Orientation Manual. Counties Manukau Health

Orientation Manual Counties Manukau Health August 2017

1. Contents 1. Contents... 2 2. Purpose of Manual... 3 2.1 Background... 3 2.2 Approach... 3 2.3 Aim... 4 2.4 Objectives... 4 2.5 Methodology... 4 3. Model for Improvement... 5 4. The Breakthrough Series... 7 4.1 Steps in the PDSA Cycle... 8 4.2 Sustaining Change... 8 5. Structures... 9 5.1 Leadership & Key Players... 9 6. Practice Engagement... 11 7. Requirements of General Practice CMH... 12 8. Audit Care Bundles... 13 8.1 Current Audit Bundles... 13 8.2 New Bundles for Year Four (2017/2018)... 16 9. Query... 17 9.1 Random selection of patients to audit... 17 9.2 Complete data collection... 17 10. Tools... 19 10.1 Trigger Tool... 19 10.2 Safety Climate Survey... 20 10.3 Patient Experience... 21 10.4 Significant Event Analysis... 21 11. Sharing the Learnings... 22 11.1 Learning Session Zero... 22 11.2 Learning Session One... 22 11.3 Learning Session Two... 22 11.4 Learning Session Three... 22 Glossary Term ADHB CMH COPD CVDRA DHB IHI PHO SiP WDHB Meaning Auckland District Health Board Counties Manukau Health Chronic Obstructive Pulmonary Disease Cardiovascular Disease Risk Assessment District Health Board Institute for Healthcare Improvement Primary Care Health Organisation Safety in Practice Waitemata District Health Board August 2017 2

2. Purpose of Manual The Safety in Practice (SiP) initiative is designed to increase quality improvement capability within general practice by targeting an issue of clinical concern and gaining skills through practical experience and collaborative learning. This manual is designed to support PHO facilitators and general practice members enrolled in the Safety in Practice initiative. It shall provide background to the programme; the support provided by the PHO Facilitators and the Safety in Practice project team; the Model for Improvement and Breakthrough Series; the individual care bundle audits; the Trigger Tool; and the Safety Climate Survey. It is designed to be a dynamic document so please provide feedback to the project team about any areas that would benefit from addition or expansion. 2.1 Background The aim of SiP is to enhance quality improvement capability of general practice teams within the Auckland region, by focusing on patient safety. In order to achieve this goal, a range of tools and resources (adapted from the Scottish Patient Safety Programme in Primary Care), alongside support from improvement and clinical experts, are provided to general practice teams to foster a patient safety culture. Current supporters of the initiative include the NZ Health Quality & Safety Commission, General Practice NZ and the Royal New Zealand College of General Practitioners, who have endorsed the accreditation of Maintenance of Professional Standards (MOPS) points for medical staff attending the Safety in Practice learning sessions as well CQI accreditation for the Trigger Tool and Safety Climate Survey. In January 2017, the Metro Auckland Clinical Governance Forum approved ongoing support from District Health Boards (DHBs), Primary Healthcare Organisations (PHOs) and key stakeholders for this initiative. 2.2 Approach The high level aims of the initiative are to reduce patient harm in primary care by developing more reliable practice systems, and to promote a safety and improvement culture within general practices. Participating practices have been taught skills in the use of improvement methodologies, including: PDSAs (small tests of change) Care bundles A primary care trigger tool A primary care safety culture survey Data for improvement. Practice-based meetings allow reflection on data collected and to identify areas of change to be tested within the practice. Four learning sessions scheduled throughout the year of the programme provide teams with coaching in the use of the Safety in Practice tools, the Model for Improvement methodology, and the Breakthrough Series collaborative method. Most significantly, particularly at the second and third learning sessions, practices have the opportunity to collaborate with others working in their area of patient safety to share and learn from each other. August 2017 3

