Background
Methods
Settings/ recruitment
Distribution of the toolkit
Name of tool | Description | Methodology | Participants | Estimated time to completion | Regions participating |
---|---|---|---|---|---|
Trigger Tool [20] | A system of rapid retrospective note review to allow clinicians to detect episodes of harm and patterns of error which might be occurring undetected in their practices. | Sample created of 25 random patients over the age of 75 to screen for any harm or patient safety incident. The Trigger Tool provides a framework for the case review that highlights any incidents of harm or near misses. The data is summarised to promote reflection on learning points and learning needs on an individual or practice level. | Single or multiple GPs or GP registrars | 90 min | All |
PC-SafeQuest [20] | An online tool which is intended to be completed by all members of the practice team allowing for a quantitative assessment of the perceived climate of safety within a practice. | Staff are invited to complete an anonymised survey on line. Once completed by a sufficient number of staff, a report can be generated summarising the findings. These are presented as a score in one of four domains, (i) workload; (ii) communication; (iii) leadership; (iv) teamwork; and (v) safety systems. These scores are then used to facilitate discussions around any issues that emerged. | All practice staff. Participation is voluntary. | 10–15 min per individual. | West Midlands East Midlands Greater Manchester South Coast |
A questionnaire to gather the experience of patients with respect to patient safety in general practice, and on patient reported safety outcomes. Questions are asked within five areas; practice activation; patient activation; experiences of patient safety events; harm; and general perceptions of patient safety. | Practice supplied with 150 envelopes containing the questionnaire, instructions for patients and a reply paid envelope. The practice will then produces the list of recipients and post the questionnaire. Completed questionnaires are returned to the authors at the University of Oxford who produce and distribute a practice specific report. | A sample of 150 patients over the age of 18 generated by the practice. A GP is expected to check that this does not include vulnerable patients. | 60 min | All | |
Prescribing Safety Indicators [20] | Indicators involve the use of CHART (Care and Health Analysis in Real Time) software to extract data on patients at risk of medication-related injury. There are 36 in total and include prescribing related to issues such as cardiovascular and respiratory disease, immunosuppression and laboratory test monitoring. | Install CHART software, download the prescribing safety indicators from PRIMIS Hub, run the computer queries on the GP clinical system and uploading the results to CHART online. The resultant data identifies at-risk patients for the practice who then upload an anonymised version to CHART online, aggregated and shared so practices can view their results in relation to other practices. | Various (including member of study team) | 60 min | West Midlands North Staffordshire South Coast |
Medicines Reconciliation Tool [20] | Used to assess the quality of medications reconciliation process on discharge with a focus on vulnerable patients. | Staff populate a data collection form using the discharge document, the consultation record and the medication record of 20 patients aged 65 and over discharged from emergency hospital between 3 and 6 months ago. This data helps to assess how promptly and how accurately medication changes suggested by the hospital have been made. It also assesses the extent to which changes have been discussed with patients. | Senior staff member collecting data from records | 100 min | East Midlands Greater Manchester |
Concise Safe Systems Checklist for General Practice [20] | A checklist covering aspects of patient safety not covered by existing tools or legislation. Specifically relates to background systems in practices such as items relating to repeat prescriptions and logs of details of minor operations. | Completion of the checklist form by a practice manager or a senior clinician and used annually. | Senior staff member | 30 min | North Staffordshire |
Data collection
Analysis
Results
List Sizea | Under 18a | 65 + a | % Non-Whiteb | Deprivation Scorea | QOF Score (2013)a | % Femaleb | |
---|---|---|---|---|---|---|---|
Study practice Average/SDc | 8824 6289 | 20.4% 4.7% | 15.5% 7.4% | 17.7% 22.6% | 21.8 12.4 | 976.7 19.6 | 51.1% 5.0% |
English Average | 7041a | 20.8%a | 16.7%a | 13%b | 21.5a | 961a | 51%b |
