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Introducing…Safer Care Transitions

1 Jun

by Justin Waring (University of Nottingham) and Harm van Marwijk (University of Manchester)

Safer Care Transitions will be one of the research themes in the NIHR PSTRC Greater Manchester which will run from 1 August 2017 until 31 July 2022.

Safer Care Transitions blog icon

Patient journeys are full of care transitions. By transitions, we mean that the responsibility for patient care is transferred or handed over from one team, department or organisation to another.

If we think about someone who experiences an accident at work, they might be seen at first by a paramedic before being transported by ambulance to their local hospital’s emergency department. There they might receive urgent care before being admitted into the hospital for follow-up care. When recovered, the patient will then be discharged home or to community setting where they could receive rehabilitation, nursing care, social care and follow-up treatments by their GP, under the primary medical responsibility of the GP.  The GPs’ medical records can follow most of such transitions and provide an overarching view, but others (patients) cannot access such data now. GPs would be seen to have an overarching responsibility to facilitate seamless management between settings but little work has been done on this.

Transitions are common to virtually all patient journeys, because healthcare services are provided by specialists and professionals who work in different clinics, surgeries and hospitals. Although there is now better understanding of what makes for safer care within each of these care settings, there is less of a clear picture about what makes for safer care transitions between these care settings, and how to develop problem-based records that capture transitions and are accessible to more than GP practices.

There is mounting evidence from around the world that care transitions are a high-risk stage in the patient journey. Research from the US, for example, suggests that as many as two out of every ten hospital discharges will experience some form of safety incident. These safety incidents take the form of incorrect medicines, missing equipment, or inappropriate care planning.  Research within the NHS suggests that it is often difficult to coordinate the involvement of different professionals and specialists because of common communication breakdowns and the difficulties of finding time to work together to identify solutions to common problems or work from a shared and validated record. A recent Healthwatch report highlighted the enormous suffering and anxiety experienced by patients as they approach hospital discharge, often because of the uncertainties about when they will go home, who will look after them, and how they will cope. Current resources constraints within the health and social care sectors have seemed to make these problems worse, with limits on the availability of social care to support safe hospital discharge.

The Patient Safety Translational Research Centre Greater Manchester is leading a programme of research that will develop new learning about what makes for safer care transitions. It will look to ways of working and technological breakthroughs in other sectors to learn lessons for the NHS. For example, many courier and supply chain services use advanced technologies to track their deliveries. There is also greater scope to empower patients to coordinate their own care through developing smart technologies that enable them to manage and share their own records with different healthcare professionals. There is also much healthcare services could learn from other industries about ensuring continuous accountability for care, so that someone is always there to speak up for and protect the safety of patients, and ways to develop such support for the most vulnerable trajectories such as around cancer and frail older people.

The projects developed in this theme will address the safety of care transitions in primary and secondary care, in mental health services, in chronic conditions, cancer care, and end of life care, to ensure learning and innovations are shared across the health and social care sectors.

Further information:

Healthwatch (2016) Safely Home, London: Healthwatch. http://www.healthwatch.co.uk/safely-home

Waring, J., Bishop, S., & Marshall, F. (2016). A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service. BMC health services research, 16(1), 297.

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1568-2

Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of internal medicine, 138(3), 161-167.

What makes a ‘good’ GP?

5 Apr

by Golda Gibson, member of the Greater Manchester PSTRC Research User Group

GoldaGibson_Dr and Pt photo_Apr17_CROPPED

My guess is that for every person there will be a slightly different answer. We all want them to be knowledgeable, to know when something might be going wrong with us and to act decisively thus protecting us from further harm. Where we may differ will be in our personal relationship with our GP, what is perhaps important for one will not necessarily be the same for another. Within us we all have what are known as ‘trigger points’, areas controlled by our emotions, past memories good and bad of how we were related to in a given situation, the ‘building blocks’ of our emotional development that affect how we behave in many circumstances and those momentous moments when we can actually act objectively. You will all be aware of that instantaneous moment when you meet someone for the first time – and dislike them!!! How can that be? It is not THAT person that is the problem, it is our response to past negative experiences which that person has now triggered. This can happen between family, friends, colleagues, the person in the street and yes, with your doctor, he/she too is just another human being with all the ‘baggage’ we all carry around with us each day.  They and we, can be reactive, defensive, introverted, extroverted. They and we, can have home problems, family problems, car problems, even late night problems, but what we want in our exchanges is for our healthcare professional (and us) to be able to ‘place’ those problems where they belong.

