1. SPSP - PC Afternoon Session:
Learning from Development Work and Overview of Programme Tools (Cont’d)
Update on current work in NHS Greater Glasgow and Clyde
Overview of the National Programme and Next Steps

2. A trip to the vets......

4. The Importance of Culture
Does this look familiar?

5. The way things are done around here
Safety Climate
“Individual and group values, attitudes, perceptions and patterns of behaviour that determine their commitment to safety management”
The way things are done around here
NHS Education for Scotland 2010
Individual group values att .. .blah blah blah
Its the way things are done around here…

6. And that can be historic, but not necessarily right…

7. Human Factors in Safety
Technical
Factors
(30-20%)
Accident
Causation
Human
Factors
Organisational
Safety
Culture
Operator
Behaviour
(70-80%) = +

8. Avianca Flight 52
Flight from bogotoa to washington, forced to wait for landing , ran out of fuel. Aggressive air traffic control would not listen

9. Avianca Flight 52
Flight from bogotoa to washington, forced to wait for landing , ran out of fuel. Aggressive air traffic control would not listen

11. After Avianca 052 The aviation world changed forever
New compulsory training
New methods of sharing mental models
New communication skills
New approach to cockpit authority – leadership and followership skills
Standardised word patterns to express risk or major concern

12. But what’s all that got to do with us?
How good is communication in your workplace?

13. Levels of maturity with respect to a safety culture
E. Risk management is an integral part of everything that we do
D. We are always on the alert for risks that might emerge
C. We have systems in place to manage all identified risks
The Levels of Safety Culture used in MaPSaF
The best way to understand an safety culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before. The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, the Generative.
Pathological, is where the prevailing attitude is ‘why waste our time on safety?’
Reactive, is where safety is taken seriously, but it only gets sufficient attention after things have already gone wrong.
Calculative or bureaucratic organisations are those which have a tick box culture and approach to managing safety. This is where an organization is comfortable with systems and numbers.
Proactive: Proactive organisations consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, not just in theory.
Generative organizations are the nirvana of a mature safety culture. They live in a state of ‘chronic unease’ and are mindful of what could go wrong, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next. At this level bad news is actively looked for, because it provides the best opportunity to learn, so messengers are trained and welcomed.
WHERE DO YOU THINK AVIATION IS NOW? WHERE DO YOU THINK YOUR SERVICE IS ??
CLEARLY WE HAVE A LONG WAY TO GO….
B. We do something when we have an incident
A. Why waste our time on safety?
PATHOLOGICAL
REACTIVE
BUREAUCRATIC
PROACTIVE
GENERATIVE

14. Safety Culture – Safety Climate

15. Safety Culture – Safety Climate
Culture eats strategy for breakfast !

17. Safequest – A Safety Climate Survey

18. NES Safety Climate Survey
5 key factors
Teamwork
Workload
Communication
Leadership
Safety systems and learning

20. Benefits of measuring safety climate
Raise awareness
‘Diagnose’ your team’s safety climate
Identify strengths and weaknesses by comparison to other teams
Starting point for reflection and change – design and implement initiatives to build a strong, positive culture
Evaluate – serial measures
Encourage teamwork, participation and inclusion
Organisational benefits
High Reliability organisations (oil / aviation industries)
Improved safety outcomes
Improved safety behaviour
Health care
Emerging evidence of an association between safety climate and clinical outcomes in secondary care (but not yet primary care):
shorter hospital stays,
fewer medication errors,
reduced rates of ventilator associated pneumonia,
fewer patient falls,
reduced bloodstream infection rates,
increased adoption of safe work practices.

23. Communication Breakdown
Team members feel free to question the decisions of those with more authority Assertiveness
Team members are comfortable expressing concerns to leadership about how things are done Assertiveness
There is open communication between team members across all areas in the practice Communication
Team members are kept up to date about practice developments Awareness
The practice leadership communicates its vision for practice development Leadership

24. Positive Change 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.

25. “Weren’t as good as we thought we were”
“Mismatch between what the clinical and non clinical staff thought”
“Prompted some very open discussion” 25

26. Insights
“Many of us in the practice staff hadn’t really made the link that us failing to communicate was a threat to patient safety ….we had a lot of really good stuff came out of it, a lot of very open discussion”

27. Take home points Surveys have many limitations
The results are yours - only you and your team can make sense of it
Interpret the ‘numbers’ in a practical manner
Involve as many team members as possible
Keep an open mind

28. Questions?

29. At your tables now take 10 minutes to discuss: What would the benefits and challenges of using the climate survey in clinical teams? What support might practices need?

