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Primary Care Collaborative
25 May 2016
Welcome
Ann Remmers
West of England AHSN
Housekeeping
• Toilets
• Fire procedure
• Mobile phones
• Confidentiality
• Breaks
Do you know each other?
If not,
SUPER QUICK intros:
Your name
+
2 words about what you do
Agenda
Session 1
• Collaboration: Everyone’s a winner
• Why do things go wrong and how can we make them
right?
Session 2
•...
Academic Health Science Networks
We are one of 15 AHSNs
across England,
established by NHS
England in 2013 to
spread innov...
Academic Health Science Networks
As the only bodies that connect NHS and
academic organisations, the third sector and
indu...
@weahsn
Connect with us
#WEPCC
Collaboration:
Everyone’s a winner
Dr Hein le Roux
Gloucestershire CCG
People and technical
Patient
Safety
Quality
Improvement
the ill patient’s journey
What? Patient Safety and Quality Improvement
What does better look like?
Pathological
• Who cares if we
are not caught?
Reactive
• Safety is
important we do
lots of it...
69 year old lady
Jan 2013: Coded as MGUS, also primary hyperparathyroidism
Feb 2013: Haematologist A&G with regular f/u bl...
In our fox holes .....
Ego & defensiveness
“Doctors differ and their patients die”
Isaac Cruikshank, 1794
“Change is not necessary, Survival is not
mandatory”
W. Edwards Deming
Share your cards …….
Values
Where are you?
From Vincent et al
A systems approach
From Vincent et al
A systems approach
From Vincent et al
A systems approach
From Vincent et al
A systems approach
From Vincent et al
A systems approach
From Vincent et al
A systems approach
Are we that different?
Why do things go wrong
and how can we make them
right?
Stephen Ray
West of England AHSN
“The most important single change in the
NHS… would be for it to become, more than
ever before, a system devoted to contin...
“A Patient Safety Incident is any
unintended or unexpected incident
that did or could have led to patient
harm.”
National ...
Person-centred view
Perfection Myth. If I try harder, I won’t make a mistake.
The Punishment Myth. If we punish a person w...
Systems view
Perfection Myth. If I try harder, I won’t make a mistake.
The Punishment Myth. If we punish a person who make...
Clinical
microsystems
5 Ps
Purpose
Patterns
ProfessionalsProcesses
Patients
Building reliable systems
• Design needs to be woven into working practices, with
repeated cycles of adaptation, small ste...
You told us…
• Time (release or enhanced effectiveness) is the key
• Use of ‘management speak’
• Ineffective collaboration...
And more….
• Time and finance are equally valued
• Simple, effective approaches that promote collaboration
• Broadly compe...
Why is it a good thing to review
patient safety incidents?
How do we make things right?
Will to do what it takes to change to a new system.
Ideas on which to base the design of the ...
The Model for Improvement
The Model for Improvement
The Model for Improvement
Case Study
• Montpelier:
• Significant Event process
• Change in reporting system (email to paper)
• Introduction into GP ...
Case Study
• Minchinhampton
• Diabetes pathway
• Missed 6-month recall opportunities
Case Study
• Churchdown
• Very early stages of development
• Telephone interruptions
• Streamlining home visits
• Priority...
Abraham Wald
Putting it into practice
Coffee break
Start: 10:00am
End: 10:20am
Stations
Stations
1. Culture in the Sequoia Room (back)
2. Approach in the Chestnut Room
3. Human factors in the Sequoia
Room (fron...
Human Factors
Natasha Swinscoe
Nathalie Delaney
Why human factors?
This is a quick taster of a technique you can use in your
practice.
Names
1. Point at yourself and say your name.
2. Point at the person next to you and say their name.
Names
1. Point at yourself and say your name.
2. Point at the person next to you and say their name.
3. Point at the perso...
Names
1. Point at yourself and say your name.
2. Point at the person next to you and say their name.
3. Point at the perso...
What does human factors mean?
Take 5 minutes working on your own or in pairs to define
the term human factors.
What does human factors mean?
Take 5 minutes working on your own or in pairs to define
the term human factors.
Also consid...
What does human factors mean?
Take 5 minutes working on your own or in pairs to define
the term human factors.
Also consid...
“Human factors are all the things that
make us different from logical,
completely predictable machines. In
simple terms th...
Topics/ themes
Communication
Team working
Leadership
Followership
Situational awareness
Resilience
Assertiveness
Flattened...
