Transcript Document

A New Zealand Primary Care
Quality and Safety Agenda
Susan Dovey
Research Associate Professor
General Practice Department
Dunedin School of Medicine
My task
What are the interventions needed in
New Zealand to transform
organisational culture and establish
early warning systems to eliminate
harm to patients
This talk
• Review what we have
• Definitions
• Propose ways to transform
organisational culture
• Consider “early warning systems”
A Brief History of
Patient Safety
• 1999: “To Err is Human” US Institute of Medicine
• 2000 “An Organization with a Memory: Report of an
expert group on learning from adverse events in the
NHS
• 2000: The Quality Improvement Committee established
under the New Zealand Public Health and Disability Act.
• 2002: WHO World Health Assembly Resolution urging
WHO and Member States to pay the closest possible
attention to the problem of patient safety
• 2004: WHO launched the World Alliance for Patient
Safety
Definitions
• Patient Safety:
– the first domain of quality
– "freedom from accidental injury" (US
Institute of Medicine and most US
sources)
– a relatively recent initiative in
healthcare, emphasizing the reporting,
analysis and prevention of medical error
and adverse events (Wikipedia)
What we have now
A complaints system
Patient
ACC
MCNZ
HDC
HR
Commissioner
PC
Ombudsm
an
The Commissioner
then…
Patient
MCNZ
Provider
HDC
DGH, HR
Commissioner or
Ombudsm
an
DP
PC
ACC
Privacy Commissioner
Patient
Ombudsm
an
DHRP
PC
Inspector
General
of
Intelligen
ce &
Security
HDC
A competency check
system
HDC
Concerne
d
Colleague
s
PCC
MCNZ
Concerne
d
Employer
s
The
Courts
Health Practitioners’
Disciplinary Tribunal
HPDT
PCC
DP
MCNZ
HDC
People providing health care: “To
err is human”
Horoscope: “’You have a small capacity for reason, some basic toolmaking skills and the use of a few simple words.’ … Yep. That’s you.”
Maintenance of
Professional Standards
• MOPS (RNZCGP):
– to maintain professional standards, commit to
quality improvement in patient care, commit to
lifelong learning
– Assists GPs to:
• maintain their registration in general practice
• meet Medical Council recertification requirements
• meet their obligations under the Health Practitioners
Competency Assurance Act (2003).
Cornerstone
• General Practice Accreditation
process
• The indicators are:
– Factors affecting patients
– Physical factors affecting the practice
– Clinical practice systems
– Practice and patient information
management
– Quality improvement and professional
development
Safety Incidents in primary
care
• 5 – 80 per 100,000 consultations
• Diagnostic error 26 – 78% of all errors
• Diagnostic error least preventable &
causes the most harm
• Treatment error 11 – 42% of errors
• Multiple causes, communication & coordination, context, patient etc Sanders J, Esmail A. The
frequency and nature of medical error in primary care: understanding the diversity across studies.
Fam Pract. 2003;20(3):231-6.
• Preventable adverse events in outpatient
setting lead to estimated 75,000
hospitalisations per year in the US (&
2587 deaths) Woods DM, Thomas EJ, Holl JL, Weiss KB, Brennan TA.
Ambulatory care adverse events and preventable adverse events leading to a
hospital admission. Qual Saf Health Care. 2007;16(2):127-31.
Captured by current
processes?
• Of the 850 who experienced an adverse
event only 3 (0.4%) complained to HDC
• Pts experiencing severe & preventable a/e
more likely to complain 2/48 (4%)
• Elderly, Pacific, socioeconomically deprived
less likely to complain
•
Bismark MM, Brennan TA, Paterson RJ, Davis PB, Studdert DM. Relationship between
complaints and quality of care in New Zealand: a descriptive analysis of complainants
and non-complainants following adverse events. Qual Saf Health Care. 2006;15(1):1722.
Most patients don’t complain –
even when harmed
‘Complaints’
Culture
• ‘Safety culture’ refers to the shared attitudes,
beliefs, values and assumptions that underlie
how people perceive and act on safety issues
within their organisation.
• The culture of an organisation may be a major
asset in continuous safety improvement or,
conversely, a major obstacle to any meaningful
change.
• Safety culture is a new concept in healthcare and
can be difficult to assess and change.
• We know that how people think in an organisation
– their values, assumptions and beliefs – has the
potential to influence how they behave when
delivering services.
Friendship clusters in a US school. Reprinted with permission from Moody J. Peer influence
groups: identifying dense clusters in large networks. Soc Netw 2001;23:261-83.
Braithwaite, J et al. Qual Saf Health Care 2009;18:37-41
Copyright ©2009 BMJ Publishing Group Ltd.
(MY) SOLUTIONS
Patient safety is what social scientists
call a "wicked problem"—one that is
messy, persistent and
multidimensional.
Towards safer, better healthcare: harnessing the natural properties of
complex sociotechnical systems
J Braithwaite, W B Runciman, A F Merry
Quality and Safety in Health Care 2009;18:37-41;
1. Resolve definition
problems
• One literature review found 25
different definitions of “medical error”
• Harm = Error ?
