The dynamics of patient safety: managing low risk symptoms in primary care through communication
Georgia Black(1), Katriina Whitaker(2)
(1)UCL Department of Applied Health Research, (2)University of Surrey
Background: Fast, safe referral pathways are crucial to the timely diagnosis of life-threatening diseases such as cancer and heart disease. The patient safety of a referral pathway depends on a range of factors from care coordination, continuity of information and patient characteristics. In England, patients with high risk symptoms receive expedited referrals that ensure a specialist appointment within a two-week period. For patients with low risk symptoms that are causing concern, a gap in safe referral routes has been identified. Delays are caused by: long waits for non-urgent referrals, multiple GP visits before referral leading to fragmented and uncoordinated care, lack of explicit pathway for follow up appointments, and variation and delay in access to diagnostic testing. Patient safety in relation to timely referral at the primary care level is managed by the patient-GP conversation in relation to symptoms, yet little is understood about what optimal interactions would involve. This video observation study used a combination of qualitative methods to explore real-life patient GP communication about symptoms.
Method: We invited men and women (aged 50 and over) reporting to primary care with symptoms (and their GP) to participate in video observation, resulting in n=200 filmed consultations with 10 GPs in 7 practices across London and Surrey. We also interviewed a sub-set of patients (n=20) and their GPs (n=7) about specific consultations. Our findings are based on the interview data and a subset of n=80 consultation videos, during which at least one new problem, or a persistent symptom was discussed. A thematic analysis approach enabled us to identify important themes regarding symptom description and elicitation in GP patient conversations with relevance to early diagnosis and patient experience.
Results: We found that safety in GP-patient conversations is dynamic, and is particularly dependent on the negotiation of differing views about the presenting problem’s significance. These negotiations may result from cognitive factors such as differences in knowledge between GP and patient, or misjudgements about true motives. They may also result from emotional factors such as fear of diagnostic procedures. We found that patient safety is particularly compromised by conversations in which the difference in views is either not recognised or stays unresolved, and may lead to deleterious patient behaviour after the consultation such as non-attendance at specialist appointments or fragmented approaches to help-seeking. This creates potential for diagnostic delay. Techniques to improve safety are difficult, requiring unintuitive rhetorical or communicative devices such as ‘teach-back’.
Implications: Our findings suggest that the dynamics of doctor-patient conversation in primary care can impact how patients behave after a consultation, with potentially harmful consequences for timely diagnosis. With increasing demands and expectations related to primary care, our findings highlight the complexity of managing patient safety in the presence of low risk symptoms. By highlighting gaps with potential to cause patient harm, our findings can be applied to augment their anticipation, detection and bridging, and ultimately lead to improving patient outcomes.
Strengthening the Processes and Practices of Disclosure and Discussion with Families After Serious Incidents in NHS Maternity Care: Initial Findings from the DISCERN Study.
Mary Adams(1), Julie Hartley(1), Rick Iedema(1), Alexander Heazell(2), Maureen Treadwell(3), Charlotte Bevan(4), Maria Booker(5) Jane Sandall (1)
(1)King's College London, (2)University of Manchester, (3)Birth Trauma Association, (4)Stillbirth and Neonatal Death Charity, (5)Birthrights
Background: One central aspect of improvement in critical incident review and investigation is listening and engaging sensitively with women, patients and families throughout investigations, to ensure that questions and concerns are heard, regret is expressed, and that any assurance that lessons have been learned is meaningful (Gallagher 2006; Iedema 2011; Wu 2017). In NHS maternity care, the stakes for improving the felt involvement of women and families in understanding incidents that have led to their harm are particularly high (Department of Health 2017; Magro 2017; Kenyon 2017). Despite a raft of high-level policy drivers directed at NHS maternity services for improving practices of candour and of women and family involvement, there is limited understanding of the actual critical factors required to enable felt improvements in these complex and highly emotive situations, processes and practices. Little is known about the consequences of attempted improvements for the different participants, including staff, involved.