When we go to the GP or any healthcare professional for that matter we are asking to be ‘made better’, we are unable to be ‘objective’ about ourselves. This childlike position is vulnerable and it is in this very situation when, if we are not received in a positive away the relationship can falter. What we are looking for is respect for our lack of knowledge, concern for our anxieties, interest in our suffering and empathic understanding of how we feel and why.

Are there such GPs about? Probably not that many but I am very lucky to have found one.

Four years ago when I first became ill my diagnoses floored me. ME!!! – (not M.E.) the one who exercised regularly, ate healthily, kept control over my weight and was still working in her 71st year in a very exacting job, I had become chronically ill, my body had let me down and all that NHS propaganda about the need for a healthy lifestyle hadn’t worked. To make matters even worse, twelve days after my diagnoses my husband had a stroke. In less than two weeks I had become a patient and a carer, my career was over and my whole world had changed irretrievably.

I met my GP not at the point of diagnoses but shortly after when treatment was being started and I was given an urgent appointment. His first words to me on entering his room were …’I’m so sorry’. Those were the first kind words I’d had said to me and they penetrated through this shocked state I was in. Without being fully aware of it I had made a mental note that day that this was the doctor I was going to deal with, this was a ‘feeling’ man, someone who without a word from me had recognised my anguish and made it his own, our ’emotional baggage’ had not got in the way of our first exchange, we were accepting of each other, I was vulnerable, sad, totally overwhelmed and angry, add to that my  ‘feisty’ personality and my anger could have destroyed the moment but his warmth towards me quietened me.  

During that first eighteen months he always made a 4-6 week follow-up appointment for me before I left his surgery, even though there were times I felt that perhaps I didn’t need it. He became my advocate, guiding me, advising me, listening to my concerns and always ready to respond. When treatment with one clinician or another wasn’t up to standard he responded. He never judged me, never made me feel I was a ‘difficult patient’ although I’m sure others might and have!  I ask questions and I expect answers and I know when I was being ‘talked down to’ with rubbish. My GP is never patronising, always and without exception he is pleased to see me, he likes me and I can tell. When I enter his office, time is mine, there is no clock saying ‘time up’, I am made to feel that I have as much time as I need.

As time went on my own condition worsened and also that of my husband. Through numerous ‘urgent’ moments my doctor was always there, guiding, advising and supporting. When I couldn’t get appointments to see him he gave me a ‘hotline’ that allowed me to make direct contact with him should I need it and a promise that he would always ‘fit me in’ should an appointment be necessary. He also connected me to a new innovative community caring system where I am able to make contact with a Nurse Practitioner directly on the day I need it if I became unwell and found it difficult to care for my husband.

My husband who was not initially with him but with another practice, is not very mobile, it is difficult for me to get him to the surgery, impossible at his previous surgery as they were on a main road next to traffic lights with no parking area whatsoever. My doctor has said to me more than once he would call and see ‘H’ at home if it would be easier for me! I have also known him just to phone me to ask how I am when he had not seen me for a while. Very rare qualities.

Some months ago I received an email from one of the doctor ‘comics’ that are delivered to the practices around the country and also electronically. In it an article asked if there was a deserving GP in your practice that was worthy of being nominated for a national champion award for the care of R.A patients. This was my chance to get my wonderful doctor recognised and acknowledged for his exceptional care to me and all his patients. I then had to set up a plan whereby I enlisted the help of the Assistant Practice Manager who in turn sought help from one of the other GPs in the practice to fill in a part of the form I couldn’t due to not being privy to that particular information, and then it was my turn to get my chance (only one) to write about this wonderful man. I knew it had to be written with a passion that conveyed just who he is and what he is to his patients. As I said, I was only going to get this one chance and they had only given me 400 words in which to do it!! There would be many practices and patients nationally who would be submitting their own nominee and there were only ten championship awards to be had in the whole of the country, my writing had to ‘stand out’, it had to make the reader ‘feel’ as I did – AND WE MANAGED IT – HE GOT THE AWARD!!! The ceremony took place at the House of Commons on the 2nd November and the awards were given by the Prime Minister Mrs Theresa May.

