Examples of Research/Evaluation Work

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					                                                                                 Multidisciplinary




‘Cybernetics’ and Patient Safety Research:
            A Retort from NES


                         Paul Bowie
       Associate Adviser in Postgraduate GP Education

                          Diane Kelly
       Assistant Director of Postgraduate GP Education

                        West Region
                        Glasgow, UK

                paul.bowie@nes.scot.nhs.uk
                diane.kelly@nes.scot.nhs.uk




                                    Quality Education for a Healthier Scotland
                  Workshop Purpose                                                 Multidisciplinary




• To describe two case studies of patient safety research in
  primary care and promote debate around differing perspectives
  on research priorities, approaches and usefulness

•   Overview of NES Research (see handouts)

•   Two Case Studies

•   Open Discussion

•   Prof. Huw Davies




                                      Quality Education for a Healthier Scotland
  Some Random Definitions of ‘Cybernetics’?                                 Multidisciplinary




“The study of control and   “The interdisciplinary study
communication in the        of the structure of regulatory
animal and the machine”     systems… It includes the
(Norbert Weiner, 1948)      study of feedback, black
                            boxes and derived concepts
“The science of effective   such as communication and
organisation”               control in living organisms.
(Stafford Beer, 1974)       Machines and organisations
                            including self-organisations”
                            (Wikipedia)




                               Quality Education for a Healthier Scotland
    What Drives NES Patient Safety Research
                                                                                           Multidisciplinary
                  Priorities?

•   Pre-defined policy
•   Solutions-focused for the frontline
•   “Usefulness”
•   “Pragmatism”
•   “Critic or contributor” (Vincent, 2009)

•   “…setting priorities to focus on the most critical aspects of patient
    safety is essential to yield the maximum possible benefit especially
    when research funds are limited.” (WHO, 2009)




                                              Quality Education for a Healthier Scotland
                                                                              Multidisciplinary




               CASE STUDY ONE

Screening Electronic Patient Records to Identify Avoidable
     Harm: A Trigger Tool Process for Primary Care




                                 Quality Education for a Healthier Scotland
                      What is a Trigger Tool?
                                                                                                      Multidisciplinary


•   A trigger tool is a checklist of clinical ‘triggers’ which a reviewer looks to identify
    when screening patient records.

•   ‘‘Triggers’’ are easily identifiable ‘flags, occurrences or prompts’ in records that alert
    reviewers to potential adverse events - previously undetected.

    - E.g. an international normalised ratio (INR) of 5.0 would be a ‘‘trigger’’ for the reviewer to

    examine the record in greater detail for evidence of the patient suffering some type of related

    haemorrhage

•   Most efficient method of detecting and ‘measuring’ error and harm?

    - incident reporting, significant event analysis, complaints & litigation

•   Evaluation of UK Safer Patients Initiative (Benning et al., 2011) – Doubt and debate

•   ‘Pseudo-innovation’ (Walshe, 2009)


                                                         Quality Education for a Healthier Scotland
Background                                                                                 Multidisciplinary




•   Policy shift - SPSP migrating to primary care

•   Primary care:

     - limited knowledge of harm/experience of safety initiatives

     1. How can we ‘measure’ and learn more about harm?

     2. How can we engage primary care workforce in more explicit and
        meaningful efforts to improve safety?

•   Interest in IHI ‘trigger tool’ and transferability to primary care

•   NES support as a research priority (Patient Safety Group and R&D)




                                              Quality Education for a Healthier Scotland
                         Transferability Research
                                                                                                                   Multidisciplinary
•   Literature review
•   Identification of candidate triggers
•   Consensus and validation methods: agreement on 10 core Triggers
    e.g. group interviews, modified Delphi, content validity index exercise

    Triggers e.g. 10 consultations in past 12 months; any home visit; abnormal blood
    results; repeat medication added or cancelled
•   Pilot test in five GP practices (500 random EPRs 5x100)
    - positive predictive value, sensitivity, specificity, inter-rater reliability

•   9.5% harm rate detected, 57% judged preventable, ‘severe’ cases originate in
    hospital care (de Wet & Bowie, 2009)
•   Conclusion: It ‘works’, but:
    - Concerns about reliability as a ‘measurement tool’
    - Feasibility in routine clinical practice
    - Alternative application as a research method?




