Parallel Session 4.6 Developing Your Team’s Safety Culture and Safety Practice in Primary Care
107
Improving Safety Culture and Safety Practice In Primary Care
-
Upload
nhsscotlandevent -
Category
Health & Medicine
-
view
353 -
download
0
description
Transcript of Parallel Session 4.6 Developing Your Team’s Safety Culture and Safety Practice in Primary Care
Improving Safety Culture and Safety Practice
In Primary Care
Scottish Patient Safety Programme Acute Focus
Central line infection rate(per thousand line days
0
2
4
6
8
10
1292% reduction
Delivering Quality in Primary Care“Design and implement a Patient Safety
Programme in Primary Care”
• Why ?• Who?• What ?• How?
PATIENT SAFETY IN PRIMARY CARE - WHY BOTHER?
• High Volume• Increasingly complex• Real harm – adverse events in primary care cause:
– 12% of Admissions to hospital Quality and Safety in Healthcare April 2007
– 5.5% of Deaths in hospital To Err is Human, 1999
• 76% of incidents in primary care are preventable Med Journal
Australia ; 169 ; 73-6)
How Safe are we?
• Consultations 98% safe • Adverse Event rate1- 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
Statistics- Commission
• 11% prescriptions contain errors
• In a care home - 50% chance of ADE
• High risk prescribing
Omission Lack of reliable care
• Methotrexate – 12% not monitored
• Mix of strengths 30%
• Prescribed daily
Causes of harm
• Drug adverse events• Medication errors• Delayed diagnosis• Clinical error• Administration errors – Results – Med rec• Communication
6048 prescriptions
• 95% Prescriptions are safe• 1 in 20 have an error • 1 in 550 serious error• 9 out of 11 from Warfarin • Processing errors not knowledge• Human factors
Why?- Human Factors
• Time pressures• Frequent distractions and interruptions• Blood monitoring errors• Little training• Team communication • IT Issues• Interface communication
Not a new agenda…….
Development and Testing Safety Improvement in Primary Care 1
Aims
• To enable 50 Primary Care teams to:
1. Identify and reduce harm to patients
2. Improve reliability of care for patients
On High Risk Medications
With Heart Failure
3.Develop safety Culture
4.Involve Patients in QI
The Tools
• Collaborative • Bundles• Patient Involvement• Trigger Tools• Safety Climate•
Knowledge
• Topics• Tools• What to spread?• How to spread?
Measurement
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
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?
Methotrexate data
Warfarin - Bundle
Warfarin dosing followed current local guidance?Patient informed of the warfarin dose and date of next test 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 12 months?
5 patients per fortnightAll or nothing measure
Warfarin Bundle Compliance
Overall Warfarin Bundle Compliance (Wave 1)
0%
20%
40%
60%
80%
100%
28thFeb
14thMar
28thMar
11thApr
25thApril
9thMay
23rdMay
6thJune
20thJune
4thJuly
18thJuly
1stAug
15thAug
29thAug
12thSept
26thSept
10thOct
24thOct
7thNov
21stNov
5thDec
19thDec
2ndJan
Heart Failure Bundle
“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
• Optimised care• Guidance/ Templates • Blood monitoring /Recalls• Reduced variation• Patient Education and Self management• More efficient • Less Stress!
Greater efficiency & confidence in practice procedures
“shortly after starting there seemed to be these patients in my messaging system all the time and that now seems much more manageable”
Less Stress for some staff in their job
• “Staff member X who manages the register and the recall for these patients, it caused her an enormous amount of stress prior to the programme”
“ Now that the programme is much more streamlined and she feels more
confident and has taken much more clinical responsibility”
Staff time-saving - patients being more proactive
“staff member X doesn’t have to continually phone people up every month, that is quite a time saver for her, patients are
now more coming in cause they understand the consequences potentially
of the side effects of the potential toxic drugs”.
Reduction in tests per patient
Tests per Patient
0
0.5
1
1.5
2
2.5
May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
The Trigger Tool and GPDetecting Harm in Primary Care
Where is all this harm?What are we going to do about it?
Dr Gordon CameronGP / Patient Safety Advisor
Not In My Back Yard?
11% of maintenance logs show significant errors which could jeopardize safety
Around 2% of worker shifts end with the potential for a significant adverse event
In the satellite workshop setting there is a 50% chance of a safety log containing a significant deviation from protocol
More than 60,000 visitors a year spend time in the “high risk zone” of this facility
But This IS Our Back Yard …
5% of UK GP prescriptions contain the potential to harm the patient
Around 2% of consultations end with the potential for a significant adverse event
In the care home setting there is a 50% chance of a Kardex containing a significant drug interaction
More than 60,000 patients in Scotland each year receive a “high risk prescription” – methotrexate, warfarin etc
EmailEmail
MeetingsMeetings
Prescribing targets
Prescribing targets
Phone calls
Phone calls
InterruptionsInterruptions
EmergenciesEmergencies
FatigueFatigue
Personal Health
Personal Health
Personal Stress
Personal Stress
If pilots had the same working day as GP’s …
…….. Would you get on a plane ?
