Approaches to reducing the most important patient errors in primary health care : patient and professional perspectives

We have previously reported a preliminary taxonomy of patient error. However, approaches to managing patients' contribution to error have received little attention in the literature. This paper aims to assess how patients and primary care professionals perceive the relative importance of different patient errors as a threat to patient safety. It also attempts to suggest what these groups believe may be done to reduce the errors, and how. It addresses these aims through original research that extends the nominal group analysis used to generate the error taxonomy. Interviews were conducted with 11 purposively selected groups of patients and primary care professionals in Auckland, New Zealand, during late 2007. The total number of participants was 83, including 64 patients. Each group ranked the importance of possible patient errors identified through the nominal group exercise. Approaches to managing the most important errors were then discussed. There was considerable variation among the groups in the importance rankings of the errors. Our general inductive analysis of participants' suggestions revealed the content of four inter-related actions to manage patient error: Grow relationships; Enable patients and professionals to recognise and manage patient error; be Responsive to their shared capacity for change; and Motivate them to act together for patient safety. Cultivation of this GERM of safe care was suggested to benefit from 'individualised community care'. In this approach, primary care professionals individualise, in community spaces, population health messages about patient safety events. This approach may help to reduce patient error and the tension between personal and population health-care.

Building Healthy Communities : GP Network, Medicare Local and Primary Health Care in the Wheatbelt Region of Western Australia

• Government reports consistently recognise the importance of Primary Health Care to an efficient health system. Barriers identified in Australia’s Primary Health Care include workforce pressures, increase rate of chronic disease, and equitable access to Primary Health Care services. • General Practitioners (GPs) are the key to the successful delivery of Primary Health Care especially in rural and remote regions such as the Wheatbelt region in Western Australia (WA). • The Wheatbelt region of WA is vast: some 72,500 residents spread across 150,000km2 in 43 Local Government Authorities catchments. Majority of the Wheatbelt residents live in small towns. There is a higher reported rates of chronic disease, more at risk of chronic diseases and less utilisation of Primary Health Care services in this region. • General practice patients in the Wheatbelt are among those most in need of Primary Health Care services. • Wheatbelt GP Network (the “Network”) was established in 1998. It is a key health service delivery stakeholder in the Wheatbelt. • The Network has responded to the health needs of the community by creating a mobile Allied Health Team that works closely with GPs and is adaptive to ensure priority needs are met. • The Medicare Local model introduced by the Australian Government in 2011 aimed to improve the delivery of Primary Health Care services by improved health planning and coordinating service delivery. • Little if any recognition has been given to the outstanding work that many Divisions of General Practice have done in improving the delivery of Primary Health Care services such as the Network. • The Network has continued to support GPs and general practices and created a complementary system that integrated general practice with the work of an Allied Health Team. Its program mix is extensive. • The Network has consistently delivered on-required contract outputs and has a fifteen (15) years history of operating successfully in a large geographical area comprising in the main smaller communities that cannot support the traditional health services model. • The complexity of supporting International Medical Graduates in the region requires special attention. • The introduction of the Medicare Local in the South West of WA and their intention to take over the delivery of health services, thus effectively shutting the Network will have catastrophic consequences and cannot be supported economically. • The Network proposes to create a new model, built on its past work that increases the delivery of Primary Health Care services through its current Allied Health Team. • The proposal uses the Wheatbelt GP Super Clinic currently under construction in Northam, part of the Network and funded by the Australian Government is a key to the proposed new model. • Wheatbelt GP Super Clinic is different from existing models of GP Super Clinics around Australia which focus predominately on co-location of services. Wheatbelt GP Super Clinic utilises a hub and spoke model of service outreach to small rural towns to ensure equitable Primary Health Care coverage and continuum of care in a financially responsible and viable manner. In particular, the Wheatbelt GP Super Clinic recognises the importance of Allied Health Professionals and will involve them in a collaborative model with rural general practice. • The proposed model advocated by the Network aims to substitute the South West WA Medicare Local direct service delivery proposed for the Wheatbelt. The Network’s proposed model is to expand on the current hub and spoke model of Primary Health Care delivery to otherwise small unviable Wheatbelt towns. A flexible and adaptive skill mix of Allied Health Professionals, Nurse Practitioners and GPs ensure equitable access to service. Expanded scope of practices are utilised to reduce duplication of service and concentration of services in major towns. This involves a partnership approach. • If the proposed model not funded, the Network and the Wheatbelt region will stand to lose 16 Allied Health Professionals and defeats the purpose of Australian Government current funding for the construction of the Wheatbelt GP Super Clinic. • The Network has considered how its model can best be funded. It proposes a re-allocation of funds made available to the South West WA Medicare Local. • This submission argues that the proposal for the South West WA Medicare Local to take over the service delivery of Primary Health Care services in the Wheatbelt makes no economic sense when an existing agency (the Network) has the infrastructure in place, is experienced in working in this geographical area that has special needs and is capable to expand its programs to meet demand.

