John McKay

A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment

Objectives: To explore the influences and perceived benefits behind general practitioners’ willingness to participate in significant event analysis (SEA) and educational peer assessment. Design: Qualitative analysis of focus group transcripts. Setting: Greater Glasgow Primary Care Trust. Participants: Two focus group sessions involving 21 principals in general practice (GPs). Main outcome measures: GPs’ perceptions of the reasons for and benefits of participating in SEA and associated educational peer assessment. Results: Pressure from accreditation bodies and regulatory authorities makes SEA compulsory for most participants who believe more in-depth event analyses are undertaken as a result. Some believed SEA was not an onerous activity while others argued that this depended on the complexity of the event. SEA that is linked to a complaint investigation may provide credible evidence to patients that their complaint is taken seriously. Writing up an event analysis is viewed as an educational process and may act as a form of personal catharsis for some. Event analyses are submitted for peer assessment for educational reward but are highly selective because of concerns about confidentiality, litigation, or professional embarrassment. Most participants disregard the opportunities to learn from “positive” significant events in favour of problem ones. Peer assessment is valued because there is a perception that it enhances knowledge of the SEA technique and the validity of event analyses, which participants find reassuring. Conclusions: This small study reports mainly positive feedback from a select group of GPs on the merits of SEA and peer assessment.

Awareness and analysis of a significant event by general practitioners: a cross sectional survey

Objectives: To determine the extent to which general practitioners (GPs) were aware of a recent significant event and whether a structured analysis of this event was undertaken to minimise the perceived risk of recurrence. Design: Cross sectional survey using a postal questionnaire. Setting: Greater Glasgow primary care trust. Participants: 466 principals in general practice from 188 surgeries. Main outcome measures: GPs’ self-reported personal and practice characteristics, awareness of a recent significant event, participation in the structured analysis of the identified significant event, perceived chance of recurrence, forums for discussing and analysing significant events, and levels of primary care team involvement. Results: Four hundred and sixty six GPs (76%) responded to the survey. GPs from single handed practices were less likely to respond than those in multi-partner training and non-training practices. 401 (86%) reported being aware of a recent significant event; lack of awareness was clearly associated with GPs from non-training practices. 219 (55%) had performed all the necessary stages of a structured analysis (as determined by the authors) of the significant event. GPs from training practices were more likely to report participation in the structured analysis of the recent event, to perceive the chance of this event recurring as “nil” or “very low”, and to report significant event discussions taking place. Conclusions: Most GPs were aware of a recent significant event and participated in the structured analysis of this event. The wider primary care team participated in the analysis process where GPs considered this involvement relevant. There is variation in the depth of and approach to significant event analysis within general practice, which may have implications for the application of the technique as part of the NHS quality agenda.

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice

Objective To explore experiences and perceptions of frontline administrators involved in the systems-based management of laboratory test ordering and results handling in general medical practice. Design Qualitative using focus group interviews. Setting West of Scotland general medical practices in three National Health Service (NHS) territorial board areas. Participants Convenience samples of administrators (receptionists, healthcare assistants and phlebotomists). Methods Transcript data were subjected to content analysis. Results A total of 40 administrative staff were recruited. Four key themes emerged: (1) system variations and weaknesses (eg, lack of a tracking process is a known risk that needs to be addressed). (2) Doctor to administrator communication (eg, unclear information can lead to emotional impacts and additional workload). (3) Informing patients of test results (eg, levels of anxiety and uncertainty are experienced by administrators influenced by experience and test result outcome) and (4) patient follow-up and confidentiality (eg, maintaining confidentiality in a busy reception area can be challenging). The key findings were explained in terms of sociotechnical systems theory. Conclusions The study further confirms the safety-related problems associated with results handling systems and adds to our knowledge of the communication and psychosocial issues that can affect the health and well-being of staff and patients alike. However, opportunities exist for practices to identify barriers to safe care, and plan and implement system improvements to accommodate or mitigate the potential for human error in this complex area.

Acceptability and educational impact of a peer feedback model for significant event analysis

Context  A model of independent, external review of significant event analysis by trained peers was introduced by NHS Scotland in 1998 to support the learning needs of general practitioners (GPs). Engagement with this feedback model has increased over time, but participants’ views and experiences are largely unknown and there is limited evidence of its educational impact. This is important if external feedback is to play a potential role in appraisal and future revalidation.