• Sentinel events ?
• Near miss ?
• Medical error
• PATIENT SAFETY INCIDENT (WHO)
2. Education: A “new
healthcare discipline”
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Anatomy
Biochemistry
Cardiology
Dermatology
Epidemiology
Fertility
Gastroenterology
Haematology
Injury prevention
Jaundice
Kidney disease
Lactation
Maternity
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Nutrition
Obstetrics
Palliative care
Quitting smoking
Rheumatology
Sexual problems
Travel medicine
Urology
Venereology
X-rays
Youth and
adolescence
• Zoonoses
Patient Safety
3. Cultural change
A key to health system transformation may
lie under-recognised under our noses, and
involves exploiting the naturally-occurring
characteristics of complex systems.
Clinicians work best when their expertise is
mobilised, and they flourish in groupings
of their own interests and preference.
Being invited, empowered and nurtured
rather than directed, micro-managed and
controlled through a hierarchy is
preferable.
Braithwaite, J et al. Qual Saf Health Care 2009;18:37-41
4. “Marketing” messages
Any message to be both remembered and acted
upon needs to be sticky.
Stickiness is a function of the intrinsic nature of a
message, how it is presented and the effect it has
on the recipient.
Sticky messages have natural appeal.
get a message to stick by:
Novel or effective communication
smooth transmission modes
embedded cues in the environment and workplace
forcing functions to facilitate compliance
a critical mass of champions or opinion leaders
Braithwaite, J et al. Qual Saf Health Care 2009;18:37-41
5. Professional Values
• A bottom-up strategy led by clinicians is
badly needed to balance the
predominantly top-down approaches
which frequently result in only modest
improvements which are difficult to
sustain.
• Politicians and bureaucrats seek to shape
clinical practice by edict, whereas in reality
it is shaped by the behaviours and
attitudes of practising clinicians.
Braithwaite, J et al. Qual Saf Health Care 2009;18:37-41
Thank You
Community-Based
Patient Safety research
• Literature on community based
patient safety events is limited
– 34 studies reported from 1994 to 2006
on general patient safety events
– 32 additional studies on medication
safety events
What we know from
International literature
• Reporting systems are the method most often
used to collect safety event data collection in
primary care
• Incident reporting systems have been trialed
and are acceptable to primary care providers
• There is a large variation in definitions
• Taxonomies of patient safety events in
community settings are proliferating
• Clinician attitudes to safety event reporting are
positive provided the reporting systems are
non-punitive, educational, and support clinical
care
Most people receive most
health care in general practice
NZers accessing hospital and general practice
2500000
2000000
1500000
children
adults
1000000
500000
0
general practice
hospital
UK National Reporting and
Learning System Data:1 Jan
2007- 31 Mar 2008
– 811,746 incident reports
• 68,596 from community services (0.08%)
• 2675 from general practice (0.003%)
National Safety Event Reporting systems
don’t work well for primary care
Care setting of incident reports, January 2007 to December 2007
All sorts of threats to patient safety exist
in primary care
Reported incidents, by type, in general practice, January 2007 to
December 2007
Reported severe harm or death to patients, by care
setting, January 2007 to December 2007
Wide variation in estimates
• Estimates of the rate of patient safety
incidents occurring in primary care
ranged from 0.00431 to 24072 per
1000 primary care consultations.
• Estimates of preventability ranged
from 45%72-76% of all “errors”.
Many different professions
are involved
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Primary care doctors
Trainees
Patients
Nurses
Other practice staff
Paramedics
Pharmacists
Computer suppliers
Academics
Acupuncturists
Optometrists
Managers
Types of patient safety
incident
• Errors in diagnosis (26%-57% of
incidents)
• Errors in treatment (7%-52%)
• Errors in investigating (13%-47%)
• Errors in office administration (9%56%)
• Errors in communication (5%-72%)
Causes / contributing factors
to patient safety incidents
• environmental hazards (3%-14%)
– work organization
• physician factors (5%-91%)
– excessive task demands
– Fragmentation
• patient factors (40%-72%)
• hospital factors (6%).
Harm from patient safety
incidents
• Ranged from 1.3 significant minor incidents per
1000 treatments to 4% of incidents resulting in
death
• 17%–39% of incidents resulting in harm
• 70%–76% of incidents having potential for harm
• Patients spoke of anger, frustration, belittlement,
and loss of relationship with and trust in their
physician
• Consequences of patient safety incidents that
were memorable to family physicians included
patient death (47% of memorable incidents), no
adverse outcome (26%) and malpractice suits
(8%)
Types of safety incident
patients are concerned about
• Two studies
– relationship concerns(37%-77%)
– access problems (29%)
WHAT DON’T WE KNOW?
Common myths: “Hospital
care carries more risks”
• no one really knows if hospital care
carries more risks than primary care
• most burden on health systems
arises from the more mundane
patient safety incidents with effects
that are magnified by frequent
repetitions and exposure of a large
number of people
More of what we don’t
know
• Much about patients: their
perceptions of patient safety issues,
their contributions to safety
• Prevalence of patient safety
problems
• International differences
• Characteristics of safe/unsafe
general practices
Questions??