                                                                      Quality Education for a Healthier Scotland
              What Happened Next
                                                                                         Multidisciplinary
    Safety Improvement in Primary Care (SIPC)


•   80 general practices participating in collaborative working – complex
    social intervention
•   Trigger Tool is a core intervention – ‘to measure harm events’ in sub-
    populations under study
•   Realistic Evaluation (Pawson & Tilley, 1997): what works, why and in what
    contexts?
•   Feedback loops (Lyn Halley & Carl de Wet): observational work, focus
    groups, documentation reviews, and semi-structured interviews




                                            Quality Education for a Healthier Scotland
                   SIPC – Interim Findings                                                       Multidisciplinary




•   Further refinement of process (de Wet & Bowie, 2011)
•   Most positively received element of intervention bundle
•   Foreseen and unforeseen consequences:
     - ‘measurement difficult’ (feasibility & reliability issues)
     - ‘real-time’ improvements
     - uncovering previously unknown harm risks
     - identification of patient safety-related learning needs
     - positively received, no resistance as yet
     - widespread implementation potential

•   Key purpose evolving: a mechanism to Screen rather than Measure?



                                                    Quality Education for a Healthier Scotland
         Potential Policy & Cultural Impact?                                                 Multidisciplinary




•   GP Appraisal
•   GP Specialist Training
•   Out-of-hours service
•   SPSP plan for primary care
•   NES educational support
•   ‘Game Changer’:
     - Awareness and acknowledgement of the scale and impact of the problem
     - Proactive engagement in learning about harm avoidance
     - “…enable the primary care team to refocus and prioritise learning and
         improvement efforts on identifying harm and developing preventative
         measures to mitigate future risks to patients’




                                                Quality Education for a Healthier Scotland
          Challenges and Further Research                                               Multidisciplinary




•   Proxy measure of harm: desirable? useful? reliability? feasible? etc.
•   How best to train the clinical workforce?
•   How best to implement further?
•   How do clinicians provide evidence of engagement?
•   Can we peer assess this activity?
•   Validate a core list of ‘never events’?

•   Even more ‘Cybernetics’?

•   Clashing or complimentary research priorities and approaches: NES
    and University sector?




                                           Quality Education for a Healthier Scotland
                                                                       Multidisciplinary


   Collective Learning,
Change and Improvement
  in Healthcare Teams



      St Andrews June 2011


            Diane Kelly




                          Quality Education for a Healthier Scotland
                                                          Multidisciplinary




The Story so far....




             Quality Education for a Healthier Scotland
Introduction                                                                      Multidisciplinary




• An idea
   – learning organisation concept
   – Theory into practice?

• Collaboration St Andrews +NES
   – Learning practice inventory
   – All members of GP team




                                     Quality Education for a Healthier Scotland
•   Rushmer R, Kelly D. R., Lough M, Wilkinson J.E, Davies H.T.O. Introducing the
    Learning Practice – I. The Characteristics of Learning Organisations in Primary
    Care. Journal of Evaluation in Clinical Practice (2005) 10:3 375-386
                                                                                                    Multidisciplinary

•   Rushmer R, Kelly D. R., Lough M, Wilkinson J.E, Davies H.T.O. Introducing the
    Learning Practice – II. Becoming a Learning Practice Journal of Evaluation in
    Clinical Practice (2005) 10:3 387-398

•   Rushmer R, Kelly D. R., Lough M, Wilkinson J.E, Davies H.T.O. Introducing the
    Learning Practice – III. Leadership, Empowerment, Protected Time and Reflective
    Practice as Core Contextual Conditions. Journal of Evaluation in Clinical Practice
    (2005) 10:3 399-405

•   Rushmer R K, Kelly D, Lough M, Wilkinson J, Greig G & Davies H T O. The
    Learning Practice Inventory: diagnosing and developing Learning Practices in the UK
    Journal of Evaluation in Clinical Practice (2007) Vol 13 No 2: 206-211

•   Kelly D, Lough M, Rushmer R, Wilkinson J, Greig G & Davies H T O. Delivering
    Feedback on Learning Organisation Characteristics – Using a Learning Practice
    Inventory Journal of Evaluation in Clinical Practice (2007) 13(5):734-40