Methods: Using a realist evaluation perspective (Pawson 2013), we approach improvements in the processes and practices of disclosure and discussion with families after serious incidents as a complex social intervention. This perspective seeks to identify ‘what works, for whom, in what circumstances, in what respects, why and to what effect?’. To inform the evaluation, we conducted a realist review that included a literature review to inform the focus of one-to-one, semi-structured, audio-recorded interviews with 22 participants, purposively selected for maximum diversity of interests in, and experiences, of incident review and investigation improvement involving women and families.
Results: Critical factors identified in the literature and explored in the interviews were: (1) the significance of multidisciplinary and cross-service working for organising dialogue with women and families; (2) the value of structured family support or advocacy, particularly for those involved in complicated and multi-agency investigation processes; (3) the necessity of robust systems to support staff undertaking these tasks; (4) the location of these innovations within wider service or Trust-level processes that routinely includes women, patients and families in the ongoing governance of safety and quality improvement work.
Implications: These findings document critical factors in the proposed policy and managerial work required to organise improvements in communicating with women and families after a serious incident in maternity care. The next stages of our study will investigate (1) in-depth and ethnographically, if and how these critical factors actually influence improvements in the experience of incident disclosure and discussion for families and for clinicians, and quality and safety improvement in a small number of NHS maternity services; (2) the generalisability of our initial findings beyond NHS maternity care.
-Department of Health. National Maternity Safety Strategy: Progress & Next Steps. Nov.2017
-Gallagher TH, et al. 2006. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med;166:1585–93.
-Iedema, R. et al 2011. Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study. BMJ, 343
-Kenyon, S, et al. 2017. Local Review of Intrapartum-Related Death In (Eds.) Draper E, Heazell et MBRRACE-UK 2017 Perinatal Confidential Enquiry: Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death.
-Magro M. 2017 Five years of cerebral palsy claims: A thematic review of NHS Resolution data. NHS Resolution.
-Pawson R. 2013 The Science of Evaluation: A Realist Manifesto. London: SAGE.
-Wu, A.W., et al. 2017. Disclosing adverse events to patients: international norms and trends. Journal of Patient Safety, 13(1), pp.43-49.
Exploring knowledge sharing to support long term condition self-management.
Nottingham University Hospitals NHS Trust
Background: In the UK, effective management of long term conditions (LTCs) is seen to be one of the greatest challenges facing health services. One of the proposed solutions for the challenge posed by increasing prevalence of LTCs is to support patients to better manage their conditions themselves, thereby reducing uptake of healthcare services and progression of severity of disease. Self management requires knowledge sharing to ensure patients have the knowledge required to manage their healthcare needs.
The promotion of self-management is set against a background of increasing recognition that patients and the public have a unique perspective as service users which it is essential to incorporate into healthcare planning and delivery. The personalised care agenda also highlights the unique expertise patients have in living with illness. Policy therefore gives credence to the experiential knowledge which patients develop. There is a growing expectation that patients will utilise this experience and knowledge in order to take more responsibility for their health and social care needs. By doing this, a more equal relationship between HCP and patient will be fostered which breaks down traditional power relationships within healthcare.
There are a range of social and cultural factors which can make knowledge sharing between social actors complex. The social context and associated cultural norms can be so embedded as to be imperceptible to the social actors operating within it. In ignoring these social and cultural factors the impact of self-management interventions may be limited and frustrations on the part of HCPs committed to promoting self-management heightened.
Method: An ethnographic approach was utilised. 93 hours of observation was undertaken of routine outpatient interactions in a UK hospital between patients diagnosed with a LTC, and a range of healthcare professionals. In addition, 33 semi-structured interviews were also undertaken with 22 patients and 11 healthcare professionals. Data was analysed thematically using the constant comparison method. Data analysis and data collection therefore took place simultaneously.
Results: 4 themes were identified.
