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Patient Centredness and

Continuity of Care

The Greg Price StoryMr. David Price and Dr. David G. Moores

Faculty/Presenter Disclosure

• Faculty: David Moores and David Price and Mirella Chiodo

• Relationships with Commercial Interests:• Grants/Research Support: None• Speakers Bureau/Honoraria: None• Consulting Fees: None• Other: None

• Potential for conflict(s) of interest:• None

Outline:

• The Greg Price Story (What can Greg Price and his family teach us?)

• Define and identify “significant event” as a preferred term for Quality and Safety Issues

• Provide an overview of the Quality and Safety in Family Practice/Primary Care Programme at the Department of Family Medicine, University of Alberta.

• Contribute to the learning of others and ourselves


Continuity of Care

“You can either learn or blame. You can’t do both. You have to take your pick.”Sidney DekkerRestorative Just Culture

“You can either be a voyeur of quality and safety or actively engage in significant event analysis.”

David Moores

International Forum 2016

Greg Price

What happened and why?

How could things have been different?

What can we learn from what happened?

What needs to change?

What is a Significant Event in health care?

What is a Significant Event in health care?

Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice.1

1Pringle, M., Bradley, C.P., Carmichael C.M. et al.Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care.

Occasional Paper No.70. (1995) Royal College of General Practitioners. London. RCGP.

Significant Events in Family Practice

Significant Event

A significant event need not be a dramatic event:

usually it is an incident/event which has significance for you. It is often an event which made you stop and think, or one that raised questions for you. It is an incident which in some way may have a significant impact on your personal or professional learning or practice behaviour.

Monthly Prevalence Estimates of Illness in the Community

(Adults 16 years and over)

White, K. L., Williams, F, Greenberg, B.G. The Ecology of Medical Care NEJM Vol. 265(18) 885-92 1961

L. Green, B. Yawn, D. Lanier, et al. The Ecology of Medical Care Revisited NEJM 344(26), 2021-2025 2001

Alberta and Canadian Health Care Landscape

Background/Context• Fee-for-service (visit) dominant

payment mechanism

• No formal lists- registration/

rostering/paneling

• Limited infrastructure support

for family practices

• Alberta Health process and

outcome data difficult to access

• Wait times for consultation/referral

problematic

Alberta Health Care Professional Landscape

Background/Context

• Population 3,785,597 (2012)

• Physicians- 8,086• Specialists- 4,251

• Generalists(FPs/GPs)- 3835

• Nurses- 33,500• Non-Hospital- 6700

• Pharmacists-4,362• Additional Prescribing (220)

19,940,991 FP/GP Visits/Yr.*

54,632 FP/GP Visits/Day

13,498,593 Rx/Yr.*Calculated AHCIP Statistical Supplement 2011-12Does not include primary care services provided by nurses. nurse practitioners, pharmacists, dentists,psychologists, social workers, OT/PT, kinesiologists

and other colleagues

What is a Significant Event Analysis or Audit?

What is Significant Event Analysis or Audit (SEA)?

• Occurs when individual cases/circumstances in which there has been a significant occurrence (not necessarily

involving an undesirable outcome for the patient) are analysed in a systematic and detailed way

• To determine what can be learned about the overall quality of care and to indicate/suggest changes that might lead to future improvements”. (Pringle et al 1995)

• Also may be known as critical event audit, critical incident analysis, structured case analysis, facilitated case discussion, root cause(s) analysis.

1. What happened and why?2. How could things have been different?3. What can we learn from what happened?4. What needs to change?

Source: Bowie and PringleSignificant Event Audit-Guidance for Primary Care Teams-National Patient Safety Agency, NHS

Introduction to Greg Price

What Happened?

Week 1•Greg sees PCP1* for a ‘routine’ MOT (Pilot’s Medical Exam).• ‘abnormal thickening of the epididymis’ noted

*Primary Care Provider

What Happened?

Week 37 (9 months)•Greg notices back pain which he thinks is ‘muscle strain’ or ‘sciatica’.

What Happened?

Week 42 (10.5 months)•Greg goes to WIC (Walk-In-Clinic) for a ‘minor’ skin condition and sees PCP2 *

*Primary Care Provider

What Happened?

Week 45 (11 months)•Greg returns to PCP1 concerning skin condition. While there his epididymis is re-examined. “Thickened but unchanged’ is documented in chart.

