Health FoundationSafety Improvement in Primary Care

SIPC

Housekeeping

• No planned fire alarm test: if you hear it – its real!

• Swap Shop • NES Stand – Evidence into Practice• Evaluation interviews• Toilets on ground, 1st and 2nd floor

SIPC1 Aims

To enable 80 Primary Care teams to:

1. Identify and reduce risk and harm to patients

2. Improve reliability of care for patients• On High Risk Medications • With Heart Failure

Improve:

Safety culture

Patient Involvement

Interface working

Knowledge

• Harm - trigger tool • Culture – Climate

Surveys• Reliability - Bundles• Patient Involvement

• What to spread ? contract

• Reflect • Celebrate success• Share challenges • Share solutions • Acquire and develop new skills • Identify support/training needs• Learn about other clinical areas• Feedback • Next Steps

Aims

Programme

09.30 – 09.50 Welcome and Agenda overview

09.50 – 11.10 Delivering Reliable Care

11.10 – 11.30 Coffee

11.30 – 12.30 Showcasing Work in the Trigger Tool

12.30 – 13.15 Lunch and Swap Shop

13.15 – 14.15 Making the most of your climate survey

14.15 – 15.15 Involving Patients in Improvement

15.15 – 15.30 Coffee and transition to Breakouts

15.30 – 16.45 Board Specific breakouts and Evaluation

You said, we did…

• Later Start • Less factual information• More discussion interaction• We’ve tried!

• Handouts of presentations• Better facilitation• Primary care relevance• Better microphones

Successes

• You are here!• Complex programme• Commitment• Evolving• Bundles – data collection

Successes

• Bundles• Trigger Tools• Patient Involvement • Safety Climate• Learning what works• Teamwork within practices, boards,

programme• Personal development

Challenges

• Time• Competing priorities• Involving team• Maintaining momentum

Challenges

• Reliability - bundles• Trigger Tool• Patient involvement• Climate Survey

External interest

• Scottish Patient Safety Programme• Health Foundation• International - IHI• Groundbreaking – Bundles/trigger

tools/Climate/Patients• Primary care is different• Influence Safety Programme for Primary care• GMS Contract

Patient Story

Danish Patient Story

Keeping us focussed

• Harm occurs• 1 in 8 admissions • 1 in 20 deaths in hospital• 11% prescriptions have errors• Commission – doing something• Omission – not doing something

Arlene Napier

Acting Head of Safety, Governance and Risk, NHS Tayside

Basketball

Delivering Reliable Care-

Every Patient Every Time

Aims of the session

• Learn from others• Share successes, challenges and practical

tips• Use data for improvement• Learn about other workstreams

Practice presentations

Presentation from Muirhead Medical Centre, NHS Tayside and Alva Medical Practice,

NHS Forth Valley

Experience of NHS Lothian

Muirhead Medical Centre

Ruth Herrington GP, Gillian Cruickshank PP, Fiona Smith HCA

January 2011

Summary – Good + Bad

•Why we are here?•Bundles•Patients•Practice

Why we are here?• Ideal opportunity to rev DMARDs system

• Limit to Azathioprine, Methotrexate• Initiated by Secondary Care: Rheumatology, Dermatology,

Gastro, Cardiology etc. = different monitoring regimes!• Work across different Practices – large number of approaches

• Interrogate safety aspect • potentially toxic drug therapy

• See how others did it and learn together• Good Team at Muirhead

NHS Tayside 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• Compliance with full bundle (ie all of

above)

Bundles – Good:

• Every two weeks we review 5 pts via Bundle• Time - 15mins• Like the graphs – see improving…• Quick action to problems ie non-attender,

pneum. Vaccine, PDSA etc.• Changed:

• Coding on bloods NPT – docman is copied to HCA + GP

• Vision computer entries #66P7 – normal, or if action required. Allows trend & ease follow

• Utilise probs - PDSA

Bundles - Not so good:

• 2pts may skew the data• DMARDs feedback to all – challenging• Hard not to look at other things re

Rx’ing• Time• Think about involving others re data

collection

Patients:

• Area to work on with the Patient Focus Group Feedback.

• Leaflet or credit card size information

• Discussed this with 3 patients

Practice:

• Clinical Meetings • Docman internal messaging• Emails• Getting there…..

