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Critical Event Analysis in Primary Care

Critical Event Analysis in Primary Care

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Critical Event Analysis in Primary Care

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  1. Critical Event Analysisin Primary Care RNZCGP Quality Symposium Wellington 2009

  2. Introduction • Practice structure • Integration with other quality activities • Examples • Future directions

  3. 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

  4. 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

  5. Weekly Team Meetings • Balanced scorecard • Week 1 – Staff • Week 2 - Patients • Week 3 – Internal Processes • Week 4 - Finances

  6. 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

  7. CHARACTERISTICS OF PRIMARY CARE CRITICAL EVENT ANALYSIS • Advantages • Small team size • Control 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

  8. 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

  9. INR testing • Problem – patient not tested for 2 months • Solution • Add a recall when patient phoned • When recalls reviewed missing patients identified • Further activity • Audit of warfarin dosing using BPAC resource • Adding diagnosis, INR range and treatment time to an alert in patient notes • Measure • Audit and number of missing INR’s

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. Has it made a difference • Team says – “Yes” • Management efficiency • Clinical improvement • Hard to quantify but qualitative analysis is positive

  16. 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

  17. Wish list • Resources for critical events • Interaction with other levels of critical events • Analysis of effectiveness of methods of critical event review