Safety Improvement in Primary Care
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Improving Patient Safety in Primary Care in NHS Scotland
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NHS Scotland Quality Strategy 2010
“Design and Implement a Patient Safety Programme in
Primary Care”
New Agenda?Who?What?How?
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SUB HEADING
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Patient Safety in Primary Care - Why Bother?
High VolumeIncreasingly complex
Adverse Events cause: 1 in 8 Admissions to hospital 1 in 20 Deaths Largely preventable
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Harm – Co-mission
• Level of harm unknown – NPSA
• 11% prescriptions contain errors
• In a care home - 50% chance of ADE
• 60,000 patients - high risk prescription pa
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0
5
10
15
20
25
30
0 1-2 3-4 5-6 7-8 9-10 11 or more
Perc
enta
ge o
f pati
ents
No. of chronically prescribed oral drugs
Proportion of population
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Harm thro Omission Lack of reliable care
Methotrexate – 12% not monitored
Mix of strengths 30%
Not prescribed weekly
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(un)Reliable Heart Failure Care
ACE inhibitor 88%
B Blocker 70%
B blocker at target dose 28%
Pneumococcal 71%
NYHA 71%
All 5 - 23%
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High Risks
•Warfarin •Methotrexate
•Patients with complex conditions
•Medication Reconciliation•Results •Communication
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Safety Improvement in Primary Care 1(SIPC 1)
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Aims
To enable 80 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
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The Tools•Collaborative
•Bundles•Patient Involvement•Trigger Tools•Safety Climate
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Knowledge
• Topics• Tools• What to spread?• How to spread?
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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
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Heart Failure Bundle
1.Maximise medical therapy –On a licensed B BlockerB Blocker at max tolerated dose
2.Functional assessment - NYHA recorded in last year
3.Immunisation - pneumococcal vaccine ever
4.Self Management- information given to patient on recognition of deterioration
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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?
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Bundles - Successes
“The care bundle was useful because it identified gaps”
“ Not as reliable as we thought we were”
Focus for improvement
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2 - Data
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Seeing Improvement
“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”
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Tayside DMARD ComplianceCompliance Tayside Practices
44% 46%
59%
35%
55%
65%68%
62%57%
71%
83% 84%80%
85% 86%
97%
84%
93%88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12 Wk13 Wk 14 Wk15 Wk16 Wk17 Wk18 Wk 19
Week
%
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NHS Forth Valley
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Lothian - Warfarin Compliance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
06/0
9/20
10
20/0
9/20
10
04/1
0/20
10
18/1
0/20
10
01/1
1/20
10
15/1
1/20
10
29/1
1/20
10
13/1
2/20
10
27/1
2/20
10
10/0
1/20
11
24/0
1/20
11
07/0
2/20
11
21/0
2/20
11
07/0
3/20
11
21/0
3/20
11
04/0
4/20
11
18/0
4/20
11
02/0
5/20
11
16/0
5/20
11
30/0
5/20
11
13/0
6/20
11
New bundle started 14/02/11
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Outcome Data
0%
2%
4%
6%
8%
10%
Sep-10 Oct-10 Nov-10 Dec-10
% IN
Rs
ou
t o
f ra
ng
e
INRs <1.5 INRs >5
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Safety Improvement in Primary Care
PATIENT INVOLVEMENT IN LOTHIAN
Isobel Miller, Public Partner
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Patient Involvement
Scottish Health Council SIGN
Public Partnership Forum
Personal involvement in own
healthcare with
own healthcare workers
Scottish Medicines Consortium
Healthcare Environment Inspectorate
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Active Patients
• Develop resources to help patients & practices
• Health professionals at one practice write leaflet
• Patients comment and suggest changes
• Edited version adopted and adapted by other
practices
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Change and Improve
• Capture experience of patients on warfarin
• Use that information to change and improve care
• Compare patients’ experience with practice’s
process map
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Process Map
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Methodology
• Focus group for warfarin patients from all
seven practices involved in pilot project
• What went well; what went not so well; what
would you change?
• Focus groups for individual practices
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Results
• Patients were happy with most parts of process
• Key topics identified
• Practices considered all issues raised
• Feedback to patients: You said - we did
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Feedback
You Said Our Response
Only half of the patients
attending the meeting
had a ‘yellow pack’
(warfarin information)
Some patients had heard about a new drug which
might be taking over from warfarin
When you attend for a blood test you will be asked if you have a yellow pack and this
will be recorded in your notes so that we know that everyone
has one who wants one
There is no information on when this will be available but any news will be given out in the education session.
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What went well?
• Better informed patients better outcomes
• Practices more open to patients’ concerns
• Patients felt listened to and practice staff had
a few surprises
• Improvements made
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What went not so well?
