Safety improvement in primary care

The Safety Improvement in Primary Care project is a remarkable success story. Promoting patient safety in general practice, it formed part of the Health Foundation’s Closing the Gap through Clinical Communities programme, bridging best practice and delivery of care.

The project involved 50 primary care teams from four health boards in Scotland, and has shown such positive results that it has gone on to form the basis of a national programme.

Clinical lead, Dr Neil Houston, explains the project and the results that have been achieved.

What prompted this project?

When we started in August 2010, the Scottish Patient Safety Programme was already doing some great work to increase safety in hospitals. However, 90% of care actually happens in primary care settings. Adverse events do happen, and we believed care could be more reliable.

We started planning a project which would work with GP practices across Scotland to increase patient safety in primary care.  

Tell us about the project

We focused on two key areas highlighted in a review by the Health Foundation. These were: heart failure, which causes the highest incidence of hospital bed days; and high-risk drugs, because 6% of hospital admissions are due to adverse drug reactions.

We planned interventions to improve the reliability of care of patients with heart failure. This meant improving the safety skills and knowledge of practice teams, and developing a safety culture within GP practices. We also wanted to involve patients in improving services.

To improve safety around high risk drugs (particularly drugs like warfarin and methotrexate), we wanted to introduce reliable systems for prescribing, management and monitoring.

What form did the project take?

We ran a breakthrough collaborative with learning sessions every four months. We collected data on each clinical area, looked at case notes to find out where patients had been harmed and identified areas for improvement. We also did an online safety climate survey to prompt practice discussion, and held focus groups with patients.

What were your tasks as clinical lead?

I chaired the project steering group, developing ideas that emerged and adapting our approach in response to ongoing evaluation. I used my experience in education and improvement to facilitate the process. There were a lot of different agendas to manage and coordinate. We had no model to go on – it was all new ground.

What were the highs and lows of running the project?

The highs were working with incredibly motivated people. It was rewarding to see strengths emerging, champions appearing, and sceptics being converted, coming back keen to educate others.

The biggest challenge was dealing with competing priorities. It was difficult for participants to return from our learning days and find time to meet, talk and engage their team in the work.

What were the key outcomes?

Practices reported that care of patients had become safer and more reliable with ‘routine annual checks’ introduced, ‘guidelines developed’ and ‘specialist clinics now taking place’. Whether we have reduced heart failure admissions will only show over time.

We found practices had improved their safety culture and were more efficient. For example, we implemented guidance on dealing with blood test results, and saw they were being managed more systematically, halving the number of blood tests needed.

What impact has the project had on staff and patients?

Our system of measuring ‘bundles of care’ (for example to identify if patients with heart failure were receiving regular reviews, appropriate drugs, vaccinations and education) spanned the work of the team and therefore led to improved teamwork.

Practices reported that they had started to involve patients and they couldn’t believe they hadn’t done it before. It had gone well and patients were delighted to be part of the work.

What is the project's legacy?

The national Scottish Patient Safety Programme in Primary Care will be rolled out to all GP practices across Scotland from 2013. This is based in part on our work and will include the care bundles, trigger tools and safety climate surveys we developed and tested. I will be the clinical lead, and all GP clinical leads from the project will be involved, for continuity of knowledge and skills.

I’ve presented our work at international conferences in the US and France, and people from all over the world want to use our tools. It’s very satisfying.