Developing, testing and implementing the NIHR School for Primary Care Research Patient Safety Toolkit in general practices in England
113
31 August 2015
01 November 2011
31 July 2015 (No cost extension of 7 months)
3 years 6 months
Patient safety, Primary care, Toolkit, Quantitative analysis, Qualitative analysis
Professor Anthony Avery, Dean of the School of Medicine; Professor of Primary Health Care, Faculty of Medicine & Health Sciences, University of Nottingham
The overall purpose of this study is to develop, test and implement the NIHR School for Primary Care Research (SPCR) Patient Safety Toolkit in general practices in England.
Primary Objectives
Secondary Objectives
Stage 1 (Developing the Patient Safety Toolkit)
Stage 2 (Testing the elements of the Toolkit)
Stage 3 (Implementing the complete Patient Safety Toolkit)
We had intended to develop a website/dashboard to promote the Patient Safety Toolkit. By stage 3 the team had developed a storyboard and were in discussions with a web developer. However, with the RCGP taking up the Patient Safety Toolkit as part of the Spotlight Project they have used our storyboard information as the basis for the information to host the toolkit on their website.
This was a multi-centre study, combining quantitative and qualitative methods. The overall purpose of this study was to develop, test and implement a Patient Safety Toolkit in general practices in England.
Stage 1
This stage had previously been completed and involved identification of tools considered suitable for identifying and addressing patient safety issues. This included:
a) Undertaking focused systematic literature reviews to identify:
b) Conducting a survey of international general practice organisations to identify any additional tools for assessing patient safety;
c) Conducting interviews with UK and international experts to explore the attributes of safe general practice;
d) Selecting a set of tools for testing in a sample of general practices
The set of tools identified in this study included the following:
Stage 2
This stage of the study involved the piloting of the above set of patient safety tools with practices recruited from the three centres; Manchester, Keele and Nottingham. Each centre was asked to recruit up to 10 practices plus we recruited an additional 15 practices in Nottingham to pilot the Prescribing Indicators tool. Each practice was only given up to 4 tools so that detailed feedback (qualitative and quantitative) could be obtained.
In each participating practice, staff were asked to complete workload diaries, which allowed the effort associated with using each of the different tools in the Patient Safety Toolkit to be assessed. The diaries included sections on the amounts of time necessary to undertake planned (and any other related but unplanned) activities. This information has been important for assessing the costs of implementing the toolkit.
We assessed the acceptability, technical feasibility, reliability, and validity of each element of the Patient Safety Toolkit. Semi-structured interviews were conducted with a diverse range of practice staff, including GPs, practice managers, nurses, and other relevant staff. These interviews explored interviewees’ expectations, experiences, perceived needs, and unintended consequences associated with implementing the tools in their practices.
Various quantitative methods were agreed and utilised to measure the results arising from using the tools. Some of these tools, such as the NHS Education for Scotland Trigger Tool, required clinicians from the practices to examine patient notes, but no patient identifiable information was fed back to the research team.
For the PREOS-PC we asked the participating practices to send out the questionnaire to a random selection of 75 patients (criteria being over the age of 18 and not classified as vulnerable). The completed forms were returned to our colleagues in Oxford who analysed the results.
Stage 3
As a result of the quantitative and qualitative analysis, the project team considered which tools to take forward for the implementation stage of the project. The tools decided on:
Stage 3 expanded the number of practices by retaining the ones used in the previous stage and by recruiting up to 10 practices each from Southampton and Birmingham. Each practice was again asked to use up to 4 tools from the toolkit. Each practice was also asked to fill in a workload diary to assess the time and effort put into each tool. Interviews were conducted at each practice following completion of the tools to explore the acceptance and validity of each tool. For the PREOS-PC all practices recruited were asked send out the questionnaire to 150 patients in their practices, the criteria remained the same as in stage 2. In one area, Keele, we sent reminders to the same patients, to identify whether the rate of response improved with the extra posting.
During stage 2 and 3, other tools were assessed that had been designed and published. As a result the team assessed another checklist instrument which was subsequently included in the completed toolkit.
The results from stage 3 indicated that:
Patient safety is a complex topic as it encompasses many aspects of care. Therefore, no tool would provide a comprehensive way of measuring patient safety. Patient safety includes prescribing and diagnostics safety, communication (within and beyond the practice), organisational culture, and patient reported problems. This project has identified tools that address all of these topics:
1) The Trigger Tool - an audit for reviewing patient notes to identify harm in primary care
2) Medicines reconciliation – to identify the safety of the interface between primary and secondary care in terms of medicine reconciliation
3) PC SafeQuest - an on-line anonymised questionnaire that can be used by all members of a general practice team to rate the perceived safety climate within the practice.
4) Manchester Patient Safety Framework - to help organisations understand how safety is perceived by staff, which allows practice groups to reflect on their safety culture.
