Mr Anthony Hill Health and Disability Commissioner Wellington - - PowerPoint PPT Presentation

Mr Anthony Hill

Health and Disability Commissioner Wellington 14:00 - 14:25 Themes in Primary Care - An Update from the HDC

Themes in Primary Care – An Update from the HDC

Anthony Hill Health and Disability Commissioner

GP17 conference

11 August 2017

HDC Vision

Consumer Centred System

Engagement Seamless Service Culture Transparency

Purpose of HDC

“To promote and protect the rights

• f … consumers and, to that end,

to facilitate the fair, simple, speedy, and efficient resolution of complaints” HDC Act 1994

HDC Approach

HDC contributes to the achievement

• f

a safe consumer-centred system in a unique way:

• Complaints resolution

Promote and protect consumer rights

• Safety and quality improvement

Strengthen the system so that it continually improves

• Public protection

Watchdog role

Complaints per year

500 1000 1500 2000 2500 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 Complaints received Complaints closed

Group providers – 2016/2017

DHB (45%) Medical centre (23%) Rest home (6%) Prison health services (3%) Pharmacy (3%) Dental clinic (3%) Disability provider (2%) Home services provider (2%) Other (13%)

Individual providers – 2016/2017

General practitioner (35%) Midwife (8%) Nurse (7%) Internal medicine specialist (6%) Orthopaedic surgeon (4%) Dentist (4%) Psychologist (4%) Psychiatrist (3%) Physiotherapist (3%) Obstetrician & gynaecologist (3%) Other (23%)

Number of complaints received about general practices and general practitioners each year

100 200 300 400 500 600 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 General practices

Top issues complained about in complaints about GPs

• 1. Missed/delayed/incorrect diagnosis (37%)
• 2. Inadequate/inappropriate clinical

treatment (34%)

• 3. Inadequate/inappropriate

examination/assessment (32%)

• 4. Disrespectful manner/attitude (32%)
• 5. Delayed/inadequate/inappropriate

referral (27%)

• 6. Failure to communicate effectively with

consumer (16%)

Case Study: Communication and Management of Test Results

• A 78 year old man presented to GP with a sore knee,

slowing of speech and a “fizzing” feeling in his feet.

• GP requested blood tests which showed that the man

had a “moderate number of reactive lymphocytes”, and the results were referred to a haematologist.

• GP informed man of the initial results and told they

were awaiting further results.

Communication and Management of Test Results

• The GP sent a referral to the outpatients

clinic at the public hospital owing to the man’s slowing of speech and the “fizzing” in his feet.

• The referral letter did not mention high

lymphocyte levels

Communication and Management of Test Results

• GP requested further blood tests and the results

are consistent with Chronic Lymphocytic Leukaemia (CLL).

• GP documented this as the man’s diagnosis but

didn’t forward the information to the outpatients clinic at the hospital, or inform the man of the diagnosis.

Findings

“As the clinician who ordered the blood tests, Dr C had a responsibility to communicate the diagnosis of CLL and its implications to Mr A. Provision of this information would have enabled Mr A to be a partner in his own treatment.”

Findings

• The GP also had a responsibility to

– arrange further assessment of the man’s condition, – put in place an ongoing management plan and – take responsibility for ensuring appropriate monitoring of the man’s condition was carried

• ut.

Findings

• GP had a responsibility to communicate to

the outpatients clinic the results of the additional tests he had ordered since the

• riginal referral that confirmed the

diagnosis of CLL

Case Study: Delayed Diagnosis: Follow-up of test results and open disclosure

• Mr B presented to Dr A with reduced energy and

breathlessness

• Dr A ordered blood tests and included a prostate

specific antigen (PSA) test

• Dr A received the PSA result, which was well above the

normal range

• Dr A filed the elevated PSA

result as “normal”, and did not discuss it with Mr B

• Over two years later, Mr B presented to Dr A with

urinary complaints.

