health foundation safety improvement in primary care sipc
Post on 19-Dec-2015
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Health FoundationSafety Improvement in Primary Care
SIPC
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Housekeeping
• No planned fire alarm test: if you hear it – its real!
• Swap Shop • NES Stand – Evidence into Practice• Evaluation interviews• Toilets on ground, 1st and 2nd floor
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SIPC1 Aims
To enable 80 Primary Care teams to:
1. Identify and reduce risk and harm to patients
2. Improve reliability of care for patients• On High Risk Medications • With Heart Failure
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Improve:
Safety culture
Patient Involvement
Interface working
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Knowledge
• Harm - trigger tool • Culture – Climate
Surveys• Reliability - Bundles• Patient Involvement
• What to spread ? contract
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• Reflect • Celebrate success• Share challenges • Share solutions • Acquire and develop new skills • Identify support/training needs• Learn about other clinical areas• Feedback • Next Steps
Aims
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Programme
09.30 – 09.50 Welcome and Agenda overview
09.50 – 11.10 Delivering Reliable Care
11.10 – 11.30 Coffee
11.30 – 12.30 Showcasing Work in the Trigger Tool
12.30 – 13.15 Lunch and Swap Shop
13.15 – 14.15 Making the most of your climate survey
14.15 – 15.15 Involving Patients in Improvement
15.15 – 15.30 Coffee and transition to Breakouts
15.30 – 16.45 Board Specific breakouts and Evaluation
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You said, we did…
• Later Start • Less factual information• More discussion interaction• We’ve tried!
• Handouts of presentations• Better facilitation• Primary care relevance• Better microphones
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Successes
• You are here!• Complex programme• Commitment• Evolving• Bundles – data collection
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Successes
• Bundles• Trigger Tools• Patient Involvement • Safety Climate• Learning what works• Teamwork within practices, boards,
programme• Personal development
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Challenges
• Time• Competing priorities• Involving team• Maintaining momentum
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Challenges
• Reliability - bundles• Trigger Tool• Patient involvement• Climate Survey
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External interest
• Scottish Patient Safety Programme• Health Foundation• International - IHI• Groundbreaking – Bundles/trigger
tools/Climate/Patients• Primary care is different• Influence Safety Programme for Primary care• GMS Contract
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Patient Story
Danish Patient Story
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Keeping us focussed
• Harm occurs• 1 in 8 admissions • 1 in 20 deaths in hospital• 11% prescriptions have errors• Commission – doing something• Omission – not doing something
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Arlene Napier
Acting Head of Safety, Governance and Risk, NHS Tayside
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Basketball
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Delivering Reliable Care-
Every Patient Every Time
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Aims of the session
• Learn from others• Share successes, challenges and practical
tips• Use data for improvement• Learn about other workstreams
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Practice presentations
Presentation from Muirhead Medical Centre, NHS Tayside and Alva Medical Practice,
NHS Forth Valley
Experience of NHS Lothian
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Muirhead Medical Centre
Ruth Herrington GP, Gillian Cruickshank PP, Fiona Smith HCA
January 2011
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Summary – Good + Bad
•Why we are here?•Bundles•Patients•Practice
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Why we are here?• Ideal opportunity to rev DMARDs system
• Limit to Azathioprine, Methotrexate• Initiated by Secondary Care: Rheumatology, Dermatology,
Gastro, Cardiology etc. = different monitoring regimes!• Work across different Practices – large number of approaches
• Interrogate safety aspect • potentially toxic drug therapy
• See how others did it and learn together• Good Team at Muirhead
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NHS Tayside 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• Compliance with full bundle (ie all of
above)
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Bundles – Good:
• Every two weeks we review 5 pts via Bundle• Time - 15mins• Like the graphs – see improving…• Quick action to problems ie non-attender,
pneum. Vaccine, PDSA etc.• Changed:
• Coding on bloods NPT – docman is copied to HCA + GP
• Vision computer entries #66P7 – normal, or if action required. Allows trend & ease follow
• Utilise probs - PDSA
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Bundles - Not so good:
• 2pts may skew the data• DMARDs feedback to all – challenging• Hard not to look at other things re
Rx’ing• Time• Think about involving others re data
collection
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Patients:
• Area to work on with the Patient Focus Group Feedback.