Improvement Advisors from Ko Awatea, WDHB and ADHB, with the assistance of a general practice Clinical Lead, have been working with PHO staff within practices to provide quality improvement support and facilitation, to assist with: Up-skilling teams in improvement methodology Identification of current systems, processes and behaviours Data analysis Re-design of practice systems and processes PDSA testing of small-scale change and familiarity with the Safety in Practice care bundle audit tools Introduction of a primary care trigger tool and safety culture survey. 2.3 Aim To enhance quality improvement capability of general practices within the Auckland region, by focusing on patient safety. 2.4 Objectives Augment capability in quality improvement methods, to improve patient care. Reduce harm to patients. Create safer and more reliable practice systems. Promote a culture of safety. 2.5 Methodology Safety in Practice utilises the Model for Improvement and the IHI Breakthrough Series Benefits of the improvement methodology when used within Safety in Practice are: Focuses on a specific improvement area Team-based approach to learning and improvement Provides opportunity to teams and individuals to learn from each other s experience Short-term learning system Three members of team attend learning sessions (away team) Additional team members working locally (practice - home team). August 2017 4

3. Model for Improvement The Model for Improvement, (developed by Associates in Process Improvement), is a simple yet powerful tool for accelerating improvement 1. The Model for Improvement is not meant to replace change models that organisations may already be using, but rather to accelerate improvement. This model has been used very successfully by hundreds of healthcare organisations in many countries to improve many different healthcare processes and outcomes. The Model has three questions, plus a method of testing change: 1. What are we trying to accomplish? 2. How will we know if a change is an improvement? 3. What changes can we make that will result in an improvement? 4. Plan-Do-Study-Act (PDSA) cycle (please see template at end of manual) is then used to test changes in realwork settings. The PDSA cycle guides the test of a change to determine if the change is an improvement. To effectively engage in the Model and work towards testing and embedding changes effectively, the following steps are taken: Forming the Team Including the right people on an improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organisation builds teams to suit its own needs. Setting Aims Improvement requires setting aims. An organisation will not improve without a clear and firm intention to do so. The aim should be time-specific and measurable; it should also define the specific population of patients that will 1 http://www.ihi.org/resources/pages/howtoimprove/default.aspx August 2017 5

be affected. Agreeing on the aim is crucial and so is allocating the people and resources necessary to accomplish the aim. Establishing Measures Measurement is a critical part of testing and implementing changes. Measures tell a team whether the changes they are making actually lead to improvement. Measurement for improvement should not be confused with measurement for research or accountability. Selecting Changes While all changes do not lead to improvement, all improvement requires change. The ability to develop, test, and implement changes is essential for any individual, group, or organisation that wants to continuously improve. There are many kinds of changes that will lead to improvement, but these specific changes are developed from a limited number of change concepts. A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Creatively combining these change concepts with knowledge about specific subjects can help generate ideas for tests of change. Testing Changes Once a team has set an aim, established its membership, and developed measures to determine whether a change leads to an improvement, the next step is to test a change in the real work setting. The PDSA cycle is shorthand for testing a change by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning. Implementing Changes After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the change is ready for implementation on a broader scale, for example, for an entire pilot population or on an entire unit. Implementation is a permanent change to the way work is done and, as such, involves building the change into the organisation. It may affect documentation, written policies, hiring, training, compensation, and aspects of the organisation's infrastructure that are not heavily engaged in the testing phase. Implementation also requires the use of the PDSA cycle. Spreading Changes Spread is the process of taking a successful implementation process from a pilot unit or pilot population and replicating that change or package of changes in other parts of the organisation or other organisations. During implementation, teams learn valuable lessons necessary for successful spread, including key infrastructure issues, optimal sequencing of tasks, and working with people to help them adopt and adapt a change. Spread efforts will benefit from the use of the PDSA cycle. Units adopting the change need to plan how best to adapt the change to their unit and to determine if the change resulted in the predicted improvement. August 2017 6

