improving safety in primary care - gpnzgpnz.org.nz/wp-content/uploads/14-02-21-improving...improving...
Post on 22-Mar-2018
214 Views
Preview:
TRANSCRIPT
Improving Safety in Primary Care
Sharing Scotland’s Experience
Dr Neil Houston
GP and National Clinical Lead
Aims of the Session Learn about:
•Context
•Safety in Primary Care – Why bother ?
•Developing and Implementing a Primary Care
Safety Programme
•What does the literature tell us about how to do QI
Discuss how this knowledge and these tools could
be used in New Zealand
Primary care in Scotland
• Practice List
• National contract – no longer !
• Free at point of care
• Extended Team Care
• 1000 GP practices
• 1200 community pharmacists
Context
• Elderly > 75 increase by 25% in 10yrs
• Multiple morbidities Dementia
• Struggling acute care
• Rising demand/costs
• Less money
• England - Reorganisation
In Short: Things cannot carry on as now
The definition of insanity is doing the same thing over and over and expecting different results.
Albert Einstein
// AUDIENCE PROFILE - GP
Overall, how do I define
success?
•Providing high quality, evidence based care.
•Being responsive to patient needs.
•Manage all aspects of patient demand efficiently.
•Control of practice expenses.
•A good, effective happy team.
•Avoid things going wrong – no major adverse effects or complaints to/from patients.
•Access to up to date guidance and evidence.
Name: George
Role: GP
Mindset:
Time poor.
Rising workload
I have limited resources while juggling a range of priorities.
As such compromises are the norm in my world
I am part of team and have autonomy from the wider health service and control over my practice.
My job is to provide safe and effective treatment in a professional manner and this means managing risk at all times.
Achieving Sustainable Quality in
Scotland’s Healthcare
20:20 Vision
• Everyone is able to live longer healthier
lives at home or in a homely setting
• Integrated health and social care
• Prevention
• Anticipation and supported self
management
• Day case treatment and avoid admissions
Patient Safety
• Preventing patients being harmed by the care
they receive
• If harm does occur identify and analyse it and
learn from it to prevent it recurring
Central line infection rate
(per thousand line days)
0
2
4
6
8
10
12
Jan-
08
Apr
-08
Jul-0
8
Oct-0
8
Jan-
09
Apr
-09
Jul-0
9
Oct-0
9
Jan-
10
Apr
-10
Jul-1
0
Oct-1
0
Jan-
11
Apr
-11
Jul-1
1
2.34
0.18
92% reduction
A One in 3
D One in 18
B One in 10
C One in 7
Q What proportion of NHS Hospital patients is
estimated to suffer some form of unintentional
harm as a result of their care?
B One in 10
£5,000
A 10%
D Not known
B 99%
50%
Q Of those patients harmed, which
percentage is judged to be preventable?
50%
£15,000
C
A 2.6%
D Unknown
B 12%
C 50%
Q What percentage of NHS acute hospital
admissions are thought to be related to sub-
optimal primary health care?
£32,000
B 12%
A 2.6%
D Unknown%
B 15%
C 6.5%
Q What percentage of NHS acute hospital
admissions are thought to be related to
adverse effects of medication ?
C 6.5%
£64,000
PATIENT SAFETY IN PRIMARY CARE - WHY BOTHER?
• Adverse events in primary care cause:
– 1 in 20 deaths in hospital
– 5 -17% of admissions linked to adverse reaction to medication
– 4% of hospital bed capacity
– 70% preventable
To Err is Human 1999
Howard et al Br J pharmacology 2006
Zhang et al BMJ 2009
Howard et al qshc 2003
How Safe are we?
Adverse Event rate 1- 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
A 5%
D 25%
B 0.6%
C 1.9%
Q In UK General Medical Practice,
what percentage of prescriptions
is estimated to contain an error?
A 5%
£1,000,000
Causes of harm
Medication adverse effects
Delayed diagnosis
Systems Issues e.g.
• Prescribing errors
• Administration errors - records
• Results Handling
• Communication
Why? Human Factors
• Time pressures
• Frequent distractions and interruptions
• Little training
• Team communication
• IT Issues
• Interface communication
Medication Reconciliation
• Unreliable at admission
• Inaccurate and delayed at discharge,
• Unreliable systems in place in primary care for updating
How reliable are we ?
• Discrepancies were found in 43% of
patients.
• Of the drugs newly prescribed- 28% were
either not continued, or some discrepancy
• Where suggested a change in dose, the
dose was not changed in 35%.
“WHO identified poor test follow up as a
major cause of harm to patients
resulting in serious lapses in patient
care”
Evidence
• Practices do not track requests for tests,
• Lack protocols on how to inform patients
of results.
• MPS 400 Clinical Risk Assessments
• 84% of practices had risks associated
with test results.
Why is a strong Safety Culture
Important?
Associated with better clinical and health care
worker outcomes.