What Happened?

Week 51 (12 months)•Greg goes back to WIC and sees PCP2 about back pain. Lab tests, x-rays and ultrasound are ordered.

What Happened?

Week 53 (12+ months)•PCP2 and Greg discuss results and the likelihood of cancer. Urgent CT ordered.

What Happened?

Week 56 (13 months)•CT completed 19 days later and confirms likely Stage III testicular cancer with spread to abdominal lymph nodes.

What Happened?

Week 57•When Greg still has not heard back regarding a follow-up to review his ultrasound results he calls WIC*. He is told that PCP2 has left the practice.

*Walk-in-Clinic

What Happened?

Week 58•When Greg still had not heard about urology appointment he called WIC. Told to contact Urologist1 office himself.

*Walk-in-Clinic

What Happened?

Week 58 (13.5 months)•Although away, the Urologist1 saw the referral request on his Electronic Medical Record (EMR). Asked his office staff to have Greg seen by another colleague- Urologist3.

What Happened?

Week 59•Greg attends ‘urgent’ surgical appointment (arranged within 1 day) with Urologist3. By this time he was complaining of leg pain and swelling.

What Happened?

Week 59 + 2 Days•Greg undergoes a removal of his testicle, as a day surgical procedure. Is sent home with no information as to “red flags” nor how to contact his surgeon.

What Happened?

Week 59 + 3 Days•Family and Greg have concerns about his increasing leg swelling and pain.

What Happened?

Week 59 + 4 Days•Unable to contact urologist, Greg is seen in the Emergency Room (A&E).

What Happened?

Week 59 + 5 Days•Greg has increasing pain and swelling of his leg and is short of breath. Greg loses consciousness. Family calls 911 (999).

What Happened?

Week 59 + 5 Days•Resuscitative efforts provided at home by EMS (Emergency Medical Services).•Greg is transported to hospital.•Resuscitation was unsuccessful.

What Happened?

Greg Price, age 31, dies unexpectedly of a pulmonary embolus on May 19, 2012, three (3) days after surgery to remove a cancerous testicle.

Greg Price

Why did Greg Price die?

“Greg was an optimist, seeing the best in everyone he met. He also was selfless, always putting others ahead of himself. Greg died prematurely. We believe he died prematurely because of multiple gaps and failures in the so-called ‘system’ of health care in Alberta.

David Price and the Price Family

“We also believe that Greg's individual experiences are not unique. The health care system is not a system at all. There are individuals who do their very best, but individuals themselves cannot do it on their own.”


“We believe that the health care system should provide Continuous, Collaborative, and Patient-Centred Care.”


Why did this happen?

What can we learn from what happened?

1. The patient was referred* to a general surgeon for an opinion about “abnormal thickening” of his epididymis. The referring physician believed this appointment would take place within a few weeks. However, it actually took three months (12 weeks) before the patient was notified about the appointment.

* Week 45/Week 59

2. The patient underwent a CT scan for suspected cancer. The test was believed to be necessary before sending him to an appropriate specialist for definitive treatment. Despite this test being critical to his care, a follow-up appointment was not made to review the results of the scan and refer him to a specialist.

3. The patient was referred to a urologist for an urgent appointment. Neither the referring physician, the walk-in clinic nor the patient knew this urologist was out of the city for an extended time.

4. After his surgery this patient was concerned about worsening lower limb swelling and pain. Although it was during ‘normal business hours’ on a weekday he was unable to reach the urologist who had performed his surgery two days previously to discuss what the implications were and to obtain advice about what to do.

5. The patient had been referred to the medical oncology service at the Tom Baker Cancer Centre (TBCC) by the urologist. Behind the scenes the TBCC was organizing an urgent outpatient appointment with an oncologist who specialized in the treatment of testicular cancer.

This patient was in the care of two and then three physicians none of whom knew or had access to his whole history. He experienced (many) delays in receiving important tests, difficulties contacting the specialists providing his care, insufficient communication from providers about appointments and results and confusion about the process for booking appointments.

Lessons to Be Learned-Price Family Perspective

“Never assume that when a referral is made to another doctor the case will be treated with any particular priority.”


“Urgent in the healthcare system doesn’t mean urgent! It is very difficult for us to understand how something classified as urgent takes 19 days to become actionable.”