Afterwards he wrote me the most beautiful thank you letter in which he told me that the personal qualities I bestow upon him are really a reflection of myself. Doesn’t that just tell you what kind of a man he is. I am extremely fortunate and blessed to have such a doctor. In this crazy 21st century NHS, with reductions and shortages in just about everything, when talking (the same story) to just one more person makes you want to tear your hair out and you begin feeling as though it is you who are the problem. When you hear yourself getting sharp and snappy on the phone to one or other department and no one is actually listening and even if they listen and promise that what you’re asking for will get done – it then doesn’t get acted upon. When I reach that rock bottom moment I have my GP.

What are patient and clinician priorities for research in primary care patient safety?

9 Dec

by Rebecca Morris, Research Fellow in General Practice theme

jla_rmorrisblog_blank_fork

Over the last few months I have been working on the James Lind Alliance (JLA) Primary Care Patient Safety Priority Setting Partnership (PSP) (to find out more about the JLA read Richard Morley’s blog ‘Welcome to the Revolution’). The aim of our PSP is to ask ‘what are the questions that patients and clinicians have about primary care patient safety?’ The final aim is to produce a list of the 10 top uncertainties (or questions) that need to be addressed by research.

What have we been doing? Anyone could submit their question about primary care patient safety to our survey which was open from June to mid-July for 6 weeks. We advertised the survey in many places with the support of our steering group, their networks, and other organisations to reach as many people as possible and we had a total of 443 questions submitted.  Thank you to everyone who took part! 

The next stage in the JLA process involved working through the list to categorise the questions into different categories and by the areas of primary care (eg pharmacy, general practice, dentistry, out of hours care, self-management or broader primary care questions).  Then we worked through the list of questions to combine duplicate or similar questions. This produced a list of 173 possible uncertainties.

What are we doing at the moment? We are currently searching the literature to see if these questions have been answered using the JLA criteria for a ‘certainty’. We have been working with Central Manchester Foundation Trust libraries that have been searching the literature and we have been reviewing the searches to see if any of these questions have been answered. Any questions not answered already will then form a list of ‘uncertainties’. There has been a great range of questions posed which has made very interesting to look through such a diverse spread of topics. The next stage is to work with our PSP to initial prioritise the list of uncertainties and then in January we will have another survey which will open to everyone to help us identify the top 30 uncertainties to take to the final workshop in March, 2017.

What’s next and how can you get involved? Thank you to everyone who has taken part so far or worked with us to identify the literature. It’s a fascinating project with lots of great questions being posed and shows how many important areas there are for primary care patient safety research. Now I want to pass it back to you to help us prioritise the key areas for primary care patient safety research from these questions so please keep your eye out for the next survey in January, 2017. Thanks!

To keep up to date with what is happening and find out when the next survey is open follow @JLA_PtSafetyPSP

Recruiting GP practices to validate the Primary Care Patient Measure of Safety (PC_PMOS)

3 Feb

by Sally Giles, Research Fellow in Core theme

Receptionist and Patient GP Surgery_cropped_small

Study aims

The NIHR Greater Manchester PSTRC project is looking to validate a tool which captures patients’ views of safety in primary care (PC_PMOS). The aim of this tool is to provide feedback to practices about the strengths and weaknesses of the safety of the care they provide from the patients’ point of view. It is intended to be part of practice’s continual quality improvement processes. Details of its development can be found here: http://qualitysafety.bmj.com/content/early/2015/07/03/bmjqs-2015-004268.full

 

What we are asking practices to do?