4. The Breakthrough Series The Breakthrough Series 2 is a collaborative method of learning designed to help multiple organisations close that gap by creating a structure in which interested organisations can easily learn from each other and from recognised experts in topic areas where they want to make improvements. A Breakthrough Series Collaborative is a shortterm (six to 15 month) learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area. The Breakthrough Series was conceptualised in late 1994 when one of IHI s founders, Paul Batalden, MD, sketched the model on a napkin at a meeting of IHI s Group Practice Improvement Network and handed it to IHI s CEO, Don Berwick, MD. Batalden and Berwick were seeking ways to accelerate improvement in healthcare beyond what IHI had achieved using traditional educational approaches. Since its inception in 1991, IHI had been successful in training thousands of people from hundreds of healthcare organisations in the fundamentals of improving quality. Berwick, Batalden, and the Board of IHI were eager to move to the next level: to provide a structure for learning and action that would engage organisations in making real, system-level changes that would lead to dramatic improvements in care. The key to thinking behind the development of the Breakthrough Series was to combine subject matter experts in specific clinical areas with application experts who could help organisations select, test, and implement changes on the front lines of care. Moreover, they knew that breakthrough change couldn t happen in a traditional didactic setting; instead, organisations would commit to working over a period of six to 15 months, alternating between learning sessions in which teams from all participating organisations would come together to learn about the chosen topic and to plan changes, and action periods in which the teams would return to their organisations and test those changes in clinical settings. The collaborative structure for Safety in Practice is as follows: 2 http://www.ihi.org/resources/pages/ihiwhitepapers/thebreakthroughseriesihiscollaborativemodelforachievingbreakthroughimprovement. aspx August 2017 7

4.1 Steps in the PDSA Cycle Step 1: Plan Plan the test or observation (including a plan for collecting data) What is the objective of the test? Document your predictions about what will happen and why Develop a plan to test the change (Who? What? When? Where? What data need to be collected?) Step 2: Do Try out the test on a small scale, for example one patient on one day. Carry out the test Document problems and unexpected observations Begin analysis of the data. Step 3: Study Set time aside to analyse the data and study the results. Complete the analysis of the data Compare the data to your predictions Summarise and reflect on what was learned. Step 4: Act Refine the change based on what was learned from the test. Determine what modifications should be made (adopt change, adapt and retest, or abandon change idea). Prepare a plan for the next test. 4.2 Sustaining Change After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the change is ready for implementation on a broader scale-for example, for an entire pilot population or for the whole practice team. Implementation is a permanent change to the way work is done and, as such, involves building the change into the organisation. It may affect documentation, written policies, hiring, training, compensation, and aspects of the organisation's infrastructure that are not heavily engaged in the testing phase. Implementation also requires the use of the PDSA cycle. August 2017 8

5. Structures 5.1 Leadership & Key Players Project Sponsors Dr Campbell Brebner - Chief Medical Advisor, Primary Healthcare - CMH Dr Stuart Jenkins - Director Primary Healthcare ADHB & WDHB Regional Group Team Members The Regional group currently governs the programme and currently meets monthly at Northern Regional Alliance (NRA), Great South Road, Penrose. Name Role Email Mobile Dr Campbell Brebner Chief Medical Advisor Primary Care CMH Campbell.brebner@middlemore.co.nz 0212241950 Dr Stuart Jenkins Director Primary Care WDHB/ADHB Stuart.Jenkins@waitematadhb.govt.nz 021322923 Dr Vikas Sethi Clinical Lead (KA/CMH) vikas.sethi@middlemore.co.nz 021501862 Suz Heslop Project Manager (KA/CMH) suz.heslop@middlemore.co.nz 021573795 Victoria Brown Project Coordinator (KA/CMH) victoria.brown@middlemore.co.nz 021920574 Ian Hutchby Improvement Advisor ian.hutchby@middlemore.co.nz 0212423681 (KA/CMH) Diana Dowdle Delivery Manager (KA/CMH) Diana.Dowdle@middlemore.co.nz 0212214200 (Chair) Dr Neil Houston Clinical Director for Quality Neil.Houston@waitematadhb.govt.nz 0272600323 and Safety in Primary Care (WDHB) Dr Lisa Fuller Clinical Lead WDHB/ADHB Francis Mathew Project Manager (WDHB) Francis.Mathew@waitematadhb.govt.nz 021521092 Kelly Fraher Improvement Specialist (WDHB) Kelly.Fraher@waitematadhb.govt.nz 021861532 Tim Denison Improvement Advisor (ADHB) TDenison@adhb.govt.nz 0211802695 Cheryl Christopher Improvement Advisor (ADHB) CChristoph@adhb.govt.nz 021735024 Tim Wood Deputy Director Funding (WDHB& ADHB) tim.wood@waitematadhb.govt.nz 021784472 August 2017 9

