Improving Safety in Primary Care

Sharing Scotland’s Experience

Dr Neil Houston

GP and National Clinical Lead

Aims of the Session Learn about:

•Context

•Safety in Primary Care – Why bother ?

•Developing and Implementing a Primary Care

Safety Programme

•What does the literature tell us about how to do QI

Discuss how this knowledge and these tools could

be used in New Zealand

In other words

• Why?

• What?

• How to..

• How not to…

• What about here?

Primary care in Scotland

• Practice List

• National contract – no longer !

• Free at point of care

• Extended Team Care

• 1000 GP practices

• 1200 community pharmacists

The Context….

Population Change

In 1981 there were 2,420 centenarians in Britain.

Last year there were 12,320

Increase In Polypharmacy - Scotland

Bruce Guthrie, Dundee

Context

• Elderly > 75 increase by 25% in 10yrs

• Multiple morbidities Dementia

• Struggling acute care

• Rising demand/costs

• Less money

• England - Reorganisation

In Short: Things cannot carry on as now

The definition of insanity is doing the same thing over and over and expecting different results.

Albert Einstein

What does it feel like to work in front

line primary care in NZ today?

What motivates us at work?

Feeling like you’re up against it?

// AUDIENCE PROFILE - GP

Overall, how do I define

success?

•Providing high quality, evidence based care.

•Being responsive to patient needs.

•Manage all aspects of patient demand efficiently.

•Control of practice expenses.

•A good, effective happy team.

•Avoid things going wrong – no major adverse effects or complaints to/from patients.

•Access to up to date guidance and evidence.

Name: George

Role: GP

Mindset:

Time poor.

Rising workload

I have limited resources while juggling a range of priorities.

As such compromises are the norm in my world

I am part of team and have autonomy from the wider health service and control over my practice.

My job is to provide safe and effective treatment in a professional manner and this means managing risk at all times.

NHS Scotland Quality

Strategy

2010

No avoidable harm

Evidence based

consistent care

Achieving Sustainable Quality in

Scotland’s Healthcare

20:20 Vision

• Everyone is able to live longer healthier

lives at home or in a homely setting

• Integrated health and social care

• Prevention

• Anticipation and supported self

management

• Day case treatment and avoid admissions

Improving Safety in Primary Care

Patient Safety

• Preventing patients being harmed by the care

they receive

• If harm does occur identify and analyse it and

learn from it to prevent it recurring

Patient Safety - Acute Focus

Central line infection rate

(per thousand line days)

0

2

4

6

8

10

12

Jan-

08

Apr

-08

Jul-0

8

Oct-0

8

Jan-

09

Apr

-09

Jul-0

9

Oct-0

9

Jan-

10

Apr

-10

Jul-1

0

Oct-1

0

Jan-

11

Apr

-11

Jul-1

1

2.34

0.18

92% reduction

A One in 3

D One in 18

B One in 10

C One in 7

Q What proportion of NHS Hospital patients is

estimated to suffer some form of unintentional

harm as a result of their care?

B One in 10

£5,000

A 10%

D Not known

B 99%

50%

Q Of those patients harmed, which

percentage is judged to be preventable?

50%

£15,000

C

A 2.6%

D Unknown

B 12%

C 50%

Q What percentage of NHS acute hospital

admissions are thought to be related to sub-

optimal primary health care?

£32,000

B 12%

Why Bother about

Safety in Primary care?

High Volume

Increasingly complex

Multi morbidity

A 2.6%

D Unknown%

B 15%

C 6.5%

Q What percentage of NHS acute hospital

admissions are thought to be related to

adverse effects of medication ?

C 6.5%

£64,000

PATIENT SAFETY IN PRIMARY CARE - WHY BOTHER?

• Adverse events in primary care cause:

– 1 in 20 deaths in hospital

– 5 -17% of admissions linked to adverse reaction to medication

– 4% of hospital bed capacity

– 70% preventable

To Err is Human 1999

Howard et al Br J pharmacology 2006

Zhang et al BMJ 2009

Howard et al qshc 2003

How Safe are we?

Adverse Event rate 1- 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

A 5%

D 25%

B 0.6%

C 1.9%

Q In UK General Medical Practice,

what percentage of prescriptions

is estimated to contain an error?