The Trigger Tool
Where is all this harm?
General information Classification of severity Number of consultations
Date of review E Temporary harm to the patient - required intervention
Telephone
Time to review record
minutes
F Temporary harm to the patient - required hospitalization
GP - surgery
CHI no
G Permanent patient harm GP - home visit
H Required intervention to sustain life Practice nurse
I Death of patient Other
Triggers Is Trigger present?
Did harm occur? Prev*
Severity? Harm origin?
?=unsure Preventable?
?=unsure ≥3 consultations in 7 days
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
New ‘high’ priority read code added
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
New allergy read code added
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
‘Repeat’ medication item discontinued
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
OOH / A&E attendance
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
Hospital admission
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
INR >5, < 1.8
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
Hb < 10
Yes No Yes New
Yes prev
No Prim ? Sec Yes ? No
eGFR reduction ≤5
Yes No Yes New
Yes prev
No Prim ? Sec Yes ? No
*Prev=tick this box if the harm incident has been recorded before. Brief description of harm event(s) Incidental findings 1. 2. 3.
© 2010 NHS Education for Scotland Measuring harm in primary care http://www.nes.scot.nhs.uk/initiatives/patient-safety
Trigger Tool Data Proforma
General information Classification of severity Number of consultations
Date of review E Temporary harm to the patient - required intervention
Telephone
Time to review record
minutes
F Temporary harm to the patient - required hospitalization
GP - surgery
CHI no
G Permanent patient harm GP - home visit
H Required intervention to sustain life Practice nurse
I Death of patient Other
Triggers Is Trigger present?
Did harm occur? Prev*
Severity? Harm origin?
?=unsure Preventable?
?=unsure ≥3 consultations in 7 days
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
New ‘high’ priority read code added
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
New allergy read code added
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
‘Repeat’ medication item discontinued
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
OOH / A&E attendance
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
Hospital admission
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
INR >5, < 1.8
Yes No Yes new
Yes prev
No Prim ? Sec Yes ? No
Hb < 10
Yes No Yes New
Yes prev
No Prim ? Sec Yes ? No
eGFR reduction ≤5
Yes No Yes New
Yes prev
No Prim ? Sec Yes ? No
*Prev=tick this box if the harm incident has been recorded before. Brief description of harm event(s) Incidental findings 1. 2. 3.
© 2010 NHS Education for Scotland Measuring harm in primary care http://www.nes.scot.nhs.uk/initiatives/patient-safety
Trigger Tool Data Proforma
Experience so far…
Generally received positively
• “It has been overall very positive, it has been a fantastic tool”
“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”
Experience
• Quick – about 90mins to review 20 sets of notes• Finding harm not previously indentified – and that
would not have been otherwise identified
• Focus for Improvement • Cultural change
• Need training and support• Not for measurement
Frequent Themes
• Missing Read codes• Huge variation in what doctors thought the
“allergy” or “adverse reaction” codes were for
• Often the most valuable safety lessons were in patients who had no triggers found in their notes
• It’s led to big changes in my practice
Trigger Tool or SEA
• SEA– Can only be used in
cases where harm has already occurred
– Needs a lot of writing up
– Very reliant on the clinician feeling able to share
– Can be threatening
• Trigger tool– Can pick up near miss
cases where no harm actually occurred
– No formal writing up needed
– Less threatening– A more powerful tool
for changing individual ways of working
That’s the good news
• We know harm exists• We know what it looks like• We know how to find it
• We’ve got a strategy to deal with it
But now for the bad news …
Culture Eats Strategy For Breakfast
Safety Culture
Safety Climate
Safety Climate Survey
• On line• Practice report• Measurement• Diagnosis• Catalyst for
change
Safety Climate Results
• My own practice
• Two years of results
Workload Average this year 4.5 Last year 5.0
Other practices average = 4.7
Leadership Average this year 5.8 Last year 5.8
Other practices average = 5.8
Teamwork Average this year 5.5 Last year 5.6
Other practices average = 5.4
Safety Systems and Learning Average this year 5.2 Last year 5.5
Other practices average = 5.6
Communication Category:
Our average 2010 = 4.4 out of a possible 7.0
Our average 2011 = 4.2 out of a possible 7.0
Average for all other practices 2011 = 4.8
Doctors and managers
Scored the communication category questions at 5.7
Doctors and managers
Scored the communication category questions at 5.7
Non managers Scored the communication category questions
