Jubilee Street Practice: Trigger Tool Findings

1. Jubilee Street Practice: Trigger Tool Findings Date: 5th July 2016

2. Introduction Main findings Context and expectations Reactions to the trial Way forward

3. Increasing demands on general practice over recent years – heavier workloads and the increasing complexity and intensity of work – means there is greater potential to make mistakes • For many clinicians the main reflective work undertaken around safety is significant event analysis and, whilst important, are low frequency and tend to hold the focus of clinical teams to the detriment of areas of high risk that remain in peripheral fields of vision. The challenge for busy GPs is knowing where to look to understand more about how safe their practice is • Trigger tools have been used in primary care for around 10 years. However, the existing design of them has drawbacks that are likely to limit uptake by busy GPs • A trigger tool has been developed and rolled out within Jubilee Street Practice (JSP) and qualitative research was required to understand how well it was received amongst practice GPs and key administrator 3

4. Jubilee Street Practice developed, tested and refined six Emis-based searches to identify patients at higher risk of iatrogenic harm • Searches covered a range of clinical activity: prescribing, critical diagnoses and results handling (falling eGFR, CKD, Heart failure, Low Hb/Ferritin, De-prescribing (polypharmacy), triple threat) • Searches were complemented by smart worksheets which guide clinicians through a reflective process in a way that is straightforward and can be completed in minutes • Completed worksheets can be exported in one click, with patient identifiers removed, to GP’s appraisal folder. So it can be used as evidence of reflective practice for revalidation 4

5. Research objectives • Qualitative research was required to assess the effectiveness of the trigger tools in engaging busy clinicians in work around safety • Specifically to evaluate the trigger tools with regard to: • Initial reactions and any perceived barriers or triggers for usage • Usability and functionality • Value within the context of working practices • Any suggested improvements 5

6. 6 x 20-30 minute depth interviews amongst GPs at Jubilee Street Practice • 3 x face to face • 3 x telephone interviews • 1 x 30 minute face to face depth interview with practice finance administrator (who has overseen logistics of the trigger tool project) • Fieldwork was conducted by Alex Prebble and Phil Croft of CSR from 27th June – 1st July in London 6

7. Context and expectations 7

8. GPs work in a difficult environment Time pressured Whilst not ‘new news’, it is important to set the context of the working environment of GPs of Jubilee Street Practice They are proud of their (and their colleagues’) professionalism and expertise but… • Their work is high volume and high pressure and as a result, they readily admit it is reactive in the main • They acknowledge they feel they cannot always do as good a job as they would like • They are aware that patient safety could be negatively affected as a result

9. Quotes We’re generally reactive. If a patient has a haemoglobin of 8 we act on it but we give responsibility to the patient for the follow up. If they don’t do it there is no system in place to follow it up or highlight that it has not been done. So you might just come across them a year later and act on it Because of the way we work in general practice and the increase in pressures over the last 5-10 years, we don’t always do as good a job as we like … so there is potentially things going on that are unsafe that we don’t know about We all understand the issue of us not always being able to pay attention to everything at all times 9

10. Time spent on reflective practice is squeezed GPs open to ideas which facilitate improvements in reflective practice GPs agree reflective practice is a very important aspect of their work and they are aware of the necessity to audit patients regularly As a result they develop their own individual approach to auditing and meeting guidelines eg reviewing after a practice closes or in their own time at home and / or discussing a patient’s needs with colleagues when necessary Often however, auditing is ad hoc and less rigorous than they would ideally want it to be

11. Positive reactions to the concept of a trigger tool A potentially valuable tool with obvious benefits Given their working environment, a tool which aids reflective practice and identifies potential risk is appealing and GPs can see the potential benefits • Allows for a degree of back checking which GPs do not always have time to undertake • Systemises reflective practice, helping to support individual GP’s ad hoc approaches • Highlights patients they might ordinarily have missed at this juncture • Ensures action can be taken sooner rather than later • Helps override patient inertia or inaction

12. Quotes This is all about best practice and safety We saw a tool like this as a way of improving patient safety and making us feel more comfortable so we definitely wanted to do it We all thought it was an excellent tool for improving safety and for identifying things that, in an ideal world, we would pick up ourselves It’s a great idea. We all saw the value in it. It’s great knowing a system is in place It’s a more systemised approach, it’s a way of making sure the lone clinician is not sat there thinking they are all sorted, they are looking at it in a more holistic way and there is a more holistic way and IT way of picking up things as well as a clinician 12

13. But some reservations re uniqueness Initially I thought this was possibly going to be another alert (of which there are many) so I thought it was going to create work Moving forward, it demonstrates the importance of clearly communicating the nature of the tool, how it is different and its benefits Within the practice there are a number of alerts that highlight potential issues for patients and at the very beginning some GPs wondered to what extent this would be different Consequently some GPs were behind the trial but reserving judgement

14. Some concern over the potential impact on workload Heart said…‘good idea’ Head said…‘hope it doesn’t significantly increase my workload’! And for all, regardless of its potential value, before inception, the level or volume of patients identified via the tool was an unknown • In reality, most GPs at Jubilee Street Practice were hopeful it would be small given their working practices • They have faith in their own expertise and professionalism and in depth knowledge of key patients likely to be most at risk • Belief that the surgery is well run and efficient and they have supportive colleagues But there was still some concern that the tool might identify too many patients at high risk of harm, place further demands on GP time and require additional resource to manage

15. Quotes I was sceptical re. workload…..I wanted to make sure we could do this in the time we have got Initially we didn’t know how much work it would generate If it was producing 50 patients each time then you would wonder how you were going to find the time to action that 15