Graded assertiveness
C – Concern. I am concerned about this patient’s penicillin
allergy.
U – Unsure. I am unsure that taz...
Stephen’s Story
https://youtu.be/wO4bLRIjOtQ
Thank you and next steps
Ann Remmers &
Natasha Swinscoe
As a result of today I will…
Your action plan
Education Pathway
Improvement Coaches Network
Learning and development events
The Improvement Journey – quality improvemen...
Next time…
• Show and Tell
• In-depth on a topic of your choice
Let us know what support you need…
Future dates
Wednesday, 7 September 2016
Swindon, United Kingdom | Hilton Swindon
Wednesday, 30 November 2016
Gloucestersh...
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
Primary Care Collaborative - Bristol, launch meeting
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Primary Care Collaborative - Bristol, launch meeting

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Primary Care Collaborative - Bristol, launch meeting

  1. 1. Primary Care Collaborative 25 May 2016
  2. 2. Welcome Ann Remmers West of England AHSN
  3. 3. Housekeeping • Toilets • Fire procedure • Mobile phones • Confidentiality • Breaks
  4. 4. Do you know each other? If not, SUPER QUICK intros: Your name + 2 words about what you do
  5. 5. Agenda Session 1 • Collaboration: Everyone’s a winner • Why do things go wrong and how can we make them right? Session 2 • Culture • Approach • Human factors Thank you and next steps Starts 9am Break 10am Lunch 12:30
  6. 6. Academic Health Science Networks We are one of 15 AHSNs across England, established by NHS England in 2013 to spread innovation at pace and scale.
  7. 7. Academic Health Science Networks As the only bodies that connect NHS and academic organisations, the third sector and industry, we are catalysts that create the right conditions to facilitate change across whole health and social care economies, with a clear focus on improving outcomes for patients.
  8. 8. @weahsn Connect with us #WEPCC
  9. 9. Collaboration: Everyone’s a winner Dr Hein le Roux Gloucestershire CCG
  10. 10. People and technical
  11. 11. Patient Safety Quality Improvement the ill patient’s journey What? Patient Safety and Quality Improvement
  12. 12. What does better look like? Pathological • Who cares if we are not caught? Reactive • Safety is important we do lots of it after every accident Calculative • We have systems in place to manage all hazards Proactive • We work on problems that we still find Generative • Safety is built into the way we work and think
  13. 13. 69 year old lady Jan 2013: Coded as MGUS, also primary hyperparathyroidism Feb 2013: Haematologist A&G with regular f/u bloods March 2013: Shared plan with patient, info printed Sept 2013: Repeat bloods Dec 2013: parathyroid surgery Jan 2014 – March 2016: 9 contacts with various GPs April 2016: Raised proteins, likely multiple myeloma, 2ww referral April 2016 SEA and reported to NRLS
  14. 14. In our fox holes .....
  15. 15. Ego & defensiveness “Doctors differ and their patients die” Isaac Cruikshank, 1794
  16. 16. “Change is not necessary, Survival is not mandatory” W. Edwards Deming
  17. 17. Share your cards …….
  18. 18. Values
  19. 19. Where are you?
  20. 20. From Vincent et al A systems approach
  21. 21. From Vincent et al A systems approach
  22. 22. From Vincent et al A systems approach
  23. 23. From Vincent et al A systems approach
  24. 24. From Vincent et al A systems approach
  25. 25. From Vincent et al A systems approach
  26. 26. Are we that different?
  27. 27. Why do things go wrong and how can we make them right? Stephen Ray West of England AHSN
  28. 28. “The most important single change in the NHS… would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end…” Don Berwick President Emeritus and Senior Fellow, Institute for Healthcare Improvement (‘A Promise to Learn; A Commitment to Act’ 2013)
  29. 29. “A Patient Safety Incident is any unintended or unexpected incident that did or could have led to patient harm.” National Patient Safety Agency
  30. 30. Person-centred view Perfection Myth. If I try harder, I won’t make a mistake. The Punishment Myth. If we punish a person who makes an error, they won’t make the error again.
  31. 31. Systems view Perfection Myth. If I try harder, I won’t make a mistake. The Punishment Myth. If we punish a person who makes an error, they won’t make the error again. Johnson’s Substitution Test. Could some equally motivated, comparably qualified staff member have made the same error under similar circumstances?