Audit and summative assessment: system development and testing

Registrars in general practice have to submit an audit project as one of four parts of summative assessment. A criterion‐referenced marking schedule has been developed in the West of Scotland, consisting of five independent criteria all of which have to be judged above minimum competence to pass. A system was developed to test the instrument using a marking exercise which calculated the sensitivity and specificity of the assessment process, for different combinations of assessors. One hundred and two registrar audit projects were then assessed by three independent assessors. Ninety‐two (90%) passed and 10 projects (10%) were referred back to the registrar as being below minimum competence. After resubmission six projects (6%) passed, two projects (2%) were still below minimum competence, and two (2%) were not resubmitted. A referral process for assessing the audit projects of general practice registrars has been developed to maximize the opportunity of finding a project below minimum competence.

Combining QOF data with the care bundle approach may provide a more meaningful measure of quality in general practice

BackgroundA significant minority of patients do not receive all the evidence-based care recommended for their conditions. Health care quality may be improved by reducing this observed variation. Composite measures offer a different patient-centred perspective on quality and are utilized in acute hospitals via the ‘care bundle’ concept as indicators of the reliability of specific (evidence-based) care delivery tasks and improved outcomes. A care bundle consists of a number of time-specific interventions that should be delivered to every patient every time. We aimed to apply the care bundle concept to selected QOF data to measure the quality of evidence-based care provision.MethodsCare bundles and components were selected from QOF indicators according to defined criteria. Five clinical conditions were suitable for care bundles: Secondary Prevention of Coronary Heart Disease (CHD), Stroke & Transient Ischaemic Attack (TIA), Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus (DM). Each bundle has 3-8 components. A retrospective audit was undertaken in a convenience sample of nine general medical practices in the West of Scotland. Collected data included delivery (or not) of individual bundle components to all patients included on specific disease registers. Practice level and overall compliance with bundles and components were calculated in SPSS and expressed as a percentage.ResultsNine practices (64.3%) with a combined patient population of 56,948 were able to provide data in the format requested. Overall compliance with developed QOF-based care bundles (composite measures) was as follows: CHD 64.0%, range 35.0-71.9%; Stroke/TIA 74.1%, range 51.6-82.8%; CKD 69.0%, range 64.0-81.4%; and COPD 82.0%, range 47.9-95.8%; and DM 58.4%, range 50.3-65.2%.ConclusionsIn this small study compliance with individual QOF-based care bundle components was high, but overall (‘all or nothing’) compliance was substantially lower. Care bundles may provide a more informed measure of care quality than existing methods. However, the acceptability, feasibility and potential impact on clinical outcomes are unknown.

Attitudes to the identification and reporting of significant events in general practice

The new National Patient Safety Agency (NPSA) aims to facilitate the mandatory reporting of relevant significant events. A questionnaire survey of 617 general practitioners was undertaken and 466 responses were received (76 per cent). A minority (18 per cent) agreed the reporting of adverse incidents should be mandatory, while a majority (73 per cent) agreed that they would be selective in their reporting in a mandatory system. Most (75 per cent) favoured a local anonymised system of reporting. A difficulty in determining when an event is “significant” was acknowledged by 41 per cent of respondents and 30 per cent agreed significant events were often not acted on. Less experienced respondents were more likely to have difficulty in determining when an event is significant (p = 0.01). The success of the NPSA system may be obstructed by the mandatory requirement to participate and in the difficulty for some in determining when an event is “significant”.

Maximising harm reduction in early specialty training for general practice: validation of a safety checklist.