at
3.5
Team members feel free to question the decisions of those with more authority
Our score 0.6 less than the average
Team members are comfortable expressing concerns to leadership about how thingsare done
Our score 0.7 less than the average
There is open communication between team members across all areas in the practice
Our score 0.5 less than the average
Team members are kept up to date about practice developments
Our score 0.4 less than the average
The practice leadership communicates its vision for practice development
Our score 0.2 less than the average
Progress in Aviation
Team Resource Training
Team members feel free to question the decisions of those with more authority
Assertiveness
Team members are comfortable expressing concerns to leadership about how thingsare done
Assertiveness
There is open communication between team members across all areas in the practice
Communication
Team members are kept up to date about practice developments
Awareness
The practice leadership communicates its vision for practice development
Leadership
Development and Testing Safety Improvement in Primary Care 1
Overall Challenges
• Understanding• Time Pressures• Competing priorities• Staff and IT changes• Team Involvement• Resources and remuneration • Practice environment - culture
Overall Successes
• Increased Knowledge and skills• Improved Patient Care• Safer Systems• Improved Team-working• Real Patient Involvement• Less stress• Greater Efficiency and confidence
Overall
• 82% say the programme has benefited their practice
• 75% say the Programme has improved the safety culture of their practice
• 81% say they plan to continue using SIPC tools/procedures
Safety Improvement in Primary Care 2
“Look at areas of major clinical risk to patients as they move across the health system.”
• Medication Reconciliation• Results handling
• Communication after outpatients
Experience so far…
• Literature review• Process mapping • Areas of risk • (un)Reliable processes• Measures• Improvement in practices and interface
What Next?
Current Activity
SIPC
• Lothian- LES• Forth Valley- LES• Tayside• Grampian • Borders• Highland
Spread• Greater Glasgow &C• Dumfries and
Galloway - LES• Ayrshire and Arran• Lanarkshire - LES• GP training• Appraisal• Pharmacy – Climate
Survey
Innovation Adoption Curve
.
“Design and implement a Patient Safety Programme in Primary
Care”
Start with GP Practices, Community Nurses
and Pharmacy
• Safer Medicines
• Safe and reliable patient care across the interface and at home
• Safety Culture and Leadership
Patient Safety in Primary Care Programme - 3 Workstreams
Safer medicines • Safe and reliable prescribing, monitoring and
administration of high alert medications
e.g.DMARDs Warfarin Insulin Lithium• Reducing high risk prescribing – data/alerts• Reliable Medication Reconciliation
Safe and Reliable Patient Care across the Interface and at home
Reliable:
• Medication Reconciliation• Management of test results• Communication at point of referral • Handling written communication
Identify risk and reduce harm for vulnerable frail adults in the home care setting
Reducing harm from:
• Falls • Pressure ulcers • Catheter associated UTIs
3. Safety Culture and leadership Ensuring:
A culture of safety and learning
e.g. Trigger tools, climate surveys safety walk rounds
Organisational learning from SEAs
Capacity and capability to support the programme
Patients become partners in making care safer
• Not all at once
• Menu
• Build over time
• Boards and practices prioritise
Patient Safety in Primary Care Programme - 3 Workstreams
Implementation Plan
• Communication • Engagement• Capacity Building• Measurement• Method ??• Central support • Linkage – Prescribing - RTC• System changes – IT – Pharmacy• Reporting and Evaluation
Successful implementation needs..
• To Build on the professionalism of front line staff
• Prioritised within existing and adapted GMS contract
• Alignment with GP Appraisal and Revalidation
• Commitment of boards
Boards need…
• Executive buy in and championing
• To Prioritise this programme
• Dedicated clinical leadership, QI and pharmacy support
• Build knowledge and skills
• PLT
In Return …
• Fewer adverse events• Fewer Admissions• Fewer Falls/ UTIs/Pressure ulcers
• Improved Interface working – SPSP• Engage with Primary care
How can we make sure the Boards are facing the right way …?
How might the current GP Contract support patient safety?
Patient safety is a core responsibility of all staff
BUT
Ensure key high risk processes are done safe and reliably
Highlight these within the GMS contract.
GP Appraisal and Revalidation
• The Trigger Tool (structured case review) • Safety Climate Survey • Care bundles • Reliability Data - test results and medication
reconciliation • High risk prescribing
• “Houston we have a problem”• By Improving safety we will have :• Safer care• Confidence in systems – less waste• Fewer things going wrong• Less stress• Improved interface working• Greater Capacity
Why Bother?
Get training……!
