Dorien Zwart

Stakeholder perspectives on handovers between hospital staff and general practitioners: an evaluation through the microsystems lens

Background Much of the research on improving patient handovers has focused on enhancing communication within the hospital system, but there have been relatively few efforts aimed at addressing the challenges at the interface between the hospital and the primary care setting. Methods A qualitative thematic analysis using a clinical microsystems lens applied to 28 semi-structured key stakeholder interviews in the Netherlands. Data were organised into seven ‘virtual’ clinical microsystem datasets composed of patients, hospital-based physicians, hospital-based nurses and community-based general practitioners. Results Five themes that contributed to effective or ineffective handovers emerged from our analysis: (1) lack of adequate information; (2) healthcare professionals’ availability and opportunity for personal contact; (3) feedback, teaching and protocols related to handovers; (4) information technology facilitated communication solutions; and (5) the role and responsibility of patients. Our analysis suggests that each healthcare professional attempted to provide the best care possible, but did this largely in isolation, and without the benefit of the knowledge and expertise of the other members of the microsystem. Conclusions The microsystem approach offers an innovative organisational construct and approach to assess the gaps in ‘hospital to community’ patient handovers, by viewing the hospital to the community interface as a clinical microsystem continuum. Our application of the microsystem approach confirms and extends earlier findings about the impact of barriers on the continuity and safety of patient transitions and their impact on the quality of patient care.

Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study

Background There is an inherent tension between allowing trainees in general practice (GP) to feel comfortable to report and learn from errors in a blame-free environment while still assuring high-quality and safe patient care. Unfortunately, little is known about the types and potential severity of incidents that may confront GP trainees. Furthermore, incident reporting by resident trainees is hindered by their concern that such transparency might result in more negative performance evaluations. Objective To explore the number and nature of incidents that were reported by GP trainees and to determine whether there were differences between the reporters and non-reporters based on their performance evaluations. Design Prospective cohort study. Methods Confidential and voluntary incident reporting was implemented in GP vocational training of the University Medical Center Utrecht, the Netherlands. Seventy-nine GP trainees were asked to report incidents over 6 months. Mixed methods were used to analyse the data. Results 24 trainees reported a total of 44 incidents. 23 incidents concerned the work process and 17 concerned problems with diagnosis or therapy. Three-quarters (34/44) of incidents were determined to be not specifically related to the inexperience of the GP trainees. While actual patient harm was determined to be minimal or absent in two-thirds of incidents (29/44), the potential for moderate, major, or catastrophic harm was 89% (39/44). Trainees performing best on their performance assessment in the domain of clinical expertise reported incidents more often (43% vs 18%, p<0.03) than those who performed at a lower level. Conclusions GP trainees rated highly by their faculty voluntarily reported incidents in the delivery of clinical care when given a safe, blame-free, and confidential reporting process. Most incidents were not found to be directly related to the inexperience of the trainee, but were caused by failing organisational processes in the healthcare delivery system. Moreover, the trainees who tended to report these incidents were those whose performance was highly evaluated in the domain of clinical expertise.

Improving Patient Safety Culture in Primary Care: A Systematic Review.

Background Patient safety culture, described as shared values, attitudes and behavior of staff in a health-care organization, gained attention as a subject of study as it is believed to be related to the impact of patient safety improvements. However, in primary care, it is yet unknown, which effect interventions have on the safety culture. Objectives To review literature on the use of interventions that effect patient safety culture in primary care. Methods Searches were performed in PubMed, EMBASE, CINAHL, and PsychINFO on March 4, 2013. Terms defining safety culture were combined with terms identifying intervention and terms indicating primary care. Inclusion followed if the intervention effected patient safety culture, and effect measures were reported. Results The search yielded 214 articles from which two were eligible for inclusion. Both studies were heterogeneous in their interventions and outcome; we present a qualitative summary. One study described the implementation of an electronic medical record system in general practices as part of patient safety improvements. The other study facilitated 2 workshops for general practices, one on risk management and another on significant event audit. Results showed signs of improvement, but the level of evidence was low because of the design and methodological problems. Conclusions These studies in general practice provide a first understanding of improvement strategies and their effect in primary care. As the level of evidence was low, no clear preference can be determined. Further research is needed to help practices make an informed choice for an intervention.

Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial.

BACKGROUND A constructive safety culture is essential for the successful implementation of patient safety improvements. AIM To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture. DESIGN AND SETTING A three-arm cluster randomised trial was conducted in a mixed method study, studying the effect of administering a patient safety culture questionnaire (intervention I), the questionnaire complemented with a practice-based workshop (intervention II) and no intervention (control) in 30 general practices in the Netherlands. METHOD The primary outcome, the number of reported incidents, was measured with a questionnaire at baseline and a year after. Analysis was performed using a negative binomial model. Secondary outcomes were quality and safety indicators and safety culture. Mixed effects linear regression was used to analyse the culture questionnaires. RESULTS The number of incidents increased in both intervention groups, to 82 and 224 in intervention I and II respectively. Adjusted for baseline number of incidents, practice size and accreditation status, the study showed that practices that additionally participated in the workshop reported 42 (95% confidence interval [CI] = 9.81 to 177.50) times more incidents compared to the control group. Practices that only completed the questionnaire reported 5 (95% CI = 1.17 to 25.49) times more incidents. There were no statistically significant differences in staff perception of patient safety culture at follow-up between the three study groups. CONCLUSION Educating staff and facilitating discussion about patient safety culture in their own practice leads to increased reporting of incidents. It is beneficial to invest in a team-wise effort to improve patient safety.

The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review

Background: A non‐dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non‐dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non‐dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success. Objectives: This study investigates how the degree of integration of a non‐dispensing pharmacist impacts medication related health outcomes in primary care. Methods: In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non‐dispensing pharmacists physically co‐located in primary care practice. We assessed the degree of integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease‐specific and patient‐centered clinical pharmacy services. Results: Eighty‐nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non‐dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient‐centered clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%. Conclusions: Full integration adds value to patient‐centered clinical pharmacy services, but not to disease‐specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non‐dispensing pharmacists should be promoted. HighlightsWhat is already known about this subjectCo‐location of a non‐dispensing pharmacist in primary care practice probably enhances integrated patient care.The degree of integration of non‐dispensing pharmacists into multidisciplinary health care teams varies between settings.What this study addsThis study shows the relative value of integration of clinical pharmacy services in primary care.Full integration may not improve the outcomes of disease‐specific clinical pharmacy services in primary care.Full integration may improve outcomes of patient‐centered clinical pharmacy services however requires additional research.

Introducing incident reporting in primary care: a translation from safety science into medical practice

In this article, we examine how incident reporting procedures become part of the way primary health care professionals deal with safety problems. Between 2006 and 2010, we studied documents, observed incident reporting committee meetings and conducted formal and informal interviews in five Dutch primary health care centres and one general practitioners out-of-hours service to describe the introduction of incident reporting procedures. In this article, we distinguish two approaches towards patient safety, the logic of risk management and the logic of medical practice. In the logic of risk management, safety is seen in terms of the prevention of recurrence of specific well-defined incidents. In the logic of medical practice, safety involves recognising uncertainties and strengthening implicit initiatives that underpin patient safety. Care providers alternated between the two logics and aligned them. Most reported incidents in primary care concern non-clinical incidents with no or limited impact on the patient. We observed that both physicians and medical assistants changed the significance of a particular incident by frequent reporting. By reporting apparently insignificant risks, those providing care were able to deal with these risks more explicitly and actively. The alignment of the two logics was different for clinical, more harmful incidents. Care providers rarely reported serious clinical incidents and we could find little evidence that they actively engaged with recommendations following the investigation of serious incidents. Both logics mutually shaped and informed each other. Incident reporting procedures made implicit initiatives explicit and the two logics ensure that safety involved multiple and different actions.