Relax at Muirhead…

NHS Forth Valley Presentation

Heart Failure/LVSD

• First cleanse the Heart Failure register

-585f-Echocardiogram shows left ventricular systolic dysfunction and if also appropriate, Heart Failure G58

Heart Failure/LVSD

Evidence based interventions for LVSD (1)

1. LVSD diagnosed on echo

2. Annual NYHA functional assessment

3. Loop diuretic if fluid overload

4. ACE or AIIR inhibitor

5. Appropriately licensed BBlocker

Heart Failure/LVSD

Evidence based interventions for LVSD (2)

6.If AF present – consider warfarin

7. Annual flu vaccination

8. Pneumococcal immunisation

9. Smoking Cessation counselling

10.Self management advice

Forth Valley LVSD Bundle

1. On a licensed BBlocker

2. BBlocker at max tollerated dose

3. NYHA in last year

4. Self Management information

5. Immunisation- pneumococcal

Alva Medical Practice

12500 patients

Semi rural

12 Doctor

Training Practice

CMR/ PTI since 1996

PDSAs

LVSD Register

Previously recorded Echo as “Normal” or “Abnormal” in HF Patients

90 patients with LVSD in practice of 12500

Repeat Reviews

Following EMIS migration - large number of patients with repeat medication not reviewed

PDSA format of managing change seems to work well in a large practice.

Allows immediate trialling of ideas among interested parties

Bundle Data

Strong – ACEI/ Bblocker prescribing

Weak – attaining maximal dose of RxAssessment of function

Recording of management advice

Initiate a Nurse Heart Function clinic

Re-examine HF Protocol

Address Training needs

EMIS Recording Template

Patient information

Coding of Mail

General issues

Communication

Web site – TT/ PDSA

Time

Resources

Raised profile of safety in PC

Enthusiasm is there!

Old Bundle:• Is the target INR recorded in patient’s notes?• INR is taken within 7 days of planned repeat INR?• Last INR recorded in yellow book?• Face to face education recorded every 3 months?

New Bundle:• INR is taken within 7 days of planned repeat INR?• Has patient been taking the ‘correct’ dose since last blood test?• Is there evidence that the last advice re warfarin dosing given to

patient followed current Lothian Guidance/INR Star/RAT?• Face to face education recorded every 3 months?

Care Bundle

Delivering Reliable Care

Key Points for Group Discussion- Finalise

• What have you done – tests of change• What went well?• What were the challenges?

Dr Andrew Martin

GP, CrieffClinical Lead, Tayside

Intro To Measuring For Improvement

• Run Charts

• Variation

• SPC Charts

What are we trying to accomplish?

How will we know that a change is improvement?

What changes can we make that will

result in improvement?

ACT PLAN

STUDY DO

Measurement?

Without measurement it is impossible to know whether

you have improved.

Run Charts

• Run Charts Defined– Run charts are used to analyze processes

according to time or order.

Charts vs. Tables

Collecting Data

• Define the data– So you get exactly what you want

• Decide level of accuracy needed• Think about consistency• Consider trade off

– Data quality vs. time to collect it• Make it become routine

– if it isn’t already

Baseline & Target

• Set a baseline by using retrospective data, or monitor for a while before introducing the change

• Need to think about variation here!• Set a target and time scale for achievement

– Agree with stakeholders– Link to objectives– Be realistic!

• Agree reporting– To whom, when & how

DMARD CompositeBaseline

R u n c h a r t w i t h t h e m e a n a s t h e c e n t r e l i n e

0

0

0

1

1

1

1

1 2 3 4 5 6 7 8 9 1 0 1 1

S a m p l e

x M e a n

DMARD Compositeafter Action

Run chart with the mean as the centreline

0

1

2

3

4

5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Sample

x Mean

DMARD Measures

Development of new staff skills & knowledge

Aim of current testing of WHO Surgical Checklist is to improve poor compliance and reliability

Decrease in experienced staff numbers

Significant amount of staff vacancies

Local Display and Feedback of Data

Uses Of Run Charts

• For improvement– Establish baseline (plan) P– Observe process/variation D– Study for changes S– Significance of change?– Guide to action? A

Measurement For Improvement

UNDERSTANDING VARIATION

What Should We Do About Variation?

• Variation is ever-present• What is significant?• Where should we start?• When should we act?• What should we do?

Types Of Variation

• “Common Cause” or “Routine” Variation– Inherent in a process

• “Special Cause” or “Exceptional” Variation– Something not part of a process

Understanding Variation

“Routine”• “common cause”

variation• due to “chance”

causes• many factors• often “unknowable”• “noise in the system”• affects process most of

the time• part of the process• variation is predictable

“Exceptional”• “special cause”

variation

• due to “assignable” causes

• usually few, not many

• can usually be identified

• not part of the process• intermittently

apparent• unpredictable

variation

What To Do About Variation?

“Routine”(“common cause variation”)

• don’t react to individual results

• look at the average and the range (limits)

• improve the whole process if these not acceptable

• or go for continuous quality improvement!