• Significant reductions in reported medication
errors
• Fewer patient falls
• Lower infection rates
• Decreased staff turnover
• Increased adoption of safe work practices
• Increased job satisfaction.
More Good News
Safety Culture
• Reflective Practice - SEAs
• Data
• Openness and transparency
Rapid tests of change
Delivering Quality in Primary Care
2011
Design and implement a Patient
Safety Programme in Primary
Care
Piloting and Testing Phase -
Essential
• The right focus?
• The right tools
• The right method
• Build capacity knowledge
• Network
• Protection from the politics
Focus
• Identify and reduce avoidable harm
• Improve reliability in high risk areas
• Develop teams safety culture
• Develop QI and safety skills
• 45 practices
• 2 years
What is a Care
Bundle?
4 or 5 elements of care
Across Patients Journey
Creates teamwork
Mix of easy and hard
All or nothing
Small frequent samples
Warfarin Bundle
Is there evidence that the last advice re warfarin dosing given to patient
followed current Guidance?
Is there evidence that the last advice re the interval for blood testing given to
patient followed current Guidance?
Has patient been taking the advised dose since last blood test?
INR is taken within 7 days of planned repeat INR?*
Face to face education recorded every 6 months?*
Overall compliance out of 5
Like What?
• Practice meeting
• Notice board
• Process mapping
• Ask patients
• Try changing something….
• Measure the effect.
DMARD Bundle
Only those prescribed Methotrexate or Azathioprine
• Full Blood Count in the last 6 weeks
• Action from abnormal results recorded
• Documented review of blood tests prior to issue of last prescription
• Ever had pneumococcal vaccine
• Documented the patient has been asked about side effects of their medication at their last blood test
• Compliance with full bundle (i.e. all of above)
1 Invite patients who have failed to comply by telephone
2 Send information stating reasons for why it is important to attend
3 Put a note on patients repeat prescription
Ensure patients prescribed Methotrexate or Azathoprine attend a monthly review for blood monitoring
Patients complying by attending blood monitoring will increase Using a variety of engagement methods
4 Restrict the amount of repeat prescription available to them to encourage attendance
5 Stop repeat prescription until they attend
PDSA - Improve Compliance of Patients Attending
Monthly Blood Monitoring
Patients now engaging and process fully
implemented
“The care bundle was useful
because it identified gaps”
“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”
Improvements
• Provided insights
• Optimised care
• Guidance/ Templates
• Reduced variation
• Patient Education and Self management
• More efficient
• Less Stress!
The Detecting and Reducing
Patient Safety Incidents in Primary
Care
Using
Structured Case Review
Trigger Tool GP / Patient Safety Advisor
Patient Safety Incident
Any unintended or expected incident
which could have or did lead to harm
for one or more patients receiving
NHS Care
Detecting Patient Safety Incidents in GP
Clinical Records: Proof of Principle
• Two GPs reviewed 500 randomly selected electronic patient
records (100 x 5 Scottish GP practices): 12-month period.
• Clinical triggers developed and tested help to pinpoint safety
incidents
• 9.5% of records contained evidence of unintentional harm to
patients
• 60+% were judged to be preventable
• Most cases low to moderate severity, all severe cases originated
in secondary care
• De Wet & Bowie, Postgraduate Medical Journal, 2009
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
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
•OOH / A&E attendance / Hospital
admission
Investigations Requests and results
•eGFR reduce <5
Gordons Video Clip
V
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
Experience
• Generally received positively
• Quick
• Finding Harm
• Focus for Improvement
• Cultural change
• Need training and support
• Not for measurement
What to do with the report?
• Close survey when all have completed
• Download / Print off
• Distribute to all team
• Arrange meeting to discuss findings
Reflection Sheet
• What positive aspects of your team’s safety culture were highlighted in the report and your discussions?
• What aspects of your safety culture do you as a team feel you could improve?
• What steps will you take to improve these aspects of your safety culture?
• What else might you change to improve your safety culture?
• Would you like any support or guidance to make changes in your practice? If so, what would be useful?
Have a look at the report
What questions does it raise?
What would be the benefits and
challenges of doing this with a
practice team ?
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”
“Weren’t as good as we thought we were”
“Mismatch between what the clinical and
non clinical staff thought”
“Prompted some very open discussion”
Approaches so far…
• Education
• Board Focus Groups
• Practice Focus Groups
• Process mapping
• Questionnaires
Insights for
staff
Responsive enthusiastic patients
appreciate being Involved
“The main learning was that they appreciate
being involved in their own care”
“The Barriers have just been
ourselves”
So Need …..
