Primary Care Collaborative 2
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Within GP practices, just as in any organisation, a better safety culture is associated with greater satisfaction and engagement from staff – the safer the culture, the better the care. This presentation aims to promote a safety culture in the primary care setting through the use of incident reporting, while supporting the GP practices involved in cohort 2 with tools and training in quality improvement methodology.
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Primary Care Collaborative 2
- 1. Launch of Primary Care Collaborative Cohort 2 24 May 2017 Bath
- 2. 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.
- 3. West of England Academic Health Science Network
- 4. A promise to learn – a commitment to act “The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of care, top to bottom and end to end.” Don Berwick, August 2013
- 6. WE BELIEVE: A MANIFESTO FOR PATIENT SAFETY IN PRIMARY CARE FROM SMALL STEPS BIG CHANGE CAN OCCUR PRIMARY CARE IS THE HE OF THE NHS WORKING TOGETHER WE CAN MAKE CHANGE HAPPEN FASTER AND BETTER SAFETY IN NUMBERSBETTER SAFETY CULTURE = BETTER, SAFER CARE FOR PATIENTS WE CAN’T CHANGE THE HUMAN CONDITIONS, BUT WE CAN CHANGE THE CONDITIONS HUMANS WORK IN HEAR THE VOICE OF THE PATIENT BE PART OF THE CIRCLE OF CARE NEVER STOP LEARNING & EXPERIMENTING REPORTING AND LEARNING FROM INCIDENTS WILL CREATE THE CONDITIONS FOR SAFER PATIENT CARE CELEBRATE SUCCESS SHARE AND LEARN BEST PRACTICE WEST OF ENGLAND ACADEMIC HEALTH SCIENCE NETWORK PRIMARY CARE COLLABORATIVE
- 7. Primary Care Collaborative Develop a safety culture that engages with patients and staff to support the delivery of safe and reliable care in primary care teams.
- 9. Collaboration: everyone’s a winner Dr Hein Le Roux
- 10. Patient Safety Quality Improvement the ill patient’s journey What? Patient Safety and Quality Improvement
- 11. 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
- 12. 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
- 13. From Vincent et al A systems approach
- 14. From Vincent et al A systems approach
- 15. From Vincent et al A systems approach
- 16. From Vincent et al A systems approach
- 17. From Vincent et al A systems approach
- 18. From Vincent et al A systems approach
- 23. In our fox holes .....
- 24. Ego & defensiveness “Doctors differ and their patients die” Isaac Cruikshank, 1794
- 26. “Change is not necessary, Survival is not mandatory” W. Edwards Deming
- 27. Share your cards …….
- 28. Values
- 31. 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.
- 32. 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?
- 34. Culture: the heart of quality improvement Anna Burhouse
- 39. 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
- 42. Enabling performance Saying yes to the mess Fostering diversity Challenging habits and assumptions Motivating people Reducing power differentials Managing performance Decision-making Simple structures Effective procedures Monitoring and coordinating Providing direction
- 50. The PDSA Cycle for Learning and Improvement Plan • Objective • Questions & predictions • Plan to carry out: Who?When? How? Where? Do • Carry out plan • Document problems • Begin data analysis Act • Ready to implement? • Try something else? • Next cycle Study • Complete data analysis • Compare to predictions • Summarize What will happen if we try something different? Let’s try it!Did it work? What’s next?
- 54. Repeated Use of the PDSA Cycle for Testing Hunches Theories Ideas Changes That Result in Improvement Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Sequential building of knowledge under a wide range of conditions Spreading AP DS A P D S AP D S A P D S AP DS A P D S A P DS Sustaining the gains
- 55. Example PDSA Testing Ramps advanced care planning A P S D A P S D Cycle 1A: 11/02/14 Identification patients by respiratory FY1 by putting a Q beside their name on ward board and handover sheets Cycle 1B: 3/03/14 Teaching the other side of the ward- gastro FY1’s Cycle 1D: 24/04/14 “re-inform & support” with Hannah & thank you cookies Cycle 1C: 14/04/14 disseminate the Q project- targeted 5 medical wards a) sign sheet b) Cert to do one c) Cert to teach one Cycle 1E: 7/05/14 Consultant lead to boost confidence in identifying Q patients
- 59. 59 “What is the variation in one system over time?” Walter A. Shewhart - early 1920’s, Bell Laboratories time UCL Every process displays variation: • Controlled variation stable, consistent pattern of variation “chance”, constant causes • Special cause variation “assignable” pattern changes over time LCL Static View StaticView Dynamic View
- 62. Probability of a “trend” Why do we need 5 data points for a trend? What is the probability of a coin landing heads or tails? One head or tail .5 .5 x .5 = .25 .5 x .5 x .5 = .125 .5 x .5 x .5 x .5 = .0625 .5 x .5 x .5 x .5 x .5 = .03125 .5 x .5 x .5 x .5 x .5 x .5 = .015625
- 71. Education Pathway Improvement Coaches Network Learning and development events The Improvement Journey – quality improvement tools and resources
- 73. Why do things go wrong and how can we make them right? Nathalie Delaney
- 74. Swiss cheese Although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the adverse event to occur.
