Patient safety and co-production, from the BMJ

I was very excited when I read about this study, about improving inpatient safety by systematically improving communication with patients and families during ward rounds. I could see immediately how this could be transferable to our own setting in the community hospital.

The entry in the paper BMJ is quite short and humble, and it is worth visiting the online version for more detail, and to see the short video clip introducing the key researchers, who describe the design and outline of the project.

https://www.bmj.com/content/363/bmj.k4764

Structured ward rounds aren’t new, and neither is the concept of ‘no decision about me without me’. No-one would deny that families are an important part of the team providing care to patients. Using a structured communication tool has been embedded in our practice for many years. Teach-back is an excellent way of ensuring that the person receiving information has truly understood. The genius idea was to do all these things as a single process, and designing the intervention with service users.

 

 

 

The lead researchers are from the Children’s Hospital in Boston, Harvard Medical School, Mothers against Medical Error, and the Patient-Centred Outcomes Research Institute. They set out to introduce a method of improving communication with families. Their theory that this would improve outcomes was based on the observation that improving communication between clinicians improves safety, and that poor commmunication is a leading cause of adverse events.

The study group was made up of over 100 people, patients, nurses, family members, doctors, health literacy experts, researchers and medical educators. They co-produced the structured ward-round tool, to be used on ward rounds where the family is present. The communication tool is called I-PASS. They also produced a training package and a range of support tools including patient information leaflets.


A word about communication tools: We use SBAR locally, whereas I-PASS is the tool used in the study. It is designed to be used for structured communication with patients and families. It focuses more on the recommendations, and adds synthesis and teach-back as part of the communication tool.

I–Illness severity (family reports if child was better, worse, or same); nurse input solicited
P–Patient summary (brief summary of patient presentation, overnight events, plan)
A–Action list (to-dos for day)
S–Situation awareness and contingency planning (what family and staff should look out for and what might happen)
S–Synthesis by receiver (family reads back key points of plan for day, prompted by presenter, supported by others as needed)


The measures used were:

  • Outcome measure: Looking at error rates, and harmful errors
  • Outcome measure: Patient and family satisfaction
  • Balancing measure: Length of ward round
  • Balancing measure: Amount of teaching on ward round.
  • Process measure: Communication processes on ward round.

Although overall error rates were unchanged, harmful medical errors decreased and Satisfaction scores rose and communication processes improved. There was no significant impact on ward round length or teaching on ward rounds.

My own experience over the years has been that I have shifted from asking family members to leave the room during rounds, to asking if they can stay. The conversations around progress and plans for care involve families and patients equally. Bringing in students adds a dimension of teaching, usually in patient-centred language, and it enriches the discussion. These conversations lead to patient-centred decisions, which are understood by relatives as well as the patients.

In the words of Helen Haskell, president of Mothers against Medical Error, one of the lead researchers, ‘It doesn’t just feel good, it can help improve the safety and quality of care – I would add, improve health literacy, agency and opportunity for realistic, patient centred care to be forefront of care planning. This study is a model of how families and care provides can co-produce an intervention to make care safer and better.’

And more realistic.

 

The Handbook of Non-Drug Interventions

Thank you to the British Journal of General Practice for pointing me in this direction. HANDI is a project launched by the Royal Australian College of General Practitioners in 2013, to promote effective non-drug treatments. Now the RCGP is partnering with the RACGP to bring this approach to the UK.

https://www.racgp.org.au/clinical-resources/clinical-guidelines/handbook-of-non-drug-interventions-(handi)/handi-interventions

The HANDI resource collects evidence based non-drug interventions relevent to and practical for GPs. Many of the interventions on the webpage are common-sense, and practical. Many of them are treatments I already use or prescribe, like the Epley manoevere, or wet combing for headlice. There are other recommendations that I had previously dismissed, not realising that there was an evidence base.

Delivering non drug interventions in practice promotes health literacy and reduces clinical dependence; for these interventions to be effective, patients and families will need to understand how they will help, and can apply the learning in the future.

Prevention of falls – co-producing safety at home.

I read the BMJ every week, and tag the articles that might influence my practice. This time, the article that caught my eye was about falls:
https://www.bmj.com/content/364/bmj.l880. The summary – assessment by an occupational therapist, and making your home safer works well in patients at high risk of falling.

We’ve all been there, talking to patients about their rugs, the hazardous route round the bed with all the slippers in the way. Patients like the way they live, and just handing out advice doesn’t always make a difference.

This article has a great wee box on the co-production of safety at home, how to make very real improvements. The language is quite technical, so I have paraphrased this below. I’m so excited about it that I may well make a waiting room display on the subject.

  • If you are 65 or older and live at home, your risk of falls in the future is higher if you’ve had a fall in the last year, use a mobility aid, need help with basic activities, take medications that might make you sleepy, or if you are worried about falling
  • An assessment of where you live by an occupational therapist could reduce your risk of falls
  • The assessment involves a visit from the occupational therapist, who will recommend changes to tasks and your environment. These suggestions aim to reduce hazards and improve your independence and safety.
  • The occupational therapist may also suggests gadgets and technology to improve your safety at home, such as an emergency buzzer.
  • Occupational therapists typically ask you to identify what you think puts you at risk of falling, and you jointly problem-solve and agree on solutions.

I love that last sentence.

WHEN PATIENTS INVENT TO HELP THEMSELVES

It has been a long time since I blogged, but not for lack of ideas, more a deluge of concepts and ideas, combined with the ever-present day job.

Today, I read an article in the BMJ, (click here to read it yourself) and it has lit a slow fuse. The article is about the ultimate patient engagement, where individuals with a condition create solutions that revolutionise care. 

Patients really understand what it is like to live with their condition, to come to terms with how it will affect their living and their dying. Patients who have been given the opportunity to understand what their condition is, and how it will progress, patients who have time to focus on their own solutions, these are the people who are coming up with the solutions that healthcare industry had never considered. 

This is the ultimate patient engagement, where patients have found what is on offer doesn’t meet their needs, where the risks are unacceptable, or the outcomes just not good enough. 

The inventions covered include a new type of surgical prosthesis for aortic root problems in Marfan’s disease, a smart ileostomy bag that tells you when it needs attention, an app to self-manage repeat prescriptions and medication compliance, another IT solution that uses CBT to improve sleep, an physiotheraby device for hand rehabilitation. 

The people behind these innovations are all persistent, have really understood the issues they are trying to solve, and have been steadfast in their pursuit of developing and sharing their ideas for the good of people like themselves. For several, they comment that it has been a long, frustrating process. Tal Goldsworthy, the inventor of the aortic root device, comments ‘If I had known it was going to be this hard, I really wouldn’t have bothered’ – but never the less, he has devised a safer alternative to aortic root replacement, and 200 patients have been fitted with his device. 

What these innovaters have found in their paths to success has been a willing clinical supporter. In general, one of the key hooks is being able to show that the innovation makes for better care without adding complexity. 

The message – ‘if you are a doctor who believes in the technology, then two words are key: be brave’. It is so much easier not to do something, but with courage you can help technology to really grow’. Patients have their own lives to enhance, and that is a powerful motivator, but we need to be there as clinicians to make new ideas work.