Barriers preventing the successful integration of mental health services into Primary Health Care in Nigeria : a mixed methods approach

RESUMO: A Nigéria tem uma população estimada em cerca de 170 milhões de pessoas. O número de profissionais de saúde mental é muito diminuto, contando apenas com 150 psiquiatras o que perfaz aproximadamente um rácio de psiquiatra: população de mais de 1:1 milhão de pessoas. O Plano Nacional de Saúde Mental de 1991 reconheceu esta insuficiência e recomendou a integração dos serviços de saúde mental nos cuidados de saúde primários (CSP). Depois de mais de duas décadas, essa política não foi ainda implementada. Este estudo teve como objetivos mapear a estrutura organizacional dos serviços de saúde mental da Nigéria, e explorar os desafios e barreiras que impedem a integração bem-sucedida dos serviços de saúde mental nos cuidados de saúde primários, isto segundo a perspectiva dos profissionais dos cuidados de saúde primários. Com este objetivo, desenvolveu-se um estudo exploratório sequencial e utilizou-se um modelo misto para a recolha de dados. A aplicação em simultâneo de abordagens qualitativas e quantitativas permitiram compreender os problemas relacionados com a integração dos serviços de saúde mental nos CSP na Nigéria. No estudo qualitativo inicial, foram realizadas entrevistas com listagens abertas a 30 profissionais dos CSP, seguidas de dois grupos focais com profissionais dos CSP de duas zonas governamentais do estado de Oyo de forma a obter uma visão global das perspectivas destes profissionais locais sobre os desafios e barreiras que impedem uma integração bem-sucedida dos serviços de saúde mental nos CSP. Subsequentemente, foram realizadas entrevistas com quatro pessoas-chave, especificamente coordenadores e especialistas em saúde mental. Os resultados do estudo qualitativo foram utilizados para desenvolver um questionário para análise quantitativa das opiniões de uma amostra maior e mais representativa dos profissionais dos CSP do Estado de Oyo, bem como de duas zonas governamentais locais do Estado de Osun. As barreiras mais comummente identificadas a partir deste estudo incluem o estigma e os preconceitos sobre a doença mental, a formação inadequada dos profissionais dos CPS sobre saúde mental, a perceção pela equipa dos CSP de baixa prioridade de ação do Governo, o medo da agressão e violência pela equipa dos CSP, bem como a falta de disponibilidade de fármacos. As recomendações para superar estes desafios incluem a melhoria sustentada dos esforços da advocacia à saúde mental que vise uma maior valorização e apoio governamental, a formação e treino organizados dos profissionais dos cuidados primários, a criação de redes de referência e de apoio com instituições terciárias adjacentes, e o engajamento da comunidade para melhorar o acesso aos serviços e à reabilitação, pelas pessoas com doença mental. Estes resultados fornecem indicações úteis sobre a perceção das barreiras para a integração bem sucedida dos serviços de saúde mental nos CSP, enquanto se recomenda uma abordagem holística e abrangente. Esta informação pode orientar as futuras tentativas de implementação da integração dos serviços de saúde mental nos cuidados primários na Nigéria.------------ABSTRACT: Nigeria has an estimated population of about 170 million people but the number of mental health professionals is very small, with about 150 psychiatrists. This roughly translates to a psychiatrist:population ratio of more than 1:1 million people. The National Mental Health Policy of 1991 recognized this deficiency and recommended the integration of mental health into primary health care (PHC) delivery system. After more than two decades, this policy has yet to be implemented. This study aimed to map out the organizational structure of the mental health systems in Nigeria, and to explore the challenges and barriers preventing the successful integration of mental health into primary health care, from the perspective of the primary health care workers. A mixed methods exploratory sequential study design was employed, which entails the use of sequential timing in the combined methods of data collection. A combination of qualitative and uantitative approaches in sequence, were utilized to understand the problems of mental health services integration into PHC in Nigeria. The initial qualitative phase utilized free listing interviews with 30 PHC workers, followed by two focus group discussions with primary care workers from two Local Government Areas (LGA) of Oyo State to gain useful insight into the local perspectives of PHC workers about the challenges and barriers preventing successful integration of mental health care services into PHC. Subsequently, 4 key informant interviews with PHC co-ordinators and mental health experts were carried out. The findings from the qualitative study were utilized to develop a quantitative study questionnaire to understand the opinions of a larger and more representative sample of PHC staff in two more LGAs of Oyo State, as well as 2 LGAs from Osun State. The common barriers identified from this study include stigma and misconceptions about mental illness, inadequate training of PHC staff about mental health, low government priority, fear of aggression and violence by the PHC staff, as well as non-availability of medications. Recommendations for overcoming these challenges include improved and sustained efforts at mental health advocacy to gain governmental attention and support, organized training and retraining for primary care staff, establishment of referral and supportive networks with neighbouring tertiary facilities and community engagement to improve service utilization and rehabilitation of mentally ill persons. These findings provide useful insight into the barriers to the successful integration of mental health into PHC, while recommending a holistic and comprehensive approach. This information can guide future attempts to implement the integration of mental health into primary care in Nigeria.