“In fact it was classified as ‘normal’. It was explained that it is in part because many doctors classify their requests as urgent to try and move their patient up the waiting list. We also were given the impression that because it was normal, we shouldn’t expect anything more and it was not the fault of the system.”


“Never ever assume there is a critical smooth handoff (handover) between doctors.”


“If you are referred to the ‘Urology Centre’ (Southern Alberta Institute of Urology) located next to the Rockyview Hospital in Calgary, do not assume that this is a centre where a team of doctors work together when in fact they work independently and therefore it appears they don’t collaborate together very closely.”


“Never ever let your doctor leave you without a surefire method of contacting them (or someone you and they both trust) 24 hours a day. We did not know that the urologist’s office wouldn’t be open on Friday when we had talked to the urologist pre-surgery.”


“We also were guilty of assuming that post-surgery, among the instructions there would be special notations of what to do and who to talk to in the event of concerns arising.”


“Don’t simply trust your doctor’s judgement and recommendation unless you have a long enough history with them to be certain, or else make sure you have checked on those things yourself to see that they are in fact valid.”

“You don’t know what you are talking about!”

Comment to Greg Price’s mother at a meeting with the Alberta Medical Association Representative Forum

Adding Insult to Injury

Quality and Safety Workshop

Background Perspective

• As a FP/GP you and I are in a strong position to influence our own care of patients, that of the practice and that of the wider healthcare community

• Understanding how and when to apply tools and metrics to improve the quality and safety of care is a key skill that can and should be learned during your education and training, as well as enhanced and practised in lifelong learning

• Working in partnership with your patients and their families, understanding their needs is vital to improving clinical care and reducing health inequalities

Royal College of General Practitioners (adapted)

Quality and Safety

Quality and Safety in Family Practice/Primary Care

• Participate in the Introduction to Quality and Safety Seminar

• Complete the six (6) Patient Safety in Primary Care Modules*

• Document Significant Events on all Clinical Rotations and submit to Quality Supervisor Dept. of Family Medicine

• Participate in the Significant Event Analysis Seminar

Residents/Registrars receive a Certificate upon successful completion of the Programme.

*TVC

How should we react to errors, near crashes,close calls?Do we… Or do we…

• Hope no one finds out

• Work harder/better/longer hours to ensure it doesn’t happen next time

• Cover it up – especially from the patient and from each other

• Identify it/Document and Report it

• Discuss with our team

• Perform analysis of what and why it happened and how it could be mitigated in the future

• Change our processes

• Inform the patient

• Share the information so others can learn from the event/our experience

https://d10k7k7mywg42z.cloudfront.net/assets/5501df86c0d67106cf02ae61/HQCA_SSA_PSR_111913.pdf

A stronger emphasis on primary care patient safety research is important because the overwhelming majority of healthcare is delivered outside hospitals, in primary care settings.

Kerr White et alThe ecology of medical careN Engl J Med 1961

Green L, Fryer G, Yawn B, Lanier D, Dovey S. The ecology of medical care revisited. N Engl J Med 2001; 344(26): 2021-5.

Hospital/Acute Care Family/General Practice

•Critical Incident

•Near Miss

• ‘Serious’ and/or ‘undesired’

•Critical Incident Analysis

•Root Cause(s) Analysis

•Significant Event

•Close call

•Good, Bad or Ugly

•Significant Event Analysis

• ‘Contributing Causes’ Analysis

Significant Event Analysis in family/general practice (primary care) is:• essential to health system reform and fine tuning

• is more encompassing of quality and safety issues when compared to Critical Incident Reporting and Critical Incident Analysis (hospital/acute care focus).

Primary Care Quality and Safety:• is an emerging focus* for postgraduate education programs in

Canada

• shared information derived from this focus will advance the understanding of the unique issues in family/general practice quality and safety and provide an overview of health systems.

* CanMEDS 2015 and CFPC Red Book


Continuity of Care

“You can either learn or blame. You can’t do both. You have to take your pick.”Sidney DekkerRestorative Just Culture

“You can either be a voyeur of quality and safety or actively engage in significant event analysis.”

David Moores

International Forum 2016

We gratefully acknowledge and thank the Price Family for their willingness to allow their tragedy and circumstance to inform and challenge current and future health professionals in quality and safety improvement.

Questions and Commentary


Continuity of Care

The Greg Price Story

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