Testing and improving the tools in daily practice…… Dr Neil Houston GP and National Clinical Lead

Development and Testing Safety Improvement in Primary Care 1 and 2

Piloting and Testing Phase 2009-2011 The right focus? The right tools? The right method? Are they practical and acceptable? Do they make a difference?

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 Trigger Tools Safety Climate Care Bundles Patient Involvement The methods and tools were the collaborative model and this is similar to the Primary care collaborative and the model for improvement Practice staff members come to learning sets, learn about the tools and then go back and engage with their teams to sue the tools and improve care The tools we tested include care bundles to take regular measurements on how reliable your systems are , Trigger tools a rapid form of structured case review to identify patient safety incidents and areas for improvement A safety climate survey to help you think about measure reflect on and improve your practice safety culture You will be hearing more about these tools during the rest of the learning set 5

Model for Improvement

Breakthrough Collaborative

Evaluation Plan Year 1 Steering group Practices interviews, data and feedback Year 2 Steering group Impact survey and interviews Data/ Learning sets Disengaged practices

Model Theory driven Realistic Sit on our steering group feedback to allow decision making How and why programme causes change? What is it about the programme that works for whom, in what contexts, in what respects and how?

Impact Outcomes and benefits How programme is experienced and delivered How were outcomes achieved What aspects were a success and why What factors made it less successful Contextual issues which lead to behaviour mod

Safety Culture

Which Culture Survey tool Hospital culture survey MAPSAF Safequest

Safety Climate Survey On line Practice report Measurement Diagnosis Catalyst for change

Process Wave 1 Completed before first learning set No preparation No communication to staff Email confusing Process not streamlined – junk emails Format – confidence intervals Negative questions No guidance on using it

Feedback “ the first round we didn’t really know what we were doing “ “we didn’t like it we found it clumsy to administer that way the results were spilt and found it very hard to feedback what iut actually means”

Year 1 evualation Hard to involve staff Hard to use Some successes Steering group ? abandon Practice evaluation Continue as good to involve team

Changes Different format Who to complete it ? Tell people at learning set about culture Prepare them Smoother Process How to make the most of it Reflection sheet

Unfortunately Unable to compare these findings to other practices 19 19

Making the most of your Results - Guidance Identify uptake - what does this tell you? Identify a +ve element of culture Identify a –ve element of culture Look in detail at the questions where you might improve Compare to other practices Compare between staff groups Compare with previous results if appropriate Summarize – Complete QOF summary sheet and Action plan Now look at a negative area of culture

“The second round was much better and because I had attend all the workshops I knew what we were trying to do” “The questions were easier , clearer so that helped “

“Weren’t as good as we thought we were” “Mismatch between what the clinical and non clinical staff thought” “Prompted some very open discussion” 22

4. More teaching about culture and human factors PDSA – Climate Survey Ensure practices can complete the survey , review report and improve practice culture Evaluation Keep adapting improving process 5.Better on line process and comms 4. More teaching about culture and human factors 3. Change the report format 2Provide guidance at 2nd learning set on how to use the report 1. Fill in before learning set 23

End of Year 2 - Impact / Change? Raised awareness with respect to perception of culture Prompted open discussion Identified poor communication /teamworking Disparity in views between clinical and admin 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” The evaluation from pilot practices was very positive 25

Changes? Increased frequency of staff meetings. At least one doctor to attend staff meeting. 2 way communication over a variety of issues. Newsletter/minutes after each meeting. Quarterly meeting involving whole practice. This is an example of what happened in the practice whose report we have been looking at

Issues Varied interpretation Hard to involve all staff Concerns re anonymity in small practices Some practices may need support and /or facilitation

Overall 75% of respondents said the Programme had improved the safety culture of their practice

The Detecting and Reducing Patient Safety Incidents in Primary Care Using Structured Case Review Trigger Tool GP / Patient Safety Advisor 29

Development Which triggers Generic and specific triggers Measure harm Which patients How many patients How often - 4 monthly Training –learring set and practice The form!

