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