- 75. “For a long time, people were saying that most accidents were due to human error. And this is true in a sense, but it’s not very helpful. It’s a bit like saying that falls are due to gravity” Prof. Trevor Kletz
- 76. What makes your working day easier or more difficult? Good/ poor communication Good/ poor leadership Good/ poor teamwork Good/ poor organisation Good/ poor attitude Positivity/ Negativity Challenges Too much/ not enough information No thanks/ praise/ feedback • Conflict • Morale • Evolving plans • Repetition • Changes • Stress • Breaks
- 78. “Workplaces and organizations are easier to manage than the minds of individuals workers. You cannot change the human condition, but you can change the conditions under which people work” James Reason
- 82. Systems
- 83. Communication
- 86. Safety Culture survey Online, anonymous survey Opportunity to tailor to meet your needs Debrief with core team Optional facilitated debrief with wider team Repeat survey after 12 months
- 95. Suzette Woodward’s top tips… 1. Learn to listen 2. Resist the pressure for a simple explanation 3. Don’t be judgemental
- 96. Abraham Wald
- 99. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety
- 100. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety Safe Practice Framework for General Practice Lesley Mackenzie, Patient Safety Programme Manager Wessex Patient Safety Collaborative Primary Care Collaborative Cohort 2 Launch 24th May 2017
- 101. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety To develop a safe practice framework which will support staff in the delivery of safe care in General Practice. To raise staff awareness of patient safety. To support staff to determine why and where improvement is required in patient safety. Our vision
- 102. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety • The safe practice framework was developed by a number of GPs and Primary Care Commissioners and agreed by Wessex Patient Safety Collaborative [WPSC] Primary Care Forum. • Test specification and measurement strategy was developed to measure the impact of any change. • The framework was tested by GP practices. • Framework was reviewed following feedback and amended. How?
- 103. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety • A voluntary self assessment tool which aims to assess the maturity and robustness of the patient safety systems. • It is presented in 2 levels; good practice and outstanding practice. • Resources about patient safety are available via links to support staff development and understanding of patient safety. • When completed the framework identifies process & systems that are working well and those which may need improvement. The framework
- 104. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety • Feedback itself is crucial to ensure the framework is useful for you. • The feedback we received; • Most useful when completed as a team. • Each team member had ownership of the good practice that was identified and wanted to take responsibility for what needed to change. • Local Medical Council [LMC] Chief Executive saw value in the framework. • Rewritten to reflect Key Lines of Enquiry and as a 2 stage approach. • Not an assurance tool. Feedback!
- 105. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety • Concerns about duplication dispelled. • Offered a planned approach to the quality work in the practice. • The process of completing the framework as a team; • generated healthy discussion • raised awareness about patient safety • started conversations • provided an opportunity to celebrate what was working well • offered a shared understanding of what was still required • encouraged the team to take ownership The outcome
- 106. Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety • West of England is using the framework for your collaborative. • Wessex keen to extend the testing phase. • We are assessing; • Ease of using the framework • Content • Impact of using the framework • We will be seeking brief feedback on these 3 areas to influence and improve the design of the framework. Working in partnership
- 107. Looking forward to the future Dr Hein Le Roux
- 108. Thinking and Linking What has worked from today’s session? What tools can you take away from today to improve your practice? What barriers are there to you taking this forward into your practice?
- 109. Looking after yourself Recognise the emotional impact of caring Acknowledge that self care is important What are the ways you care for and support yourself and each other in your team?
- 110. As a result of today I will…