A 5%

£1,000,000

Over the next 5 minutes in Scotland

5 serious prescribing errors

One per minute……..

“What is your experience of

where things go wrong in

Primary care?”

Causes of harm

Medication adverse effects

Delayed diagnosis

Systems Issues e.g.

• Prescribing errors

• Administration errors - records

• Results Handling

• Communication

Why? Human Factors

• Time pressures

• Frequent distractions and interruptions

• Little training

• Team communication

• IT Issues

• Interface communication

Medication Reconciliation

Medication Reconciliation

• Unreliable at admission

• Inaccurate and delayed at discharge,

• Unreliable systems in place in primary care for updating

How reliable are we ?

• Discrepancies were found in 43% of

patients.

• Of the drugs newly prescribed- 28% were

either not continued, or some discrepancy

• Where suggested a change in dose, the

dose was not changed in 35%.

“WHO identified poor test follow up as a

major cause of harm to patients

resulting in serious lapses in patient

care”

Evidence

• Practices do not track requests for tests,

• Lack protocols on how to inform patients

of results.

• MPS 400 Clinical Risk Assessments

• 84% of practices had risks associated

with test results.

Safety Culture

Why is a strong Safety Culture

Important?

Associated with better clinical and health care

worker outcomes.

• Significant reductions in reported medication

errors

• Fewer patient falls

• Lower infection rates

• Decreased staff turnover

• Increased adoption of safe work practices

• Increased job satisfaction.

And now for the Good News….

• Systems Thinking

• IT systems

• Prescribing / Results

Cephalosporins—Items/1000 patients per day Comparison of CHPs vs FV and Scotland

More Good News

Safety Culture

• Reflective Practice - SEAs

• Data

• Openness and transparency

Rapid tests of change

Questions / Comments?

The What

Delivering Quality in Primary Care

2011

Design and implement a Patient

Safety Programme in Primary

Care

World First

Development and Testing

Safety Improvement in Primary Care 1

and 2

Piloting and Testing Phase -

Essential

• The right focus?

• The right tools

• The right method

• Build capacity knowledge

• Network

• Protection from the politics

Focus

• Identify and reduce avoidable harm

• Improve reliability in high risk areas

• Develop teams safety culture

• Develop QI and safety skills

• 45 practices

• 2 years

The Tools

•Collaborative

•Care Bundles

•Trigger Tools

•Safety Climate

•Patient Involvement •

Model for Improvement

Breakthrough Collaborative

“In God we trust.

All others bring

data.”

W. E. Deming

Measurement – Care Bundles

What is a Care

Bundle?

4 or 5 elements of care

Across Patients Journey

Creates teamwork

Mix of easy and hard

All or nothing

Small frequent samples

Warfarin Bundle

Is there evidence that the last advice re warfarin dosing given to patient

followed current Guidance?

Is there evidence that the last advice re the interval for blood testing given to

patient followed current Guidance?

Has 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 6 months?*

Overall compliance out of 5

Its about what you do

with the data…….

Like What?

• Practice meeting

• Notice board

• Process mapping

• Ask patients

• Try changing something….

• Measure the effect.

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

• Documented the patient has been asked about side effects of their medication at their last blood test

• Compliance with full bundle (i.e. all of above)

1 Invite patients who have failed to comply by telephone

2 Send information stating reasons for why it is important to attend

3 Put a note on patients repeat prescription

Ensure patients prescribed Methotrexate or Azathoprine attend a monthly review for blood monitoring

Patients complying by attending blood monitoring will increase Using a variety of engagement methods

4 Restrict the amount of repeat prescription available to them to encourage attendance

5 Stop repeat prescription until they attend

PDSA - Improve Compliance of Patients Attending

Monthly Blood Monitoring

Patients now engaging and process fully

implemented

“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”

Reliable Med Rec

One patient’s experience

Improvements

• Provided insights

• Optimised care

• Guidance/ Templates

• Reduced variation

• Patient Education and Self management

• More efficient

• Less Stress!

