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Quality Education for a Healthier Scotland

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

Multidisciplinary

Workshop Purpose


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

Multidisciplinary

Some Random Definitions of ‘Cybernetics’?


The study of control and
communication in the
animal and the machine

(Norbert Weiner, 1948)



The science of effective
organisation


(Stafford Beer, 1974)




The interdisciplinary study
of the structure of regulatory
systems… It includes the
study of feedback, black
boxes and derived concepts
such as communication and
control in living organisms.
Machines and organisations
including self
-
organisations

(Wikipedia)

Quality Education for a Healthier Scotland

Multidisciplinary

What Drives NES Patient Safety Research
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)

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CASE STUDY ONE

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

Quality Education for a Healthier Scotland

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What is a Trigger Tool?


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

Multidisciplinary

Background


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)

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Transferability Research


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?


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What Happened Next

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

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SIPC


Interim Findings


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
?

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Potential Policy & Cultural Impact?


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

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Challenges and Further Research


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

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Introduction


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

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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



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

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Questions for NES


Can/How to support teams


Many assumptions


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Chapter 1 a
-

Primary research


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




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Key findings


Informal collective learning is a responsive coping mechanism
generated by patient need


How

Experiential

Evolving

Implicit


Relational


Natural tendency towards QI

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Chapter 1 b



Designing a facilitated intervention



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

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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

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Findings


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

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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

Chapter 1 c
-

Learning practice programme
(LPI +
facilitation)

Quality Education for a Healthier Scotland

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Chapter 2 a
-

Primary research


into collective learning, change and improvement in
secondary care teams


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Findings


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

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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

Chapter 2 b


Secondary Care

Quality Education for a Healthier Scotland

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2 c
-

Recommendations


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

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Tools have an important role....but


-

they are not enough


-

More is needed and the time is NOW


-

Discuss



Epilogue