•   Kelly D.R., Lough J.M., Rushmer R., Greig G., Crossley J., Davies H.T.O.
    Diagnosing a learning practice: the validity and reliability of a Learning Practice
    Inventory (LPI) Quality and Safety in Health Care (2011);20:209-215


                                                       Quality Education for a Healthier Scotland
                   Questions for NES                                          Multidisciplinary




•   Can/How to support teams
     – Many assumptions




                                 Quality Education for a Healthier Scotland
               Chapter 1 a - Primary research                                              Multidisciplinary




•   Into collective learning, change and improvement in primary care teams (GP,
    pharmacy and dental practice teams)

•   Bunnis S., Kelly D.R. The unknown becomes the known:collective learning and
    change in primary care teams. Medical Education (2008) 42 (12) 1185-1194
•   Bunnis S., Kelly D.R. Research paradigms in medical education research
    Medical Education (2010) 44(4):358-66




                                              Quality Education for a Healthier Scotland
                       Key findings
                                                                                 Multidisciplinary




• Informal collective learning is a responsive coping mechanism
  generated by patient need
• How
   Experiential
   Evolving
   Implicit
• Relational
• Natural tendency towards QI




                                    Quality Education for a Healthier Scotland
Chapter 1 b –
Designing a facilitated intervention                                              Multidisciplinary




•   To promote collective learning and improvement
•   In GP teams – whole team approach
•   Use of LPI was starting point
•   6 Facilitated sessions over 1 year
•   Action research Evaluation




                                     Quality Education for a Healthier Scotland
                                                                                               Multidisciplinary




•   Bunnis S., Gray F., Kelly D. Collective learning, change and improvement in
    health care: trialling a facilitated learning initiative with general practice teams
    Journal Evaluation in Clinical Practice (2011)
•   Bunnis S, Gray F. Kelly D. Collective learning, change and improvement in
    healthcare: piloting a facilitated learning initiative with general practice teams. In
    PREPARATION




                                                  Quality Education for a Healthier Scotland
                           Findings
                                                                                      Multidisciplinary




•   Intervention introduces tools, processes and shows how to use them to
    enhance shared learning and create more effective collective change
•   Teams designed and introduced ways to enhance their own
    effectiveness
•   Whole team engagement maximised effectiveness
•   Engagement enhanced by practice generation of data via the Learning
    practice inventory.




                                         Quality Education for a Healthier Scotland
Chapter 1 c- Learning practice programme (LPI +
facilitation)
                                                                                     Multidisciplinary




  •     LPP used with
      –    Scottish CHP (Community health partnership)
      –    Dental team in England
      –    Hospital Nurses in USA
      –    Plans for use with practices across health authority area
           in North of England




                                        Quality Education for a Healthier Scotland
Chapter 2 a - Primary research
                                                                              Multidisciplinary




• into collective learning, change and improvement in
  secondary care teams




                                 Quality Education for a Healthier Scotland
                       Findings
                                                                                Multidisciplinary




• Fluidity of membership
• ‘Team’ a contested notion
• Potential for QI in secondary care inhibited:
   – Professional boundaries
   – Assumptions re contribution to team effectiveness
   – Untapped expertise and awareness.




                                   Quality Education for a Healthier Scotland
Chapter 2 b – Secondary Care
                                                                                     Multidisciplinary




  •    Chose NOT to assume possible to repeat LPP in secondary
       care

  •    Chose to build on Paul’s research and focus on medication
       handling

  •    Aim- to enhance patient safety through collective learning

  •     Chose to undertake Participatory research with a care of the
        elderly ward
      –     Phase 1- observational study
      –     Phase 2 - interviews




                                        Quality Education for a Healthier Scotland
              2 c- Recommendations
                                                                                  Multidisciplinary




• Create opportunities for ward staff AND management staff to
  engage in reflective dialogue

• Through use of ‘burning questions’
   – to reach deeper sense of their identity as a team
   – Give managers and staff a way to begin to identify, prioritise
      and respond to patient safety issues




                                     Quality Education for a Healthier Scotland
Epilogue
                                                                                   Multidisciplinary


•    Tools have an important role....but

    - they are not enough

    - More is needed and the time is NOW

    - Discuss




                                      Quality Education for a Healthier Scotland

				
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