Questions

The Detecting and Reducing

Patient Safety Incidents in Primary

Care

Using

Structured Case Review

Trigger Tool GP / Patient Safety Advisor

Patient Safety Incident

Any unintended or expected incident

which could have or did lead to harm

for one or more patients receiving

NHS Care

Detecting Patient Safety Incidents in GP

Clinical Records: Proof of Principle

• Two GPs reviewed 500 randomly selected electronic patient

records (100 x 5 Scottish GP practices): 12-month period.

• Clinical triggers developed and tested help to pinpoint safety

incidents

• 9.5% of records contained evidence of unintentional harm to

patients

• 60+% were judged to be preventable

• Most cases low to moderate severity, all severe cases originated

in secondary care

• De Wet & Bowie, Postgraduate Medical Journal, 2009

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

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 Section Secondary care, other providers

•OOH / A&E attendance / Hospital

admission

Investigations Requests and results

•eGFR reduce <5

Gordons Video Clip

V

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

Experience

• Generally received positively

• Quick

• Finding Harm

• Focus for Improvement

• Cultural change

• Need training and support

• Not for measurement

Questions?

Safety Culture

How does the SafeQuest Safety

Climate Survey work in practice?

5 key factors:

• Teamwork

• Workload

• Communication

• Leadership

• Safety systems and learning

Safety Climate Survey

• On line

• Practice centred

• Measurement

• Diagnosis

• Catalyst for change

Not the Safety Climate

Survey!

What to do with the report?

• Close survey when all have completed

• Download / Print off

• Distribute to all team

• Arrange meeting to discuss findings

Reflection Sheet

• What positive aspects of your team’s safety culture were highlighted in the report and your discussions?

• What aspects of your safety culture do you as a team feel you could improve?

• What steps will you take to improve these aspects of your safety culture?

• What else might you change to improve your safety culture?

• Would you like any support or guidance to make changes in your practice? If so, what would be useful?

Have a look at the report

What questions does it raise?

What would be the benefits and

challenges of doing this with a

practice team ?

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”

“Weren’t as good as we thought we were”

“Mismatch between what the clinical and

non clinical staff thought”

“Prompted some very open discussion”

Involving Patients in making care safer

Experience so far Neil Houston

National Clinical lead

Approaches so far…

• Education

• Board Focus Groups

• Practice Focus Groups

• Process mapping

• Questionnaires

NHS Lothian - Warfarin

Insights for

staff

Responsive enthusiastic patients

appreciate being Involved

“The main learning was that they appreciate

being involved in their own care”

“The Barriers have just been

ourselves”

So Need …..

• Encouragement

• Resources

Ideas of where to start

So What?

Overall Successes - Improved:

• Patient Care

• Systems

• Knowledge, Skills & Attitudes

• Safety Culture

• Team-working

• Patient Involvement

• Efficiency

Bundle

Compliance Warfarin Bundle Compliance

0%

20%

40%

60%

80%

100%

14th

Feb

'11

28th

Feb

'11

14th

Mar

'11

28th

Mar

'11

11th

Apr

'11

25th

April

'11

9th

May

'11

23rd

May

'11

6th

June

'11

20th

June

'11

4th

July

'11

18th

July

'11

1st

Aug

'11

15th

Aug

'11

29th

Aug

'11

12th

Sept

'11

26th

Sept

'11

10th

Oct

'11

24th

Oct

'11

7th

Nov

'11

21st

Nov

'11

5th

Dec

'11

19th

Dec

'11

2nd

Jan

'12

16th

Jan

'12

Overall Lothian Orchard

MTX 2.5MG TABS AS % OF ALL ORAL RX :

FV VS OTHER HBS

Challenges

• Understanding

• Facilitation

• Time Pressures

• Competing priorities

• Team Involvement

• Resources and remuneration

• Practice environment - culture

Overall

• 82% say the programme has benefited

their practice

• 75% say the Programme has improved

the safety culture of their practice

Measures

• Process Measures – Bundles

• Outcome Measures

• Better INR Control <1.5 > 5 Within target

• Reduced Admissions

• Reduced readmissions < 30 days

• Improved safety culture

Rapid Organic Spread

• 60 Practices + 6 HB

• Spread to 90% practices in

2 Areas

• 3 more boards testing

• GP training

• GP Appraisal

Implementing the Scottish Patient Safety Programme in Primary Care

The wider context

Phased

Approach

Stage 1 General Medical Services

Prototype and Testing

2010- 12

Launched March 2013

Stage 2 Pharmacy and Nursing Proto-typing and testing

from late 2013

Stage 3 Dentistry and Optometry Exploratory work late

2014

SPSP-PC- The Ambition

To reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting.

