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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Quality and safety

Definition

Quality in healthcare means the best possible health outcomes given the available circumstances and resources, consistent with patient centred care.1

Safety in healthcare is reducing the risk of unnecessary harm to an acceptable minimum level.2 Patient safety is the freedom from hazards due to medical care or medical error in the general practice setting and is considered to be one of the dimensions of the quality framework for general practice.3 Harm can arise in healthcare, by omission or commission, and from the environment in which the healthcare is carried out.3

In reality, the total absence of harm in the healthcare setting is unachievable and so the concept of safety relates to reducing the risk of unnecessary harm to an acceptable minimum level. An acceptable minimum level refers to the level of risk that is generally acceptable given the level of current knowledge, available resources and the context in which care is delivered weighed against the risk of having or not having treatment.

Systemic errors are based on the concept that although individuals make errors, characteristics of the systems within which they work can make errors more likely. Error inquiry in patient safety then focuses on circumstances rather than on operator characteristics. More errors are likely to be eliminated by focusing on systems than on individuals.2

Quality and safety initiatives in general practice often involve quite complex terminology and consistent use of language is required to enable constructive approaches to gaining skills in this area. This curriculum uses patient safety terms and language consistent with the World Health Organization and the taxonomy of the World Alliance for Patient Safety,2 the Australian Commission on Safety and Quality in Health Care and the RACGP Standards for general practices.4

Curriculum in practice

The following case illustrates how the quality and safety curriculum applies to general practice:

  • Linda, 32 years of age, had a skin lesion removed from her back 6 months ago by a locum GP. She who now presents for a repeat prescription of the oral contraceptive pill. You notice that she has not been back since removal of the lesion. She explains that she had to urgently visit a family member interstate a few days after the lesion was removed, but that she has been well. You notice that the histology of the lesion was a malignant melanoma and realise that Linda has not received this result.

Rationale and general practice context

Quality improvement in general practice

Quality improvement is an essential general practice activity that involves examining practice structures, systems and clinical care. Improvement needs to be based on evidence produced by the practice's own data. This data can be gathered from patient or staff feedback, an audit of clinical databases or the analysis of near misses and mistakes.2

The challenge of quality in general practice is demonstrated by the gap between what is known to be best practice care and the delivery of care (outside of patient factors and healthcare costs).3

Quality improvement focuses on the growing body of knowledge relating to effective quality improvement strategies within the general practice setting,3 as detailed in the RACGP Quality Framework for Australian General Practice.3

The quality framework aims to improve quality in Australian general practice by incorporating the four levels of the general practice system of care:

  • the individual general practitioner at the consultation level
  • the setting of this care
  • the regional level
  • the national level.

The framework is then divided into the six main areas that influence quality in general practice:

  • capacity
  • competence
  • finance
  • knowledge and information management
  • patient focus
  • professionalism.

This framework provides a regulatory setting for quality improvement in general practice. Quality improvement processes are an increasingly important aspect of practice management processes and GPs need to be familiar with the key principles of quality improvement and its implementation.3

Patient safety

Although patient safety is only one aspect of quality improvement for general practice, it has been identified as an emerging core competency for GPs.5 Patient safety incorporates all the elements that can contribute to an adverse event during the provision of healthcare.

Safety covers events ranging from harm caused as a result of a wrong clinical procedure or decision, to the adverse effects of drugs, hazards posed by medical devices, substandard products, human shortcomings or system errors. These events may occur in hospital settings, primary healthcare clinics, nursing homes, pharmacies, patients' homes and in clinical trials.6

General practice can involve many invasive procedures, from seemingly simple actions such as immunisation to more complex tasks such as major skin flap surgery. Many of these activities can be subject to error which can result in patient harm. Because of this, there is a range of patient safety knowledge and skills across many general practice activities and contexts, such as the ability to identify causes of lapses in safety and processes for ensuring the correct procedure is done at the correct site on the correct patient.7

Patient safety is achieved primarily through the development and implementation of strategies that reduce the risk of events that could cause harm to patients. Practices need to engage in quality improvement activities to improve quality and safety for patients in areas such as practice structures, systems and clinical care.2

Collecting, classifying and aggregating data and information about these events, particularly with regard to preventive, mitigating and recovery strategies, is a central part of the process of improving patient quality and safety. Classification of patient safety data requires universal agreement and understanding of key terms and concepts as well as a standardised method for examining data.2

Although by international standards the quality of Australian general practice is generally high, the risk of harm to patients, health workers, general practice organisations and their patient communities are always present.

