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

2. Development and Testing Safety Improvement in Primary Care 1 and 2

3. 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?

4. 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

5. 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

6. Model for Improvement

7. Breakthrough Collaborative

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

10. 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?

11. 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

12. Safety Culture

13. Which Culture Survey tool
Hospital culture survey
MAPSAF
Safequest

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

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

16. 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”

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

18. 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

19. Unfortunately Unable to compare these findings to other practices19 19

20. 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

21. “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 “

22. “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

23. 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

24. 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

25. 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

26. 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

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

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

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

30. 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!

32. 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

33. 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

34. 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”

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

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

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

43. 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

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

45. 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

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

47. 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

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

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

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

51. Scottish Patient Safety Programme in Primary Care March 2013

52. 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.

53. 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.

54. 3 workstreams
safety culture
Safer medicines
Safety at the interface

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

56. Collaborative within a Collaborative

57. 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

58. New tools ...

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

60. 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.