“Exceptional”(“special cause variation”)

• investigate each point outside the limits

• look for the special cause and do something about it

• almost always something to find

• opportunities to learn

Two Kinds Of Mistake

Mistake 1• Respond as if there is

exceptional variation when there is only routine variation happening

• Might make things worse

• Wasted effort anyway

Mistake 2• Fail to spot

exceptional variation – assume there is just random variation at work

• Miss an opportunity– to reduce variation– improve quality– learn something

Control Charts

Definition:- A statistical tool to determine if a

process is in control.– Control charts are used to determine

whether a process will produce a product or service with consistent measurable properties.

(How the process behaves over time)

TimeT1 T2 T3 T4 T

5T6 T7 T8 T9

Observed valu

e

Normal System Variation(common/routine variation)

TimeT1 T2 T3 T4 T5 T6 T7 T8 T9

Observed valu

e

Special Variation

Lithium Monitoring

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11

Sample

Coun

t

UCL

LCL

Process Avg

UWL

LWL

Control Charts

• The following control chart shows the improvement of a process. The standard deviation decreases as the process becomes more capable.

Out of Control In Control Process Improved(reduced variation)

Conclusion

• SPC methods are valuable for:– Understanding variation in clinical data– Distinguishing two fundamentally different kinds

of variation– Indicating when and how to act to improve

quality– Identifying good practice from which to learn and

those in need of help to improve

Run Charts and Variation

Key Points for Group Discussion

• What are you doing with your data?• What does your data tell you?• When will it tell you something?• How can you use your data to drive improvement?

Trigger Tools

Trigger Tool Session Aims

• Learn from each other• Share successes and challenges • Where are patients being harmed• Identify Solutions• Identify issues for programme

Showcasing Work on the Trigger Tool

• Downfield Surgery

• Milton Surgery

Group Discussion

Share your experience of using the trigger tool

• What went well?• What have been the challenges?• How are patients being harmed?• What have you done as a result?

Safety Culture

Safety Climate

Session Aims

• Review the safety climate report

• Develop your skills in using the report

• Consider how you might use it

What is culture?

All based on ourmental processes, beliefs, knowledge, and values

What we think

Culture is learned, not biologically inherited

What we do What we produce = the outcomes

Adapted from Reason

Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures.

“The way we do things around here”

Charles Vincent: Patient Safety (2010)

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Benefits of measuring your safety climate

• Raise awareness• ‘Diagnose’ • Identify strengths and weaknesses• Starting point for reflection and change • Measure improvement • Encourage teamwork, participation and

inclusion

Your Safety Culture/ Climate

• Climate is a perception and changing • Being part of this programme will be

changing your culture • Likely to dip after one year more insight

and then improve year 2 • Like trigger tool is a measure but perhaps

more valuable as a catalyst for change

Using the Safety Climate

• Tests of change – how can we use it as a catalyst for change

• Experience so far - unclear• Competing Priorities• Report hard to interpret?• Challenging for some practices to discuss?• Anyone used it succesfully?

Next test of change• Run a facilitated session on how to use the result• Clear guidance

Developing a safety climate

• The report is one step in a process to build a strong safety culture

• Further steps– Share results with all practice team members– Discuss the results– reflect on whether perceptions match up with

reality

• Aim– Identify an area that needs attention– Identify what tests of change could be

undertaken

Participation• Identify the number of team members that

participated in the survey

• Reflect on:– How many team members participated and how many were

expected to participate?– Why did some team members not participate?

• Potential Implications– A large number of participates ensure the results reflect the

perceptions of your whole practice– When was the survey conducted, e.g. during school holidays?

Section 1: Practice Safety Climate

Section 1: Your Practice Safety Climate

Action Reflective questions Potential implications

Identify a factor where your practice has scored a positive perception.

Do you think this positive perception is accurate?

How has this been achieved?

What lessons can be learned and actions taken to ensure this area stays positive/improve?

What can be transferred to other areas?

Sometimes a positive perception and the reality does not quite ‘match up’  This question is helpful to allow members to reflect on practice and team strengths

Identify a factor where your practice has scored a less positive perception.

Do you think this less positive perception is accurate?  

Why is this specific area specifically perceived less positive?  

What actions could be taken to improve in this area?

It may not always be possible or desirable to ‘improve’, given practices’ other priorities.

Section 1: (Cont’d)Action Reflective questions Potential implications

Compare your team’s results to the average of other practices.

Are your scores (perceptions) mostly comparable?

Are there any areas where your perceptions are more positive or negative than average?

Is there any proof to substantiate the observed differences?

This would be the case for the majority of teams and areas. A difference does not imply ‘better or worse’ or ‘right or wrong’. However, it does provide an opportunity for team reflection and consideration.

Section 2: Results by Professional Role

Section 2: Results by Professional Role

Sections 2 & 3 : Results by Professional Role and Individual Experience

Action Reflective questions Potential implications

Look for any obvious differences between staff groups.

Are there any obvious differences between staff groups? Is one staff group consistently perceiving things more positive/negative than another?

