Primary Care Collaborative 2

Swindon, 7 September 2016

Please sit with your local colleagues…

Welcome

Ann Remmers

Housekeeping

• Toilets• Fire procedure• Mobile phones• Confidentiality• Breaks• Lunch

The West of England Academic Health Science Network• We are one of 15 AHSNs across England, established by

NHS England in 2013 to spread innovation at pace and scale.

• 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 citizens.

• The Patient Safety Collaborative (PSC) was officially launched in Autumn 2014 and were borne out of the Berwick report in the safety of patients published in August 2014.

The Primary Care Collaborative• One year project working with 14 GP practices to help

develop a safe and open culture particularly through the use of incident reporting.

• Quality Improvement methodology development• 2nd event of the 4 planned for the year• SCORE Survey underway for most practices – aim for debrief

by Nov 16• Most individual practice visits have been completed

Currently the only Primary Care Collaborative across England

Previously at the Primary Care Collaborative

Dr Hein le Roux

Previously at the primary care collaborative…

Arrange to meet with the core team to establish priorities for our primary PDSA and first improvement taskBe more aware of human factors in practice dynamicsChange name of “Significant Event Meeting” to “Learning Event…” x 2Collaborative working strategies – moving a tennis ball – making one simple change at a timeDevelop a map of responsibilities x 2Discuss / feedback with rest of practice x 3Disseminate the SCORE questionnaire x 6Explore ways of changing my organisational cultureGo through PDSA cycles with my teamImprove communication within the nursing team/ doctor/ reception and management staffImprove communications across all sites to ensure timely and effectiveLook at buddy systemLook at existing data procedures to see what we can improve to help with patient safetyLook at insulin passports and if patients use themLook at planning improvement – use of the website to enter projects and share better with staff

Look into practice recall systems and check if patients are being appropriately recalled x 3Make links with other practices in this pilotMake time for interface clinician/ administrationMake time to plan with discussion & communicationPlan 1 step at a time and see what worksPlan some change!Read Berwick reportReflect on todayReview guidance on NCR reportingSign up for the LIFE website x 3Use PDSA template and get large one printed or white board to go in reception and waiting roomUse the A3 sheet for new projectsUse the planning & improvement toolUse the West of England AHSN website x 2Work on a more “open” culture

As a result of today I will…

“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, 2013 A promise to learn - a commitment to act

What is a patient safety incident?

“any unintended or unexpected occurrence that could have or did lead to harm.”

What is a significant incident?

“an occurrence thought by anyone in the team to be significant in the care of patients or the conduct of the practice.”

Severity of incidentsNone – No harm / No harm (harm prevented)Low – Any unexpected or unintended incident which required extra observation or minor treatment and caused minimal harm, to one or more personsModerate – Any unexpected or unintended incident which resulted in further treatment, possible surgical intervention, cancelling of treatment, or transfer to another area and which caused short term harm, to one or more persons. Severe – Any unexpected or unintended incident which caused permanent or long term harm, to one or more persons.  Death – Any unexpected or unintended incident which caused the death of one or more persons.

Near miss… or good catch?

A “good catch” is a positive incident where staff member’s actions showed great initiative in preventing an incident from progressing, or safety net systems in place worked.

