A New Zealand Primary Care Quality

and Safety Agenda

Susan DoveyResearch 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

ACC

HR Commiss-

ioner

Ombudsman

PC

MCNZ

Patient

HDC

The Commissioner then…

MCNZ

DGH, HR Commiss-ioner or

Ombudsman

PCACC

DP

Provider

Patient

HDC

Privacy Commissioner

Ombudsman

Inspector General

of Intelligen

ce & Security

HDC

DHRP

Patient

PC

A competency check system

Concerned

Colleagues

Concerned

Employers

The Courts

PCC

HDC

MCNZ

Health Practitioners’ Disciplinary Tribunal

HPDT

PCC DP

HDCMCNZ

People providing health care: “To err is human”Horoscope: “’You have a small capacity for reason, some basic tool-making 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 & co-

ordination, 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.

• 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):17-22.

Captured by current processes?

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.

Copyright ©2009 BMJ Publishing Group Ltd.

Braithwaite, J et al. Qual Saf Health Care 2009;18:37-41

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.

(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”

• Anatomy• Biochemistry• Cardiology• Dermatology• Epidemiology• Fertility• Gastroenterology• Haematology• Injury prevention• Jaundice• Kidney disease• Lactation• Maternity

Patient Safety

• Nutrition• Obstetrics• Palliative care• Quitting smoking• Rheumatology• Sexual problems• Travel medicine• Urology• Venereology• X-rays• Youth and

adolescence• Zoonoses

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” messagesAny 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 communicationsmooth transmission modesembedded 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

0

500000

1000000

1500000

2000000

2500000

general practice hospital

children

adults

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%)

Care setting of incident reports, January 2007 to December 2007

National Safety Event Reporting systems don’t work well for primary care

Reported incidents, by type, in general practice, January 2007 to December 2007

All sorts of threats to patient safety exist in primary care

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• 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??

Contributing Factors

Patient Characteristics Incident Characteristics

Mitigating Factors

Patient Outcomes

OutcomesOrganisational

Outcomes

Action Taken After The Incident

Ameliorating Actions

Actions to reduce future risk

CONCEPTUAL FRAMEWORK FOR ICPS

Incident Type

Detection

Conceptual Framework

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 co-morbidities

are • Systems to support safe care may be poorly defined and

idiosyncratic

Common myths 2: “No really serious threats to patient safety happen in primary care”• From sentinel event reports:

– Serious or life-threatening events: 7% to 22%

• From malpractice databases:– 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 MeasuresFour 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

– 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