Welcome to Learning Session 1 August 2018 Mihi Whakatau Te Aroha - - PowerPoint PPT Presentation

August 2018 Mihi Whakatau

Welcome to Learning Session 1

Te Aroha

Te aroha Te whakapono Me te Rangimarie Tatou tatou e Te aroha Te whakapono Me te Rangimarie Tatou tatou e

House-keeping

Parking Emergency exits Toilets Phones silent or vibrate Knowledge Survey

Welcome to Safety in Practice

Tim Wood

Deputy Director Funding Development & Funding Manager Primary Healthcare ADHB / WDHB

Safety in Practice Team



Angela Lambie – Pharmacy



Diana Phone – Pharmacy Clinical Lead



Dr Eleri Clissold – Strategic Clinical Lead



Dr Lisa Eskildsen – GP Clinical Lead



Harshna Mistry – Programme Manager WDHB



Michael Hammond – Project Manager



Shona Muir – Improvement Advisor ADHB



Sreeja Nair - Data Administrator



Sue French – Improvement Advisor WDHB

Supporters



PHO GP Practice Facilitators

 Nicki Brentnall – Procare  Rosey Buchan – Comprehensive Care  Carol Ennis and Jean Lyle – Auckland PHO  Kim McCrae – Alliance Health +  Paula Asiata and Jadene Wheeler - NHC



Pharmacy

 Lynne Bye – School of Pharmacy



Dr Stuart Jenkins – Clinical Director Primary Care ADHB / WDHB



Tim Denison – Director of Performance Improvement

Improving Patient Safety in Primary Care

Learning outcomes

Describe…

 Why focus on safety?  Where and why do things go wrong?  What can you do?  How do you go about it?  Tools and resources of the programme

Background 6-7:30pm

Individuals who are new to SIP

 Background Safety in Primary Care  SIP programme  What each Primary Health Care Team PHCT will do  The Science of Improvement  Activity PDSA cycles

Specifics 7:50-9:00pm

Everyone

GP PHCT



Practical aspects – the “how to”



Clinical modules



Prescribing (Safety) Indicators Pharmacy PHCT



Practical aspects – the “how to”



Modules



Process and outcome measures Breakout rooms

 Joint PHCT sessions  Clinical modules  Knowledge survey & Evaluation of evening

@saferpracticenz www.safetyinpractice.co.nz

Remember NZMC number!

Patient Safety in Primary Care

Dr Lisa Eskildsen GP

Clinical Lead (GP) Safety in Practice - Waitemata and Auckland DHB

Patient Safety

“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”

• Hippocrates (460-377 BC)

To Err Is Human, Institute of Medicine,2000

Patient Safety to date: an acute hospital focus

Central line infection rate

(per thousand line days)

How safe are we in Primary Care?

Adverse Event Rate - 1- 2% Consultations

(event with possibility of causing harm to a patient)

“Absolute number of those harmed may be just as large or greater than secondary care” It’s the VOLUME

13.6 million GP consultations 2017

“What is your experience of where things go wrong in Primary Care ?”

Examples

Causes of harm

Medication adverse effects Delayed diagnosis Systems Issues:



Results Handling



Prescribing errors



Administration errors - records



Communication

Harm from Medication

 6.5% of all admissions related to Adverse

Drug Reactions

 4% bed capacity  50-67% Preventable

Which medicines?

Deaths - NSAIDs and anti-platelets

>50% of preventable, medication-related admissions involved

NSAIDS Anti-coagulants Opioids Diuretics Anti-platelets

*Waitemata DHB 2016

d

• No. of admissions with high risk medicine ADEs

(n=4,253) occurring outside of hospital (Aug 14-Dec 16)

Anticoagulants Analgesics

Medication related Harm

New Zealand 2017

 28% of inpatients experienced harm  29% originating in community and precipitated an admission  40% caused by opioids and antiplatelet/anticoagulants

and implicated in most serious harms; hypotension, bleeding, delirium, confusion, constipation

Hospital based trigger tool, NZMJ Aug 2017

HQSC ‘A Window on the Quality of NZ Healthcare’ 2017

8% of primary care patients in New

Zealand report being given the wrong drug or dose in the last 12 months

45% having to seek help for the error

More than 40% of medication errors result from inadequate reconciliation at points of transfer of care – such as discharge. 20% of these were believed to result in harm.

