Aneurin Bevan Health Board – Monmouthshire Locality Office
Quality & Patient Safety Locality Group
Title
1000 Lives+ Patient Safety Walkrounds in
Primary Care
Sponsor
Clinical Director
Author
Clinical Governance Co-ordinator
Date of meeting
29th June 2010
Action required
For Discussion
Introduction
Monmouthshire Locality has conducted pilot 1000 Lives+ Patient
Safety Walkrounds in four practices in Monmouthshire. 12 questions
were put to clinical and non-clinical members of the practice team.
This paper brings together the trends and themes of the responses to
those questions, and highlights issues which are pertinent to InHouse and Aneurin Bevan Health Board (ABHB). A synopsis of the
walkround process and copy of the questions is detailed in Appendix
A.
Summary of main issues
Issues pertinent to Practices

3 out of the 4 practices visited had recent cases of near
misses but not all incidents are reported on to the Locality.
 Practices have conducted patient surveys and have
suggestion boxes, but not many practices have PPI groups.
 Communication through Clinical Workstation is generally felt
to be good but sudden breakdown of Pathology Links without
forewarning can leave practices very exposed and create
serious clinical risks
 Border practices who have patients resident in England have
to implement 2 different smear taking protocols creating
clinical governance risks.
Issues pertinent to ABHB

Communication
o With clinicians and service users around discharge and
referrals.
o With Out of hours
o With District Nurses

Cross border issues.

Rurality and access including to MIU and for the frail and
elderly.
 Mixed response on incident feedback from the Health Board and
not knowing which incidents to report.
 CWS – identified as a potential channel for communication
during pandemics/emergencies.
Areas for Action/Top Issues
Practices






Consider PPI groups (Locality can provide advice)
Consider reporting more incidents and near misses to Locality.
Share good practice
Sharing of extreme weather experiences.
Keep highlighting cross border issues.
Promote Grass Routes
ABHB






Improve communication at the Acute sector/Primary care
interface particularly relating to discharge information and
patient referrals.
Out of Hours communication. (Work has already commenced on
this with a change in the format of the front sheet sent to
practices. OOH have asked for feedback from practices on the
new format and welcomed suggestions for improvement).
Provide guidance on Incident Reporting: Make the process
easier.
Feed back to practices on incidents.
Work to address capacity and communication issues between
District Nurses and practices
Possibility of a District Nurse forum.
Examples of good practice
 Regular
practice
meetings
held
to
facilitate
good
communication.
 Extreme weather – practice responses were good and could
provide an opportunity to learn from each other.
 Alerts set up for patients with same name.
 Open no-blame culture reported in house.
 Dispensit system working well.
Walkround process
Walkrounds were conducted in an open informal manner and without
exception practices gave positive feedback. It is important to ensure
membership of visiting teams is carefully chosen to ensure an
appropriate skill set. Visiting team members should have an induction
to ensure all are comfortable with the process and be informed on
how to handle any sensitive issues that may arise. At each walkround
preliminary scene setting and simple groundrules define the purpose
of the walkround and ensure the practice is aware that any
performance issues that arise will be highlighted but left for the
practice to process through established channels. The primary care
contractual relationship makes walkrounds by ABHB staff a different
prospect to that in secondary care but this is facilitated by ensuring
the reciprocal nature of the process leading to objectives for both the
practice and the Health Board.
Conclusion and next steps
1000 Lives Primary Care Walkrounds are a positive experience for all
parties. Conducted in an open, informal and reciprocal manner they
provide useful information of relevance to the whole health
community. Acceptance across all practices in ABHB as a useful
process will partly be determined by the demonstration of information
leading to positive change. To that end, OOH have begun work on the
front sheet sent to practices after each patient contact. Addressing
other highlighted issues will give practices assurance of the
usefulness of this process.
Recommendations
This paper highlights key learning issues for practices, the Locality
and ABHB. The Q&PS Group are asked for views.
Background
None
papers
Links
to 1,5,8,12,18,19,23,24
Standards
for
Health Services
Resource
implications
Appendix A
Patient Safety Walkround in Primary Care
Process
The Medical Director, a Non Officer Member of ABHB Monmouthshire
Locality, and an external clinician had an initial meeting to discuss the
format of the visits and to develop a suitable framework of questions
using those provided by the 1000 Lives team as a template.
Questions were chosen for open-ended and non-threatening qualities.
The practices received the questions prior to the visits.
Each visit took approx 2 hours. Each member of the visiting team
paired up with one of the practice team, matching clinician with
clinician and non-clinician with non-clinician and went through the
questions together in private.
Each of the visiting team provided a written report based on the
responses to the questions.
While the walkround process is relatively easy to implement there are
issues which must be addressed before there can be a
recommendation to roll this out to all practices.
1. Were you able to care for
your patients this week as
safely as possible? If not,
why not?
2. Can you describe how
communication
between
caregivers either inhibits or
enhances safe care?
3. Can you describe your
ability to work as a team?
4. Are you aware of any ‘near
misses’ that might have
caused harm but didn’t?
5. What examples of the
environment do you consider
might increase the risk of
harm?
6. Is there anything you feel
the team could do to reduce
the risk of an adverse event?
(examples
here
might
include patients with the
same name; having regular
opportunity
to
discuss
safety)
7. Can you think of a way in
which the system (the health
community)
or
the
environment
fails
the
practice on a consistent
basis?
8. Error Handling
Do you always report
errors?
If you prevent/intercept
an error, do you always
report it?
If you make or report an
error,
are
you
concerned
about
personal consequences?
Do you know what
happens
to
the
information you report?
Do you get sufficient
feedback?
9.
Have
you/the
team
developed
any
personal
checking practices that you
do specifically to prevent
making an error?
(examples
here
include
memory
aids;
doublechecking; forcing functions –
these are an aspect of a
design that prevents a user
from taking an action without
explicitly performing another
action).
10. Do you discuss patient
safety issues with service
users? Do patients and their
families voice any concerns?
11. What intervention from
the LHB would make the
work
you
do
safer
for
patients?
(examples here would be
organizing
interdisciplinary
groups to evaluate a specific
problem; assist in changing
the attitude of a particular
group; facilitating interaction
between 2 specific groups)
12.
What
would
make
walkrounds more effective?