BackgroundMaking health care safer is a key policy priority worldwide. In specialty training, medical educators may unintentionally impact on patient safety e.g. through failures of supervision; providing limited feedback on performance; and letting poorly developed behaviours continue unchecked. Doctors-in-training are also known to be susceptible to medical error. Ensuring that all essential educational issues are addressed during training is problematic given the scale of the tasks to be undertaken. Human error and the reliability of local systems may increase the risk of safety-critical topics being inadequately covered. However adherence to a checklist reminder may improve the reliability of task delivery and maximise harm reduction. We aimed to prioritise the most safety-critical issues to be addressed in the first 12-weeks of specialty training in the general practice environment and validate a related checklist reminder.MethodsWe used mixed methods with different groups of GP educators (n = 127) and specialty trainees (n = 9) in two Scottish regions to prioritise, develop and validate checklist content. Generation and refinement of checklist themes and items were undertaken on an iterative basis using a range of methods including small group work in dedicated workshops; a modified-Delphi process; and telephone interviews. The relevance of potential checklist items was rated using a 4-point scale content validity index to inform final inclusion.Results14 themes (e.g. prescribing safely; dealing with medical emergency; implications of poor record keeping; and effective & safe communication) and 47 related items (e.g. how to safety-net face-to-face or over the telephone; knowledge of practice systems for results handling; recognition of harm in children) were judged to be essential safety-critical educational issues to be covered. The mean content validity index ratio was 0.98.ConclusionA checklist was developed and validated for educational supervisors to assist in the reliable delivery of safety-critical educational issues in the opening 12-week period of training, and aligned with national curriculum competencies. The tool can also be adapted for use as a self-assessment instrument by trainees to guide patient safety-related learning needs. Dissemination and implementation of the checklist and self-rating scale are proceeding on a national, voluntary basis with plans to evaluate its feasibility and educational impact.

Good practice statements on safe laboratory testing: A mixed methods study by the LINNEAUS collaboration on patient safety in primary care

ABSTRACT Background: The systems-based management of laboratory test ordering and results handling is a known source of error in primary care settings worldwide. The consequences are wide-ranging for patients (e.g. avoidable harm or poor care experience), general practitioners (e.g. delayed clinical decision making and potential medico-legal implications) and the primary care organization (e.g. increased allocation of resources to problem-solve and dealing with complaints). Guidance is required to assist care teams to minimize associated risks and improve patient safety. Objective: To identify, develop and build expert consensus on ‘good practice’ guidance statements to inform the implementation of safe systems for ordering laboratory tests and managing results in European primary care settings. Methods: Mixed methods studies were undertaken in the UK and Ireland, and the findings were triangulated to develop ‘good practice’ statements. Expert consensus was then sought on the findings at the wider European level via a Delphi group meeting during 2013. Results: We based consensus on 10 safety domains and developed 77 related ‘good practice’ statements (≥ 80% agreement levels) judged to be essential to creating safety and minimizing risks in laboratory test ordering and subsequent results handling systems in international primary care. Conclusion: Guidance was developed for improving patient safety in this important area of primary care practice. We need to consider how this guidance can be made accessible to frontline care teams, utilized by clinical educators and improvement advisers, implemented by decision makers and evaluated to determine acceptability, feasibility and impacts on patient safety.

Quality improvement and person-centredness: a participatory mixed methods study to develop the ‘always event’ concept for primary care

Objectives (1) To ascertain from patients what really matters to them on a personal level of such high importance that it should ‘always happen’ when they interact with healthcare professionals and staff groups. (2) To critically review existing criteria for selecting ‘always events’ (AEs) and generate a candidate list of AE examples based on the patient feedback data. Design Mixed methods study informed by participatory design principles. Subjects and setting Convenience samples of patients with a long-term clinical condition in Scottish general practices. Results 195 patients from 13 general practices were interviewed (n=65) or completed questionnaires (n=130). 4 themes of high importance to patients were identified from which examples of potential ‘AEs’ (n=8) were generated: (1) emotional support, respect and kindness (eg, “I want all practice team members to show genuine concern for me at all times”); (2) clinical care management (eg, “I want the correct treatment for my problem”); (3) communication and information (eg, “I want the clinician who sees me to know my medical history”) and (4) access to, and continuity of, healthcare (eg, “I want to arrange appointments around my family and work commitments”). Each ‘AE’ was linked to a system process or professional behaviour that could be measured to facilitate improvements in the quality of patient care. Conclusions This study is the first known attempt to develop the AE concept as a person-centred approach to quality improvement in primary care. Practice managers were able to collect data from patients on what they ‘always want’ in terms of expectations related to care quality from which a list of AE examples was generated that could potentially be used as patient-driven quality improvement (QI) measures. There is strong implementation potential in the Scottish health service. However, further evaluation of the utility of the method is also necessary.