Adverse events in primary care

360 million consultations 1 in 100 3.6 million

Oct- Dec 2

003

Jan - Mar 2

004

Apr - Jun 2004

Jul - Sep 2004

Oct - D

ec 2004

Jan - Mar 2

005

Apr- Jun 2005

Jul- Sep 2005

Oct - D

ec 2005

Jan - Mar 2

006

Apr - Jun 2006

Jul - Sep 2006

Oct - D

ec 2006

Jan - Mar 2

007

Apr - Jun 2007

Jul - Sep 2007

Oct - D

ec 2007

Jan - Mar 2

008

Apr - Jun 2008

Jul - Sep 2008

Oct - D

ec 2008

Jan - Mar 2

009

Apr - Jun 2009

Jul - Sep 2009

Oct - D

ec 2009

Jan - Mar 2

010

Apr - Jun 2010

Jul - Sep 2010

Oct - D

ec 2010

Jan - Mar 2

011

Apr - Jun 2011

Jul - Sep 2011

Oct - D

ec 2011

Jan - Mar 2

012

Apr - Jun 2012

Jul - Sep 2012

Oct - D

ec 2012

Jan - Mar 2

013

Apr - Jun 2013

Jul - Sep 2013

Oct - D

ec 2013

Jan - Mar 2

014

Apr - Jun 2014

Jul - Sep 2014

Oct - D

ec 2014

Jan - Mar 2

015

Apr - Jun 2015

Jul - Sep 2015

Oct - D

ec 2015

0

100,000

200,000

300,000

400,000

500,000

600,000

Incidents reported on NRLS from Oct 2003 - Dec 2015

Incid

ents

Sub

mitt

ed

Incident typeOct 2014 - Dec 2014

Jan 2015 - Mar 2015

Apr 2015 - Jun 2015

Jul 2015 - Sep 2015 TOTAL

Patient accident 86,429

86,100

83,471

79,600

335,600

Implementation of care and ongoing monitoring / review

57,263

60,443

58,716

55,838

232,260

Medication

49,033

48,169

51,114

48,294

196,610

Treatment, procedure

46,368

45,860

46,704

44,566

183,498

Access, admission, transfer, discharge (including missing patient)

42,301

40,095

42,450

42,496

167,342

Documentation (including electronic & paper records, identification and drug charts)

29,052

28,321

29,132

27,779

114,284

Infrastructure (including staffing, facilities, environment)

29,380

28,257

26,727

27,897

112,261

Clinical assessment (including diagnosis, scans, tests, assessments)

22,486

22,723

23,457

22,187

90,853

Self-harming behaviour

16,304

16,949

17,782

16,796

67,831

Consent, communication, confidentiality

16,570

16,123

17,340

16,890

66,923

Disruptive, aggressive behaviour (includes patient-to-patient)

12,669

12,799

13,996

13,565

53,029

Medical device / equipment

12,252

12,057

12,690

12,106

49,105

Infection Control Incident

8,584

9,230

8,851

8,134

34,799

Patient abuse (by staff / third party)

2,517

2,546

2,175

2,039

9,277

Other

16,522

15,940

17,035

16,307

65,804

Total

447,730

445,612

451,640 434,494

1,779,476

NRLS data collection reported by all sectorsEngland and Wales October 2014 – September 2015

Incident Decision Tree

Deliberate Harm Test Incapacity Test Foresight Test Substitution Test

Start Here

Were the actions asintended?

Does there appear to be evidence of ill health or substance abuse?

Did the individual depart from agreed protocols or safe features?

Would another individualcoming from the same professional group, possessing comparable qualifications and experience, behave in the same way in similar circumstances?

System Failure

Review system.

Were there any deficiencies in training, experience or supervision?

Were there significant mitigating circumstances?

Consult relevant regulatorybody.Advise individual to consult Trade Union representative.

Consider:* Referral to disciplinary/ regulatory body* Reasonable adjustment to duties* Occupational Health referral* Suspension

Highlight any system failures identified.

Is there evidence that the individual took an unacceptable risks?

Were the protocols and safe procedures available, workable, intelligible, correct and in routine use?

Consult relevant regulatorybody.Advise individual to consult Trade Union representative.

Consider:* Corrective training* Improved supervision* Reasonable adjustment to duties* Occupational Health referral

Highlight any system failures identified.

Does the individual have a known medical condition?

Consult relevant regulatorybody.Advise individual to consult Trade Union representative.

Consider:* Reasonable adjustment to duties* Occupational Health referral* Sick leave

Highlight any system failures identified.

Were adverse consequences intended?

Consult relevant regulatorybody.Advise individual to consult Trade Union representative.

Consider:* Suspension* Referral to police and disciplinary/ regulatory body* Occupational Health referral

Highlight any system failures identified.

Inci

dent

Deci

sion

Tre

e ba

sed

on Ja

mes

Rea

son'

s Cul

pabi

lity M

odel

YES

YES

YES

YES

YES

YES

YES YES

YES

YESNo

No

No

No No

No No

No

No

No

Our survey said…

Scenario time…What is the impact of this incident?

Do you agree that others in your practice would benefit from knowing about this event scenario?

Would you be prepared to report this scenario as part of an anonymous and confidential reporting system?

None Low Moderate Severe Death

Scenario time… 1Mr Hamilton was on long term warfarin therapy as antithrombotic prophylaxis. For several years his INR was being monitored on a monthly basis in the surgery. When going through the routine hospital letters, Dr Miranda received notification that Mr Hamilton had been recently discharged from hospital having suffered an embolic cardiovascular accident (CVA). The doctor, on reviewing Mr Hamilton’s INR noticed that the most recent INR reading was 2.2 and that the preceding month his INR was 1.8. His target INR was 3.5. No alteration had been made in Mr Hamilton’s dosage to try and bring the INR near the target level.

