Safety Improvement in Primary Care

Improving Patient Safety in Primary Care in NHS Scotland

NHS Scotland Quality Strategy 2010

“Design and Implement a Patient Safety Programme in

Primary Care”

New Agenda?Who?What?How?

SUB HEADING

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

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

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

Harm thro Omission Lack of reliable care

Methotrexate – 12% not monitored

Mix of strengths 30%

Not prescribed weekly

(un)Reliable Heart Failure Care

ACE inhibitor 88%

B Blocker 70%

B blocker at target dose 28%

Pneumococcal 71%

NYHA 71%

All 5 - 23%

High Risks

•Warfarin •Methotrexate

•Patients with complex conditions

•Medication Reconciliation•Results •Communication

Safety Improvement in Primary Care 1(SIPC 1)

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

The Tools•Collaborative

•Bundles•Patient Involvement•Trigger Tools•Safety Climate

Knowledge

• Topics• Tools• What to spread?• How to spread?

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

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

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?

Bundles - Successes

“The care bundle was useful because it identified gaps”

“ Not as reliable as we thought we were”

Focus for improvement

2 - Data

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”

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

%

NHS Forth Valley

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

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

Safety Improvement in Primary Care

PATIENT INVOLVEMENT IN LOTHIAN

Isobel Miller, Public Partner

Patient Involvement

Scottish Health Council SIGN

Public Partnership Forum

Personal involvement in own

healthcare with

own healthcare workers

Scottish Medicines Consortium

Healthcare Environment Inspectorate

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

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

Process Map

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

Results

• Patients were happy with most parts of process

• Key topics identified

• Practices considered all issues raised

• Feedback to patients: You said - we did

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.

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

What went not so well?

• Practices did not engage with large focus

group issues

• Not all practices participated

• Patients were not representative

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

Other Boards

• Patient Self Care

• Board Groups

• Practice groups

“The main learning was that they appreciate being involved in their own

care”

“Barriers have just been ourselves”

Need

Resources

Facilitators

Expertise

The Trigger Tool and GP-SafeQuest

Measuring – Learning – Improving

Carl de Wet MBChB DRCOG MRCGP MMed (Fam)

GP / Patient Safety Advisor

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…

SUB HEADING

The trigger tool: Review of medical records Rapid, focused, structured, activeScreen for undetected harm / error

SUB HEADING

SUB HEADING

SUB HEADING

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

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

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

Summarise your review

SUB HEADING

MeasureLearnImprove

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

Safety culture

Safety climate

Cautions• Perceptions NOT reality

• Results are NOT ‘right’ and ‘wrong’ and NOT ‘strong’ or ‘weak’

• Snapshot in time

• Participation is key

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

http://www.nes.scot.nhs.uk/initiatives/patient-safety/educational-research-and-tools

Trigger Tool experience so far

It has been overall very positive, it has been a fantastic tool

Causes of Harm

– Adverse drug reactions - ADRs– Co – prescribing – Unrecorded ADR’s– Missing read codes– Lack of follow-up– Not Monitoring drugs

Expectations

• Hard to do

• Time Consuming

• Would not find harm

• Threatening

Experience

• Quick

• Finding Harm

• Cultural change

Challenges

Improvement

Logistics

Training

Variation

? For measurement

Safety Climate Survey

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”

Insights

“We weren’t as good as we thought we were”

• Practices are interested • Acts as a catalyst

Challenges

• Who?

• Better process and report

• Need guidance and support

• Understanding/using it

• Anonymity

Collaborative

• A positive experience

• Promotes teamwork

• Stimulating and challenging

• All share, all learn

• Need training

• Need support

• Local vs national ? – PLT sessions

Challenges Boards and Practices

• Time

• Competing Priorities

• Engaging Team

• Skills and knowledge - Tools

• Culture

• Leadership

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?

SIPC 2

“Look at three areas of major clinical risk to patients as they move across the health

system.”

Areas of Focus

• Medication Reconciliation

• Managing results

• Shared care and communication after out patients

Develop Knowledge

• What does the evidence say

• Process mapping

• Areas of risk

• Key reliable processes

• Patient involvement

• Measures and Improvement

“Design and implement a Patient Safety Programme in Primary Care”

2011- 13

SUB HEADING

Themes

Safer medicines• High Risk Medicines• Co- prescribing

Improving safety across the interface (care pathways)

• Reliable Results Handling• Medication Reconciliation

Themes

Reliable care for Chronic diseases

Healthcare Acquired InfectionAntibiotic prescribingHand washing

Culture and LeadershipSafety ClimateTrigger Tool

Based on

SIPC 1 and 2

Medication Reconciliation

Co-prescribing

Other work….

Process

• Feedback on Draft Plan

• Scoping

• Develop aims/measures/tools

• Implementation strategy

• Launch 2013

Feedback

Themes appropriate

Methodology OK

Barriers

• Engagement

• Knowledge

• Time - Prioritise – PLT

Need secondary care involved

Implementation will need:

• Communication

• IT Support

• Linkage

• Board Support and commitment

• Prioritisation- narrow and deep

• Contractual Levers

• Appraisal/ Revalidation

Developing Patient Safety in Primary Care in NHS Scotland

Questions?

How do we sustain and spread this work?

Volunteers?

Neil.houston@nhs.net