• Leaflet or credit card size information
• Discussed this with 3 patients
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Practice:
• Clinical Meetings • Docman internal messaging• Emails• Getting there…..
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Relax at Muirhead…
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NHS Forth Valley Presentation
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Heart Failure/LVSD
• First cleanse the Heart Failure register
-585f-Echocardiogram shows left ventricular systolic dysfunction and if also appropriate, Heart Failure G58
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Heart Failure/LVSD
Evidence based interventions for LVSD (1)
1. LVSD diagnosed on echo
2. Annual NYHA functional assessment
3. Loop diuretic if fluid overload
4. ACE or AIIR inhibitor
5. Appropriately licensed BBlocker
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Heart Failure/LVSD
Evidence based interventions for LVSD (2)
6.If AF present – consider warfarin
7. Annual flu vaccination
8. Pneumococcal immunisation
9. Smoking Cessation counselling
10.Self management advice
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Forth Valley LVSD Bundle
1. On a licensed BBlocker
2. BBlocker at max tollerated dose
3. NYHA in last year
4. Self Management information
5. Immunisation- pneumococcal
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Alva Medical Practice
12500 patients
Semi rural
12 Doctor
Training Practice
CMR/ PTI since 1996
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PDSAs
LVSD Register
Previously recorded Echo as “Normal” or “Abnormal” in HF Patients
90 patients with LVSD in practice of 12500
Repeat Reviews
Following EMIS migration - large number of patients with repeat medication not reviewed
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PDSA format of managing change seems to work well in a large practice.
Allows immediate trialling of ideas among interested parties
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Bundle Data
Strong – ACEI/ Bblocker prescribing
Weak – attaining maximal dose of RxAssessment of function
Recording of management advice
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Initiate a Nurse Heart Function clinic
Re-examine HF Protocol
Address Training needs
EMIS Recording Template
Patient information
Coding of Mail
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General issues
Communication
Web site – TT/ PDSA
Time
Resources
Raised profile of safety in PC
Enthusiasm is there!
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Old Bundle:• Is the target INR recorded in patient’s notes?• INR is taken within 7 days of planned repeat INR?• Last INR recorded in yellow book?• Face to face education recorded every 3 months?
New Bundle:• INR is taken within 7 days of planned repeat INR?• Has patient been taking the ‘correct’ dose since last blood test?• Is there evidence that the last advice re warfarin dosing given to
patient followed current Lothian Guidance/INR Star/RAT?• Face to face education recorded every 3 months?
Care Bundle
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Delivering Reliable Care
Key Points for Group Discussion- Finalise
• What have you done – tests of change• What went well?• What were the challenges?
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Dr Andrew Martin
GP, CrieffClinical Lead, Tayside
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Intro To Measuring For Improvement
• Run Charts
• Variation
• SPC Charts
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What are we trying to accomplish?
How will we know that a change is improvement?
What changes can we make that will
result in improvement?
ACT PLAN
STUDY DO
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Measurement?
Without measurement it is impossible to know whether
you have improved.
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Run Charts
• Run Charts Defined– Run charts are used to analyze processes
according to time or order.
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Charts vs. Tables
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Collecting Data
• Define the data– So you get exactly what you want
• Decide level of accuracy needed• Think about consistency• Consider trade off
– Data quality vs. time to collect it• Make it become routine
– if it isn’t already
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Baseline & Target
• Set a baseline by using retrospective data, or monitor for a while before introducing the change
• Need to think about variation here!• Set a target and time scale for achievement
– Agree with stakeholders– Link to objectives– Be realistic!