30. The Trigger Review Method
Dr. Carl de Wet

31. Identifying Harm in Primary Care
Using the structured case review otherwise known as the ‘Trigger Tool’

32. Overview Background What is the trigger review method?
Practical application…
Discussion

35. The trigger tool Review of medical records
SUB HEADING
The trigger tool
Review of medical records
Rapid, focused, structured, active
Screen for undetected incidents
Triggers = ‘prompts’ = alerts to potential harm 35

36. SUB HEADING 36

37. SUB HEADING 37

38. What the TT can do What it can not
SUB HEADING
What the TT can do What it can not
Help find undetected patient safety incidents Detect all incidents
Detect more incidents than any other method Tell you the why, where, what and what now
It can be fitted into a single session Improve care by itself
Measure harm at regional and national levels Practice level measurement or ‘benchmarking’. 38

39. The trigger tool process
STEP 1: Planning and preparation
STEP 2: Review a random sample of records
STEP 3: Reflection and further action.

40. Patient and medical records What patient group? Practitioner level
Individual and Team responsibilities?
Practice team
Primary-secondary care interface
2. Review records
3. Reflection, further action
1. Plan and prepare
Can triggers be detected?
Yes. For each detected trigger, consider: No
Three main tasks
Search for triggers,
Search for harm
Describe the characteristics of detected harm
Five questions
Are triggers present
Did harm occur?
How serious was the harm incident?
Where did the incident of harm originate?
Was the harm incident preventable?
The focus is harm, not error. Ask yourself: ‘Would I have wanted this to happen to me or my family?’
Only review the specific period in the record (three months).
Choose full calendar months to facilitate the review.
The maximum spend on reviewing any record should be twenty minutes. The objective is to detect ‘obvious’ problems, rather than every single episode.
If there is reasonable doubt whether harm occurred, the incident should not be recorded.
The focus is patient safety incidents and not error. Ask yourself: ‘Would I have wanted this to happen to me or my family?’
Did a patient safety incident occur?
Review the next record
No. Continue to next trigger or record
Yes. Describe the incident and judge:
Severity?
Preventability?

41. POPULATIONS Patients: On Warfarin On DMARDS In a care home
Recently discharged
With multiple medications
Multiple morbidities

42. Medical records and triggers
Sections in GP records
Triggers
Clinical encounters
(documented consultations)
≥3 consultations in 7 consecutive days 
Medication-related
(acute and chronic prescribing)
Repeat medication item stopped 
Clinical read codes
High, medium, low, allergies
New ‘high’ priority or allergy read code 
Correspondence Section
Secondary care, other providers
OOH / A&E attendance / Hospital admission 
Investigations
Requests and results
eGFR reduce <5, Hb < 10.0, INR > 5.0
Systematic – start in one section and work way through.
Selective / focused
May have to ‘read up’ a specific time in another section
Hospital admission – any that is overnight, including elective
Clinical read codes vary according to the type of software that you use – GPASS, VISION, EMIS 42

47. Rectify, prevent or improve
‘R’s after review
Review further
Reflect
Rectify, prevent or improve
Report
Repeat
What it can do
What it cannot do
Find previously undetected incidents of harm
Decide whether an error had occurred or not
Evaluate through serial measures
Assure reliability, which is dependant on the team and method
Identify patient safety learning needs
Provide an in-depth understanding of the harm incidents
Help to prioritize, plan and implement improvement
Improve safety and care without further action
Provide material for reflection and collective learning
Disseminate the learning without further action
Review = do you need MORE Information?
Reflect =
Rectify = different levels
Report = share, disseminate, formal, informal, local, wider, SIPC, etc
Repeat = when, who, why, what?
Reflect
What has been found?
Why did it happen?
Can it be fixed?
Prioritize what should be fixed
How can it be fixed?
How can we measure / know that it has been fixed?
What are the personal / professional / practice implications of all of this
Rectify
Implement change
Evaluate change
Report / Share / Spread
Improvement (prioritize, inform)
Learning (individuals and teams)
Measurement (including serial, assurance, benchmarking?, research) 47