Scenario time… 2Nunney, carer for Ray, has handed in a form for Blue Badge disabled parking for completion by the doctor. Nina, the receptionist attaches the form to Ray’s notes and puts them in Dr Bennett’s tray for his attention. When Dr Bennett checks the tray, there was no Blue Badge form. It had become detached from the paper clip. Dr Bennett asked Nina why Ray’s notes were in his tray. He was told the reason, and it was surmised that the form had become detached. After 30 mins of searching, Nina finally found the form in amongst Dr Bennett’s other paperwork.

Scenario time… 3Mrs Cooper arrived at reception to collect a prescription for her son Jim. The prescription, although generated, had not been signed and Dr Penny, duty doctor was asked to do so by Nina on reception. Dr Penny noticed that the telephone advice slip, which the practice used for all telephone calls, was still attached to Jim’s file. The details on the advice slip didn’t seem to match with the prescription. Dr Penny checked Jim’s case notes and the computer entry. Unfortunately there was no entry relating to the consultation but a prescription for penicillin V syrup had been printed in Jim’s name. Dr Penny spoke to Mrs Cooper and obtained a history. This was documented in Jim’s notes. A prescription for paracetamol was done, and the printed prescription for penicillin destroyed. In addition there were three previous entries for penicillin V with no data regarding its indication in the case notes.

Scenario time… 4Ms X attended the surgery with breakthrough bleeding and abdominal pain. Amongst other investigation a cervical swab was taken which returned as positive for chlamydia. She was prescribed azithromycin, and advised that her partner should be treated (partner was not a patient at the practice). She re-consulted 4 months later with similar symptoms which again gave a positive chlamydia result. On questioning, she was asked if her partner had been treated after the first attack. She replied that he had not, as he had no symptoms and thought it unnecessary. She was given further treatment and advised that her partner must contact his GP or sexual health clinic for treatment.

Scenario time… 5Dr Gilmore noticed that a patient, Mrs Wayne had been making regular monthly appointments to see her.However, during consultation the topic frequently changes to Mrs Wayne’s husband, and her concerns about him. The consultations are lasting 30 minutes, resulting in Dr Gilmore running late. This is stressing Dr Gilmore, and causing frustration to the patients waiting to be seen.

Scenario time… 6Ms Berry, 32, attended the surgery complaining of anxiety symptoms. Dr Perkins decided to prescribe some Inderal to help with physical symptoms. He did not notice that Ms Berry had a previous history of asthma, although she was not currently taking any medication. Ms Berry became dyspnoeic and wheezy overnight, and called 999. She was taken to hospital, where a diagnosis of beta-blocker induced asthma was made. She was given appropriate treatment and discharged the following day.

Scenario time… 7Jo, one of the GPs in the surgery received a phone call on their mobile during their lunch break from Bill, their partner. Bill was unable to pick up their children from the private nursery at 5pm as Bill was working late.Jo would therefore have to pick up their children after surgery finished at 6pm. The nursery had been informed of this by Bill, and were aware that children would be picked up closer to 6.30pm – although the nursery closed at 6pm. This meant one of the nursery staff had to wait behind with the two children for 30 mins after closing time, and they made it clear when Jo came to pick them up that the nursery was not pleased with the situation.

Acute / general hospital

Ambulance service

Community and general dental service

Community nursing, medical and therapy service (incl. community hospital)

Community optometry / optician service

Community pharmacy

General practice

Learning disabilities service

Mental health service

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NRLS: Degree of harm by care setting, by quarter, Oct 2014 - Sep 2015

Percent

None Low Moderate Severe Death

What happens to your NRLS submission

Paulette Knight, Quality & Safety Manager, NHS England South

(South Central)

Flowchart of internal actions by NHS SSC Quality and Safety team

The value of the NRLS as a tool to improve quality of care

Steps were then taken to spread the message that change was needed:1. An action, learning bulletin was developed and distributed amongst CCGs. It was also

shared with general practice managers and the director of nursing for CCGs within all south (south central). The action learning bulletin is a rich resource of information, sharing best practice in cold chain management together with practical tips and supporting documents.

2. Support for practices has been provided by the public health England immunisation team. This is not only been available on occasions where a breech in practice has been identified or where concerns have been raised by the care quality commission but is also an ongoing service which can be accessed by contacting (england.Screeningandimms@nhs.net).