Institute of Medicine’s Preventing Medication Errors

Medication Reconciliation

 Unreliable at admission?  Inaccurate and delayed at discharge?  Many DHB implementing improved medication

reconciliation during admissions

 Unreliable systems in place in primary

care

Institute for Healthcare Innovation

“Preventing harm from medications, or adverse drug events (ADEs) remains a top patient safety priority … across the continuum of care” “Many organisations have demonstrated that implementing medication reconciliation at all transitions of care is an effective strategy for preventing ADE”

IHI (2017) Medication reconciliation to prevent ADE

HQSC

“Evidence based process … shown to significantly reduce medication related errors and harm that can occur at transition points of care”

HQSC (n.d.) Medication reconciliation: A Guide for Health Professionals

Managing Test Results Safely

The WHO identified that the rates of test follow-up remain suboptimal, resulting in serious lapses in patient care, delays to treatment and litigation.

Summary of the evidence on patient safety : Implications for research World alliance for patient safety World Health Organisation 2008

Managing Test Results Safely

“Lack of formal tracking systems to oversee the management of laboratory test

• rdering and results handling is

problematic and a significant source of error in primary care world wide”

Numerous references including The Health Foundation: Evidence scan : Levels of harm in Primary Care 2013

MPS

88% of practices identify

test results handling being a key area of risk

Risk assessment based on 400 practices

HDC

Numerous HDC cases which have looked at the management of patient results in General Practice, and found practitioners and health services wanting

RNZCGP Policy Brief 2016

Equity

Factors that pre-dispose populations to poorer health outcomes may also expose them to greater risks of errors, oversights, miscommunications and care which is less appropriate to their needs.

Why do adverse events occur?

Everyone makes mistakes

We try to be perfect but it’s not possible Systems that depend on perfect human performance are fatally flawed

The Swiss Cheese model

Adverse Event Causation

Accident Causation Technical Factors Human Factors Operator Behaviour Safety Culture

= +

(30-20%) (70-80%)

Asdf asdf asdf sadf

Deep Water Horizon oil rig disaster – Gulf of Mexico, 2010

Asdf asdf asdf sadf

Deep Water Horizon oil rig disaster – Gulf of Mexico, 2010 Substandard cement Faulty shut-

• ff valve

Procedures not followed

Asdf asdf asdf sadf

Deep Water Horizon oil rig disaster – Gulf of Mexico, 2010 Substandard cement Faulty shut-

• ff valve

Procedures not followed Poor safety culture Inadequate training

Adverse Event Causation

Accident Causation Technical Factor Human Factors Operator Behaviour Safety Culture

= +

(30-20%) (70-80%)

Accident Causation Technical Factor Human Factors Operator Behaviour Safety Culture

= +

(30-20%) (70-80%)

Adverse Event Causation

Human Factors

Understanding and improving the “fit” between people and their working environment to ensure a more safe, productive and efficient workplace

What factors make us more prone to making mistakes?

 Stress  Fatigue  Unfamiliarity  Fragmentation  Lack of knowledge  Lack of quality / quantity

information

 Patient factors

What factors make us more prone to making mistakes?

 Stress  Fatigue  Unfamiliarity  Fragmentation  Lack of knowledge  Lack of quality / quantity

information

 Patient factors

SYSTEMS

 Poor design / interface  Systems for repeat

prescribing

 Systems for results

handling

 Alert fatigue  Lack of continuity –

locums, staff shortages

 Workload

But we are Human!

 Clinicians ignore alerts  Critical drug interactions 88- 89% ignored  Allergy drug interactions 69 - 91% ignored  Selective set of alerts – 67% accepted

Payne et al 2002 Wengart et al 2003 Shah et al 2006

Accident Causation Technical Factor Human Factors Operator Behaviour Safety Culture

= +

(30-20%) (70-80%)

Adverse Event Causation

Safety Culture

Positive Safety Culture

 Safety a priority  Eliminate “shame and blame”  Accept staff will make errors  Build systems to make care safer  Foster a culture where people can speak up  Team training  Organizational learning from errors and near-misses

Levels of maturity with respect to a safety culture

• A. Why

waste our time on safety?