• Agree reporting– To whom, when & how
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DMARD CompositeBaseline
R u n c h a r t w i t h t h e m e a n a s t h e c e n t r e l i n e
0
0
0
1
1
1
1
1 2 3 4 5 6 7 8 9 1 0 1 1
S a m p l e
x M e a n
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DMARD Compositeafter Action
Run chart with the mean as the centreline
0
1
2
3
4
5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Sample
x Mean
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DMARD Measures
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Development of new staff skills & knowledge
Aim of current testing of WHO Surgical Checklist is to improve poor compliance and reliability
Decrease in experienced staff numbers
Significant amount of staff vacancies
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Local Display and Feedback of Data
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Uses Of Run Charts
• For improvement– Establish baseline (plan) P– Observe process/variation D– Study for changes S– Significance of change?– Guide to action? A
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Measurement For Improvement
UNDERSTANDING VARIATION
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What Should We Do About Variation?
• Variation is ever-present• What is significant?• Where should we start?• When should we act?• What should we do?
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Types Of Variation
• “Common Cause” or “Routine” Variation– Inherent in a process
• “Special Cause” or “Exceptional” Variation– Something not part of a process
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Understanding Variation
“Routine”• “common cause”
variation• due to “chance”
causes• many factors• often “unknowable”• “noise in the system”• affects process most of
the time• part of the process• variation is predictable
“Exceptional”• “special cause”
variation
• due to “assignable” causes
• usually few, not many
• can usually be identified
• not part of the process• intermittently
apparent• unpredictable
variation
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What To Do About Variation?
“Routine”(“common cause variation”)
• don’t react to individual results
• look at the average and the range (limits)
• improve the whole process if these not acceptable
• or go for continuous quality improvement!
“Exceptional”(“special cause variation”)
• investigate each point outside the limits
• look for the special cause and do something about it
• almost always something to find
• opportunities to learn
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Two Kinds Of Mistake
Mistake 1• Respond as if there is
exceptional variation when there is only routine variation happening
• Might make things worse
• Wasted effort anyway
Mistake 2• Fail to spot
exceptional variation – assume there is just random variation at work
• Miss an opportunity– to reduce variation– improve quality– learn something
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Control Charts
Definition:- A statistical tool to determine if a
process is in control.– Control charts are used to determine
whether a process will produce a product or service with consistent measurable properties.
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(How the process behaves over time)
TimeT1 T2 T3 T4 T
5T6 T7 T8 T9
Observed valu
e
Normal System Variation(common/routine variation)
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TimeT1 T2 T3 T4 T5 T6 T7 T8 T9
Observed valu
e
Special Variation
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Lithium Monitoring
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11
Sample
Coun
t
UCL
LCL
Process Avg
UWL
LWL
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Control Charts
• The following control chart shows the improvement of a process. The standard deviation decreases as the process becomes more capable.
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Out of Control In Control Process Improved(reduced variation)
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Conclusion
• SPC methods are valuable for:– Understanding variation in clinical data– Distinguishing two fundamentally different kinds
of variation– Indicating when and how to act to improve
quality– Identifying good practice from which to learn and
those in need of help to improve
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Run Charts and Variation
Key Points for Group Discussion
• What are you doing with your data?• What does your data tell you?• When will it tell you something?• How can you use your data to drive improvement?
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Trigger Tools
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Trigger Tool Session Aims
• Learn from each other• Share successes and challenges • Where are patients being harmed• Identify Solutions• Identify issues for programme
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Showcasing Work on the Trigger Tool
• Downfield Surgery
• Milton Surgery
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Group Discussion
Share your experience of using the trigger tool
• What went well?• What have been the challenges?• How are patients being harmed?• What have you done as a result?
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Safety Culture
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Safety Climate
Session Aims
• Review the safety climate report
• Develop your skills in using the report
• Consider how you might use it
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What is culture?
