SAFETY, SKILLS & IMPROVEMENT NHS EDUCATION FOR SCOTLAND SAFETY, - - PowerPoint PPT Presentation

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SAFETY, SKILLS & IMPROVEMENT NHS EDUCATION FOR SCOTLAND SAFETY, - - PowerPoint PPT Presentation

Dec 02, 2023 238 likes •492 views

NHS EDUCATION FOR SCOTLAND SAFETY, SKILLS & IMPROVEMENT NHS EDUCATION FOR SCOTLAND SAFETY, SKILLS & IMPROVEMENT Using FRAM to design change in Quality Im Improvement projects A case stu tudy using pri rimary care sepsis id

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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Using FRAM to design change in Quality Im Improvement projects

A case stu tudy using pri rimary care sepsis id identification and management

Dr Duncan McNab Associate Adviser Patient Safety and Quality Improvement NHS Education for Scotland

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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Effective im improvement in interv rvention

  • Rigorously define the problem
  • Understand system
  • System readiness for change
  • Contextual factors which could impact on the feasibility and effectiveness
  • How intervention fits with current work system
  • Understand goals, skills, networks of those in system
  • Co-design improvement interventions - ability to adapt it to local

conditions

Marshall M, de Silva D, Cruikshank L et al What we know about designing an effective improvement intervention (but too often fail to put into practice). BMJ Qual Saf. 2017;26(7):578-582. doi: 10.1136/bmjqs- 2016-006143 Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. The Milbank Quarterly. 2004;82(4):581-629.

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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Sepsis

80% begin in community Stratify risk

  • Pulse
  • Temperature
  • Respiratory rate
  • Blood pressure
  • Oxygen level
  • Consciousness level

Early treatment

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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Sepsis id identifi fication and management

Patient decides to contact healthcare Out-of- hours NHS24 GP receptionist Ambulance Clinical assessment Hospital Self present to A and E Out-of-hours district nurse direct access

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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Im Improvement efforts

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NHS EDUCATION FOR SCOTLAND

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Sepsis – aims

  • To understand current system
  • Contextual factors which could impact on the feasibility and effectiveness
  • Understand goals, skills, networks of those in system
  • Co-design improvement intervention
  • Intervention fits with current work system
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NHS EDUCATION FOR SCOTLAND

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Sepsis – data collection

  • Interview of staff (n=22)
  • Understand system and identify areas for improvement
  • GP, GPST, GP receptionist, ANPs, NHS24, District nurses, Combined

Assessment Unit (CAU), A and E, Out of hours admin and clinical teams

  • Case note review
  • 50 adult out-of-hours admissions due to infective condition
  • 76 adult in-hours admissions due to infective condition
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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Sepsis – analysis

  • Identify functions
  • Use as themes within qualitative data manager
  • Identify function aspects
  • Assess function variability – quantitative and qualitative data
  • Analysis of qualitative data of possible areas for improvement
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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Co Co-design of f im improvement in interv rvention

  • FRAM workshop and workbook
  • Data presented for each function – conditions, interactions, variability
  • Reconcile improvement suggestion themes with current work systems
  • How fit with current work systems?
  • How affect other parts of system?
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NHS EDUCATION FOR SCOTLAND

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Sepsis - FRAM

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NHS EDUCATION FOR SCOTLAND

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Sugg ggested areas for im improvement

  • Feedback to facilitate reflective learning
  • Communication pathways
  • Early warning scores
  • Electronic templates
  • Education – administrative and clinical staff
  • Key information summaries
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SAFETY, SKILLS & IMPROVEMENT

Feedback to facilitate reflective le learning

  • System based reflective tool
  • Facilitate co-design local

protocols

  • Explore their role in system

and effects of performance variability

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NHS EDUCATION FOR SCOTLAND

SAFETY, SKILLS & IMPROVEMENT

Explore effects of f performance variability

Admissions from out-of-hours and in-hours with an infective cause Number (%) with all physiological parameters recorded Out of hours admission with infective cause (n=50) 32 (64) Out of hours admission and sepsis mentioned as possible cause (n=29) 10 (34) In-hours GP admissions with infective cause (n=76) 11 (14.5) In-hours GP admissions where sepsis mentioned as possible cause (n=11) 2 (18.2)

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SAFETY, SKILLS & IMPROVEMENT

  • “I saw this man on a visit and from the moment I walked in I knew I

was admitting him. We had the information that he was getting chemo and was a bit shaky. I did his temp and pulse and thought – right you’re going in – so I didn’t do the other values.” GP2

  • Essential that we understand the potential effects at a local and wider

system level - incorporated into reflective case tool

Explore effects of f performance variability

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Communication pathways

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Early warning scores

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Early warning scores - pil ilot with community nurses

  • Consider how

proposed changes influence rest of system

  • Identify concerns

regarding change

Functions needed to ensure resources available Guidance/ training on use of early warning scores Communication/ escalation policy

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SAFETY, SKILLS & IMPROVEMENT

Ele lectronic templates

  • “You’re typing in as you’re going to the next visit while on the phone

to the hospital – the (electronic) template is not helpful or usable”GPST3

  • Inform national work
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Education – administrative and cli linical staff

  • Obtain multiple perspectives on system

functioning

  • Exploring work-as-done vs work-as-

imagined

  • “In general our staff are good at saying

this person doesn't sound well and they let us know quickly” - GP3

  • “I don't know if I would necessarily

recognise it in a patient coming in because a lot of it is like fever and sickness - it could be anything..” - Receptionist 2

No guidance – recognition or communication Variable time to perform task Available information variable Can access surgery

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Key in information summaries

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Benefits of f th the FRAM

  • Multiple perspectives
  • Identified simple changes

(resources)

  • Informed existing work

streams (communication, KIS)

  • Role in system/ effects of

decisions

  • How proposed change fits

with system

  • Identify concerns
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Conclusions

  • Aim of Quality Improvement is to improve overall system

performance not one component

  • FRAM can help
  • Those designing change to understand the system in its specific context
  • Reconcile improvement suggestions with work-as-done
  • Consider how changes affect whole system and individuals in system
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SAFETY, SKILLS & IMPROVEMENT