Gender differences in financial barriers to primary health care in New Zealand

Gender differences in health status and use of health care services have been established in the developed world; less attention, however, has been paid to gender differences in financial barrier to primary health care. Such barrier, however, represent potentially avoidable mortality and morbidity. This paper aims to examine gender differences in financial barrier to primary health care in New Zealand.

Analysis of organisational climate to improve the adequacy of primary health care in the State of Kuwait

This study covers two areas of contribution to the knowledge, firstly it tried to investigate rigourously the relationships of a number of factors believed that they may affect the climate perception, classified into three types to arrive to prove a hypothesis of the important role that qualification and personal factors play in shaping the climate perception, this is in contrast with situational factors. Secondly, the study tries to recluster the items of a wide-range applied scale for the measurement of climate named HAY in order to overcome the cross-cultural differences between the Kuwaiti and the American society, and to achieve a modified dimensions of climate for a civil service organisation in Kuwait. Furthermore, the study attempts to carry out a diagnostic test for the climate of the Ministry of Public Health in Kuwait, aiming to diagnose the perceived characteristics of the MoPH organisation, and suggests a number of areas to be given attention if an improvement is to be introduced. The study used extensively the statistical and the computer facilities to make the analysis more representing the field data, on the other hand this study is characterised by the very highly responsive rate of the main survey which would affect the findings reliability. Three main field studies are included, the first one was to conduct the main questionnaire where the second was to measure the "should be" climate by the experts of MoPH using the DELPHI technique, and the third was to conduct an extensive meeting with the very top management team in MoPH. Results of the first stage were subject to CLUSTER analysis for the reconstruction of the HAY tool, whereas comparative analysis was carried on between the results of the second and third stages on one side, the first from the other.

Revitalizing health for all : international Indigenous representative group. Learning from the experience of comprehensive primary health care in Aboriginal Australia — A commentary on three projects

This paper presents a regional commentary (hereafter ‘the commentary’) on the three Australian projects of the Teasdale-Corti Global Health Research Partnership Program. The three Australian projects are: Victorian Aboriginal Health Service Ltd (VAHS), Melbourne, Victoria—Forty Years of Comprehensive Primary Health Care; Central Australian Aboriginal Congress Inc. (Congress), Alice Springs, Northern Territory—Ingkintja, Male Health Program; and Urapuntja Health Service (UHS), Utopia, Northern Territory—Outstation Health Care. It highlights common themes and lessons in respect to the Revitalising Health for All project in the context of Aboriginal and Torres Strait Islander health in Australia.

Quality of work life among primary health care nurses in the Jazan region, Saudi Arabia : a crosssectional study