3. Fridge magnets depicting the 4 Rs (read, reset, record, react) of best practice and the contact details for the public health immunisation team, have been widely distributed across south central.

4. Ongoing audit has been arranged which will measure whether the message has been effectively shared and instigate further change where deemed necessary.

Number of incidents

Oct 2014 - Dec 2014

Jan 2015 - Mar 2015

Apr 2015 - Jun 2015 TOTAL

Medication 471 485 346 1,658Implementation of care and ongoing monitoring / review 296 293 370 1,518Documentation (including electronic & paper records, identification and drug charts) 108 147 178 581Clinical assessment (including diagnosis, scans, tests, assessments) 98 134 177 596Access, admission, transfer, discharge (including missing patient) 151 117 163 598Treatment, procedure 95 94 154 450Consent, communication, confidentiality 92 86 98 377Infrastructure (including staffing, facilities, environment) 68 55 54 240Patient accident 56 51 56 207Medical device / equipment 27 20 29 110Infection Control Incident 27 45 22 126Self-harming behaviour 4 6 26 50Disruptive, aggressive behaviour (includes patient-to-patient) 5 5 4 22Patient abuse (by staff / third party) 0 6 4 14Other 81 107 130 456Total 1,579 1,651 1,811 7,003

NRLS data collection reported by general practiceEngland and Wales October 2014 – June 2015

Number of incidents BGSWOct 2015 - Dec

2015Jan 2016 - Mar

2016Apr 2016 - Jun

2016TOTAL

Medication 3 16 8 27Implementation of care and ongoing monitoring / review 1 1 0 2Documentation (including electronic & paper records, identification and drug charts)

0 1 6 7

Clinical assessment (including diagnosis, scans, tests, assessments) 1 2 4 7

Access, admission, transfer, discharge (including missing patient) 1 2 2 5

Treatment, procedure 0 0 0 0Consent, communication, confidentiality 2 1 1 4Infrastructure (including staffing, facilities, environment) 0 0 0 0Patient accident 0 0 0 0Medical device / equipment 0 0 0 0Infection Control Incident 0 0 0 0Self-harming behaviour 2 1 2 5Disruptive, aggressive behaviour (includes patient-to-patient) 0 0 0 0Patient abuse (by staff / third party) 0 0 0 0Other 0 0 0 0Total 10 24 23 57

NRLS data collection from General Practice BGSW region

NRLS data collectionPercentage BGSW expressed as a monthly average

M IoC D CA A T CCC I PA Md ICI ShB DAB Pab O0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Pre-May 2016Post-May 2016

Central alerting system

GP eform

Thinking Differently about Patient Safety

Dr Suzette Woodward, National Campaign Director, Sign up to Safety

A large part of my career has been in clinical risk and patient safety

….throughout I have had this nagging feeling (to paraphrase Eric Morecambe)

we are playing all the right notes – but not necessarily in the right order

Thinking differently

‘The field of patient safety needs to move forward over the next fifteen years with a

unified view of the future of patient safety to create a world where patients and those who care for them are free from avoidable harm’

Tejal GhandiNational Patient Safety Foundation, US

People are polarised, overwhelmed, isolated and withdrawn

Sign up to Safety

• Not a top down initiative

• People know their own situations better than us

• Locally owned safety

• Trust, kindness and celebration

400

Today…

• Safety in primary care• Learning• Culture• Profound simplicity

Primary care

Acute settings

Healthcare provided90%

Acute settings

Primary care

Focus from national organisations on safety

90%

Safety along a continuum of care

Patient continues to take aspirin

due to lack of pre admission

advice

Patient told to starve pre-op

Operation delayedPatient dehydrated

Patient allergic to opioids

Administered morphine post op

Patient collapsesLow blood pressure due to drug allergy,

dehydration and significant blood loss

Missing medication on

discharge – prescription

from GP takes 5 days

Patient fearful of ‘hazardous home’

reluctant to eat and drink because it involves walking

Patient increasingly

unsteady and falls

Patient reliant on stick to walk in constant pain

refuses operation on

right hip

Chronic

Playing risk with time

Martin Marshall

Understanding the reality of healthcare and safety

Variety of strategies

Variety of interventions

Ultra safe

Islands of reliability

Adapting and flexible

Ultra adaptable

Unpredictable

Acute care Primary care

Range of context

Acute Care Primary Care

Make it individualised – make it personal

Patient Safety in the Home• Addressing safety in the home presents unique

challenges

• You can help the system:– Understand how we can support the patient, family, and

other unpaid caregivers to provide safer care– Recognise the hazards of the unregulated and

uncontrollable home environment – Have appropriate strategies in place for the challenges of

transitions, communication, and continuity of care amongst an array (and potentially different people every time) of paid and unpaid care providers