Is the difference in only one area?

Why is there variation between groups? How can perceptions be aligned (if this is considered important)?

If there are differences between only one group, it is more likely to be important. This is a good opportunity to share individual experiences.  

It can be difficult and even counter-productive to try and establish which group’s perception is ‘right’.

Compare with previous results

• Are there any noticeable differences

• What might need to be done

Finally…

• Has the discussion in your practice team identified areas where you can agree to focus improvement efforts

• Are there any tests of change that could be undertaken

Making the most of your Climate Survey

Key Points for Group Discussion

• What is your experience of using the climate survey?

• How might you use this after today to develop your safety climate?

• What help would you like to use your report?• Any feedback on the format of the report

Safety Climate

Do we need to alter course?

Patient Involvement

Patient Involvement

Session Aims

• Share experience of involving patients

• Identify barriers

• Highlight opportunities/ methods

Why patient centredness is important

Her Last Journey Home – Welsh Ambulance Service

Patients at the Pinnacle

Board groups - real interest Common themes

Information• Information patients receive is variable and often only at

diagnosis and not at follow up appointment –• would like an information update at annual review

• Patients need reassurance about the drugs specifically – Side effects– Drug interactions and interactions with food OTC

• “Health centres not having agreed policies for level of information they provide”

Results

• Many patients would find it reassuring to receive notification of normal results

• Some patients appreciate having a print out of their results and their changed dosage

• Many patients would like a patient held record with their blood results in them

Self Care/Monitoring

• Some feel able to manage their conditions• Uncertain about recognising if they were

becoming unwell or side effect of their medication

• Some patients feel they would be better off if they could some self monitor their condition

• “Poor attitude of patients and some health professional to self management

Difficulties on discharge form hospital

“Apparent lack of care when leaving hospital”

Access• On the whole access is not too

troublesome tho continuity can be • “No continuity of care – why can’t I see the

same GP – we need a fast track service

Running a practice focus group for patients with “heart condition”

• Letters from us - 14 out of 30 responses• Some surprises and fears• Call beforehand• Hassle free logistics• Questions evolved form board groups and our

own questions• Useful report

What information, if any, have you received from your GP practice about your condition?

Patients felt well informed about their condition and confident in asking about anything they were concerned about.

“Dr [name] gave me this leaflet with coloured zones on it

I found it very useful.

1 patient stated that they did not always feel well informed but referred to some problems with their memory as possibly playing a part

How confident do you feel about managing your condition at home?

Most of the group agreed that they had sufficient information and knowledge on how to manage their condition at home.

Review memory at clinic review not just physical aspects

Results

• Some patients would appreciate the GP calling them when results are back whether action was required or not.

• “When you’ve had your blood samples taken nobody ever rings up and says everything is fine. They’ve got so many people … surely it must be possible just to let you know all is well.”

 

Self management

General consensus showed a patient confidence in knowing what to do if their condition worsened.

A hand held record he could take personal responsibility for and carry to the various places he receives treatment

What is your experience of accessing your usual GP or a GP or nurse that knows you at

the practice?

The majority of patients agreed that you are always able to see a GP or Nurse when requested

When one patient spoke of his slightly more negative experience some others disagreed and explained their situation as much more positive.

What do you think about the follow up care you received from your

practice after being discharged?

Communication issues between the hospital and the practice rather than the after care received.

One patient felt they could have received a little more attention from the practice after hospital discharge.

General comments

“No individual in the health centre is anything less than excellent but the

process is less good than the individuals.”

Actions

Discuss with partners - Good process – useful insights

Share with all of team

Actions• Send report to patients• Use Patient Leaflets• Screen for Cognitive impairment• Results Leaflet• Communication – flu / part time / Results• You said, we did notice board/ TV

Practice group

• Invites• Questions• Expertise• Writing it up • Feedback to patients• Others planned

Telephone interviews

• Semi structured interviews

Patient ExperienceQuestionnaire

• Validated questions• Covering areas raised by focus groups• Local adaptation• Support• Analysis available• Volunteers

Patient Experience Questionnaire

Just Ask

• What could the practice have done differently to improve your experience of care today …?

• What was good about today? • What was not so good?• What do we need to change?

Patient Involvement

Key Points for Group Discussion

• How have you involved patients in this programme?

• What are the barriers? What stops you asking / involving patients?

• What might you do next to involve patients?

Range of options

• Patient self care information • Focus groups• Telephone interview• Questionnaires• What could the practice have done

differently to improve your experience of care today ?

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Home Strait

• Board groups

• Evaluation – important for us to receive your feedback

• Thank you!

Breakout Sessions

• NHS Tayside: Conference Suite 6

• NHS Forth Valley: Wallace Suite 1

• NHS Lothian: Wallace Suite 2

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