Background: Quality of work life (QWL) is defined as the extent to which employee is satisfied with personal and working needs through participating in the workplace while achieving the organisation’s goals. QWL has been found to influence the commitment and productivity of employees in healthcare organisations, as well as in other industries. However, reliable information on the QWL of PHC nurses is limited. The purpose of this study was to assess the QWL among PHC nurses in the Jazan region, Saudi Arabia. Methods: A descriptive research design, namely, a cross-sectional survey was used in this study. Data were collected using Brooks’ survey of quality of nursing work life (QNWL) and demographic questions. A convenience sample was recruited from 143 PHC centres in Jazan, Saudi Arabia. The Jazan region is located in the southern part of Saudi Arabia. A response rate of 91% (N = 532/585) was achieved (effective RR = 87%, n = 508). Data analysis consisted of descriptive statistics, t-test and one way-analysis of variance. Total scores and sub-scores for QWL Items and item summary statistics were computed and reported, using SPSS version 17 for Windows. Results: Findings suggested that the respondents were dissatisfied with their work life. The major influencing factors were unsuitable working hours/shifts, lack of facilities for nurses, inability to balance work with family needs, inadequacy of family-leave time, poor staffing, management and supervision practices, lack of professional development opportunities, and inappropriate working environment in terms of the level of security, patient care supplies and equipment, and recreation facilities (Break-area). Other essential factors include the community’s view of nursing and inadequate salary. More positively, the majority of nurses were satisfied with their co-workers, satisfied to be nurses and had a sense of belonging in their workplaces. Significant differences were found according to gender, age, marital status, dependent children, dependent adults, nationality, ethnicity, nursing tenure, organisational tenure, positional tenure, and payment per month. No significant differences were found according to education level and location of PHC. Conclusions: These findings can be used by PHC managers and policy makers for developing and appropriately implementing successful plans to improve the QWL. This will help to enhance the home and work environments, improve individual and organisation performance and increase nurses’ commitment.

The relationship between quality of work life and turnover intention of primary health care nurses in Saudi Arabia

Background Quality of work life (QWL) has been found to influence the commitment of health professionals including nurses. However, reliable information on the QWL and turnover intention of primary health care (PHC) nurses is limited. The aim of this study was to examine the relationship between QWL and turnover intention of PHC nurses in Saudi Arabia. Methods A cross-sectional survey was used in this study. Data were collected using Brooks’ survey of Quality of Nursing Work life (QNWL), the Anticipated Turnover Scale and demographic data questions. A total of 508 PHC nurses in the Jazan region, Saudi Arabia completed the questionnaire (RR = 87%). Descriptive statistics, t-test, ANOVA, General Linear Model (GLM) univariate analysis, standard multiple regression (SMR), and hierarchical multiple regression (HMR) were applied for analysis using SPSS v17 for Windows. Results Findings suggested that the respondents were dissatisfied with their work life, with almost 40% indicating a turnover intention from their current PHC centres. Turnover intention was significantly related to QWL. Using SMR, 26% of the variance in turnover intention was explained by the QWL, p < 0.001, with R² = .263. Further analysis using HMR found that the total variance explained by the model as a whole (demographics and QWL) was 32.1%, p < 0.001. QWL explained an additional 19% of the variance in turnover intention, after controlling for demographic variables. Conclusions Creating and maintaining a healthy work life for PHC nurses is very important to improve their work satisfaction, reduce turnover, enhance productivity and improve nursing care outcomes.

Community-based asylum seekers’ use of primary health care services in Melbourne

Objective: To investigate primary health care service utilisation and health presentations among asylum seekers living in Melbourne. Design and setting: Retrospective audit of files of people who attended three Melbourne asylum-seeker health clinics between 1 July 2005 and 30 June 2006. Main outcome measures: Rates of reasons for the encounter, diagnostic tests or investigations required, treatments prescribed and referrals. Results: Data were collected from 998 consultations corresponding to 341 people. Eighty-eight per cent of visits involved people with no Medicare access, owing to their visa status. The most common reasons for the encounter were general and unspecified symptoms or problems (rate, 59.9 per 100 encounters; 95% CI, 55–65), followed by musculoskeletal conditions (27.1; 95% CI, 24–30), and psychological problems (26.5; 95% CI, 23–30). The rate of referrals was 18.3 per 100 encounters (95% CI, 16–21). Conclusions: The three clinics providing services to asylum seekers in Melbourne are delivering care to a considerable number of people with complex health needs. A substantial number of asylum seekers present to clinics with psychological and social problems. Most cannot access government-subsidised health care. This must be addressed urgently by policy change at the federal and state and territory levels.

Thai family support (TFS) : working with families of young substance users in primary health care