Safety strategies for care in the home

Safety in primary care

1. Safety is along a continuum of care; rarely individual incidents

2. Safety is seen through the eyes of patients and requires safety strategies for care in the home

3. Understand the reality – that healthcare has a range of context which each need different approaches and strategies

Learning

In memory of Richie William

a chapter of accidents and misunderstandings

a catalogue of chance events and failings at the hospital, rather than gross negligence by

the doctors

1learn to listen

2resist the pressure to find a

simple explanation

3Don’t be judgemental

There are not enough trees in the rainforest to write a set of

procedures that will guarantee freedom from harm

James ReasonIn Close Calls – Carl Macrae

We collect too much and do too little

Culture

Safety culture is not created by a set of tasks or a policy document or notices on the walls

it is a way of being, noticing, understanding and learning from small moments of organisational life

The big 3*

Human Error

At risk behaviour

Reckless behaviour

*These are not mutually exclusive and can over lap with each other in definition and they can all occur in the same mishap

Just culture

• People who make an error (human error) are cared for and supported

• People who don't adhere to policies (risky behaviour) are asked first before being judged

• People who intentionally put their patients or themselves at risk (reckless behaviour) are accountable for their actions

Find the facts and evidence early without the need to find blame

Care for the people caught up in incidents

Human factors

Mental workload Fatigue Boredom

Alerts Distractions

Device/product design

Design of environment Teamwork Abbreviati

ons

Create a culture where clinicians and patients can have a conversation one human being to another

Simplicity to Profound simplicity

Just do it

TheoryGap

10-17 years

Sign up to Safety

Through line

We want people to talk to each other about what they know about keeping

people safer

This will be the thread throughout all our work for the final year

Fundamentallywe want people to talk to each other

About…….the implementation gap

….when they think something is unsafe ….when something has gone wrong….when something has gone right

Safe Conversations• Story telling• Active listening• Huddles, briefing

and debriefing• Fika• Facilitated

conversations

Learn as much as possible

Share what you know

and

Never be judgemental

Sign up to SafetyThinking differently about patient safety

View from the Front Line

Dr San SumathipalaGP at the London Medical

Practice

Words for "error" in most Indo-European languages originally meant "wander, go astray" (for

example Greek plane in the New Testament, Old Norse villa, Lithuanian klaida, Sanskrit

bhrama-), but Irish has dearmad "error," from dermat "a forgetting."

“An error doesn't become a mistake until you refuse to correct

it.” Orlando Aloysius Battista

An organisation with memory

Too busy to reflect

The professional expectation

P

•reflect on planned activity ( “expected things”)

U

•reflect on unplanned activity ( “unexpected things”)

L

•what are the learning points ( “the reflection )

S

•sharing the learning points in order to make improvements ( “  sharing a strategy” )

E

•encouragement to undertake the improvements and then evaluate them ( i.e. start the PULSE cycle again) ( “encourage and evaluate “ )

“Those who cannot learn from history are doomed to repeat it.”

George Santayana

Thank You

Panel discussion

Our survey said… please add your vote

We have this problem too… but no solution!

We are working on this… would be great to share ideas

We’ve come up with a solution that works for us and are happy to share

Share & Learn

Facilitated discussion

Wanted / For Sale

Wanted For Sale

Thank you and next steps

Ann Remmers

As a result of today I will…

Education PathwayImprovement Coaches NetworkLearning and development eventsThe Improvement Journey – quality improvement tools and resources

Next time…

• Learn & Share• Human Factors and Systems Thinking• Enhanced SEAhttp://www.qihub.scot.nhs.uk/safe/patient-safety/enhanced-significant-event-analysis.aspx • Top 10 tips for primary care on…• Look how far we’ve come…

Future dates

Wednesday, 30 November 2016Gloucestershire | Stonehouse Court Hotel

Wednesday 1 March 2017Bath, United Kingdom | Royal United Hospital

AHSN Stakeholder Survey 2016

Tell us how you think we’ve done.

Visit: www.yougov.com/weahsn and help us shape our future.