Operational Group The Operational Group is made up of the regional project team (see above) and the PHO facilitators (see below), and meetings are held every six weeks at the NRA in Great South Road, Penrose. It currently has the following members: Name Role PHO Email Carol Ennis Primary Care Nurse Director Auckland PHO Carol@aucklandpho.co.nz David Harrison Nurse Leader East Health davidh@easthealth.co.nz Jean Lyle Practice Facilitator Auckland PHO Jean@aucklandpho.co.nz Jennell Bonner Practice Advisor National Hauora Coalition jennellb@nhc.maori.nz Judy Cameron Practice Facilitator judy@aucklandpho.co.nz Kim MacRae Practice Advisor Alliance Health Plus kimm@alliancehealth.org.nz Rosey Buchan Nurse Leader Comprehensive Care/ rbuchan@comprehensivecare.co.nz Workforce development Waitemata PHO Maureen Tuigamala Lead Network Performance National Hauora Coalition marleent@nhc.maori.nz Nicki Brentnall Quality Coordinator Procare NicolaB@procare.co.nz Philippa Little Practice Advisor Alliance Health Plus philippal@alliancehealth.org.nz Rachel Ta'ufo'ou Practice Advisor Alliance Health Plus rachelt@alliancehealth.org.nz August 2017 10

6. Practice Engagement To ensure consistency across the region was achieved, Ko Awatea and the Counties Manukau, Auckland and Waitemata District Health Boards worked together to engage 23 GP practices for year one of the programme (June 2014 June 2015). They then set about identifying three high-risk areas that, if improved, would have the biggest impact on reducing patient harm, and they were: Reconciling medicines immediately after hospital discharge; Handling lab results; and Management of Warfarin (a blood thinning drug). All three areas saw significant improvements, with the overall reliability of: The reconciliation of medication immediately after hospital discharge process increasing from 15% to 62%; The management of the lab results process increasing from 60% to 90%; and The management of the Warfarin process increasing from 10% to 74%. These first year results were so positive the SiP programme was expanded in year two (2015/2016); the number of GPs increased to 32 and a new care bundle (Opioid prescription) was added. Improvements showed: The reconciliation of medication immediately after hospital discharge process increasing from 30% to 80%; The management of the lab results process increasing from 29% to 88%; The management of the Warfarin process increasing from 35% to 78%; and The management of the Opioids process increasing from 20% to 58%. The programme is currently ending its third year (2016/2017), and has expanded to include a total of 42 GP practices and two more care bundles; the management of cervical smears and COPD (chronic lung disease) patients. Improvements showed: The reconciliation of medication immediately after hospital discharge process increasing from 39% to 85%; The management of the lab results process increasing from 70% to 97%; The management of the Warfarin process increasing from 23% to 90%; The management of the Opioids process increasing from 10% to 38% The management of Cervical smear increasing from 25% to 42%; The management of Chronic lung disease from 20% to 42%. The three Auckland DHBs agree to pay up to $5,400 to each of the participating practices as a reimbursement towards staff time spent attending the collaborative learning activities and working on their chosen bundle within their practice. August 2017 11

