Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff perspectives

Evaluation of the psychometric performance of the Spanish and Catalan versions of the patient reported experiences and Outcomes of Safety in Primary Care (PREOS-PC)-Compact questionnaire

BACKGROUND

Patients provide a unique, irreplaceable, and essential perspective in evaluating patient safety. The suite of Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) tools are a notable exception to the scarcity of patient-reported patient safety measures. Full evaluation of their performance has only been attempted for the English version, thereby limiting its international applicability.

OBJECTIVES

To assess the psychometric performance of the Spanish and Catalan versions of the PREOS-PC-Compact.

METHODS

Cross-sectional validation study. We used Classical Test Theory methods to examine scale score distribution, internal consistency, and construct validity; and Item Response Theory (IRT) methods to further explore construct validity.

RESULTS

3287 patients completed the Spanish version, and 1007 the Catalan version. Similar results were obtained for both versions. Confirmatory Factor Analysis supported a single construct for each scale. The correlations between PREOS-PC-Compact scales and known group analysis suggested adequate construct validity (inconclusive for known groups at the provider level). All four multi-item scales demonstrated adequate internal consistency reliability (α > 0.7), which was only confirmed for test-retest reliability for 'Practice activation.' A sample between 60-90 patients per practice was estimated sufficient to produce scores with reliability > 0.7 for all scales except for harm scales. IRT models showed disordered thresholds for 'Practice activation' and 'Harm burden' but showed excellent fit after reducing the response categories.

CONCLUSION

The Spanish and Catalan versions of the PREOS-PC-Compact are broadly valid and reliable tools to measure patient safety in Spanish primary care centres; confirmation of lower-than-expected test-rest reliability merits further examination .

Examining drivers of self-harm guideline implementation by general practitioners: A qualitative analysis using the theoretical domains framework

OBJECTIVES

This study aimed to (1) examine barriers and enablers to General Practitioners' (GP) use of National Institute for Health and Care Excellence (NICE) guidelines for self-harm and (2) recommend potential intervention strategies to improve implementation of them in primary care.

DESIGN

Qualitative interview study.

METHODS

Twenty-one telephone interviews, semi-structured around the capabilities, opportunities and motivations model of behaviour change (COM-B), were conducted with GPs in the United Kingdom. The Theoretical Domains Framework was employed as an analytical framework. Using the Behaviour Change Wheel, Behaviour Change Techniques (BCTs), intervention functions and exemplar interventions were identified.

RESULTS

GPs valued additional knowledge about self-harm risk assessments (knowledge), and communication skills were considered to be fundamental to high-pressure consultations (cognitive and interpersonal skills). GPs did not engage with the guidelines due to concerns that they would be a distraction from patient cues about risk during consultations (memory, attention and decision processes), and perceptions that following the guidance is difficult due to time pressures and lack of access to mental health referrals (environmental context and resources). Clinical uncertainty surrounding longer term care for people that self-harm, particularly patients that are waiting for or cannot access a referral, drives GPs to rely on their professional judgement over the guidance (beliefs about capabilities).

CONCLUSIONS

Three key drivers related to information and skill needs, guideline engagement and clinical uncertainty need to be addressed to support GPs to be able to assess and manage self-harm. Five intervention functions and ten BCT groups were identified as potential avenues for intervention design.

Development of 2 Short Patient-Report Questionnaires of Patient Safety in Primary Care

OBJECTIVES

The Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) is a valid and reliable instrument (61 items across 5 domains) of patients' perceptions of safety. Stakeholder feedback has supported shorter versions for improving choice and facilitating uptake of routine patient-centered evaluation. We sought to develop 2 shorter versions of PREOS-PC: one including the shortest possible scales that met established measurement performance standards and a screening version including a single item per domain.

METHODS

A total of 1244 patients from 45 general practices across England completed PREOS-PC questionnaires. All scale items in PREOS-PC underwent Item Response Theory analysis, applying standard criteria for the item reduction. Cognitive debriefing from 10 patient interviews allowed for the assessment of the instruments' readability. The instruments' psychometrics properties were reassessed in a validation sample of 1557 patients in 21 English general practices.

RESULTS

"PREOS-PC Compact" includes 25 items and 2 open-ended questions across the 5 domains, 44% of the length of the original instrument. "PREOS-PC Screen" consists of 6 items: the best-performing single items for 2 domains, 1 item modified from original items for each of the remaining 3 domains, and 1 open-ended question. The evaluation of the instruments confirmed they were acceptable to patients and met standards for readability; construct, convergent, and divergent validity; and reliability.