All based on ourmental processes, beliefs, knowledge, and values
What we think
Culture is learned, not biologically inherited
What we do What we produce = the outcomes
Adapted from Reason
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Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures.
“The way we do things around here”
Charles Vincent: Patient Safety (2010)
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Benefits of measuring your safety climate
• Raise awareness• ‘Diagnose’ • Identify strengths and weaknesses• Starting point for reflection and change • Measure improvement • Encourage teamwork, participation and
inclusion
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Your Safety Culture/ Climate
• Climate is a perception and changing • Being part of this programme will be
changing your culture • Likely to dip after one year more insight
and then improve year 2 • Like trigger tool is a measure but perhaps
more valuable as a catalyst for change
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Using the Safety Climate
• Tests of change – how can we use it as a catalyst for change
• Experience so far - unclear• Competing Priorities• Report hard to interpret?• Challenging for some practices to discuss?• Anyone used it succesfully?
Next test of change• Run a facilitated session on how to use the result• Clear guidance
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Developing a safety climate
• The report is one step in a process to build a strong safety culture
• Further steps– Share results with all practice team members– Discuss the results– reflect on whether perceptions match up with
reality
• Aim– Identify an area that needs attention– Identify what tests of change could be
undertaken
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Participation• Identify the number of team members that
participated in the survey
• Reflect on:– How many team members participated and how many were
expected to participate?– Why did some team members not participate?
• Potential Implications– A large number of participates ensure the results reflect the
perceptions of your whole practice– When was the survey conducted, e.g. during school holidays?
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Section 1: Practice Safety Climate
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Section 1: Your Practice Safety Climate
Action Reflective questions Potential implications
Identify a factor where your practice has scored a positive perception.
Do you think this positive perception is accurate?
How has this been achieved?
What lessons can be learned and actions taken to ensure this area stays positive/improve?
What can be transferred to other areas?
Sometimes a positive perception and the reality does not quite ‘match up’ This question is helpful to allow members to reflect on practice and team strengths
Identify a factor where your practice has scored a less positive perception.
Do you think this less positive perception is accurate?
Why is this specific area specifically perceived less positive?
What actions could be taken to improve in this area?
It may not always be possible or desirable to ‘improve’, given practices’ other priorities.
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Section 1: (Cont’d)Action Reflective questions Potential implications
Compare your team’s results to the average of other practices.
Are your scores (perceptions) mostly comparable?
Are there any areas where your perceptions are more positive or negative than average?
Is there any proof to substantiate the observed differences?
This would be the case for the majority of teams and areas. A difference does not imply ‘better or worse’ or ‘right or wrong’. However, it does provide an opportunity for team reflection and consideration.
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Section 2: Results by Professional Role
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Section 2: Results by Professional Role
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Sections 2 & 3 : Results by Professional Role and Individual Experience
Action Reflective questions Potential implications
Look for any obvious differences between staff groups.
Are there any obvious differences between staff groups? Is one staff group consistently perceiving things more positive/negative than another?
Is the difference in only one area?
Why is there variation between groups? How can perceptions be aligned (if this is considered important)?
If there are differences between only one group, it is more likely to be important. This is a good opportunity to share individual experiences.
It can be difficult and even counter-productive to try and establish which group’s perception is ‘right’.
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Compare with previous results
• Are there any noticeable differences
• What might need to be done
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Finally…
• Has the discussion in your practice team identified areas where you can agree to focus improvement efforts
• Are there any tests of change that could be undertaken
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Making the most of your Climate Survey
Key Points for Group Discussion
• What is your experience of using the climate survey?
• How might you use this after today to develop your safety climate?
• What help would you like to use your report?• Any feedback on the format of the report
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Safety Climate
Do we need to alter course?