  32. 32. Clinical microsystems 5 Ps Purpose Patterns ProfessionalsProcesses Patients
  33. 33. Building reliable systems • Design needs to be woven into working practices, with repeated cycles of adaptation, small steps. • Find what works, adapt or abandon what does not. • When you know what works on a small scale, look to implement more widely. • Ask the people who are on the receiving end of care whether the new methods result in good care. • Open culture, flat hierarchies, challenge is not a threat but a source of new ideas and improvement
  34. 34. You told us… • Time (release or enhanced effectiveness) is the key • Use of ‘management speak’ • Ineffective collaboration between GPs • Lack of a systematic approach in the practice • Areas for improvement come from outside the practice • Difficulty sharing learning between practices • GPs feel threatened by implied criticism
  35. 35. And more…. • Time and finance are equally valued • Simple, effective approaches that promote collaboration • Broadly competitive in nature
  36. 36. Why is it a good thing to review patient safety incidents?
  37. 37. How do we make things right? Will to do what it takes to change to a new system. Ideas on which to base the design of the new system. Execution of the ideas.
  38. 38. The Model for Improvement
  39. 39. The Model for Improvement
  40. 40. The Model for Improvement
  41. 41. Case Study • Montpelier: • Significant Event process • Change in reporting system (email to paper) • Introduction into GP coffee session
  42. 42. Case Study • Minchinhampton • Diabetes pathway • Missed 6-month recall opportunities
  43. 43. Case Study • Churchdown • Very early stages of development • Telephone interruptions • Streamlining home visits • Priority follow-ups – Data collection stage
  44. 44. Abraham Wald
  45. 45. Putting it into practice
  46. 46. Coffee break Start: 10:00am End: 10:20am
  47. 47. Stations
  48. 48. Stations 1. Culture in the Sequoia Room (back) 2. Approach in the Chestnut Room 3. Human factors in the Sequoia Room (front)
  49. 49. Human Factors Natasha Swinscoe Nathalie Delaney
  50. 50. Why human factors? This is a quick taster of a technique you can use in your practice.
  51. 51. Names 1. Point at yourself and say your name. 2. Point at the person next to you and say their name.
  52. 52. Names 1. Point at yourself and say your name. 2. Point at the person next to you and say their name. 3. Point at the person opposite you, and say your name.
  53. 53. Names 1. Point at yourself and say your name. 2. Point at the person next to you and say their name. 3. Point at the person opposite you, and say your name. Why is 3 hardest?
  54. 54. What does human factors mean? Take 5 minutes working on your own or in pairs to define the term human factors.
  55. 55. What does human factors mean? Take 5 minutes working on your own or in pairs to define the term human factors. Also consider: • Have you heard human factors called anything else? • What topics fall under human factors?
  56. 56. What does human factors mean? Take 5 minutes working on your own or in pairs to define the term human factors. Also consider: • Have you heard human factors called anything else? • What topics fall under human factors? Which definition from the list do you most agree with? Are there any you disagree with? Why?
  57. 57. “Human factors are all the things that make us different from logical, completely predictable machines. In simple terms they are all those things that enhance or reduce human performance in the workplace.” Denis Wilkins
  58. 58. Topics/ themes Communication Team working Leadership Followership Situational awareness Resilience Assertiveness Flattened hierarchy/ authority gradient Cognitive biases
  59. 59. Graded assertiveness C – Concern. I am concerned about this patient’s penicillin allergy. U – Unsure. I am unsure that tazocin can be given to someone with a penicillin allergy. S – Safety. I am worried that it is unsafe to give this patient tazocin as he has a known allergy to penicillin. S – Stop. Please stop. We need to take a moment whilst I look it up.
  60. 60. Stephen’s Story https://youtu.be/wO4bLRIjOtQ
  61. 61. Thank you and next steps Ann Remmers & Natasha Swinscoe
  62. 62. As a result of today I will…
  63. 63. Your action plan
  64. 64. Education Pathway Improvement Coaches Network Learning and development events The Improvement Journey – quality improvement tools and resources
  65. 65. Next time… • Show and Tell • In-depth on a topic of your choice Let us know what support you need…
  66. 66. Future dates Wednesday, 7 September 2016 Swindon, United Kingdom | Hilton Swindon Wednesday, 30 November 2016 Gloucestershire | Stonehouse Court Hotel Wednesday 1 March 2017 Bath, United Kingdom | Royal United Hospital

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