CONCLUSIONS

PREOS-PC Compact meets high-performance standards while reducing patient burden for routine monitoring of patient safety in primary care. PREOS-PC Screen is a concise tool apt for incorporation into audits and to target more in-depth review as needed.

A comparative assessment of two tools designed to support patient safety culture in UK general practice

BACKGROUND

The NHS has recognised the importance of a high quality patient safety culture in the delivery of primary health care in the rapidly evolving environment of general practice. Two tools, PC-SafeQuest and MapSaf, were developed with the intention of assessing and improving patient safety culture in this setting. Both have been made widely available through their inclusion in the Royal College of General Practitioners' Patient Safety Toolkit and our work offerss a timely exploration of the tools to inform practice staff as to how each might be usefully applied and in which circumstances. Here we present a comparative analysis of their content, and describe the perspectives of staff on their design, outputs and the feasibility of their sustained use.

METHODS

We have used a content analysis to provide the context for the qualitative study of staff experiences of using the tools at a representative range of practices recruited from across the Midlands (UK). Data was collected through moderated focus groups using an identical topic guide.

RESULTS

A total of nine practices used the PC-SafeQuest tool and four the MapSaf tool. A total of 159 staff completed the PC-SafeQuest tool 52 of whom took part in the subsequent focus group discussions, and 25 staff completed the MapSaf tool all of whom contributed to the focus group discussions. PC-SafeQuest was perceived as quick and easy to use with direct questions pertinent to the work of GP practices providing useful quantitative insight into important areas of safety culture. Though MaPSaF was more logistically challenging, it created a forum for synchronous cross- practice discussions raising awareness of perceptions of safety culture across the practice team.

CONCLUSIONS

Both tools were able to promote reflective and reflexive practice either in individual staff members or across the broader practice team and the oversight they granted provided useful direction for senior staff looking to improve patient safety. Because PC SafeQuest can be easily disseminated and independently completed it is logistically suited to larger practice organisations, whereas the MapSaf tool lends itself to smaller practices where assembling staff in a single workshop is more readily achieved.

Future Health Today: codesign of an electronic chronic disease quality improvement tool for use in general practice using a service design approach

OBJECTIVE

To codesign an electronic chronic disease quality improvement tool for use in general practice.

DESIGN

Service design employing codesign strategies.

SETTING

General practice.

PARTICIPANTS

Seventeen staff (general practitioners, nurses and practice managers) from general practice in metropolitan Melbourne and regional Victoria and five patients from metropolitan Melbourne.

INTERVENTIONS

Codesign sessions with general practice staff, using a service design approach, were conducted to explore key design criteria and functionality of the audit and feedback and clinical decision support tools. Think aloud interviews were conducted in which participants articulated their thoughts of the resulting Future Health Today (FHT) prototype as they used it. One codesign session was held with patients. Using inductive and deductive coding, content and thematic analyses explored the development of a new technological platform and factors influencing implementation of the platform.

RESULTS

Participants identified that the prototype needed to work within their existing workflow to facilitate automated patient recall and track patients with or at-risk of specific conditions. It needed to be simple, provide visual snapshots of information and easy access to relevant guidelines and facilitate quality improvement activities. Successful implementation may be supported by: accuracy of the algorithms in FHT and data held in the practice; the platform supporting planned and spontaneous interactions with patients; the ability to hide tools; links to Medicare Benefits Schedule; and prefilled management plans. Participating patients supported the use of the platform in general practice. They suggested that use of the platform demonstrates a high level of patient care and could increase patient confidence in health practitioners.

CONCLUSION

Study participants worked together to design a platform that is clear, simple, accurate and useful and that sits within any given general practice setting. The resulting FHT platform is currently being piloted in general practices and will continue to be refined based on user feedback.

Development of the prototype concise safe systems checklist tool for general practice

BACKGROUND

In the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion.

METHODS

An extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews.

RESULTS

In testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful.

CONCLUSIONS

As a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.

Patient safety challenges in primary health care: a scoping review

ABSTRACT Objectives: to identify the patient safety challenges described by health professionals in Primary Health Care. Methods: a scoping review was conducted on the LILACS, MEDLINE, IBECS, BDENF, and CINAHL databases, and on the Cochrane, SciELO, Pubmed, and Web of Science libraries in January 2019. Original articles on patient safety in the context of Primary Health Care by health professionals were included. Results: the review included 26 studies published between 2002 and 2019. Four categories resulted from the analysis: challenges of health professionals, administration challenges of health services, challenges with the patient and family, and the potential enhancing resources for patient safety. Conclusions: patient safety challenges for Primary Care professionals are multiple and complex. This study provides insight into resources to improve patient safety for health care professionals, patients, administrators, policy makers, educators, and researchers.