Improving patient safety culture in general practice: an interview study

BACKGROUND When improving patient safety a positive safety culture is key. As little is known about improving patient safety culture in primary care, this study examined whether administering a culture questionnaire with or without a complementary workshop could be used as an intervention for improving safety culture. AIM To gain insight into how two interventions affected patient safety culture in everyday practice. DESIGN AND SETTING After conducting a randomised control trial of two interventions, this was a qualitative study conducted in 30 general practices to aid interpretation of the previous quantitative findings. METHOD Interviews were conducted at practice locations (n = 27) with 24 GPs and 24 practice nurses. The theory of communities of practice--in particular, its concepts of a domain, a community, and a practice--was used to interpret the findings by examining which elements were or were not present in the participating practices. RESULTS Communal awareness of the problem was only raised after getting together and discussing patient safety. The combination of a questionnaire and workshop enhanced the interaction of team members and nourished team feelings. This shared experience also helped them to understand and develop tools and language for daily practice. CONCLUSION In order for patient safety culture to improve, the safety culture questionnaire was more successful when accompanied by a practice workshop. Initial discussion and negotiation of shared goals during the workshop fuelled feelings of coherence and belonging to a community wishing to learn about enhancing patient safety. Team meetings and day-to-day interactions enhanced further liaison and sharing, making patient safety a common and conscious goal.

Controversy and consensus on a clinical pharmacist in primary care in the Netherlands

Background Controversy about the introduction of a non-dispensing pharmacist in primary care practice hampers implementation. Objective The aim of this study is to systematically map the debate on this new role for pharmacists amongst all stakeholders to uncover and understand the controversy and consensus. Setting: Primary health care in the Netherlands. Method Q methodology. 163 participants rank-ordered statements on issues concerning the integration of a non-dispensing pharmacist in primary care practice. Main outcome measure: Stakeholder perspectives on the role of the non-dispensing pharmacist and pharmaceutical care in primary care. Results This study identified the consensus on various features of the non-dispensing pharmacist role as well as the financial, organisational and collaborative aspects of integrating a non-dispensing pharmacist in primary care practice. Q factor analysis revealed four perspectives: “the independent community pharmacist”, “the independent clinical pharmacist”, “the dependent clinical pharmacist” and “the medication therapy management specialist”. These four perspectives show controversies to do with the level of professional independency of the non-dispensing pharmacist and the level of innovation of task performance. Conclusion Despite the fact that introducing new professional roles in healthcare can lead to controversy, the results of this Q study show the potential of a non-dispensing pharmacist as a pharmaceutical care provider and the willingness for interprofessional collaboration. The results from the POINT intervention study in the Netherlands will be an important next step in resolving current controversies.

Pilot study on identification of incidents in healthcare transitions and concordance between medical records and patient interview data

Objective To investigate whether transitional incidents can be identified from the medical records of the general practitioners and the hospital and to assess the concordance of transitional incidents between medical records and patient interviews. Design A pilot study. Setting The study was conducted in 2 regions in the Netherlands: a rural and an urban region. Participants A purposeful sample of patients who experienced a transitional incident or are at high risk of experiencing transitional incidents. Main outcome measures Transitional incidents were identified from both the interviews with patients and medical records and concordance was assessed. We also classified the transitional incidents according to type, severity, estimated cause and preventability. Results We identified 28 transitional incidents within 78 transitions of which 3 could not be found in the medical records and another 5 could have been missed without the patient as information source. To summarise, 8 (29%) incidents could have been missed using solely medical records, and 7 (25%) using the patients’ information exclusively. Concordance in transitional incidents between patient interviews and medical records was 64% (18/28). The majority of the transitional incidents were unsafe situations; however, 43% (12/28) of the incidents reached the patient and 18% (5/28) caused temporary patient harm. Over half of the incidents were potentially preventable. Conclusions This pilot study suggests that the majority of transitional incidents can be identified from medical records of the general practitioner and hospital. With this information, we aim to develop a measurement tool for transitional incidents in the medical record of general practitioner and hospital.

Adequate validatie van triagesystemen ontbreekt

SamenvattingOp de meeste huisartsenposten wordt de telefonische triage digitaal ondersteund door de Nederlandse Triage Standaard. Deze standaard werd in 2011 ontwikkeld op basis van de NHG-telefoonwijzer en een systeem voor fysieke triage op de spoedeisende hulp, het Manchester Triage System. De triagestandaard wordt breed toegepast, maar de validiteit is nog niet goed onderzocht. Dat laatste geldt overigens voor de meeste triagesystemen.