1. A primary care perspective Implementing Incident Management Hayley Lord February 2009

2. The local journey Lessons to be learned Where to from here Outline

3. Pinnacle Group Ltd (PGL) A management services organisation supporting:  5 PHOs  Pinnacle Incorporated General Practice network  400,000+ ESUs  100 general practice teams

4. A Commitment to Quality 12 years of quality plans Practice systems Population health Professional development Pinnacle network Cornerstone accredited

5. A Commitment to Quality QP – incremental changes, education, support, feedback and rewards Special focus: encouraging reporting and learning from events

6. Pinnacle’s Journey  QP6: Meetings to introduce Clinical Governance (2002) Research re event reporting Lord & Lillis: nzfp vol32 no4 Aug 2005 Introduced clinical audit  QP7: Clinical Governance practice meetings – key messages: No blame: no shame culture Cultivate a positive, safe team approach

7. Pinnacle’s Journey  QP8: Practices established and implemented Incident Management Programme Launched voluntary reporting system QAA obtained  QP9: RNZCGP Accreditation - external confirmation Lillis, Ward & Lord: nzfp vol34 no3 June 2007  QP10: Integrated PMP into quality programme – support development of PHO quality platforms. Establish centralised database; encourage reporting

8. Pinnacle’s Journey  Research re Incident Management – how big are the barriers? Lillis S, Lord H, Ward D NZ Family Physician 2008;35:253-256  QP11: Ongoing reporting; focus on repeat prescribing – audit, errors Publication of results pending HarpOn launched QP12: Ongoing education, support Reaccreditation of general practice teams

9. Lord H, Lillis S NZ Family Physician 2005: 32: 247-250 Barriers and Solutions to Implementation of Significant Event Management in General Practice

10. Lillis S, Lord H, Ward D NZ Family Physician 2008;35:253-256

13. Where to from here  Feedback Feedback Feedback  Reporting levels match incident/risk  National system