Normative social roles – both patients and HCPs understood the expectations of their respective social roles and were largely compliant with these. HCPs retained control of the practice of healthcare and this perpetuated these normative social roles
The influence of profession – patients shared different knowledge with HCPs with different professional roles and this could give a conflicting assessment of the patient.
Understandings of expertise – HCPs were perceived to be the experts within this context and patients struggled to recognise their own expertise in relation to their healthcare management.
Value of knowledge – clinical knowledge, which was the remit of HCPs, was valued more highly than the experiential knowledge which patients contributed. Patients’ ability to share their own clinical knowledge was restricted.
Implications: The social context in which healthcare is practiced influences what knowledge is shared and how this is achieved. It favours sharing of clinical knowledge from HCPs to patients, and disadvantages patients in their ability to share their unique knowledge based on lived experience of illness. The opportunities for patients to be supported in their knowledge, skills and confidence within routine healthcare interactions is limited. This influences their confidence and ability to self-manage their healthcare needs. Both patients and HCPs need support to recognise their understandings of their roles in order for them to move beyond accepted behaviours to develop more effective partnership working. Policy alone cannot promote the cultural change required to challenge normative social relationships or the power dynamics prevalent within healthcare. Recognising the social practices embedded within healthcare practice is a crucial initial step to develop appropriate interventions and engender lasting cultural change to ensure that the personalised care agenda can be operationalised effectively.
Crafting problems to solve: An ethnographic study of the implementation of the Patient Activation Measure
Natalie Armstrong(1), Sarah Chew(1), Liz Brewster(2), Graham Martin(3), Carolyn Tarrant(1)
(1)University of Leicester, (2)Lancaster University, (3)University of Cambridge
Background: The concept of patient activation, and use of the associated Patient Activation Measure (PAM), has gained ground internationally over recent years. Patient activation is a latent construct referring to people’s knowledge, skills and confidence to actively manage their health; the PAM is a validated scale that measures the construct. Interest in the concept and its measurement has been growing as research has seemed to suggest that higher levels of activation are associated with positive health behaviours, better clinical outcomes, better patient experiences, and lower healthcare costs.
Methods: We completed an ethnographic study of six healthcare organisations’ implementation of the PAM as part of a Learning Set facilitated by NHS England. The six organisations comprised five clinical commissioning groups and one disease registry. Our study design focused on the ‘core teams’ involved in designing and running the PAM work at each site, on the learning set and its activities, and on implementation and staff and patient experiences across a purposive selection of PAM-related projects at the frontline. In total we carried out 123 hours of observation, conducted 112 interviews, and collected approximately 180 documents. Data were analysed using a constant comparative approach.
Results: Drawing on our ethnographic study, we focus here on the work national and local policymakers undertook in order to position and implement a tool championed at a national level and designed to measure the construct of ‘patient activation’. This presentation will explore the process of problem creation that then positioned the measure as an appropriate solution. Drawing on the six healthcare organisations’ work as part of the nationally convened ‘learning set’, we use comparative analysis of observations, interviews and documents to show how organisations worked to position the tool alongside their wider work on person-centred care and to identify and craft problems it could, at least potentially, solve.
Those leading work in the six organisations saw activation as aligning well with a wider move towards and increasing emphasis on person-centred care. The tool’s apparent ability to provide objective ‘hard’ data appealed as they perceived it as a means of quantifying what had to date been seen as soft, process-oriented qualitative constructs. They saw potential for different ‘logics’ of use, including as an outcome measure and as a means of tailoring care at both individual and population level.
Over the course of our time working alongside them, the six organisations developed numerous projects in which the PAM was variously positioned, and which involved a significant variety of patient and healthcare professional groups. The apparent desire to use the PAM widely and in sometimes quite diverse ways could challenge the organisations’ ability to clearly articulate the problem they were seeking to use the PAM to solve. The desire for ‘hard’ data on a construct like patient activation was clear, but the rationale behind this and the purposes for which such data could then credibly be used were sometimes more opaque. Local policymakers’ constructions of these problems could be challenged by healthcare professionals being asked to use the PAM in practice.
