quality and safety through primary health care: the role of the acsqhc chris baggoley agpn national forum 6

1. Quality and safety through primary health care: the role of the ACSQHC

3. ACSQHC The Australian Commission on Safety and Quality in Health Care - Commenced in 2006 - Reports to all Health Ministers - Commissioners diversity - Committee structure: Inter-Jurisdictional Committee Private Hospital Sector Committee Primary Care Committee Information Strategy Committee - Stakeholders / Colleagues include: Consumers Professional organisations Health Service Executives Safety and quality organisations

4. Primary Care Committee

5. ACSQHC Our Programs Australian Charter of Healthcare Rights Open Disclosure Basic Care Issues Healthcare Associated Infection Patient Identification Medication Safety Clinical Handover Recognition and Response to Clinical Deterioration Falls Guidelines Tools Accreditation and Credentialing Information Strategy

6. Patient Safety in Primary Healthcare Characteristics of primary care setting (compared to acute care setting) Patients less sick Procedures less invasive Contribution to outcomes of patients, families, carers greater Dispersed network of providers Fewer resources available for patient safety infrastructure Opportunity for longer term relationships

7. Medical Journal of Australia - June 2009

8. Clinical Handover Projects Inpatient care to community care: improving clinical handover in the private mental health setting. Wood et al MJA (2009) 190:11:S144-S149 Pushing the envelope: clinical handover from the aged care home to the emergency department. Belfrage et al MJA (2009): 190:11:S117-120 A shared electronic health record: lessons from the coalface. Silvester B, Carr S, MJA (2009): 190:11:S113-116

9. Self descriptor � not developed in trial but recommended who ACH can accept back from hospital � changes in status of current residents mobility� medications IVs behaviour Insulin Levels of care info � like by hospital staff useful for DC planning Self descriptor � not developed in trial but recommended who ACH can accept back from hospital � changes in status of current residents mobility� medications IVs behaviour Insulin Levels of care info � like by hospital staff useful for DC planning

10. back Minimum information set Extensive consultation and refinement from trial Minimum information set Extensive consultation and refinement from trial

11. What would improve discharge clinical handover? Identifying key discharge information Dedicated envelope with checklist? - one-way or two-way envelope Increased awareness of need for clinical handover�how? Dedicated staff to liaise with ACHs, plan & oversee discharge i.e. to ensure safe clinical handover

12. Patient Safety in Primary Healthcare: literature review 3 questions 1. What are the main patient safety risks relevant to primary care? 2. What research has been conducted regarding solutions to these risks? 3. What are the gaps in the evidence base about patient safety in primary care?

13. Patient Safety in Primary Healthcare: literature review What are the main patient safety risks relevant to primary care? Process errors - administration (7 - 40%) includes message handling, recall systems - investigation (8 - 70%) includes each step in process - treatment (2 � 45%) includes medication errors - communication (4 � 15%) impact of health literacy noted - payment (1 � 4%) cost of health care; fear of litigation

14. Patient Safety in Primary Healthcare: literature review What are the main patient safety risks leading to harm relevant to primary care? Process errors (80%) medication errors � prescribing and dosage � most frequent communication errors prevalent Diagnosis errors (20%) greatest severity of harm Vast majority of literature derived from general practice

15. Patient Safety in Primary Healthcare: literature review Factors associated with harm - Missing clinical information - Failure to maintain equipment, including sterilisation - Failure to review and manage polypharmacy - Errors in transcription and dispensing of medication - Processes and nature of work in a pharmacy - Poor knowledge and understanding about medications - Poorly displayed consumer medication information

16. What research has been conducted regarding solutions to these risks? No simple solutions Need solutions for: - Organisational change - Prescribing - Communication - Diagnosis - Supporting patient self-management

17. What research has been conducted regarding solutions to these risks? Any approach requires consideration of: - systems for reporting errors organisation nationally - �ground up� implementation methods - safety education in core curricula - managers, leaders, doctors and nurses embracing safety - careful design of systems to aid safety (eg IT) - avoid blame and litigation - development of informed patients - cooperation between service providers

18. What are the gaps in the evidence base about patient safety in primary care? Problems with evidence - lack of evidence, especially regarding solutions - evidence descriptive, expert opinion, commentary - lack trials regarding medication - lack evaluation of technology including IT systems, decision support.