• Practices did not engage with large focus
group issues
• Not all practices participated
• Patients were not representative
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What would we change?
• Practice specific focus groups
• Increase educational aspect of focus group
• Explore ways to involve hard to reach groups
• Share the experience
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Other Boards
• Patient Self Care
• Board Groups
• Practice groups
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“The main learning was that they appreciate being involved in their own
care”
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“Barriers have just been ourselves”
Need
Resources
Facilitators
Expertise
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The Trigger Tool and GP-SafeQuest
Measuring – Learning – Improving
Carl de Wet MBChB DRCOG MRCGP MMed (Fam)
GP / Patient Safety Advisor
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Overview
1. The trigger tool (12 minutes)
• What, why and how?
• The story so far…
• 2. GP SafeQuest (8 minutes)
• What, why and how?
• The story so far…
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SUB HEADING
The trigger tool: Review of medical records Rapid, focused, structured, activeScreen for undetected harm / error
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SUB HEADING
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SUB HEADING
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SUB HEADING
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Educational Solutions for Workforce Development
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
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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
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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 SectionSecondary care, other providers
•OOH / A&E attendance / Hospital admission
Investigations Requests and results
•eGFR reduce <5
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Summarise your review
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SUB HEADING
MeasureLearnImprove
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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
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Safety culture
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Safety climate
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Cautions• Perceptions NOT reality
• Results are NOT ‘right’ and ‘wrong’ and NOT ‘strong’ or ‘weak’
• Snapshot in time
• Participation is key
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Benefits of measuring safety climate
• Awareness
• Identify perceived strengths and weaknesses
• Starting point for reflection and change
• Evaluate – serial measures
• Encourage teamwork, participation and inclusion
• Organisational benefits
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http://www.nes.scot.nhs.uk/initiatives/patient-safety/educational-research-and-tools
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Trigger Tool experience so far
It has been overall very positive, it has been a fantastic tool
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Causes of Harm
– Adverse drug reactions - ADRs– Co – prescribing – Unrecorded ADR’s– Missing read codes– Lack of follow-up– Not Monitoring drugs
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Expectations
• Hard to do
• Time Consuming
• Would not find harm
• Threatening
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Experience
• Quick
• Finding Harm
• Cultural change
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Challenges
Improvement
Logistics
Training
Variation
? For measurement
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Safety Climate Survey
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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”
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Insights
“We weren’t as good as we thought we were”
• Practices are interested • Acts as a catalyst
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Challenges
• Who?
• Better process and report
• Need guidance and support
• Understanding/using it
• Anonymity
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Collaborative
• A positive experience
• Promotes teamwork
• Stimulating and challenging
• All share, all learn
• Need training
• Need support
• Local vs national ? – PLT sessions
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Challenges Boards and Practices
• Time
• Competing Priorities
• Engaging Team
• Skills and knowledge - Tools
• Culture
• Leadership
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Outcome Measures?
• In targeted group of patients:• 20% reduction in INRS > 5 and < 1.5• 20% reduction in admissions
• Improvement in safety culture - years • Reduce Harm - TT as a measure?
• Timescale?
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SIPC 2
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“Look at three areas of major clinical risk to patients as they move across the health
system.”
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Areas of Focus
• Medication Reconciliation
• Managing results
• Shared care and communication after out patients
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Develop Knowledge
• What does the evidence say
• Process mapping
• Areas of risk
• Key reliable processes
• Patient involvement
• Measures and Improvement
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“Design and implement a Patient Safety Programme in Primary Care”
2011- 13
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SUB HEADING
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Themes
Safer medicines• High Risk Medicines• Co- prescribing
Improving safety across the interface (care pathways)
• Reliable Results Handling• Medication Reconciliation
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Themes
Reliable care for Chronic diseases
Healthcare Acquired InfectionAntibiotic prescribingHand washing
Culture and LeadershipSafety ClimateTrigger Tool
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Based on
SIPC 1 and 2
Medication Reconciliation
Co-prescribing
Other work….
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Process
• Feedback on Draft Plan
• Scoping
• Develop aims/measures/tools
• Implementation strategy
• Launch 2013
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Feedback
Themes appropriate
Methodology OK
Barriers
• Engagement
• Knowledge
• Time - Prioritise – PLT
Need secondary care involved
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Implementation will need:
• Communication
• IT Support
• Linkage
• Board Support and commitment
• Prioritisation- narrow and deep
• Contractual Levers
• Appraisal/ Revalidation
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Developing Patient Safety in Primary Care in NHS Scotland
Questions?
How do we sustain and spread this work?
Volunteers?