East Midlands (EM) | Greater Manchester (GM) | South Coast (SC) | North Staffordshire (NM) | West Midlands (WM) | Total | |
---|---|---|---|---|---|---|
GP | 8 | 4a | 5 | 3 | 1b | 21 |
PM | 1 | 2 | – | 4 | 8 | 15 |
Practice Nurse | – | – | – | 1 | 2 | 3 |
HCA | – | – | – | 1 | – | 1 |
Total number of interviews | 9 | 6 | 5 | 9 | 10 | 39 |
Thematic analysis
Theme | Sub-theme 1 | Sub-theme 2 | Trigger tool | PC-Safe-Quest | PREOS-PC | Prescribing Safety Indicators | Medicines Reconciliation Tool | Concise Safe Systems Checklist for General Practice |
---|---|---|---|---|---|---|---|---|
1. Tool Design | 1.1 Utility | Inform patient safety Training aide Provide evidence of safe practice. | Did not uncover enough learning points for those using SEA. | Provided a useful practice-wide staff perspective. | Provided a novel patient perspective. | Produced useful patient specific information. | Produced useful information. | Produced useful information that prompted reflection on safety issues. |
1.2 Usability | Format Time to completion Integration with existing systems | Was time consuming in the selection of individual records. | Completed online and easy to follow. | Resource intensive due to the addressing and packing of multiple envelopes. | Required either existing IT knowledge or additional help and support. | Straightforward to use. | Easy to use and quick to complete | |
2. Organisational factors | 2.1 Staff training | Existing skill set | Was straightforward to use though a preference for an electronic version was expressed. | No training needed though an email address for each staff member was required. | Issues arose selecting random patients and using ‘mail merge’ to address letters and envelopes. | Staff training was required to run the software and upload the results. | No formal training required. An electronic version preferred. | No training required |
2.2 Available resource | Staffing levels, Time constraints | |||||||
2.3 Existing patient safety approaches | Comparative effectiveness | |||||||
3. Environmental context | 3.1 Clinical commissioning group | Existing initiatives | N/A | N/A | N/A | N/A | Repeated the work of a CCG initiative in one area. | N/A |
3.2 Central policy | Financial Incentives Fragmented policy |
Tool design
“It’s probably a part of creating this ethos of patient safety as much as anything … creating an environment where people are mindful of patient safety” GP Registrar – GM03
“…it makes you aware of what could go wrong; you know, what you need to be doing for the patient safety” - Practice Nurse NS05
“I think probably the learning point here was “What does it mean to patients themselves?” because it may mean something else to them, and something else to us.” - Practice Nurse WM02
“… as managers we tend to miss out on things because we are so busy with paperwork and this and that you forget your staff and it’s nice to get a feedback of the staff, of what they think and how they feel, and patient safety, communication and all that kinda stuff. So it does highlight a lot of interesting points.” – Practice Manager WM08
“So the managers obviously think we’re doing a great job, the non-managers not so convinced, looking at that [report]. Perhaps that is something we need to address. I suppose that’s one of the strengths of using this sort of approach, that you pick up things which you perhaps actually thought you were doing okay, but maybe we’re not doing as well as we could… the major utility of something like this is to repeat it and see if there is an improvement.” – GP EM08
“I think if I could convince a trainee to perhaps do it as a project, which I think could be really useful for them as well, then that might work really well and I think maybe I would consider doing that… in fact it’s now a requirement of completion of general practice training that they must have done either an audit or a quality improvement project and this would be ideal.” – GP EM08
“So if I present this report to a [CQC] inspector, he will probably be quite surprised, ‘Where the hell did you get this from?’ and you’d actually be able to quantify it and provide some kind of qualitative interpretation as to what this actually means. They’ll probably consider it as a good or an outstanding, to be honest with you.” – Practice Manager WM07
“The questions are well laid-out - yes/no answers and any comments that you want to make…very easy to follow.” - Practice Manager NS04
“For me the fact that there was a good uptake suggests that it was quite straightforward to access… and the fact that it didn't take long to fill in, I mean, if it was me I, I would just look, ‘Oh God, this is taking 25 minutes. I'm not going to do it.’ So I think for a lot of people it's doable.” - Practice Manager WM07