CONCEPTUAL FRAMEWORK FOR ICPS
Conceptual Framework
Contributing Factors
Patient Characteristics
Incident Type
Incident Characteristics
Detection
Mitigating Factors
Patient
Outcomes
Outcomes
Organisational
Outcomes
Action Taken After The
Incident
Ameliorating Actions
Actions to reduce future
risk
ICPS
Primary care characteristics
that are challenging for
protecting safety
• Health care is seldom continuously monitored
• Health professionals often have less control
• More than one site is often required for an episode of
care (having implications for patient and information
transfer)
• Sites where primary care is provided are not
necessarily designed for this purpose
• Episodes of primary care may extend over very long
time frames – sometimes years
• patients present with undifferentiated problems
• diagnoses are often uncertain and multiple comorbidities are
• Systems to support safe care may be poorly defined
and idiosyncratic
Common myths 2: “No really
serious threats to patient
safety
happen
in reports:
primary care”
• From
sentinel event
– Serious or life-threatening events: 7% to 22%
• From malpractice databases:
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–
–
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Death: 3.4% to 37%
Severe or permanent disability: 14% to 19%
Moderate or temporary disability: 26% to 35%
Low severity: 18% to 48%
• Medical errors: 5-80 per 100,000 consultations
– Errors in diagnosis: 26%-78% of all errors
– Treatment errors: 11%-42% of all errors
– 60-83% of all errors are preventable.
The key issue facing QIC
wrt sentinel event reporting
• Disengaged primary care
– Because of:
• Perceptions that they are “excused”
because of a hospital orientation to the
programme
• Lack of sufficient organisational structure to
engage
• Lack of an educational focus
• No monitoring
Background
• U.S. involvement
• Most widely read paper in Quality & Safety
in Health Care 2002
– Dovey SM, Meyers DS, Phillips RL, Green LA,
et al. A Preliminary Taxonomy of Medical
Errors in Family Practice. Qual Safety Hlth
Care 2002; 11: 233-8.
• BMA Book of the Year 2006.
– Patient Safety: Research into Practice
(Walshe K, Boaden R, eds). Open University
Press, McGraw-Hill Education: Manchester,
2006.
WHO
• Methods and Measures for Patient
Safety Research: 1st Expert
Consultation meeting, Dec 2006.
• article for BMJ/National Patient
Safety Agency website
www.saferhealthcare.org.uk
– ‘What we know’ article: Monitoring
threats to patient safety in community
settings: a review of the literature.
Epistemological Issues
• Lilford and colleagues have developed an
analysis of some of the issues related to
the characteristics of patient safety events
and the methods used to study them:
• Some background
– Many patient safety events are rare, but
– High frequency but lower harm, immediacy or
causality incidents may contribute more harm
overall than high profile, rare events
Community Based
Measures
Four main strategies to advance methods
and measures:
1. Prospectively collected safety event data
using simple descriptive taxonomies
2. Methods of in-depth analysis of safety
events incorporating theories of causation
and harm
3. Electronic event collection systems
4. Development of methods to incorporate
patient/client views
A Brief History of Patient
Safety Research
• Up to 1999: Hospital-based specialties,
EXCEPT
• Hospital-base, non-specialty focus:
– Harvard Medical Practice Study, 1991
– Australian Incident Monitoring Study, 1993
– Utah and Colorado, 1999
• Primary care base:
– Pharmaco-vigilance studies
– AIMS, primary care, 1997-98
Patient Safety Research:
Data
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Review of medical records
Interviews with health-care providers
Direct observation
Incident reporting systems
External audit and confidential inquiries
Studies of claims and complaints
Information technology and electronic medical
records
– Administrative data
– Autopsy reports
– Mortality and morbidity conferences
Primary Care Patient
Safety Research
• "In terms of patient safety, it’s something that has been
left off the agenda in primary care. The work hasn’t been
done like it has in the secondary care sector,"
• "We understand how big a problem it is, but we haven’t
concentrated on it enough, and we don’t have very good
means of measuring or identifying specifics or putting
numbers on it… our knowledge base is very limited and
restricted."
• "All the big agencies, such as the National Patient Safety
Agency, are beginning to understand that there is a
whole amount of work to be done in primary care."
BMJ 2009;338:b525
Primary Care Patient Safety
research by…
• Review of medical records
– None
• Interviews with health-care providers
– 3 interview studies with health care providers
– 1 with patients
– 2 focus group studies
• Direct observation
– none
• Incident reporting systems
– 10 studies in 7 countries, 21 papers
• External audit and confidential inquiries
– none
Primary Care Patient Safety
research by…
• Studies of claims and complaints
– 3 studies, 2 in the US, 1 in Hungary
• Information technology and electronic
medical records
– none
• Administrative records
– 3 studies of significant event reports from the
UK
• Autopsy reports
– none
• Mortality and morbidity conferences
– none
Other Primary Care Patient
Safety Research
• Surveys
– 5 studies in the US, UK, and Canada
• Mixed-method research
– 6 studies