Mr Anthony Hill Health and Disability Commissioner Wellington 14:00 - 14:25 Themes in Primary Care - An Update from the HDC
Themes in Primary Care – An Update from the HDC Anthony Hill Health and Disability Commissioner GP17 conference 11 August 2017
HDC Vision Engagement Consumer Seamless Transparency Centred Service System Culture
Purpose of HDC “To promote and protect the rights of … consumers and, to that end, to facilitate the fair, simple, speedy, and efficient resolution of complaints ” HDC Act 1994
HDC Approach HDC contributes to the achievement of a safe consumer-centred system in a unique way: • Complaints resolution Promote and protect consumer rights • Safety and quality improvement Strengthen the system so that it continually improves • Public protection Watchdog role
Complaints per year 2500 2000 1500 Complaints received Complaints closed 1000 500 0 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017
Group providers – 2016/2017 DHB (45%) Medical centre (23%) Rest home (6%) Prison health services (3%) Pharmacy (3%) Dental clinic (3%) Disability provider (2%) Home services provider (2%) Other (13%)
Individual providers – 2016/2017 General practitioner (35%) Midwife (8%) Nurse (7%) Internal medicine specialist (6%) Orthopaedic surgeon (4%) Dentist (4%) Psychologist (4%) Psychiatrist (3%) Physiotherapist (3%) Obstetrician & gynaecologist (3%) Other (23%)
Number of complaints received about general practices and general practitioners each year 600 500 400 300 General practices 200 100 0 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017
Top issues complained about in complaints about GPs 1. Missed/delayed/incorrect diagnosis (37%) 2. Inadequate/inappropriate clinical treatment (34%) 3. Inadequate/inappropriate examination/assessment (32%) 4. Disrespectful manner/attitude (32%) 5. Delayed/inadequate/inappropriate referral (27%) 6. Failure to communicate effectively with consumer (16%)
Case Study: Communication and Management of Test Results • A 78 year old man presented to GP with a sore knee, slowing of speech and a “fizzing” feeling in his feet. • GP requested blood tests which showed that the man had a “moderate number of reactive lymphocytes”, and the results were referred to a haematologist. • GP informed man of the initial results and told they were awaiting further results .
Communication and Management of Test Results • The GP sent a referral to the outpatients clinic at the public hospital owing to the man’s slowing of speech and the “fizzing” in his feet. • The referral letter did not mention high lymphocyte levels
Communication and Management of Test Results • GP requested further blood tests and the results are consistent with Chronic Lymphocytic Leukaemia (CLL). • GP documented this as the man’s diagnosis but didn’t forward the information to the outpatients clinic at the hospital, or inform the man of the diagnosis.
Findings “As the clinician who ordered the blood tests, Dr C had a responsibility to communicate the diagnosis of CLL and its implications to Mr A. Provision of this information would have enabled Mr A to be a partner in his own treatment.”
Findings • The GP also had a responsibility to – arrange further assessment of the man’s condition, – put in place an ongoing management plan and – take responsibility for ensuring appropriate monitoring of the man’s condition was carried out.
Findings • GP had a responsibility to communicate to the outpatients clinic the results of the additional tests he had ordered since the original referral that confirmed the diagnosis of CLL
Case Study: Delayed Diagnosis: Follow-up of test results and open disclosure • Mr B presented to Dr A with reduced energy and breathlessness • Dr A ordered blood tests and included a prostate specific antigen (PSA) test • Dr A received the PSA result, which was well above the normal range • Dr A filed the elevated PSA result as “normal”, and did not discuss it with Mr B
Delayed Diagnosis: Follow-up of test results and open disclosure • Over two years later, Mr B presented to Dr A with urinary complaints. • Dr A ordered another PSA test, which came back significantly above the normal range • During, or soon after the consultation, Dr A noticed the earlier elevated PSA result • Dr A informed Mr B of the new PSA test result, but did not disclose the missed result from two years earlier at that time • Dr A informed Mr B of the missed result approximately two months after discovering it
Delayed Diagnosis: Follow-up of test results and open disclosure Findings – Dr B Breach of Right 4(1) • failed to recognise and take appropriate action on the abnormal PSA result Breach of Right 6(1) • failed to inform Mr B promptly about the missed PSA test result “… Dr A should have made contact with Mr B in a timely manner once realising his error, and certainly before Mr B left for his overseas trip”.
What is a consumer- centred system? It is about Engagement An engaged consumer is an empowered consumer “If health is on the table, then the patient • and family must be at the table, every table, now.” Leape and Berwick et al (2009) There is increasing evidence that involving • patients in decision making has positive effects in terms of patient satisfaction, Engagement adherence to treatment regimes and even their health outcomes Van Steenkiste et al (2007); O’Connor et al (2003)
What is a consumer- centred system? It is about Seamless Service The complexities of modern medicine demand that clinicians no longer work as “cowboys” – working alone in their specialist field • Modern medicine is most effective when it functions like a system – “diverse people working together to direct their specialised capabilities toward common goals for patients. They are coordinated Seamless by design. They are pit crews. ” service Gawande (2011) • It is essential that different units within the same system communicate well Hill (2011)
What is a consumer- centred system? It is about Transparency “ Disclosure is a professional obligation…and is a marker of patient-centred care. It also reflects the transparency of an Transparency organisation, which is believed to be a key component of safe organisations.” Etchegaray et al (2012)
The recurring message 2013 2001 1988 2009 Mid – 2014 RCGP Cartwright Bristol Report Leape Staffordshi Inquiry Inquiry re
What is a consumer- centred system? It is about Culture Culture matters. It goes to the Culture very core of the quality of care provided.
Themes in primary care complaints • Management of referrals • Test result follow-ups – Clarity of roles between primary and secondary care • Clinically indicated examinations and assessments • Continuity of care – multiple GPs • Locum GPs – training and orientation • Getting the basics right
Delayed diagnosis of Cancer 2004-2013 • Analysis of complaints in which the primary care management had contributed to delayed diagnosis
Delayed diagnosis of Cancer • Over the last ten years, 243 general practitioners have been complained about in relation to a delayed diagnosis of cancer, with the number of complaints per year increasing significantly over that time. • The factors leading to a delayed diagnosis most commonly identified by our expert clinical advisors related to: – the cancer presenting with non-specific or atypical symptoms; – poor communication with secondary care; – appropriate referrals not being made; – inappropriate reliance on negative test results; and – the GP failing to adequately take, review or consider relevant patient history.
Delayed diagnosis of Cancer • Brought together the clinical recommendations made in the cases, including: – undertaking clinically indicated examinations and tests; – examining patients in the context of their past history; – being aware of the limitations of diagnostic testing; – providing ‘safety - netting’ advice – having robust follow-up systems – advocating for patients in the secondary care system
Case Study: Clarity of roles - Test result follow up • A man in his 60s presented to an ED at a public hospital, with left-sided chest pain, shortness of breath, a feeling of illness, and a chronic cough. • An ED senior medical officer reviewed the man and ordered a chest X-ray. • Senior medical officer diagnosed pneumonia and recommended admission to the ward, but the man declined. • Senior medical officer told the man to follow up with his GP, but did not specify a timeframe for this. • Discharge summary sent to the man’s GP
Clarity of roles - Test result follow up • The chest X-ray was reported on the following day, and recommended a follow-up X-ray in 10 –14 days’ time to ensure resolution. – findings were “a dense pneumonic consolidation” in the left upper lobe of the lung. • The senior medical officer and the GP both received the chest X-ray report, but neither took any action in respect of it. • The man did not present to the GP for follow-up of his pneumonia.
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