• Dr A ordered another PSA test, which came back

significantly above the normal range

• During, or soon after the consultation, Dr A noticed

the earlier elevated PSA result

• Dr A informed Mr B of the new PSA test result, but

did not disclose the missed result from two years earlier at that time

• Dr A informed Mr B of the missed result

approximately two months after discovering it

Delayed Diagnosis: Follow-up

• f test results and open

disclosure

Findings – Dr B Breach of Right 4(1)

• failed to recognise and take appropriate action on the

abnormal PSA result

Breach of Right 6(1)

• failed to inform Mr B promptly about the missed PSA

test result

“… Dr A should have made contact with Mr B in a timely manner

• nce realising his error, and certainly before Mr B left for his
• verseas trip”.

Delayed Diagnosis: Follow-up

• f test results and open

disclosure

What is a consumer- centred system?

• “If health is on the table, then the patient

and family must be at the table, every table, now.” Leape and Berwick et al (2009)

• There is increasing evidence that involving

patients in decision making has positive effects in terms of patient satisfaction, adherence to treatment regimes and even their health outcomes Van Steenkiste et al (2007); O’Connor et al (2003)

An engaged consumer is an empowered consumer

Engagement

It is about Engagement

What is a consumer- centred system?

• Modern medicine is most effective when

it functions like a system – “diverse people working together to direct their specialised capabilities toward common goals for patients. They are coordinated by design. They are pit crews.”

Gawande (2011)

• It is essential that different units within

the same system communicate well

Hill (2011)

It is about Seamless Service

Seamless service

The complexities of modern medicine demand that clinicians no longer work as “cowboys” – working alone in their specialist field

What is a consumer- centred system?

“Disclosure is a professional

• bligation…and is a marker of

patient-centred care. It also reflects the transparency of an

• rganisation, which is believed to

be a key component of safe

• rganisations.”

Etchegaray et al (2012)

Transparency

It is about Transparency

The recurring message

1988 Cartwright Inquiry 2001 Bristol Inquiry 2009 Leape 2013 Mid – Staffordshi re 2014 RCGP Report

Culture It is about Culture Culture matters. It goes to the very core of the quality of care provided.

What is a consumer- centred system?

Themes in primary care complaints

• Management of referrals
• Test result follow-ups

– Clarity of roles between primary and secondary care

• Clinically indicated examinations and assessments
• Continuity of care – multiple GPs
• Locum GPs – training and orientation
• Getting the basics right

Delayed diagnosis of Cancer 2004-2013

• Analysis of complaints in

which the primary care management had contributed to delayed diagnosis

Delayed diagnosis of Cancer

• Over the last ten years, 243 general practitioners have

been complained about in relation to a delayed diagnosis of cancer, with the number of complaints per year increasing significantly over that time.

• The factors leading to a delayed diagnosis most

commonly identified by our expert clinical advisors related to: – the cancer presenting with non-specific or atypical symptoms; – poor communication with secondary care; – appropriate referrals not being made; – inappropriate reliance on negative test results; and – the GP failing to adequately take, review or consider relevant patient history.

Delayed diagnosis of Cancer

• Brought together the clinical

recommendations made in the cases, including:

– undertaking clinically indicated examinations and tests; – examining patients in the context of their past history; – being aware of the limitations of diagnostic testing; – providing ‘safety-netting’ advice – having robust follow-up systems – advocating for patients in the secondary care system

Case Study: Clarity of roles - Test result follow up

• A man in his 60s presented to an ED at a public

hospital, with left-sided chest pain, shortness of breath, a feeling of illness, and a chronic cough.

• An ED senior medical officer reviewed the man and
• rdered a chest X-ray.
• Senior medical officer diagnosed pneumonia and

recommended admission to the ward, but the man declined.

• Senior medical officer told the man to follow up with

his GP, but did not specify a timeframe for this.