Our Aim

All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.

95% of practices undertaking Safety

Climate Surveys and Trigger tool case

note review by April 2014

Scottish QOF

Safety Culture and

Leadership

95% of practices implement systems for

reliable prescribing and monitoring of

high risk medications by 2016.

95% of Practices have safe and reliable

systems for medicines reconciliation

following discharge by 2016

Safer Medicines

95 % of GP practices have safe and reliable

systems for handling written

communication received from external

sources

95% Health Boards and GP practices have safe

and reliable results handling systems

Safe and reliable patient

care within practice and

across the interface

The How?

Method – Breakthrough

Collaborative

Method – Breakthrough

Collaborative

Co-ordination and Expertise

Local Commitment and expertise

essential

• Executive safety

• GP clinical leadership

• Programme manager within each NHS board

• Quality improvement expertise

Local learning sets

National Launch

March 2013

• All Boards

• Collaborative events

• 95% doing trigger tool and

climate survey

• 80% Working in High risk

area

• Variation and Dilution

Innovation Adoption

Curve

.

What’s in it for Clinicians

Doing the best for your patients

Working better as a team

More confidence in your systems

Less things going wrong

Less stress

More Efficient

Better Interface working

// AUDIENCE PROFILE – How will the GP benefit from the Patient Safety Programme. Rational.

•Safer care.

•More effective use of resources.

•Reduces complaints.

•Reduce the frustration of working with the hospital.

•Reduces harm.

•Better processes.

•Less things going wrong.

•Transparent and clearer communication.

•Allows people to talk about ‘harm and adverse events’.

•Helping the patient to take more responsibility for their care.

Emotional.

•Greater job satisfaction.

•Increases confidence in systems and processes.

•Less worry.

•Less discomfort and pain when things go wrong.

•Increases the feeling of support.

•Reduces stress.

Name: George

Role: GP

What’s in it for boards?

• Fewer adverse events

• Fewer complaints

• Fewer Admissions

• Safe effective prescribing

• Improved Interface working

• Engagement with Primary care

What can you learn from our and

other’s experience ?

How to do it

• Will

• Ideas

• Execution

Building Will

• Literature

• Patient Stories

• Clinical Leaders

• Front line Experience

• The “right” areas of focus

Design and planning

• Convince people there is a problem

• Convince them there is a solution – have

to test it

• Clinical and admin network

• Strong Core

• QI expertise

• Appropriate data collection

• Be realistic

Testing and development

Evidence

• Test sites

• Protected time – do not underestimate

• Central core and networks

• Adaptable and flexible

• Have a method – model of change

• Resources and training

• Work with innovators

• Adapt to local context – Evaluate

Organisational Issues

Need

• An organisational priority

• Organisational capacity - QI / admin

• Leadership - clinical and organisational

• Professionally led

• Pump Priming

The right people

• Executive support

• Clinical Leaders

• QI skills

• Education skills

• IT support

Teams with skills

Sustain and Spread

• Factored in at the start

• Do not crack on too quickly

• Extensive development periods

• Testing

• Evaluate

• Influence

• Levers

Levers

• National Priority

• Boards told to prioritise:

• Professionalism – tools are evidence for GP

Appraisal

• Contract ??

What not to do ?

• Too many areas

• No clinical buy in

• Tools not tested

• Get everyone to start at once

• No data

• No Central core

• No Process

• Spray and Pray

• No training or Support

The Risk

Development and Testing

Safety Improvement in Primary Care 1

and 2

New Zealand – Already under way

• Counties Manakau/ PHOs –15 practices

• Ko Awatea

• Test these approaches

• Learning already

• Learning sets

• Start up time

• QI Expertise

• Co-ordination

How might we further test and

develop approaches to improving

patient safety in Primary care?

• Opportunities

• Challenges

• Next Steps

• neil.houston@nhs.net

• http://www.healthcareimprovementscotlan

d.org/our_work/patient_safety/spsp/patien

t_safety_in_primary_care.aspx