Capturing and Learning from Incidents Across the Primary/Secondary Care Interface! Sian Rowlands1, Huw Williams2, Maureen Fallon1, Navroz Masani1, Alice Casey1, Graham Shortland1, Adrian Edwards2, Andrew Carson-Stevens1,2*! ! 1. Quality Improvement Faculty, Cardiff and Vale University Health Board, Wales, UK ! 2. Healthcare Quality and Communication Group, Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Wales, UK! further details contact Andrew Carson-Stevens:
[email protected] !
Reporting culture!
!
40
Demonstration projects with cost-benefit analyses
30 20
4!
10 0
(c Chart) UCL
17.082
Warfarin issues identified by incident report system
No. Incidents
14
100.0%
30
93.5%
12 8 6
CL
8.391
25
70.0%
Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14
Number of reports
20
2
20
64.5% 60.0% 50.0%
15
40.0% 10
Other outcome, process and balancing measures included:! ! System responsiveness! Time for risk management team to acknowledge report (P)! Time for risk management team to complete investigation of each report (P)! Time to provide feedback to reporters (P)! ! Narrative quality! Duration between incident occurring and professional reporting it (P)! Overall quality of incident reports from primary care at CVUHB (O)! ! Reporting culture! Number of identified issues for improvement (O)!
30.0% 20.0% 4
5
0
No notification patient on Warfarin
Warfarin initiated in community
3
Request to initiate
! !
2 Patient education
• Education and training • Protocol for referral of ‘stable’ or ‘unstable’ patients
!
• Produce & implement SBAR for INR discharge • Track incidents & feed back to UHB & clinical areas
• Link with GPs, Pharmacy & Haematology to agree SBAR • Medical Director to disseminate • Collect incident data and track days between events
!
!
! !
! ! ! A SBAR to improve understanding and communication of INR, and an agreed definition of a ‘stable’ INR between primary and secondary care was essential. Removing INR as a barrier to discharge remains a cultural challenge; increased awareness of the availability of community services for patients taking Warfarin is helping to address this issue. ! ! The cost of discharge delay was estimated at £38,874 per month, based on a case note review of 25 patients delayed as a result of unstable INRs in one calendar month. Unnecessary hospitalization costs were £466,488 per annum for CVUHB.! ! The new community-based anticoagulation service outlined in the Driver Diagram above has a potential cost saving of c. £300k. ! ! 60
80.0%
77.4%
Project start
! Hospital doctors to initiate safe discharge!
90.0%
87.1%
4 0
• Establish project team ! leaders • Engage key • Engage key stakeholders in education and Welsh Government • Mentor other health organizations • Utilize tools to calculate costbenefit
Case study of Warfarin-related incidents!
16
10
!
31 Warfarin-related incidents were reported within the first 4 months of the project; a thematic content analysis informed a Pareto Chart of the key areas for intervention. !
Number of incident reports
20 18
Align with education and CPD (national)
!
!
!
2 Home with unstable INR
10.0% 0.0%
Warfarin incidents typically resulted in discharge delays; reasons for this included:! • Poor secondary care understanding and communication of INR to GPs (tackled in May 2013 via a SBAR – see Run Chart of Days Between Warfarin Incidents);! • Variation of ‘stable’ INR definitions/different INR protocols in place for acceptance of patients in primary care (tackled in February 2014 by testing of agreed definition); ! • Capacity for community team to pick up patients with ‘unstable’ INRs. ! !
Run Chart of Days Between Warfarin Incidents 50
40
30 Warfarin Incident Median
20
SBAR
10
0
21/2/14
!
Progress taskforce
!
• ! Link with primary & secondary care colleagues to agree clinical definition • Cost savings & funds required for new model • Consult with Taskforce & LMC to sign off & present to UHB for approval
• Produce & implement agreed ! definition of ‘stable’ • Produce service proposals and obtain UHB sign off • Draw up Enhanced Service for GPs to deliver
7/1/14
Board-level endorsement
• Produce and implement ! question framework • Produce and implement reporting aide memoire • Create triggers/blocks to prompt inclusion of key data
Agreed definitions Monitoring Slow loading protocol Receipt and demonstrating utilization of funds
13/11/13
50
!
!
• • • •
24/10/13
60
GPs to manage patients with ‘stable’ INRs & initiate slow loading for atrial fibrillation (AF)
4/10/13
Target
!
patients on Warfarin at CVUHB by 31/03/2014 !
20/8/13
Cumulative Frequency
60
!
1/8/13
!
!
•
& timely discharge &
10/7/13
!
Liaise with clinical areas including ART, Pharmacy & Haematology Cost savings & funds required for new model Consult with Taskforce, Clinical Boards, GPs & LMC to sign off & present to UHB for approval
•
•
25/6/13
!
Standard Operating Procedure / guidance for reporting!
!
• Establish supervisory link with Haematology & Pharmacy ! • Draw up proposal to extend ART service • Develop protocols for monitoring & discharge
10/6/13
Narrative quality
Change!Ideas:!
! monitoring of all
29/5/13
Co-production of e-report form
Change!Concepts:!
! To achieve safe
!
!
Cumulative frequency of reporting GP practices
!
Aim/Primary! Outcome:!
!
!
2! How did we know that a change was an improvement?
!
29/5/13
! To develop, test and implement a quality incident ! learning and reporting system ! at CVUHB by 01/07/14.!
!
23/5/13
!
Aim/Primary! Outcome:!
!
• Early identification • Allocation of additional team members resources • Communication with GPs for ongoing dosing • Reconfigure from 5 to 7 day service
19/5/13
!
Acute Rehabilitation Team (ART) to manage ‘unstable’ INRs for patients on Warfarin!
Secondary!Drivers:!
16/5/13
• •
!
System accessibility Acknowledgement and feedback audit Issue analysis Primary and secondary care Memorandum of understanding
!
8/5/13
!
• •
• Design e-reporting form with inbuilt alerts/reminders to sit on desktop ! • Set incident reporting and response times • Align with electronic system • Integrate primary care/secondary care systems • Introduce and develop collaborative incident review • Establish secondary care leads for incident analysis and response in all areas
!!!!!
2/5/13
System responsiveness!
!
Primary!Drivers:!
4/4/13
!!!!!
!
Change!Concepts:!
28/3/13
!
Secondary!Drivers:!
18/3/13
We aimed to develop and enhance the existing reporting and learning system (RLS) for General Practitioners at Cardiff and Vale University Health Board (CVUHB) to allow identification of system issues, affecting the quality of patient care at the primary / secondary care interface. ! ! Our goals were defined in the following areas:
! System responsiveness – The risk management team investigating or providing feedback to the reporter within 14 days; ! ! Narrative quality – Improve the standard of free text incident description so at least 80% of reports score >8/10 on quality assessment; and! ! Reporting culture – Increase the number of GP practice groups reporting to the RLS by 25%!
Primary!Drivers:!
Driver diagram to minimise Warfarin-related incidents!
11/3/13
!
5!
What changes did we make that led to an improvement?!
5/3/13
3!
1/3/13
1! What are we trying to accomplish?!
Number of days between Warfarin incident
*For
Testing of an integrated and responsive primary/secondary care incident reporting system has enabled us to improve working across our healthcare community to capture and learn from incidents and ensure patient-centred, safe care. ! !