We are asking local general practices to help us recruit patients to complete this tool which is a survey. Patients will be recruited by the reception/administration staff at general practices on the researcher’s behalf. Every adult patient (over the age of 18) presenting for their appointment at the practice over a designated 4 week period will be invited to participate in the study until 50 patients have completed it. They will be asked by the reception/administration staff at the practice to complete the PC_PMOS survey either before or after their appointment. Each practice will be provided with a secure questionnaire return box for patients to put their questionnaires in. Participants will also be invited by the reception/administration staff at the practice to complete the questionnaire again within one week of undertaking the first questionnaire for test-retest reliability purposes. Those who are willing to complete the questionnaire again will be given the opportunity to opt in and are asked to provide their email address and phone number so a link to the questionnaire can be emailed to them. The first 10% of patients who respond will be emailed a link to the questionnaire to complete.  The anonymised feedback provided by patients on this survey will be made available to practices after the study has been completed. In addition, each staff member at the practice will be required to complete a safety culture survey which should take no more than 20 minutes to complete. Demographic information about the practice and patient profile would also need to be provided to the research team.

 

What are the benefits of being involved in this study?

Completing the questionnaire will help the researchers to develop a reliable and valid tool that patients can use to provide feedback about the safety of their care to general practices. Each GP practice will receive a summary of the findings for their practice.

 

Payment

Each practice will receive £500 for taking part in the study. They will need to provide their financial details so that a contract can be drawn up and they are added to the University of Manchester financial system as a ‘supplier’. Once they have signed the contract, we then raise a requisition for a purchase order that relates to the services the practice has agreed to supply.

 

Contact

For further information about the study and to sign up to take part, please contact:

Dr Sally Giles, Research Fellow, NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Tel: 0161 306 8020, Email: sally.giles@manchester.ac.uk

 

 

Patient Safety: Blame the Doctor?

20 Aug

by Gavin Daker-White, Research Fellow, Multimorbidity theme, NIHR Greater Manchester PSTRC, University of Manchester

“Physician, heal thyself” (Luke, 4:23)

Part Two - Blame the system

This is the second of 3 blogs that discusses the results of a review of qualitative studies of patient safety in primary care as undertaken by researchers at the NIHR Greater Manchester PSTRC and NUI Galway. The review, published in August 2015 (and available here) examined 48 studies grouped into 5 topic areas:

  1. Patients’ perspectives around safety (8 articles)
  2. Staff perspectives on safety (14 articles)
  3. Medication safety (10 articles)
  4. Organisational or management issues (7 articles)
  5. Care transitions between primary care and hospitals (9 articles)

 The findings of the review were seen to boil down to those that blamed patients for safety failures, those that blamed doctors and those which explained safety failures by shortfalls in clinical systems or the organisation of care. This blog looks at the role of health service staff in patient safety in primary care. ‘Staff’ includes doctors, nurses or other health workers. Two of the studies we included in our review were focused on the role of practice receptionists, who often have a key role in patient safety through communicating with patients and dealing with repeat prescriptions. Administrative staff are also key to patient safety in primary care.

As was noted in Part One of this series of blogs, an important component of “feeling safe” relates to trust in care providers and the quality of inter-personal communication during interactions with health service staff. In the group of 8 studies that were concerned with patients’ perceptions, 2 were concerned principally with the consequences of real harms experienced by study participants. The results highlighted the role of past experiences in health seeking behaviour and showed how apparently trivial insults could spiral into more serious harm within a breakdown in the clinical relationship. These issues could be ameliorated for some people by training (of both staff and patients) concerning effective communication in clinical encounters.

Fourteen of the 48 articles we reviewed were focused on staff perspectives on patient safety. These studies were located in several different countries (USA, UK , Netherlands, Canada, Denmark, Germany  and Australia) and thus the kinds of processes and factors identified can be considered broadly relevant in western medical contexts. For staff, the main issues in patient safety concerned the characteristics or behaviour of staff or patients, doctor-patient communication and professional roles and responsibilities. Again, the main value of the synthesis in this group of papers appeared to be throwing light on those instances where the findings of different studies contradicted each other. For health service staff, these instances related to clinical autonomy, responsibility and emotional engagement with patients. For example, listening to patients was considered important so as not to miss vital information but it might threaten safety if the information given was perceived as irrelevant or distracting from the main issues at hand.

One commonly identified feature of clinical work in primary care was a perceived unwillingness to follow protocols, with GPs preferring to variously follow gut instincts or “do their own thing” (Elder et al., 2006). However, for health service staff the bulk of their concerns related to systems issues and the organisation of care, which is the subject of the concluding blog in this series. For staff, an important aspect related to the need for effective teamwork to promote safety within a context where staff can be held personally responsible for their actions.