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Patient Involvement
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Patient Involvement
Session Aims
• Share experience of involving patients
• Identify barriers
• Highlight opportunities/ methods
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Why patient centredness is important
Her Last Journey Home – Welsh Ambulance Service
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Patients at the Pinnacle
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Board groups - real interest Common themes
Information• Information patients receive is variable and often only at
diagnosis and not at follow up appointment –• would like an information update at annual review
• Patients need reassurance about the drugs specifically – Side effects– Drug interactions and interactions with food OTC
• “Health centres not having agreed policies for level of information they provide”
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Results
• Many patients would find it reassuring to receive notification of normal results
• Some patients appreciate having a print out of their results and their changed dosage
• Many patients would like a patient held record with their blood results in them
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Self Care/Monitoring
• Some feel able to manage their conditions• Uncertain about recognising if they were
becoming unwell or side effect of their medication
• Some patients feel they would be better off if they could some self monitor their condition
• “Poor attitude of patients and some health professional to self management
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Difficulties on discharge form hospital
“Apparent lack of care when leaving hospital”
Access• On the whole access is not too
troublesome tho continuity can be • “No continuity of care – why can’t I see the
same GP – we need a fast track service
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Running a practice focus group for patients with “heart condition”
• Letters from us - 14 out of 30 responses• Some surprises and fears• Call beforehand• Hassle free logistics• Questions evolved form board groups and our
own questions• Useful report
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What information, if any, have you received from your GP practice about your condition?
Patients felt well informed about their condition and confident in asking about anything they were concerned about.
“Dr [name] gave me this leaflet with coloured zones on it
I found it very useful.
1 patient stated that they did not always feel well informed but referred to some problems with their memory as possibly playing a part
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How confident do you feel about managing your condition at home?
Most of the group agreed that they had sufficient information and knowledge on how to manage their condition at home.
Review memory at clinic review not just physical aspects
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Results
• Some patients would appreciate the GP calling them when results are back whether action was required or not.
• “When you’ve had your blood samples taken nobody ever rings up and says everything is fine. They’ve got so many people … surely it must be possible just to let you know all is well.”
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Self management
General consensus showed a patient confidence in knowing what to do if their condition worsened.
A hand held record he could take personal responsibility for and carry to the various places he receives treatment
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What is your experience of accessing your usual GP or a GP or nurse that knows you at
the practice?
The majority of patients agreed that you are always able to see a GP or Nurse when requested
When one patient spoke of his slightly more negative experience some others disagreed and explained their situation as much more positive.
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What do you think about the follow up care you received from your
practice after being discharged?
Communication issues between the hospital and the practice rather than the after care received.
One patient felt they could have received a little more attention from the practice after hospital discharge.
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General comments
“No individual in the health centre is anything less than excellent but the
process is less good than the individuals.”
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Actions
Discuss with partners - Good process – useful insights
Share with all of team
Actions• Send report to patients• Use Patient Leaflets• Screen for Cognitive impairment• Results Leaflet• Communication – flu / part time / Results• You said, we did notice board/ TV
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Practice group
• Invites• Questions• Expertise• Writing it up • Feedback to patients• Others planned
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Telephone interviews
• Semi structured interviews
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Patient ExperienceQuestionnaire
• Validated questions• Covering areas raised by focus groups• Local adaptation• Support• Analysis available• Volunteers
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Patient Experience Questionnaire
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Just Ask
• What could the practice have done differently to improve your experience of care today …?
• What was good about today? • What was not so good?• What do we need to change?
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Patient Involvement
Key Points for Group Discussion
• How have you involved patients in this programme?
• What are the barriers? What stops you asking / involving patients?
• What might you do next to involve patients?
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Range of options
• Patient self care information • Focus groups• Telephone interview• Questionnaires• What could the practice have done
differently to improve your experience of care today ?
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Home Strait
• Board groups
• Evaluation – important for us to receive your feedback
• Thank you!
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Breakout Sessions
• NHS Tayside: Conference Suite 6
• NHS Forth Valley: Wallace Suite 1
• NHS Lothian: Wallace Suite 2