5) Concise Safe Systems Checklist - allows practices to think about those background systems which are important for patient safety, but are often overlooked. It is deliberately designed not to include items already covered by legislation or mandatory requirements.
6) The General Practice Safety Checklist - identifies hazards across the wider work systems that may threaten patient safety, as well as those hazards that have an impact on the health, safety and well-being of all involved.
7) Prescribing Indicators - these are a set of computerised indicators to assess prescribing safety.
8) Patient Safety Questionnaire – to assess patient reported experiences and outcomes of patient safety in primary care
Some of these tools have been adapted from other sources, some have been accepted as they are and others have been designed and developed as a result of this project.
Ricci-Cabello I, Gonçalves DC, Rojas-García A, Valderas JM. Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments Fam Pract. 2015 Feb;32(1):106-19.
Bell B, Reeves D, Marsden K, Avery A. Safety Climate in English General Practices: Workload Pressures May Compromise Safety, Journal of Evaluation in Clinical Practice
Ricci-Cabello I, Pons-Vigués M, Berenguera A, Pujol-Ribera E, Slight S P, Valderas J M. Patients’ Perceptions and Experiences of Patient Safety in Primary Care in England. submitted to:BMJ Qual & Saf
Ricci-Cabello I, Avery AJ, Reeves D, Kadam UT, Valderas JM. Measuring Patient Safety in Primary Care: The development and validation of the “Patient Reported Experiences and Outcomes of Safety in Primary Care” planned for submission to: (PREOS-PC). Annals of Family Medicine
Ricci-Cabello I, Avery A, Valderas JM et al. Patients’ reports and evaluations of patient safety in English general practices: a cross sectional study.
Bell B, et al The Development and Testing of the NIHR-SPCR Patient Safety Toolkit for General Practices in England
Bell B, Avery A, Marsden K et al The Patient Safety Toolkit Development
Perryman K, Marsden K, Campbell S, Avery T Barriers and enablers for the adoption of patient safety tools to improve patient safety in UK primary care -
Litchfield I, Greenfield S, Avery A, Perryman K, Marsden K, A qualitative exploration of the influences on the adoption of patient safety innovations in primary care
Marsden K, Litchfield I, Doos L, Greenfield S An evaluation of two safety climate tools in primary health care: staff perspectives
14/08/2014 Report Link: Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method
10/10/2014 Report Link: Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments.
02/03/2015 Report Link: Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study
01/09/2015 Report Link: Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis
25/05/2016 Report Link: Measuring Patient Safety in Primary Care: The Development and Validation of the “Patient Reported Experiences and Outcomes of Safety in Primary Care” (PREOS-PC)
17/06/2016 Report Link: Patients’ perceptions and experiences of patient safety in primary care in England
15/06/2017 Report Link: Patients’ evaluations of patient safety in English general practices: a cross-sectional study
09/08/2017 Report Link: Identifying patient and practice characteristics associated with patient-reported experiences of safety problems and harm: a cross-sectional study using a multilevel modelling approach
23/02/2018 Report Link: A Patient Safety Toolkit for Family Practices
The NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre has been closely involved in this project and has contributed to funding a national roll-out (via a recently successful RCGP ‘Spotlight’ project). http://www.rcgp.org.uk/clinical-and-research/toolkits/patient-safety.aspx
Mr Antony Chuter, a patient with a long-term condition and experience of medication-related harm, led the public and patient involvement for this research project.
During the development of the PREOS-PC, several focus groups were undertaken with patients and this knowledge and guidance was used to enhance the questionnaire.
In addition, we have had GPs on our steering group to advise and support this project.
The toolkit has a number of tools that are individually useful in supporting general practices in their delivery of care to patients. Taken together this toolkit offers a powerful asset to improve patient safety in primary care.
At present there has been little impact of the Toolkit but the hosting of the toolkit on the RCGP website offers a huge potential for supporting practices in improving patient safety. As part of the RCGP Clinical Innovation and Research Centre’s (CIRC) efforts to engage with GPs across the UK on the Patient Safety Toolkit website, the Clinical Priorities Team is working with RCGP Faculties to hold four interactive workshops across the UK. They will be held in Bristol, Sheffield, Nottingham, and Glasgow in November.
The RCGP will be collating statistics on the use of the Patient Safety Toolkit website, which will be analysed on a regular basis.
The Patient Safety Collaboration in the East Midlands has supported the development of a database specifically for the patient questionnaire. At present it is in pdf form so that practices need to print off copies and either hand out or post them to their patients. The database will allow practices to email the questionnaire to patients. Completed returns will be emailed back only to the practice, which will then analyse the responses. However, overall anonymised results will be available on a local and national basis. This has the capacity to provide a unique assessment of patients’ attitudes to safety in general practice.
This project was funded by the National Institute for Health Research School for Primary Care Research (project number 113 )
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.
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