“I think it had more than 40 questions, I thought it was quite a long questionnaire so if I was a patient who had received it I may not complete it because, why would somebody complete such a long survey?” – Practice Manager WM09
“It might be better if something could be written into the clinical system like, when you go to Sainsbury’s, the random person gets a questionnaire, or the random person gets a voucher – if you get a random pop-up after, you know, X amount of patients. ‘Oh, right, I’ve gotta fill this one in, and then look back on that one.’ If it was, more like that and integrated...” – Practice Manager WM04
“there’s an expectation amongst GPs that these sorts of tools will be...because the electronic records systems now are so good…I think it just seems a little bit strange - in a way- going back to a pen and paper system where you’re having to manually read through lists of medications and then reconcile them with manual lists on the screen.” - GP Registrar GM03
Organisational Factors
“I certainly wouldn’t expect the staff…they wouldn’t have a clue where to start … No, it’s got to be simple and to the point, and relative to their work, their everyday work.” - Practice Manager WM04
“You can’t teach an old dog new tricks, so…it’s my knowledge of all that, you know, learning new software again and stuff. When you’re only using it once or twice, you can’t get to grips with it.” – Practice Nurse WM02
“I think if we did anything like it again, I’d ask ‘the company’ to facilitate PREOS you know? When you think what an hourly rate for a practice manager is, stuffing envelopes…because I haven’t got the manpower to pass it down.” – Practice Manager WM04
“it's a very big - it's got lots of different dimensions with GPs involved, you've got to send it out to patients, you've got internal … I think you've got to streamline it in a way… 'Oh, this sounds interesting. How much time and cost is it? I'm not interested now.” Practice Manager WM07
“I think you really need one sheet of paper that we can do everything on or try and streamline it down… People aren't going to do lots and lots of different tools…if you ask too much of someone they won't do it.” – GP EM02
“…it’s probably helpful and an important way to try and identify some of these incidents that are not...don’t lead to complaints, or they don't lead to harm. From a clinical point of view I think it’s probably just a bit too cumbersome and time-consuming to be useful and I don't think we’re going to continue using it in our practice…” – GP Registrar GM03
Existing approaches
“You don't have the time to go through 10/20 sets of notes before you find one learning point because...there will be a pile of complaints, there’ll be a pile of SEAs and these are things which are prioritised because they’re more likely to lead to learning points than these sorts of trawls of triggers and things like that.” - GP Registrar GM03
Environmental context
“...’cause we’ve already done things like this with the CCG, so I felt a bit like I was redoing the sort of thing that I’d already been doing.” GP GM02
“…but I think it needs to go in at the commissioning side and I think we need to tie this in to a better template of use…then it actually does get built in.” Practice Nurse EM05
“To be perfectly honest, it was the GP that picked up on it, from an income point of view - as another income stream. Because, you know, the way they’re pulling money off us in all directions, we’ve got to look at everything. We’re running a business, at the end of the day, so we’ve got to be doing things that are financially rewarding for the practice.” – Practice Manager WM04
Fragmented policy
“…[adoption is difficult] because you’re dealing with CCG, you’re dealing with NHS England, City Council, the nurses, you’re dealing with the patients, you’re dealing with your policies and procedures, you’re dealing with an audit. You got the day to day running of the surgery and then you’re going back to the action plans and the reports and all that kinda stuff. So there’s a whole sort of set of things that you need to do…” – Practice Manager WM08
“There’s so many things, ok? That you can’t keep going ‘yet another’…all the GPs are bombarded with different practices and I don’t know, ‘ideas’ from all this and departments - I’m not sure whether they would be welcoming this. I mean I’m certain it would be useful but how much time anybody is going to spend looking in to it? I’m not certain...” GP SC03