• B. We do

something when we have an incident

• C. We

have systems in place to manage all identified risks

• D. We are

always on the alert for risks that might emerge

• E. Risk

management is an integral part of everything that we do Pathological Reactive Bureaucratic Proactive Generative

• Practice safety is not

new

• Apply systems thinking
• Each of us are part of a

system

• System needs to be

made safe

So how can we improve Safety in Primary Care?

A quality improvement programme for primary care that has a particular focus to reduce preventable patient harm

ADHB WDHB

 Warfarin  Medication Reconciliation  Results Handling  NSAIDS  Methotrexate

Nearly 1000 practices

82% Benefited their practice 75% Improved safety culture

2014 Pharmacy pilot National 2017

From Haggis to Pavlova

SiP Collaborative

 2014/15 23 practices  2015/16 32 practices  2016/17 40 practices  2017/18 61 practices - 4 urgent care clinics 20 community pharmacies pilot 2018/19 64 general practice, 46 pharmacies, 1 urgent care Joint learning sessions

Community Pharmacy so far

 Testing and development  Adapt Scottish tools for NZ use  Expert group  20 Community Pharmacy teams  Collaborative 9 months pilot  Review (feedback)  Sustain and Spread

Programme Aims

 Reduce preventable harm to patients  Create safer more reliable systems  Promote a culture of safety  Develop quality improvement skills

Evidence based focus on high risk areas

General Practice

 Results Handling  Medication Reconciliation  Warfarin  NSAIDs  Opioids  DMARDs – methotrexate azathioprine

 Protecting kidneys + prevention AKI

Community Pharmacies

 Medication Reconciliation  Anticoagulants  NSAIDS  Opioids

Urgent care

 Deteriorating patient  NSAIDs

Using IHI Break Through Series Collaborative approach

Primary Health Care Teams

LS1 LS2 LS3 LS4

Supports: visits / emails / calls PHO facilitators – Clinical Leads – IAs Practice Visit New Practices Prework Development

• f topic,

framework and changes Learning Session

What could we measure?

3 to 5 elements of care Across patient’s journey Different members of practice team Mix of easy and hard All or nothing Small frequent samples

Sharing and Learning

Supports Cornerstone / Foundation

Results Handling - 23 Incident management - 28 Quality Improvement - 29 Culture of safety and

teamwork - 38

MOPS Audit

Video

What will primary healthcare teams do?

Eleri Clissold

Sue French Shona Muir Tim Denison

Improving Patient Safety in Primary Care Quality Improvement Tools

Learning objectives

By the end of this session you will have a fundamental understanding

• f:



What Quality Improvement is and why it is important



The Model for Improvement, and its four key elements



How to set up and run a Plan, Do, Study and Act improvement cycle (and practice it)



How to translate what you did in the PDSA practice run into your workplace

What is Improvement anyway…

Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. (HRSA, USA 2011) Improving quality is about making healthcare safe, effective, patient-centred, timely, efficient and equitable. (The Health Foundation, UK 2013) Research enables us to determine what is possible Audit tells is what is actual Improvement science was designed to reduce the gap between what is actual and what is possible.

(courtesy of Barbara Corning-Davis 2018)

How can QI help us create change

What do you want to achieve– what is the problem what is your aim

What will you measure/audit What actions will you take to deliver on your aim

Getting started - Writing an Aim Statement

An aim statement:



Describes the goal of your improvement work in specific terms (but it does not tell you how)



Describes your intention objectively, and in observable terms



Describes your aim in quantifiable and observable terms A good aim statement will describe the 5 ‘W’s Apply the 5 ‘W’ What Who Where When why

“Increase the number of patients receiving Warfarin education every 12 months” Better: “Increase the number of patients on Warfarin receiving appropriate education every 12 months by 20%” Best: “increase the number of patients receiving yearly warfarin education from 30% to 80% within 12 weeks ”

Example of an Aim Statement for Warfarin management

Why we measure and what we measure?

