The Trigger Review Method Carl de Wet and Paul Bowie What’s in it for them … by the end of the session, will be able to do a TT review, understand how it can be made useful and satisfy QOF

Session outline Quiz Quick presentation Case study (practical example) Discussion

Quiz A – 3 20% B – 5 ? C – 6 85% D – 7 100% E – 2 9.5% F – 1 40% G – 4 H - 8 20% ? 85% 100% 9.5% 40%

The trigger Review Method

Paul Bowie and John McKay Paul.bowie@nes.scot.nhs.uk

Varying degrees of evidence of each method’s reliability, validity, acceptability (usability), feasibility, transferability 15

…It could be another tick box exercise… (GP7) …I can see the benefits of using it formatively rather than to produce a report that’s going to sit on someone’s desk … I just worry it’ll be sold as just another hoop to jump through… (GP1) …It could be another tick box exercise… (GP7) …I think practice nurses get a bit frustrated that more and more gets put onto them without that particularly reflecting in their pay packet… It’s just another job to get done to some people I think… (PN4) …If a practice asks a nurse to do it would they then encourage the nurse to present the findings? I doubt it. Would they just encourage the nurse to fill out the form and sent it back? Yes… (GP8) …If it’s going to become part of QOF they’re going to find the cheapest person they can to do it…I would be a bit worried about that – I think it would become a bit worthless… (GP1)

…It was enjoyable… Kind of provokes you to think about what you’re doing, so from that point of view its good… (GP7) …It’s probably to do with the attitude you have when you’re doing it because it’s very easy to superficially skip through these things and say ‘oh I found nothing’. If you’ve got a defensive mind or [go] ‘oh yeah everything we do is fine’ then you probably won’t spot these things … you would go in and probably make an excuse for why these things happened and maybe not look into full depth. But I think if you’ve got an open mind and think about how you can improve the system and think of things without blame I think it does pick up a lot of things. I think it’s been very useful for us… (GP1) …We all like to think we’ve all been doing that all along and you know people get quite defensive at a suggestion that they haven’t been, but there’s a huge difference between doing something instinctively as a kind of inherent part of your job and actually stopping and thinking about it for a minute and doing it in a methodical way…it’s far more likely to produce an outcome, I think…It’s just a wee nudge… (PN4)

Remember... The focus is patient safety incidents and not error. Ask yourself: ‘Would I have wanted this to happen to me or my family?’ Only review the specific period in the record (three months). Choose full calendar months to facilitate the review. The maximum spend on reviewing any record should be twenty minutes. The objective is to detect ‘obvious’ problems. If there is reasonable doubt whether a PSI occurred, don’t record it. You are unlikely to find something ‘dramatic’ The majority of records may not have triggers or PSI Acts of omission should rarely, if ever, be document - ?discuss acts of omission / commission? 18

How to get value from your trigger reviews …It’s terrible that in general practice you have to actually hide physically [laughing] I think to do this you probably should… (GP) Focus on systems? Provide protected time Empower your nursing colleagues Involve your team Any volunteers? The reflective type or IT boffin? Incorporate it into ‘normal work’ (SEA, audit, appraisal)

Final thoughts … carl.dewet@nes.scot.nhs.uk

Case study 1: Mrs. Annette Curtain 01/01/1935

‘Quantifying harm for the sake of measurement ‘activity’ is non-productive’ Roger Resar, 2003, QSHC. ‘The priority is to turn measurement for improvement into tangible change in practice’ Scott, I; Phelps, G. 2009 Int. Med J. ‘…the trigger tool is not in itself an ‘improvement methodology’, but it enables data acquisition and subsequent analysis of areas where harm is occurring… Quantifying harm for the sake of measurement ‘activity’ is non-productive…’ 33

Applying the Trigger Review Method after a brief educational intervention: Potential for teaching and improving safety in GP specialty training? John McKay*,1 Carl de Wet*§,1,2 Moya Kelly*,1 and Paul Bowie* 1 The training intervention ‘Positive experience’ ‘Case-based scenarios helped us to focus on what to look for, good idea to have a practice beforehand’ ‘Left confident that we could apply the process’ ‘Liked the handouts, good reference a few weeks later’ Acceptability ‘Initially a bit annoying but good when you get into it’ ‘More interesting when audit is your own and relevant to you’ ‘Very good experience, sharing with colleagues and leading to further audit’ Feasibility ‘Very simple and quick to go through - triggers can be done in 2 minutes’ ‘Duration of time taken ok’ Potential usefulness ‘Highlighted many interface issues ‘Good to see all the potential, all the things we're doing to stop potential harm’ ‘Helped to change our [practice] protocol’ ‘Good link with appraisal and revalidation’ Acts of omission should rarely, if ever, be document - ?discuss acts of omission / commission? 34