16. Reactions to the trial

17. Overall very positive reactions GPs and the finance administrator agree the tool has become embedded in working practices at Jubilee Street Practice and part of their routine The benefits are numerous • Easy to use • Changing working practices, providing a more systematic approach to reflective practice which can complement individual ad hoc approaches and increase confidence in clinical judgements • Increases workload but in a positive way leading to improved patient care and clinical practice which all GPs value • Having one person oversee the implementation, management and follow up ensures the tool is less time consuming for GPs Beneficial to GPs and patient care

18. Encouragingly most concerns are assuaged GPs reassured that the number of patients identified each time is likely to be small and manageable In the main, GPs involved are relieved that the number of patients identified is relatively small (between 0 and approx. 4 patients per month per GP) This relief is felt in two ways: • Less increase in workload than feared (although, it still presents GPs with another task to complete and prioritise) • Safety ie reassured they have not been missing significant volumes of patients and provides evidence that existing individual ad hoc approaches to reflective practice are clearly pretty effective

19. Valuable in identifying risk amongst patients who may slip through the net In reality, many patients identified through the tool are high on GPs’ radar as they are often regular visitors and GPs feel they are on top of their condition But the tool also… Identifies patients who are not top of mind and enables action to be taken which may result in avoiding medical issues in the future Highlights patients who have not taken action as a result of previous GP advice and it is a call to action for the GP to contact them Flags up conditions which may have been overlooked by GPs / not coded even though action taken Prevention and safety benefits for the wider patient cohort …

20. Quotes As a safety mechanism it is very valuable. I know at least 1 patient I picked up in the last 6 months whose kidney function had deteriorated and for some reason it wasn’t actioned and this was a reminder to do something about it Its value lies in finding hidden risks and identifying errors before they happen – it’s telling us if something could go wrong more than us being reactive, we’re anticipating it It does make you look harder at risks and if any action is required 20

21. Specific benefits Works well in tandem with the e-clinic • Valuable in providing insight re more vulnerable patients where it is often more difficult to spot problems when they have a variety of problems and are on several medications eg dementia patients in nursing homes • NB. Incentivising CKD is felt to be a key element of making it top-of-mind and encouraging usage GPs have seen tangible benefits even in the short time of the trial

22. Indications the tool is changing behaviour GPs are also aware that the tool has changed the way they look at a patient’s data • It encourages them to look more holistically and in depth at the patient’s records • Looking at other relevant data and even historical information to compare changes in data over time Positive impact on working practices and patient care

23. Quotes It’s very useful. It’s made me look at results in a different way I’m looking at things more holistically now to try and get an overall picture of health and the medication they are on Before if it had come back with an eGFR of 70 I would have thought ‘that looks fine’ but now I will look back and compare previous results and ask ‘why’ a bit more Definitely more thorough and less willing to dismiss things 23

24. Ease of use is praised Very few issues regarding ease of use The tool itself is simple and easy to use; it can be run on Emis and is in a format GPs are familiar with ie a simple spreadsheet, with 2 obvious boxes to fill in Furthermore, the worksheets are easily exported into an appraisal file which a number of GPs have done Any actions are felt to be easy to undertake

25. ...although access could be further improved Any ways to reduce GP switching between patient notes and trigger tool will always be welcomed Although GP engagement is generally high there are ways this could be increased • Access to the trigger tool template should be made easier • Eg via an icon on desktop • Or simply ensuring the latest / most up to date templates and spreadsheets are immediately obvious in the file • Enable direct access to the Excel spreadsheet via a link on the session list

26. Coordinator is essential for implementation At Jubilee Street Practice, the set up and on going management is carried out by the finance administrator • Set up the tool and overseer functionality throughout • Runs it each month / quarter • Highlights patients at high risk for GPs to action • Follows up on any patients not actioned

27. Proactivity of the coordinator is essential I’m like a dog with a bone Coordinator plays a critical role in prompting action. They require persistence and perseverance (esp in the early stages) until habits are formed by GPs Using a variety of methods to prompt action ensures actions are difficult for GPs to forget (or ignore!) • Patient name highlighted in a discrete colour on their session lists • Message reminder appearing on GPs screens • Emails • In-tray • Verbal follow ups / chasing They also valuable in identifying and informing the GP of less common occurrences eg patient identified by > 1 trigger tool

28. THE WAY FORWARD 28

29. The way forward • Launch guidelines to GP practices • Clearly communicate the concept and explain how it differs from other alerts / tools a GP practice uses • Highlight the benefits succinctly to an audience that will invariably be concerned about potential impact on workload • Tone of voice: reassuring (re impact upon workload and ease of use) and positive / confident re benefits to clinical practice • Demonstrate ‘buy in’ for the tool from the practice partners to increase GP engagement • Provide tangible evidence to support the effectiveness of the tool to build confidence • Short term: provide tangible evidence from Jubilee Street Practice trial ie impact upon workload; outcome statistics from the trial eg number of patients flagged, average per GP broken down by tool; provide case studies eg improving care of vulnerable patients • Longer term: Evidence based statistics that demonstrate increased patient awareness, change in behaviour, reductions in referrals to e-clinic, case studies etc 29

30. The way forward • Importance of coordination • Emphasise the need to have one person to oversee the implementation, management and follow up. This ensures the tool is less time consuming for GPs ands runs as smoothly as possible. • Qualities required are organisation and a willingness to be persistent in chasing GPs! • Suggestions re tool improvement • See if access to the trigger tool template could be made easier • Eg via an icon on desktop • Or simply ensuring the latest / most up to date templates and spreadsheets are immediately obvious in the file • Enable direct access to the Excel spreadsheet via a link on the session list 30

31. Phil Croft and Alex Prebble phil/alex@csrinternational.com Phil Croft Director Alex Prebble Associate Director 31