Implications: The PAM as a tool was championed at a national level and healthcare organisations encouraged and supported to engage with it and put it to use locally. The work that the six organisations undertook as they sought to identify and craft problems at their local level to which the PAM and the data it generated could credibly be seen as an appropriate solution was sometimes significant.
Exploring and designing an intervention to improve communication between older people with multimorbidity and primary care staff
Rebecca Goulding(1), Gail Davidge(2), Sarah Peters(3), Thomas Blakeman(2), Harm van Marwijk(4), Peter Bower(2)
(1)The University of Manchester, (2)NIHR School for Primary Care Research; Centre for Primary Care and Health Services Research; Division of Population Health, Health Services Research and Primary Care; School of Health Sciences; Faculty of Biology, Medicine and Health; The University of Manchester, (3)Manchester Centre of Health Psychology; Division of Psychology and Mental Health; School of Health Sciences; Faculty of Biology, Medicine and Health; The University of Manchester, (4)Division of Primary Care and Public Health, Brighton and Sussex Medical School, University of Brighton
Background: Older people (65+) with multimorbidity are more likely to experience patient safety incidents. In primary care, threats to patient safety often arise as a result of breakdowns in communication between patients and staff. Thus, interventions to improve communication could help reduce risks to patient safety.
Research and policy regarding communication typically focus on the behaviour of staff. However, important aspects of communication are patient- as opposed to provider-initiated. In primary care, this includes the majority of interactions and expressions of opinions and concerns. The important role of patients in patient safety is also increasingly being recognised by bodies such as NICE and the WHO, particularly in the context of multimorbidity.
Little is known about how older people with multimorbidity communicate with staff and how they could be supported to have safer interactions. In order to design an intervention to empower patients to improve communication and reduce risks to patient safety, we explored the barriers to and enablers of communication for this population in primary care.
Methods: We took a person-, evidence- and theory based approach to intervention development; involving key stakeholders, carrying out qualitative research and making use of the COM-B model of behaviour change.
In-depth interviews were conducted with 28 older people with multimorbidity and 18 clinical and administrative staff working in general practices. The interview schedule was based on the COM-B model and explored capability, opportunity and motivation. Interviews were audio-recorded and transcribed, and data were analysed thematically in relation to the COM-B model.
Findings were presented to patient and carer, and staff and expert stakeholder groups, who helped identify priority areas to be addressed by the intervention. Individuals from both groups then worked collaboratively with the research team to design the intervention and review a prototype.
Results: Patients reported barriers to and enablers of communication in relation to all aspects of the COM-B. Capability: Interacting with practices and staff required a range of knowledge and interpersonal skills. Patients often acquired these over time and as a result of experience. Opportunity: Staff demeanour and practice policies could help patients feel at ease and able to talk about anything, or rushed and discouraged from voicing concerns or asking questions. Motivation: Patients valued empathy and explanations but rarely requested these if they were not offered. Patients were also unlikely to provide feedback when communication issues arose. Instead, they would delay appointments and/or avoid certain staff.
Many patients wanted or were receptive to receiving more information and encouragement to speak up from their practices. If available, patients also said they would use tools to help them prepare for interactions, particularly if they had a few things or something harder to discuss.
The key objectives, features and functions of the designed intervention will be presented at conference.
Implications: Findings from the in-depth interviews showed patient communication behaviours evolved over time as a result of experience. At times, the learning was positive and enabled patients to get more out of their healthcare interactions. However, learning could also be negative and lead to avoidance.
As such, we have designed an intervention to proactively provide patients with the knowledge and skills they need to communicate effectively; and avoid and address communication issues. The acceptability and feasibility of delivering this intervention is now being evaluated, prior to a trial of its effectiveness.
In the meantime, our better understanding of how older patients with multimorbidity communicate with primary care staff and how this might be improved could help inform practices and policy makers how best to increase the involvement of patients in their own care.