7. Requirements of General Practice CMH Each participating practice is required to establish a two to three (minimum) person Patient Safety Champion team that should preferably comprise of a GP, a practice nurse and a senior administration team member. The following are the accountabilities of the participating general practices within Counties Manukau Health (CMH) for the 2017/2018 programme: Attend four evening learning sessions (August, November, March & June/ July) Collect monthly care bundle data on a sample of patients on the safety and reliability of a chosen care bundle Attend facilitated, practice-based meetings to reflect on this data and identify areas of change to be tested within the practice Implement and drive the changes within the practice. 1. Improving the Reliability of High Risk Processes Practices will collect data on their practice systems in the chosen clinical area and submit to the DHB by the 10th of each month (from August 2017 to June 2018) Practices should review the data and decide what changes to make to their practice systems to make their care safer and more reliable in this area. They will be encouraged to share changes they have made in their practices at learning sessions. For 2017/2018 the clinical areas are: Medication reconciliation following discharge Prescribing and monitoring of Warfarin Test result handling system Prescribing and monitoring of Methotrexate and Azathioprine (DMARDs) * Opioid prescribing Management of Cervical Smears Management of COPD Antenatal care* Pediatric prescribing (Anti-microbial) * Polypharmarcy* CVDRA* Diabetes* Gout* *New for 2017 2. Developing Practice Culture Practices choose one of the following tools they wish to use to develop their practice s culture. Practices will be taught how to use these tools in learning sessions and/or in facilitated practice sessions. The tools are: A Trigger Tool (structured case review) with a sample of patients to identify and reduce patient safety incidents (NB: this tool will be conducted as a facilitated session within the practice with the Safety in Practice Clinical Lead, Improvement Advisor and your PHO facilitator at the start of the programme) A Safety Climate Survey to understand how best to establish and nurture an enhanced patient safety culture within the practice Significant event analysis a process to maximise the learning from adverse events to prevent recurrence Patient Experience how to partner with your patients for best care. Practices will reflect on the learning from the tools and identify any actions to be taken as a consequence. August 2017 12

8. Audit Care Bundles 8.1 Current Audit Bundles A care bundle is a structured way of improving processes of care to deliver enhanced patient safety and clinical outcomes. It s a way of ensuring that patients receive all the evidence-based care to which they are entitled. In relation to care bundles, this means ensuring that patients receive optimum care at every contact. The principle of SiP is that the practices can complete a simple set of measures that capture the key moments for a particular area of care. Each month, the practice must audit a minimum of 10 patient records and see if the measures were achieved. Based on these results, change ideas can be tested. Each audit bundle had a document developed with the rationale/evidence for why the question was used. The bundles all follow a similar process: Run a query in patient management system Randomly select 10 patients from list Complete audit on 10 patients Add data to the spreadsheet Submit data to project team. Based on the findings of these audits and other quality improvement activities (e.g. process mapping, data analysis, cause and effect analysis), opportunities to improve how the care associated with the bundle is provided can be identified. The measures are collected monthly and then a run chart is produced so they can identify areas of their systems that need to be improved. See below for an example of a run chart for medication reconciliation. August 2017 13

Below are the aims and audit questions for each of the current care bundles: Reliable System for Managing Cervical Smears Aim 100% eligible women will have the opportunity to have their cervical smear and the results acted upon appropriately within a clinically recommended timeframe. This bundle looks at how effective practice process are for managing women aged 20-69 who needs a cervical smear or how follow up plans are managed. The audit will determine if there is: 1. Documented evidence that a smear has been completed within the clinically defined timeframe 2. An appropriate recall for their next smear within the PMS system 3. A clear clinical reason why a smear is not required and documented (if applicable) 4. Documented evidence that the last smear result was conveyed to the patient with a clear follow up plan? 5. Overall compliance. COPD Management This bundle looks at the processes in place to help prevent the progression of COPD and in turn reduce the morbidity of patients. Aim 100% of all COPD patients to receive optimal care in a safe standardised process. For all selected COPD patients, identify that there is: 1. An up-to-date smoking history and cessation advice recorded yearly in non-smokers and at every visit in smokers 2. Is there documented spirometry and chest x-ray for all patients with diagnosed COPD 3. Documented evidence that the patient s ability to use an inhaler device has been assessed by a nurse or doctor in the past six months 4. Documented evidence of advice on physical activity including pulmonary rehabilitation and Self- Management education where appropriate 5. Documentation of vaccination pneumococcal and influenza status with appropriate recalls 6. Documented evidence of exacerbation management in the last 12 months 7. Overall compliance. Medication Reconciliation Aim All discharge summaries received will be reviewed with both medication reconciled and actions completed within seven working days. 1. Has medication reconciliation occurred within seven calendar days of the EDS being received? 2. Has the patient's regular medication list been updated? 3. Is it documented that any significant medication changes have been discussed with the patient or their representative within seven calendar days of receipt? 4. Have all the measures been met? August 2017 14