Living with substance users negatively impacts upon family members in many ways, and distress is common. Despite these deep and wide-ranging impacts, supportive interventions for family members in their own right are rarely available. Thailand has substantial and growing problems with substance use, and there is very little support or family members of drug users, especially in community setting. The Thai Family Support (TFS) program was designed for implementation in primary health care units (PCUs) in Thailand. TFS was based on two approaches with existing empirical support in Western contexts—the 5-step method and CRAFT—with adaptations to a Thai setting that included integration with Buddhist practices. Its aims were to increase well-being of family members, reduce mental distress, improve family relationships between family members, and engage substance users in behaviour change. A small-scale randomised controlled trial on TFS with a Delayed Treatment control was conducted, with assessments at 8 weeks (Post 1) and 20-24 weeks (Post 2). Structured interviews with participants and PCU staff and an examination of five case studies augmented the quantitative results. Mixed Model Analyses were applied to quantitative outcomes, and thematic analysis was used for qualitative data. Thirty-six participants (18 in each of Immediate and Delayed Conditions) were recruited. A significant difference at Baseline between the two conditions was observed on the Thai GHQ-28 and Gender, but it was not possible to statistically control for these effects. There was a significant Time by Condition interaction on the Thai GHQ-28, WHOQOL-BREF-THAI and FAS, reflecting greater improvements in the Immediate condition by Post 1, but with the Delayed condition meeting or exceeding that effect by Post 2. On FES Cohesion and Conflict, there were falls across conditions at Post 2, but only Cohesion also showed a Time by Condition interaction, and that effect was consistent with a delayed impact of treatment. Overall, TFS by PCU staff in the Delayed Condition gave similar results to TFS conducted by the researcher, supporting the viability of its dissemination to standard health services. Qualitative data also confirmed the quantitative results. Most participants reported physiological and psychological improvements even though their substance-using relative did not change their drug use behaviour. After completing TFS, participants reported increased knowledge, group support and sharing feeling, having positive patient-professional relationship, having greater knowledge of substance abuse and social support. In particular, they changed their behaviour towards the substance user, resulting in improvements to family relationships. PCU staff gave similar responses on the efficacy of TFS, and saw it as feasible for routine use, although some implementation challenges were identified. The cultural adaptation and in particular the religious activities, were recognised by participants and PCU staff as an important component of TFS to support psychological health and well-being. Findings from this study showed the impact of substance use on family members and difficulties that they experienced when living with the substance users, resulting distresses and burden that may develop severe mental health disease. Drug use policies should be modified to support family members and response to their needs effectively for early prevention. This study also gave preliminary support for application of the TFS program in rural primary care settings and identified some policies that will be required for it to be disseminated more broadly.

Comprehensive primary health care: a pathway to social inclusion and improved health

Originating from the World Health Organization of alma Ata in 1978, the philosophy of Comprehensive Primary Health Care (CPHC) includes the interconnecting principles of equity, access, empowerment, community self-determination and intersectoral collaboration in order to achieve better health outcomes for all people. It encompasses addressing the social, economic, cultural and political determinants of health. CPHC when implemented correctly should lead to social inclusion. However, implementing CPHC is complex due to misunderstandings about what it encompasses and about how to achieve the intended goals. This workshop aims to explore a range of issues that are tackled through a diverse range of primary health care services that target: community health, youth mental health, HIV/AIDS, homelessness, and marginalised disadvantaged groups.

Expanded scope roles in primary health – what makes them work?

Introduction The demand for better integration between primary and secondary healthcare frequently leads to discussion about expanded scope of practice for nursing, paramedic and allied health professionals and the role these clinicians could play in facilitating improved access to timely and appropriate healthcare. From workforce perspective, expanded scope of practice has also been advocated as a mean of fostering workforce retention. Models of expanded scope roles in nursing and paramedicine have been trialled nationally and internationally in both acute and community care settings. Where they have been successful, trials have resulted in reduction in hospital presentation and admission; improved patient access and timeliness; and patient satisfaction. This paper will examine the characteristics of successful expanded scope programs. Method Exploratory case-study analysis of successful integration of expanded health care roles across primary healthcare settings in rural Australia. Results & Conclusions One size does not fill all. Successful models of integrated expanded health care roles in primary health care settings are built on stakeholder’s capacity and preference; community need; and political will. Collaborative, congruent, multi-disciplinary care teams that prioritise patient-centred care within a dynamic primary care setting have merit and are more likely to foster flexibility and sustainability.

Making context work in primary health care

Health care in the community setting is one of the more challenging contexts for evidence-based practice. Community-based care comprises more than simply transplanting hospital care into people’s homes; in addition to the provision of supportive services, it also takes a range of approaches to health care practice that promotes optimal health and builds the capacity of individuals and communities to respond to their health needs. Primary health care is comprised of the diverse activities that build sustainable community capacity to achieve health and well-being throughout all of life’s stages. The expansive nature of primary health care means that a map for practice is not feasible; however a framework which can be adapted to suit the variety of situations and practice settings can be identified. The focus of this chapter is to broadly define and explore the principles of primary health care and consider the contexts of primary health care in relation to evidence-based practice.