Trigger tool Its quite proactive in the sense that you don’t wait for the event to happen ,these are all about near misses Strength early on was to focuss on same population ad the care bundle

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 Specific changes made in response to things picked up during reviews: New protocol for recording adverse drug reactions Minimum annual FBC checks for all Warfarin patients Minimum annual Digoxin levels check Better systems for highlighting possible drug interactions when deciding the next dose of Warfarin Much better at coding relevant read codes Checking that locums are familiar with practice systems for Warfarin patients 33

Evaluation “I have had a lot of problems with the trigger tool website, I am finding it quite frustrating” “the trigger tool hasn’t really demonstrated terribly much harm for us to work on” “I don’t think we have got as much from the trigger tool as we could have done” “I realised that (admin) was struggling to put it onto the intranet. Admin member still needed coaching and so that held us back a bit when she found she wasn’t confidently carrying out the trigger tool”

Year 2 and beyond Not for Harm Not for measurement For insights Catalyst for change Culture New patient group More training Making changes??

Evolving Process Patient Safety incidents not harm Form Scoring Focus on Reflection Planning /making change

Key Successes: Varying degrees of evidence of each method’s reliability, validity, acceptability (usability), feasibility, transferability 40

PDSA – Climate Survey 2 Try different populations groups Ensure practices can use the trigger tool gain insights and make changes to reduce patient safety incidents Evaluation Keep adapting improving process/ training etc 5. Change form to drive change 4. Change severity scale 3. Change to looking for Patient Safety incidents 2 Try different populations groups 1. Develop and test Forms 43

Experience Generally received positively Quick Finding Harm Focus for Improvement Cultural change Need training and support Not for measurement 44

Improvements??? It highlighted that the haemoglobin has not been done and now we make sure that is part of the protocol Coding drug reactions Recall systems

Ongoing Issues The population to focus on? Time? Suitable for all practitioners Getting the team involved

Overall Programme successes 82% of individuals had applied safety & improvement knowledge & skills 82% say participation in the programme has benefited their practice 81% say they plan to continue using SIPC tools/procedures when programme comes to an end

Successes - Improved: Patient Care Systems: Monitoring & Safety Procedures Knowledge, Skills & Attitudes of Staff Safety Culture Team-working Patient Involvement Efficiency

Challenges Understanding Facilitation Time Pressures Competing priorities Team Involvement Resources and remuneration Practice environment - culture

Organic Spread Additional Boards Spread within boards Appraisal GP Training Ongoing improvements

Scottish Patient Safety Programme in Primary Care March 2013

Our Ambition To reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting. The programme ambition and aim support the Scottish Government’s Quality Strategy of safe, effective person-centred care. Primary care is a priority for the Scottish Government and will continue to be so.

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.

3 workstreams safety culture Safer medicines Safety at the interface

Spread 1,000 GP practices and 4,000 GPs 1, 200 community pharmacies Patients, GPs, practice managers, nurses, receptionists and community pharmacists

Collaborative within a Collaborative

Menu of local priorities Focus in the first year Nationally required Menu of local priorities Trigger tool (twice a year) Safety climate survey (once a year) Warfarin DMARDs Medicines reconciliation Two elements included in the QOF 14 NHS boards implementing enhanced services incorporating bundle elements of programme Most boards are focussing on one high risk area, a few doing two

New tools ...

The Primary Care Team Expanding to involve the whole primary care team.

Aims To involve pharmacists in primary care in driving improvements in communication and closer working between pharmacy teams and GP practices. Use improvement tools: To improve reliability of processes for safe prescribing, monitoring and dispensing of high risk medicines using a care bundle. To improve the reliability of medicines reconciliation when patients are discharged from an acute hospital To raise awareness of factors that contribute to ‘safety culture’ through use of a safety climate survey for pharmacy teams in community setting.