Opioid Prescribing Aim 100% of prescribing for Opioid Derived Analgesia will follow a safe standardised process. 1. Is there a clear indication within the clinical record for a moderate to strong opioid derived analgesic to be used/initiated? 2. Is there evidence that the analgesic ladder has been used prior to the patient being prescribed a moderate to strong opioid derived analgesic? 3. Is there a clear management plan? (side effects, breakthrough pain, self-management) 4. Has clinical review occurred effectively prior to the second prescription being issued? 5. Have all measures been met? Results Handling Aim 100% of all lab results will be actioned within seven days. 1. Was a definitive decision recorded by a clinician on EACH test result within seven calendar days of being received? 2. Have the decisions for EACH test result been actioned by the practice including appropriate recalls and tracking of the actions? (if no actions are required record at N/A) 3. Was the patient informed as instructed? (If no instruction record at N/A) 4. Overall compliance. Warfarin Management Aim 100% of patients on Warfarin will be managed within safe margins around the therapeutic target and 100% of practices will have developed consistent processes around INR testing. 1. Is there evidence that the last advice on Warfarin dosing given to the patient followed current local guidelines? 2. Is there evidence that the last advice re the interval for blood testing given to the patient followed current local guidelines? 3. Since the last blood test, has the patient been taking the correct dose as ordered by the treating GP? 4. Has the INR been taken within seven days of the planned repeated INR? 5. Is it recorded that the patient has received education about warfarin in the last 12 months? 6. Have all measures been met? Measure Rationale Following the first 18 months of SiP, change packages were developed. These include the rationale for the audit questions, guidance for completion, driver diagrams and changes that have been successfully tested by previous participants. Change packages for all bundles are available on the SiP website http://www.safetyinpractice.co.nz. August 2017 15

8.2 New Bundles for Year Four (2017/2018) For year four, the following bundle has been developed based on the bundle of the same name developed in Scotland. Disease Modifying Anti-Rheumatics Drugs (DMARDs) Aim 100% of patients on Disease Modifying Anti-Rheumatics Drugs (DMARDs), particularly Methotrexate and Azathioprine, have their drugs safely prescribed and reliably monitored. 1. Has there been a full blood count in the past 12 weeks (AZA) / 8 weeks (MTX) as per local guidance? 2. If any abnormal results in the previous 12 weeks (WBC <3.5 x 10 9 /L, Neutrophils <2.0 x 10 9 /L, Platelets <150 x 10 9 /L, ALT >x2 upper limit (>60) has action been recorded in the consultation record? 3. Is there a documented review of blood tests prior to issue of the last prescription? 4. Has the patient ever had or declined an influenza vaccine in the last 12 months? 5. Has the patient been asked within the last 3 months about any side effects, e.g. nausea, mouth ulcers, fever, sore throat, abdominal pain, jaundice, dry cough, shortness of breath, diarrhoea? 6. Has the patient been given written information about the DMARD they are taking within the last 12 months? 7. Have all measures been met? Practices who have completed two or three years of SiP and have completed all areas of the programme can work on developing their own bundle in an area of care alongside the Clinical Lead and Improvement Advisor. One practice embarked on this in year three, and the result is now a new care bundle for year four being: Cardiovascular Disease Risk Assessment (CVDRA) Aim 100% of all eligible patients will have had a cardiovascular disease risk assessment (CVDRA) carried out and the results conveyed to them in a safe and standardised process. 1. If the patient is eligible for a CVDRA recall to be in place, is there a recall? 2. Was the most recent recall acted upon/lab forms given? 3. If lab tests were completed was a CVDRA completed? 4. Was a clinical decision made as a result of the CVDRA? 5. Have the required actions been completed/significant risk factors addressed? 6. Has documented smoking cessation advice been offered at every opportunity in the last year for all smokers? The below audit bundles are also being developed based on feedback from practices and PHOs. These bundles will have a strong link to system level measures. These bundles will be developed over the next year alongside practices that have been in the programme for the last three years. The proposed bundles are: Diabetes Gout Antenatal care Paediatric prescribing (anti-microbial) Polypharmacy. August 2017 16

