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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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?
  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]