19. Error rates 5 � 80 per 100,000 consultations Clinical negligence data base - failure or delay in diagnosis 50% - medication prescription error 5% - failure or delay in referral 5% - failure to warn of side effects 5% - commonest recorded outcome: death 21% Woodward, S Clinical Risk (2005) 11, 142-144 �Patient Safety in Primary Healthcare: our national challenge�

20. �Patient Safety in Primary Healthcare: our national challenge� Seven steps to patient safety Build a safety culture Lead and support staff Integrate risk management activity Promote reporting Involve and communicate with patients and the public Learn and share safety lessons Implement solutions to prevent harm Woodward, S Clinical Risk (2005) 11, 142-144

22. The Role of a National Safety and Quality Framework - Basis of strategic and operational safety and quality plans - Mechanism for refocusing activities, reviewing investments and designing goals - Promote discussion with consumers, clinicians, managers, researchers and policy makers.

23. 1. Patient Focused This slide depicts the Patient Focused element of the Framework. You might wish to note that access to health care is always most important for consumers and is supported by Health Ministers. Health literacy warrants consideration by us all � it features strongly in the NHHRC Report.This slide depicts the Patient Focused element of the Framework. You might wish to note that access to health care is always most important for consumers and is supported by Health Ministers. Health literacy warrants consideration by us all � it features strongly in the NHHRC Report.

24. 2. Driven by Information The second key element of the proposed safety and quality Framework emphasises the importance of information.The second key element of the proposed safety and quality Framework emphasises the importance of information.

25. 3. Organised for Safety And the third element highlights the importance of the health system � clinicians, organisations and governments � being organised for safety.And the third element highlights the importance of the health system � clinicians, organisations and governments � being organised for safety.

26. Framework Consultation Outcomes � Consumer workshops

27. Framework Consultation Outcomes � Consumer workshops

28. Framework Consultation Outcomes � Consumer workshops

29. E- Discharge Summaries Electronic discharge summaries: the current state of play - Need to overcome barriers of software heterogeneity and lack of standardisation in data exchange protocols Clinical language needs to be standardised Importance of carefully and strategically managing the introduction of new technology is paramount Craig et al, Health Info Man. Journal (2007) 36(3) 30-36

30. E- Discharge Summaries Effects of electronic communication in general practice - Disappointingly small number of studies demonstrating improvement of the quality of care by electronic communication Authors puzzled by the discrepancy between the scarcity of documented impact on the quality of care and the abundance of electronic communication projects in conference proceedings Van dor Kam et al, Int J Med Inf (2000) 59-70

31. E- Discharge Summaries Effects of electronic communication in general practice - Possibly many electronic communication projects failed and nobody wants to present findings 25 of 30 publications described only positive effects Negative effects described Information overload for physicians No cost saving Lack of confidentiality Increase in work load for consultant - Effects could be so complex that hard to measure Van dor Kam et al, Int J Med Inf (2000) 59-70

32. Framework Consultation Outcomes General Practice Victoria Most important issues for safe, high quality care: - Consistent approach - Funding, organisational and governance models - Supporting workforce - Adequate handover and communication

33. Framework Consultation Outcomes General Practice Victoria Biggest improvements in last five years for safety and quality: - Change from focussing on changing clinician behaviour to focussing on the organisation - Quality improvement requires a multidimensional, systematic and multi-level approach - Recognition that continuous quality improvement processes are needed - Importance of electric systems recognised

34. Framework Consultation Outcomes General Practice Victoria Barriers to improving safety and quality: - Variability in access to guidelines - Guidelines focus on single diagnosis and not on real patients - Limited availability of interpreters - Limited time for clinicians to develop clinical leadership - Poor data quality - Lack of national evaluation framework - Lack of support to GP workforce to ensure safety and quality

35. Framework Consultation Outcomes Aboriginal Medical Services Alliance NT � Aboriginal Primary Barriers to implementation of safety and quality work: - Workload and high turnover - Limited knowledge, spread and sustainability of CQI approaches in health services - Clinical information systems issues - Role for CQI in aboriginal health workers - Engagement of health boards and community - Ongoing funding not certain and complex

36. Framework Consultation Outcomes Primary Care Committee Key areas for the Framework: - More informed approach for working with rural sector - Develop robust e-health system to gather reliable data - Provide better communication to, and by, the primary care sector - Support evidence-based, cost effective prevention program

37. Framework Consultation Outcomes Primary Care Committee Key areas for the Framework: - Develop tangible programs with measurable impacts - Examining legislative compliance, incentive issues and reward for appropriate behaviour - Supporting development needs for a culture that drives safety and quality - Developing a business case for safety assurance measures