48. T - Timeline Time Actions Immediate
Acknowledge, apologize, contain, prevent
Short term
Reflect, collective learning, prioritize, SEA, audit
Medium term
Implement changes - prevent, reduce, quality)
Long term
Sustain, evaluate, culture, share

49. Experience Quick – about 90mins to review 25 sets of notes
Finding harm not previously indentified – and that would not have been otherwise identified
Focus for Improvement
Cultural change
Need training and support
Not for measurement

50. ‘…Quantifying harm for the sake of measurement ‘activity’ is non-productive…’
Roger Resar, 2003, QSHC.
‘…The priority is [to] turn measurement for improvement into tangible change in practice…’
Scott, I; Phelps, G Int. Med J.
‘…the trigger tool is not in itself an ‘improvement methodology’, but it enables data acquisition and subsequent analysis of areas where harm is occurring… Quantifying harm for the sake of measurement ‘activity’ is non-productive…’ 50

51. Lothian Trigger Tool Case Note Review
January 2012
Over 75’s
One or more of the following:
Ischaemic Heart Disease
Diabetes Mellitus
Chronic Obtrusive Pulmonary Disease (COPD)
Atrial Fibrillation
Left Ventricular Systolic Dysfunction
Rheumatoid Arthritis
On 6 or more repeat medications.
Data for a total of 240 patients.

53. Triggers: There were a total of 199 triggers:
37 (15.4%) ‘repeat’ medication item discontinued
25 (10.4%) had an OOH/ A+E attendance
38 (15.8%) had a new ‘high’ priority read code added
21 (8.8%) had a hospital admission
37 (15.4%) >3 consultations in 7 days
14 (5.8%) INR >5, <1.8
4 (1.7%) had a Hb<10
12 (5.0%) had an drop in eGFR change >5
11 (4.6%) had a new allergy read code added

54. Harm 47 episodes of harm 78.7% originated in Primary Care;
10.6% originated in Secondary Care
10.7% were unsure of origin.
72.3% were not considered to be preventable
17% were considered to be preventable
10.7% were unsure if they were preventable

55. Incidental findings Medication issues
Right cataract extraction. Reduction in dose of Pyridostigmine suggested by Neurologist in 08/11 - but not changed on computer
Has not requested doxazosin from repeat meds since 6/7/11 despite regular GP review.
Patient non-compliant with Adcal D3 commenced in Sept 11. Practice nurse to phone patient to discuss
Nausea with Tramadol - stopped
Coding issues
ADR to amlodipine not coded

56. Incidental findings Follow up issues
No U+E tested since 27/10/10 despite CKD coding. Last eGFR stable at 49.
Annual haemoglobin not not for >1 year. Need to update INR protocol
Haemoglobin not done since 2010 in secondary care. To be done again when next attends
Needs U&E checked, housebound patient and usual Nurse for bloods on sick leave so delay in re-check
Failure to check Ca and Mg as recommended by hospital in context of palpitations - reminder added
Urinalysis showed ++ blood - MSU negative - no follow up arranged
Several items duplicated on repeat. OCP on repeat -BP not checked since 2010.