9. Query A query has been developed for all bundles in MedTech and My Practice. Current queries are available from the Safety in Practice website: http://www.safetyinpractice.co.nz. For each query: - Download the query from http://www.safetyinpractice.co.nz - Open the relevant patient management system - Double click the downloaded query and this will open the query within the patient management system. For COPD and cervical smear queries, please open files and view screen shot of MedTech. Below is an example of the query for discharge summaries from the past three months for the medicine reconciliation audit. 9.1 Random selection of patients to audit Once a list of patients who have been prescribed Warfarin in the past three months has been generated, 10 patients then need to be randomly selected. The ideal way to complete this process is to order the patient list by date of last prescription then select every third or fourth patient on the list. For smaller practices with a limited number of patients on their register, this might need to be every second patient or possibly the most recent 10 INR results if there are less than 20 patients. 9.2 Complete data collection The data can be collected in two ways; either by printing and completing the Bundle Data Collection Form Data or by entering directly into the Data Collection Form tab on the spreadsheet (below). Each question has defined responses, generally yes or no. A decision must be made on whether the patient being reviewed meets these criteria. If it is unclear if they do, select No. August 2017 17

Practice Name Note: This sheet is not for entering data on your computer, it is only for printing and completing by hand. Once you have done this, enter your data on the appropriate data collection form. Please circle response as appropriate Review Month Patient Is there evidence that the last advice on Warfarin dosing given to patient followed current local guidelines or used computer assisted decision making? Is the target INR and duration of treatment clearly documented in the notes? Since the last blood test, has the patient been taking the correct dose as ordered by the treating GP? Has the INR been taken within 7 days of the planned date? Is it recorded that the patient has received education about warfarin in the last 12 months? Comments 1 Y N Y N Y N Y N Y N 2 Y N Y N Y N Y N Y N 3 Y N Y N Y N Y N Y N 4 Y N Y N Y N Y N Y N 5 Y N Y N Y N Y N Y N 6 Y N Y N Y N Y N Y N 7 Y N Y N Y N Y N Y N 8 Y N Y N Y N Y N Y N 9 Y N Y N Y N Y N Y N 10 Y N Y N Y N Y N Y N Spreadsheet completion With the information collected on the paper form, complete one line per patient using the drop down boxes as shown below: Review Date Is there evidence that the last advice on Warfarin dosing given to patient followed current local guidelines or used computer assisted decision making? Is the target INR and duration of treatment clearly documented in the notes? Since the last blood test, has the patient been taking the correct dose as ordered by the treating GP? Has the INR been taken within 7 days of the planned date? Is it recorded that the patient has received education about warfarin in the last 12 months? 01/08/2014 Yes Yes Yes Yes Yes Yes 01/08/2014 Yes Yes No Yes Yes No Overall Compliance August 2017 18

10. Tools 10.1 Trigger Tool In addition to the audit bundles, each practice in year one to three of the programme was required to complete the Trigger Tool at least once during the year. The SiP Trigger Tool was created using a tool developed in Northland 3 and taking into consideration the Scottish experience. In year four of the programme, the Trigger Tool will be utilised as follows: For CMH practices for new practices a compulsory tool at the start of the programme led by the SiP Clinical Lead. A Trigger Tool is a simple checklist used to screen medical records for potential harm. They facilitate the structured, focused and rapid review of a sample of medical records by primary care clinicians. Trigger tools are ways of identifying and documenting patient harm using a systematic record review process so that steps can be taken to minimise the risk of harm and to improve the patient experience of care. Triggers are flags for patient harm. They act as a prompt to the reviewer to search the record in more depth for a potential unintended consequence of treatment. The focus of the Trigger Tool is on identifying avoidable harm, not error. It is therefore about the systems of care, not the individuals who deliver the care. The scale and type of harm that is detected is variable and dependant on a number of factors. The practice can complete it on any patient group they like, but the recommended approach is considering a patient group they are concerned about (as per page six of the tool) The triggers that practice look for are: 1. 2 consults with a Prescriber in seven days 2. New diagnosis of cancer within three months 3. New allergy/adverse reaction add to PMS 4. Cessation of medications 5. Reduction in medication 6. Out of hours / A&E attendance 7. Hospital discharge 8. Hb < 100 9. egfr <35 10. Death within review period. The Trigger Tool is designed to be completed within two to three hours and then discussed at practice meetings to see what learnings can be taken from the triggers and the instances of harm. 3 http://journal.nzma.org.nz/journal/127-1390/6014/ August 2017 19