One issue put forward by GPs as contributing to safety failures reflected the stressful nature of the job and the kind of work/life balance apparently necessary to operate “safely”. So far as the particularities of clinical and diagnostic work are concerned the dangers of false assumptions and explanations arrived at too hurriedly were both identified as threats to patient safety. The dangers in instantaneous judgements, perhaps based on stereotypes of presenting patients, was also identified as an issue in the ten medication studies. As in the patient studies, effective communication was considered essential, but potentially problematic given competing agendas and pressures on time and resources. There were also problems for GPs in managing rare drugs prescribed by other specialists, perhaps for conditions that were at the limits of their competence to manage (Rahmner et al., 2010).

Taking all of the studies into account, staff had the potential to compromise safety in the following ways:

  • Communication mediated by receptionists
  • Deference on the part of patients can impact effective communication
  • Poorly performing GPs
  • Lack of face-to-face contact between health workers
  • Ad hoc approaches

 Other findings pointed to the ways in which staff can help promote safety:

  • Create a feeling of safety
  • Understand patients’ circumstances, clinical history and needs
  • Training in doctor-patient communication
  • Share knowledge and training with colleagues
  • Teamwork / promote a safety learning culture
  • Open, blame free and effective communication between staff

 On the face of it, the above findings suggest that engendering patient safety in primary care is something that takes time. However, time is often seen to be at a premium in primary care. Further, the relationship between some of the issues we have identified needs further investigation. For example, are some GPs “poorly performing” because of stress or burnout, or due to deficiencies in training or clinical practice? The main point to note is that effective communication between patients and health workers and between different health workers themselves appear as the most important factors. Often, it seems as though the time available for consultations or other communication in health services is challenged by the way that services are set up, organised or run. These considerations form the subject of next week’s blog, which will be the final post in this series.

References

Elder NC, Graham D, Brandt E, Dovey S, Phillips R, et al. (2006) The Testing Process in Family Medicine: Problems, Solutions and Barriers as Seen by Physicians and Their Staff: A study of the American Academy of Family Physicians’ National Research Network. Journal of Patient Safety 2: 25-32.

Rahmner PB, Gustafsson LL, Holmstrom I, Rosenqvist U, Tomson G (2010) Whose job is it anyway? Swedish general practitioners’ perception of their responsibility for the patient’s drug list. Ann Fam Med 8: 40-46.

Hearing without Listening: Part Two

18 Aug

by Max Scott, Patient

  • Part four of the blog series “The desperate fight to be heard, and supported, when living with the invisible struggles of Multimorbidity”
  • Introduction to blog series here

Ears_Listen_Max Scott blog

In the days and weeks following my Pituitary surgery, I began to read up on other patients’ experiences, who’d had similar surgery.  I remember reading one comment from a patient, who said “once you’ve had the surgery and are on your replacement therapy medications, the doctors are never far away from you”.  When I read that, my heart sank a little. I wasn’t sure if I wanted that.  I wanted to lead as normal a life as possible, and not have a medical team holding my hand every step of the way. But I needn’t have worried as that was not what I experienced!

Despite having multiple health conditions (my Medic Alert card makes depressing reading), some of which have completely changed the way I’m able to live my life, I usually have to make the first move in getting checked out. Some of the comments that I’ve had to endure are quite unbelievable!  Here are just a few. My own GP, upon me asking to have a particular check-up: “You don’t want to be making a career out of having tests”. To say I was gobsmacked was an understatement, as well as very upset and insulted. He is, by nature a gentle man, and I can only think that such an out of character outburst was “inspired” by costing concerns, but the effect it had was devastating. It is a very dangerous attitude to take with a patient. I wrote to the surgery to make my feelings known. The most I received in return was a response stating that “he is sorry if he upset you”. This is very different from saying “I’m sorry for getting it wrong”. The end result is that I avoided going to my GP for a long while after, even when I felt I needed to, and even now, I have lost confidence in asking him for any specific examinations. That I had to experience such rudeness in the first place was appalling. A perfect example of “Hearing without listening”.

I’ll leave you with a taster for my next blog; another comment said to me during an appointment, but not with my GP this time. “Are you worried about feeling well”?