CRITICAL EVENT ANALYSISIN PRIMARY CARERNZCGP

Quality Symposium

Wellington 2009

INTRODUCTION

Practice structure

Integration with other quality activities

Examples

Future directions

PARAPARAUMU MEDICAL CENTRE

3 Practice teams

4500 patients

Established for 20 years – previous practice for about 20 years prior to that.

Middle SES

2 main age groups Elderly Young families

Paraparaumu Medical

Receptionists/Administrators

Receptionists/Administrators

Receptionists/Administrators

Nurses

Doctors

Nurses

Doctors

Nurses

Doctors

FRAMEWORK OF QUALITY AT PMC Cornerstone – accreditation PHO reporting-immunisations, cervical

screening Patient satisfaction survey – twice a year with

registrars Own audits and goals Peer review – doctors, nurses, receptionist

meetings Standardised procedures

Clinical (advanced forms)Non-clinical

WEEKLY TEAM MEETINGS

Balanced scorecardWeek 1 – StaffWeek 2 - PatientsWeek 3 – Internal ProcessesWeek 4 - Finances

CRITICAL EVENT PROCESS Fits into the weekly meeting cycle Team process – team solutions Simple Informal – but not unplanned High face value Non- judgemental Potential and actual events (before the

event) Not time consuming Process based Time frame for review

Implement new process

Critical event triggers review

Review and revise process

Develop new process

CHARACTERISTICS OF PRIMARY CARE CRITICAL EVENT ANALYSIS Advantages

Small team sizeControl over all aspects of the process

Broad definition of critical event Continuous improvement process

all events trigger a review of process and a review time

Potential and actual events Before the event (vs audit) Appropriate to business size Local problems and local solutions Evolutionary

DISABILITY FORMS Problem – disability form lost Review

Multiple processes Multiple places to put the forms No defined timeframes

Solution Clearly defined process Forms collected Logged Put in a folder Written up Monday lunchtime Available for collection Monday afternoon

Measure Number of lost forms and time spent searching

INR TESTING

Problem – patient not tested for 2 months Solution

Add a recall when patient phonedWhen recalls reviewed missing patients

identified Further activity

Audit of warfarin dosing using BPAC resourceAdding diagnosis, INR range and treatment

time to an alert in patient notes Measure

Audit and number of missing INR’s

CHILD APPOINTMENT

Patient rang for appointment for infant Relieving nurse Doctor short

Receptionist ascertained this was not and emergency told the mother that the child would be seen Told mother to leave message on nurses answer

phone

CHILD APPOINTMENT (2)

Message left on nurses answer phone Nurse called back in 20 minutes Mother had taken child to another provider Child admitted to hospital with viral infection Felt we could do better Talked to mother, receptionist, nurse Revised then process and clarified the

message to patients

Measure patients seen by other providers Patient satisfaction survey

BROKEN NOSE 15 year old Fractured nose at sporting event Seen at an A&M – xray Presented Monday morning Rang ENT registrar Faxed referral Told appointment would be on Wednesday 5 weeks later letter of apology

BROKEN NOSE (2)

Reviewed our process Clearly communicate our expectations to the

patient and to ask them to call up if there were any problems

Difficulty – lack of forum to discuss this critical event

Measure Further similar critical events

REQUIREMENTS All the team involved Everyone can comment Regular meetings – continual focus Specific to local needs – not PHO or DHB

although some critical events cross boundaries

Clear face value validity Improving patient care

Simple methods – root cause, 5 why’s – “What is really going on?”

Clear systems which can be adapted and continuously improved

IT platform

HAS IT MADE A DIFFERENCE

Team says – “Yes” Management efficiency Clinical improvement Hard to quantify but qualitative analysis is

positive

FUTURE DEVELOPMENTS

Within practice Increasing clinical focus More critical events in peer review and nurses

meetings Clearer linkage between standardised process,

audit and critical events Measuring the effect of critical event analysis

WISH LIST

Resources for critical events Interaction with other levels of critical events Analysis of effectiveness of methods of

critical event review