• Encouragement
• Resources
Ideas of where to start
Overall Successes - Improved:
• Patient Care
• Systems
• Knowledge, Skills & Attitudes
• Safety Culture
• Team-working
• Patient Involvement
• Efficiency
Bundle
Compliance Warfarin Bundle Compliance
0%
20%
40%
60%
80%
100%
14th
Feb
'11
28th
Feb
'11
14th
Mar
'11
28th
Mar
'11
11th
Apr
'11
25th
April
'11
9th
May
'11
23rd
May
'11
6th
June
'11
20th
June
'11
4th
July
'11
18th
July
'11
1st
Aug
'11
15th
Aug
'11
29th
Aug
'11
12th
Sept
'11
26th
Sept
'11
10th
Oct
'11
24th
Oct
'11
7th
Nov
'11
21st
Nov
'11
5th
Dec
'11
19th
Dec
'11
2nd
Jan
'12
16th
Jan
'12
Overall Lothian Orchard
Challenges
• Understanding
• Facilitation
• Time Pressures
• Competing priorities
• Team Involvement
• Resources and remuneration
• Practice environment - culture
Overall
• 82% say the programme has benefited
their practice
• 75% say the Programme has improved
the safety culture of their practice
Measures
• Process Measures – Bundles
• Outcome Measures
• Better INR Control <1.5 > 5 Within target
• Reduced Admissions
• Reduced readmissions < 30 days
• Improved safety culture
Rapid Organic Spread
• 60 Practices + 6 HB
• Spread to 90% practices in
2 Areas
• 3 more boards testing
• GP training
• GP Appraisal
Phased
Approach
Stage 1 General Medical Services
Prototype and Testing
2010- 12
Launched March 2013
Stage 2 Pharmacy and Nursing Proto-typing and testing
from late 2013
Stage 3 Dentistry and Optometry Exploratory work late
2014
SPSP-PC- The Ambition
To reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting.
Our Aim
All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.
95% of practices undertaking Safety
Climate Surveys and Trigger tool case
note review by April 2014
Scottish QOF
Safety Culture and
Leadership
95% of practices implement systems for
reliable prescribing and monitoring of
high risk medications by 2016.
95% of Practices have safe and reliable
systems for medicines reconciliation
following discharge by 2016
Safer Medicines
95 % of GP practices have safe and reliable
systems for handling written
communication received from external
sources
95% Health Boards and GP practices have safe
and reliable results handling systems
Safe and reliable patient
care within practice and
across the interface
Local Commitment and expertise
essential
• Executive safety
• GP clinical leadership
• Programme manager within each NHS board
• Quality improvement expertise
Local learning sets
National Launch
March 2013
• All Boards
• Collaborative events
• 95% doing trigger tool and
climate survey
• 80% Working in High risk
area
• Variation and Dilution
What’s in it for Clinicians
Doing the best for your patients
Working better as a team
More confidence in your systems
Less things going wrong
Less stress
More Efficient
Better Interface working
// AUDIENCE PROFILE – How will the GP benefit from the Patient Safety Programme. Rational.
•Safer care.
•More effective use of resources.
•Reduces complaints.
•Reduce the frustration of working with the hospital.
•Reduces harm.
•Better processes.
•Less things going wrong.
•Transparent and clearer communication.
•Allows people to talk about ‘harm and adverse events’.
•Helping the patient to take more responsibility for their care.
Emotional.
•Greater job satisfaction.
•Increases confidence in systems and processes.
•Less worry.
•Less discomfort and pain when things go wrong.
•Increases the feeling of support.
•Reduces stress.
Name: George
Role: GP
What’s in it for boards?
• Fewer adverse events
• Fewer complaints
• Fewer Admissions
• Safe effective prescribing
• Improved Interface working
• Engagement with Primary care
Building Will
• Literature
• Patient Stories
• Clinical Leaders
• Front line Experience
• The “right” areas of focus
Design and planning
• Convince people there is a problem
• Convince them there is a solution – have
to test it
• Clinical and admin network
• Strong Core
• QI expertise
• Appropriate data collection
• Be realistic
Testing and development
Evidence
• Test sites
• Protected time – do not underestimate
• Central core and networks
• Adaptable and flexible
• Have a method – model of change
• Resources and training
• Work with innovators
• Adapt to local context – Evaluate
Organisational Issues
Need
• An organisational priority
• Organisational capacity - QI / admin
• Leadership - clinical and organisational
• Professionally led
• Pump Priming
Sustain and Spread
• Factored in at the start
• Do not crack on too quickly
• Extensive development periods
• Testing
• Evaluate
• Influence
• Levers
Levers
• National Priority
• Boards told to prioritise:
• Professionalism – tools are evidence for GP
Appraisal
• Contract ??
What not to do ?
• Too many areas
• No clinical buy in
• Tools not tested
• Get everyone to start at once
• No data
• No Central core
• No Process
• Spray and Pray
• No training or Support
New Zealand – Already under way
• Counties Manakau/ PHOs –15 practices
• Ko Awatea
• Test these approaches
• Learning already
• Learning sets
• Start up time
• QI Expertise
• Co-ordination
How might we further test and
develop approaches to improving
patient safety in Primary care?
• Opportunities
• Challenges
• Next Steps
• neil.houston@nhs.net
• http://www.healthcareimprovementscotlan
d.org/our_work/patient_safety/spsp/patien
t_safety_in_primary_care.aspx
top related