We measure to:

 Enable us to ‘see’ how we are doing  ‘See’ the variation that lives in our daily

processes and routines

 Tell us whether we are getting closer to our

aims?

 What are we doing well, or not? And Why

Warfarin Prescribing

How does this differ from my prediction?

Plan Do Study Act

• Identify the issue

Use Data? Feedback? Brain storming

• What could change?

Patient experience? Communication?

• What will happen?

Test your idea

Training? Resources?

• Prepare
• Start small

Just 1 or 2 patients

• Monitor your progress
• Reflect on your test
• What has changed?

Who has it affected Was this positive or negative

• Act on your reflections
• Implement positive changes

Spread change carefully

• Decide: Adapt, adopt or abandon

Another PDSA cycle What is involved in a PDSA cycle

Measure the impact of your change

In teams of 8 people each person to have one of the following roles:

• Timekeeper – must have stopwatch (use your phone)
• Team participants (6 – ‘do-ers’) – assign each person

a number

• Observer & note taker – note decisions made by participants.

Practicing PDSA

Instructions:

• Your existing work process is to move the ball from person to

person following the sequence on the right

• Please practice this process and note the time it takes (in

seconds) to complete the entire process

• Every numbered person must touch the ball with both hands
• Time keeper and observer please measure & record :
• Time - how long the team takes to complete the process (in

seconds)

• The number of times they drop the tennis ball
• Changes made to the process

1 2 3 4 5 6 1

Break out Exercise

1. To reduce the time taken for every person to touch the ball in sequence by the end of the third round of testing. 2. To reduce the number of times we drop the ball with each cycle.

Rules:

• The sequence on the right must be adhered to
• You will have 30 seconds to plan what you are going to do
• You may only test one change idea at a time
• You will have 1 ½ minutes to complete the task
• Record the time and number of ball drops after each change
• There will be 3 cycles of testing

Team Aim

1 2 3 4 5 6 1

Time taken Number of drops What changes you made What will you measure?

Ready, set, go…..



We will start when I say ‘go’

1 2 3 4 5 6 1

Using a PDSA template

AIM: Person responsible When will this be done PLAN: Person responsible All Sue Eleri Eleri Shona All All DO: Describe what actually happened when you ran the test STUDY: Describe the measured results and how they compared to the predictions Time taken is greater than 1 ½ minutes, balls dropped exceed 20 times. Failed to achieve predictions. ACT: Will you adapt/ adopt or abandon the change idea and why? Before test starts Before test starts

• Adapt. We will keep people in sequence order, but explore a different method of passing the ball

Predict what will happen when the test is carried out Measures to determine if prediction succeeds Because we are in sequence order it will be quick and less balls dropped Time taken & number or balls dropped Lots of balls dropped because we are terrible at playing catch, this increased the time taken Before test starts Before test starts Before test starts Before test starts Before test starts List the tasks needed to set up this test of change When will this be done 1 Volunteer for team coordinator 2 Volunteer to record 3 Volunteer for time keeping 4 Assign team number 5 Get everyone in sequence order 6 Give instructions 7 Check understanding of instructions PDSA Worksheet for testing change (overall goal you wish to achive) We aim to reduce the time it takes for everyone to touch the ball in sequence. Every goal will require multiple smaller tests of change Describe your first (or next) test of change Line everyone up by sequence order Shona Before the test starts

How can you translating the exercise into real life

• Once you have defined the problem - don’t jump to a solution without

involving the team in developing a solution

• Encourage creativity with the team
• Don’t be afraid of letting a theory or ‘hunch’ come through – and then testing it
• Explore assumptions without judgment – put every idea on the table
• Don’t get so caught up in ‘doing’ that you don’t collect data
• Test small, grow each test cycle
• Don’t be afraid of a solution not working
• Measure and keep data – it will keep you focused on your aim

Return at 7:50 pm

GP teams Main Ballroom (here) Pharmacies Commodores Room (upstairs)