National GP ConferenceKilkenny 19-11-12

Dr. Philip Crowley, National Director Quality Improvement

General Practice, Quality and safety the national

context

The challenges that face us

Funding cuts Ensuring a future general practice workforce Limited measurement of quality Media, trust and morale New divisions – focus vs integration Fire fighting (comfortable) Vs process, practice

and care improvement

HSE Health Policy Direction

Clinical Leadership

Primary Care Team Development

Involving service users and staff

Planning for the Future

Demographic changes

Adverse risk factor profiles

GP and staff manpower situation

Chronic disease - scale of the challenge

Population pyramids, 2011 and 2040

Source: CSO

Projected increase in GP Consultations

20% increase by 2015 33% increase by 2021 Estimated 20 million

consultations in general practice

1.9 million consultations take place in OPD

Source: ESRI

A National Survey of Chronic Disease Management in Irish General Practice

Darker C, Martin C, O’Dowd T, O’Kelly F, O’Kelly M, O’Shea B. IMJ.

Chronic disease - the potential

Structured DM programme 4.1% reduction in Stroke/PVD/MI in a 3 year

Reduce deaths by 10% in 10yrs; Leg amputations by 40% in 5 years; MI by 10% in 10 years

Heart Failure shared care model would prevent > 4,000 hospitalisations per year

Asthma management programme – decreased mortality and 50% reduction in hospitalisation

GP Trainees

60% of current GP Trainees are still undecided as to whether they will emigrate

12.3% of current trainees are definitely planning to emigrate.

25% are planning to definitely stay in Ireland.

The future has arrived

Demographic changes are here

Chronic disease management will swamp our existing health services

GP retention is crucial

Can we meet the future?

Irish GPs GP Training top class Increasing availability

of infrastructure Practice Nurses ICT Build resourcing

What Patients and Families want

Health professionals and managers who:●Listen●Believe, understand●Take concerns seriously

Solve the puzzle (why, when, how, by whom etc)●What preventive measures would have been taken●Trust professionals to put things right●To learn●To prevent re-occurrence of harm●Include patients in the process

So urc e : Ma rg a re t Murphy , O p e n Le c ture Ro ya l Co lle g e o f Phys ic ia ns (2 0 1 1 )

Adverse event -the second victim

Staff may experience Feelings of incompetence and

isolation Denial of responsibility –

discounting of importance of event Emotional distancing Overwhelming guilt Symptoms of Post Traumatic

Stress Disorder

(HSE/CIS 2013)

The ‘Kindness Paradox’

We frequently work under conditions no other workforce would tolerate

Why?

Compassion binds us

- but also blinds us

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Inhibitors of compassion

Personal

FatigueStress

Over-exposure Excess Demand

DepressionInjustice

InjuryTyranny/Bullying/Abuse

Tricky Challenges

1. Managing angry or dissatisfied patients

2. De-escalate volatile encounters

3. Deliver bad news

4. Enlisting patients into their own treatment

5. Engage de-motivated others16

Empathic Communication

increased adherence to treatment, and fewer malpractice complaints.

greater urgency in addressing problems such as cancer.

Patients' perceptions of empathy are positively related to more favourable health outcomes.

Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Me d  2011;86:996-1009.

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We all need basic Heart Support Understand your role in care of suffering

Stay close to patients / mission

Refill the tanks - Take an occasional ‘ c a re p a us e ’

Avoid the angry trap “Little by little, your frustrations mount”.

Limit commitments but commit to work

Preserve personal and collegial relationships

Quality in Irish General Practice

CME network

Quality vocational training

ICGP Quality in Practice initiatives

Out of hours cover – integrating practices

Same day access, cervical screening and

immunisations

ICT penetration – disease registers?

Leadership – ICGP

Quality Improvement challenges

Lack of information, benchmarking Variability Isolated GPs Lack of use of guidelines and risk assessment tools Out of Hours cover and patient info Transitions of care Medication reconciliation and prescribing errors Premises and disability access

Opportunities to improve quality

Involve local community/patients

CHO + primary care network to engage with hospital trusts

Clinical leadership in CHOs

Work together to manage standards and share audit

Measuring performance – prescribing data: preventative inhalers, statin dosage, PPI duration, benzos and antibiotic use

Collaborative prescribing – community pharmacy partnership

ICT supported decision prompts, guidelines and risk tools

73% Reduction in Pressure Ulcers

0

5

10

15

20

25

February March April May June July August

Collaborative methodology

February

April JuneFinal Celebratory

Event

New QI Division

Quality Improvement Division

Partnering with

Patients

Capacity building

Strategy and

Innovation

Information Unit

Partnering with Staff

QI Networks

PriorityProgrammes

Quality Improvement

“We have two jobs: our job and the job of improving our job”

Donald Berwick

In conclusion

Irish general practice demonstrates high quality Central role of ICGP and clinical leaders in

general practice Lack of information on clinical care process Variation and outliers inevitable We need to work together to improve quality

through training, evidence use and acceptable performance measurement

Philip Crowley

Philip.crowley@hse.ie www.hse.ie/go/qps