• Discharge summary sent to the man’s GP

Clarity of roles - Test result follow up

• The chest X-ray was reported on the following day,

and recommended a follow-up X-ray in 10–14 days’ time to ensure resolution.

– findings were “a dense pneumonic consolidation” in the left upper lobe of the lung.

• The senior medical officer and the GP both received

the chest X-ray report, but neither took any action in respect of it.

• The man did not present to the GP for follow-up of

his pneumonia.

Clarity of roles - Test result follow up

• Three months later the man presented to an

accident and medical clinic, as he had hit his left upper arm the previous day and could not lift his arm.

• The doctor ordered a shoulder X-ray.
• The radiologist’s report state:

– no significant change from a previous X-ray “with mild subacromial spurring redemonstrated. This would not exclude underlying cuff injury or degeneration.” – A mass in the left upper lobe of the lung, visible in the first

• f the two views taken, was not commented on.

Clarity of roles - Test result follow up

• Seven months later man presented to the ED

with left-sided chest pain.

• A chest X-ray and left shoulder X-ray were

carried out.

– shoulder X-ray reported “a very large left upper lung mass”. Subsequently, the man was diagnosed with T3N1 squamous cell carcinoma of the left upper lobe.

• He underwent concurrent chemotherapy and

radiation therapy but, sadly, he died.

Findings - GP and SMO

“[The GP] should have been more proactive in confirming his assumption that [the SMO] would be acting on [the X-ray report], and I am critical that he did not do so.” “While it is usual practice that the ordering clinician is responsible for following up a test result, ED doctors are in a unique position, and it is not always appropriate for them to follow up these tests (although they should inform GPs when they are handing over responsibility for follow-up). “

Finding - DHB

• The DHB did not have a clear, effective, and

formalised system in place for the reporting and following up of test results.

• The DHB did not provide services to the man

with reasonable care and skill, and breached Right 4(1) of the Code.

Case Study

Case study – Recall systems

• Mr A had an elevated PSA result of 7.2µg/L (normal

range being 0.0-6.5).

• Dr B noted that the man probably had benign

prostatic hyperplasia and that the test should be repeated in 6 months.

• There is no record that a recall was set within the

practice system and Mr A was not advised of the result.

Case study – Recall systems

• Dr C ordered a PSA test for Mr A.
• Mr A’s PSA result was 10.5µg/L.
• Dr C did not inform Mr A of the result but decided

to recall Mr a for further testing in 3 months time. He did not document this.

• A recall had been set in the practice management

system for 5 August 2015. This recall was not actioned.

Case study – Recall systems

• Mr A presented to Dr B complaining of urinary

related symptoms.

• Following examination a plan was made to conduct

a PSA and mid stream urine test.

• On 9 November 2015, Mr A’s PSA result was 15.3

µg/L.

• Mr A was referred to a urologist and was later

diagnosed with prostate cancer.

Case study – Recall systems

Findings – Dr B Breached Right 6(1)

• Failed to advise Mr A of the first elevated test results and

management plan. Findings – Dr C Breached Right 4(1)

• Failed to order further tests to rule out other causes for

second elevated result and for failing to adequately document. Breached Right 6(1)

• Failed to provide Mr A with information regarding the
• rdering of a PSA test, the second elevated PSA test

result, the implication of it and the plan to test again.

Case study – Recall systems

Findings – Medical Centre Breached Right 4(1)

• Failed to contact Mr A in August 2015 for further PSA

testing.

• Adverse comment was made about the medical centres

Test Result Policy at the time of the events.

Case study – Recall systems

Recommendations Dr B

• Apologise.
• Undertake a random audit of his clinical records.

Dr C

• Apologise.
• Undertake a random audit of his clinical records.
• Undertake training on effective comunication.

Medical Centre

• Apologise
• Undertake an audit to ensure that PSA test results in the last month

have been reviewed and annotated and recalls for further testing set.

• All staff involved in the management of test results meet to discuss

the decision and the new test results and medical record management system.

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