57. 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

58. Remember...
The focus is patient safety incidents and not error. Ask yourself: ‘Would I have wanted this to happen to me or my family?’
Only review the specific period in the record (three months).
Choose full calendar months to facilitate the review.
The maximum spend on reviewing any record should be twenty minutes. The objective is to detect ‘obvious’ problems, rather than every single episode.
If there is reasonable doubt whether harm occurred, the incident should not be recorded.
Acts of omission should rarely, if ever, be document - ?discuss acts of omission / commission? 58

59. Questions?

60. Common Pathway for all Tools
Look/ Measure
Reflect
Identify Risk /Lack of reliability
Make Improvements

62. Successes - Improved: Patient Care Systems
Knowledge, Skills & Attitudes
Safety Culture
Team-working
Patient Involvement
Efficiency

63. Less Stress for some staff in their job
“Staff member X who manages the register and the recall for these patients, it caused her an enormous amount of stress prior to the programme”
“ Now that the programme is much more streamlined and she feels more confident and has taken much more clinical responsibility”

64. Staff time-saving - patients being more proactive
“staff member X doesn’t have to continually phone people up every month, that is quite a time saver for her, patients are now more coming in cause they understand the consequences potentially of the side effects of the potential toxic drugs”.

65. Challenges - Practices
Understanding
Time Pressures
Competing priorities
Staff and IT changes
Team Involvement
Resources and remuneration
Practice environment - culture

66. Overall 82% say the programme has benefited their practice
75% say the Programme has improved the safety culture of their practice

67. What was it really like for a practice

69. What was it really like…for a board team

70. Board Experience Steep learning curve Professional development
Clinical Lead and QI support essential
Network with other boards
Need leadership and Prioritised
Start small

72. Organic Spread Lothian- 85 practices Forth Valley- 56 GG&C – 10
Dumfries and Galloway -
Lanarkshire
GP Training
Appraisal

73. Current work in NHS Greater Glasgow and Clyde

74. SPSP Experience in NHS GG&C
Dr Paul Ryan
Clinical Director
North East Sector, Glasgow City CHP

75. SPSP Experience in NHS GG&C
Climate Survey
Trigger Tools
Significant Event Review
5 Clinical Areas
13 Practices 5 DN Teams

76. SPSP Experience in NHS GG&C
Medicine Reconciliation
DMARDS
LVSD
Insulin Administration
Pressure Ulcer Prevention

77. Medicines Reconciliation Care Bundle for all 5 GP practices (collated)
TARGET 90%
There are 11 GP practices who are continuing to collect data on a monthly basis to improve the reliability of the process for 3 Care Bundles, namely, DMARDS (Disease Modifying Anti Rheumatic Drugs), Medication Reconciliation and LVSD (Left Ventricular Systolic Dysfunction). GP Practices are being encouraged to complete Tests of Change and remain enthusiastic in their participation of this SPSP Primary Care Programme. The chart in Fig 2 depicts the percentage compliance for the GP practices who are participating in the Medicines Reconciliation Care Bundle from January to September 2012.
Fig 2 illustrates that, for the Medicines Reconciliation Care Bundle, that all GP practices, except one, have improved their overall compliance. One practice has consistently been achieving 100% compliance for July, August and September 2012.

78. Medicines Reconciliation Care Bundle for all 5 GP practices (individual)
There are 11 GP practices who are continuing to collect data on a monthly basis to improve the reliability of the process for 3 Care Bundles, namely, DMARDS (Disease Modifying Anti Rheumatic Drugs), Medication Reconciliation and LVSD (Left Ventricular Systolic Dysfunction). GP Practices are being encouraged to complete Tests of Change and remain enthusiastic in their participation of this SPSP Primary Care Programme. The chart in Fig 2 depicts the percentage compliance for the GP practices who are participating in the Medicines Reconciliation Care Bundle from January to September 2012.
Fig 2 illustrates that, for the Medicines Reconciliation Care Bundle, that all GP practices, except one, have improved their overall compliance. One practice has consistently been achieving 100% compliance for July, August and September 2012.

79. DMARD Care Bundle Compliance – collated practices
TARGET 80%
DMARDs

80. Methotrexate 2.5mg tab scripts as a % of all MTX tab: scripts by HB Sep 06 to Jul 2012
GG&C
GG&C now 98.1%

81. Annotated run chart for the Prevention of Pressure Ulcers for one of the District Nursing Teams
The annotated run chart shows a steady increase in the percentage compliance for the Prevention of Pressure Ulcers for one of the District Nursing Teams. Since August 2012 the reliability of the process has achieved 100% and has remained at this level for the subsequent two months.

82. % Compliance all 4 DN Areas

83. % Compliance for LVSD Care Bundle