10.2 Safety Climate Survey The Safety Climate Survey comprises five subject areas (Communication, Workload, Leadership, Teamwork and Safety Systems & Learning) with between four to eight questions for each area. It is designed to give the practice a picture of staff perceptions in each domain and then facilitate discussion to identify opportunities to improve. It provides comparisons between clinical and non-clinical staff, and management and non-management within the practice. In years one to three of SiP, each practice was required to complete the Safety Climate Survey as part of the programme. In year four of the programme, the Safety Climate Survey will be available as an optional tool chosen from a group and completed alongside the care bundle. The survey is ideally completed by every member of staff (https://www.surveymonkey.com/r/cxfttbb) with questions scored from not at all (1) to to very great extent (7). Each domain has a number of questions but generally takes less than 10 minutes per staff member to complete. The results are then collated and returned to the practice. Below is an example of one domain s results: With the results in hand, a practice discussion is held and the reflection tool completed. August 2017 20

10.3 Patient Experience Patient experience content for the programme has developed over the past three years as the programme has evolved. Four to five practices in year two worked on patient questionnaires and changing the way they practiced based on the feedback. In year four, patient experience will be available as a tool for practices to use alongside their chosen bundle. More information is to follow. 10.4 Significant Event Analysis The Significant Event Analysis is a tool new to Safety in Practice. It has been introduced to the New Zealand climate by Dr Neil Houston based on its use in Scotland. There are various tools and questions that can be utilised for this and an example will be available on the SiP website. Significant Event Analysis also called Significant Event Review or Analysis is a technique to reflect on and learn from individual cases to improve quality of care overall. Significant event audits should form part of your individual and practice- based learning and quality improvement. Whether clinical, administrative or organisational, the significant event analysis process should enable the practice to answer the following questions: What happened? Describe what actually happened in detail. Consider, for instance, how it happened, where it happened, who was involved and what the impact or potential impact was on the patient, the team, organisation and/or others. Why did it happen? Describe the main and underlying reasons positive and negative contributing to why the event happened. Consider, for instance, the professionalism of the team, the lack of a system or a failing in a system, lack of knowledge or the complexity and uncertainty associated with the event. What have you learned? Demonstrate that reflection and learning have taken place on an individual or team basis and that relevant team members have been involved in the analysis of the event. Consider, for instance, a lack of education & training; the need to follow systems or procedures; the vital importance of team working or effective communication. What have you changed? Outline the action(s) agreed and implemented, where this is relevant or feasible. Consider, for instance, if a protocol has been amended, updated or introduced; how was this done and who was involved; how will this change be monitored. It is also good practice to attach any documentary evidence of change e.g. a letter of apology to a patient or a new protocol. August 2017 21

11. Sharing the Learnings Learning sessions are a great opportunities to share experience and the learning that a practice has experienced up to that point. Some practices will have the opportunity to share their experiences by presenting, but at each session there are many other experiences of value that won t have been presented. Feedback templates are a simple way of sharing these learnings across the collaborative. 11.1 Learning Session Zero No feedback templates required for Learning Session Zero. 11.2 Learning Session One There is a standardised template (circulated to the teams with an example of how to complete) that is completed by the practice teams prior to the learning session. On the evening of the learning session, the templates are displayed within the venue in the bundle groups to facilitate shared learning across the bundles and across the collaborative in general. The first template: - Give practices the opportunity to readily identify and talk with each other about their improvement work - Shares what the goals are that have been identified so far within the chosen bundle - Includes baseline data, if available. 11.3 Learning Session Two The second template provides information about the practice and: - How the practice has achieved buy-in from the rest of the practice team - Their initial change ideas - An example of a PDSA can be a great success or failure, but ideally achieved learning - If something has changed can be annotated on a chart or using a text box in PowerPoint. 11.4 Learning Session Three The third template: - Shows the progression of change ideas - Shares an example of a PDSA can be a great success or failure, but ideally achieved learning - Shares achievements to date what progress has been made, even if not showing in data. August 2017 22