyHighlight these within the GMS contract.
GP Appraisal and Revalidation• The Trigger Tool (structured case review)• Safety Climate Survey• Care bundles• Reliability Data - test results and medication reconciliation• High risk prescribing
Why Bother?• “Houston we have a problem”• By Improving safety we will have :• Safer care• Confidence in systems – less waste• Fewer things going wrong• Less stress• Improved interface working• Greater Capacity