Research into the frequency and nature of error in primary healthcare has produced mixed findings.8 This may be due to the different methods of collecting data about adverse events leading to differences in reported rates.9 However, incident monitoring techniques can be successfully applied to Australian general practice. These techniques could facilitate the identification of factors that contribute to adverse events, and facilitate development of preventive interventions.10

Factors that influence safety and quality in general practice can be seen as a combination of personal, contextual and task-dependent factors,11 suggesting the need for GPs to assess the risk attributed to clinicians, systems and patients.12 Although patients are usually seen as passive (ie. as the victims of error), there is considerable scope for them to play an active role in ensuring that their healthcare is appropriate, thereby preventing mistakes13 and providing feedback to practice systems to improve general practice quality.4

Effective communication

The importance of effective and open communication is a common theme in research about patient safety. Communication errors are reported to be the leading causes of patient harm. Communication occurs at a number of levels and can be verbal or written. The presence of effective communication tools such as briefings, handover, good record keeping, patient information materials and checklists and behaviours such as clinician assertiveness can reduce the rate of harm.14

Poor communication after an adverse event (not just the original injury), can determine the decision to take legal action. Concern about the standards of care, the need for an explanation, compensation and the belief that staff and organisations should be accountable, are emerging as reasons for litigation.15

The systems approach to quality and safety

Research suggests that adverse events related to medicines are common in primary healthcare,16 that medication errors are widely distributed among doctors and that a reduction in medication errors requires a systems approach.17

Although there is a tendency for healthcare team members to define error as a breach of standards by an individual,18 a systems approach that identifies contributing factors in the environment and builds defences against potential harm, regardless of the cause, is more appropriate. This approach takes a complementary role to competence in the individual.19 Members of high performing teams generally have a clear understanding of their roles, and the demands on other team members, and work within a climate of openness and trust where team leaders are receptive to alternate views.20

Risk management in the healthcare system involves all levels of an organisation and is concerned with the creation and maintenance of safe systems of care.21 Systems utilised by the primary healthcare provider will vary, but may include tools such as monitoring and reporting, practice system audits, recall systems, incident logging and relevant continuous professional development activities.7

Promoting a culture of safety and quality in healthcare settings is one of the pillars of the safety and quality movement. A patient safety culture recognises the inevitability of error and actively seeks to create safeguards for patients.22

Quality improvement requires a collaborative effort of all general practice staff, and staff need to feel empowered to contribute to quality and safety.4

Consistent use of risk management systems helps reduce clinical risk and ensures that practice errors are identified and processes improved to reduce the likelihood of recurrence.

The journey of general practice can mean that as workplace situations and patient populations change, some knowledge and skills are enhanced, while other areas are diminished. This emphasises the role for ongoing vigilance of self and others in relation to competence, performance and maintaining the ability to refer appropriately. Advances in the 'science' of general practice, such as new medicines, new technology and improved evidence about efficacy and effectiveness, also mean that the risks to patients change. Therefore, key workplace attitudes that foster general practice patient safety promote:

  • a just, supportive and transparent culture
  • skills and knowledge in error awareness
  • a systems approach.

Clinical governance and clinical leadership

Clinical governance and clinical leadership, as described in the Practice management curriculum statement, are central to reform in the areas of quality and safety.14 Refer to this statement when undertaking education in quality and safety.

Related curriculum areas

Patient safety affects all areas of health, but curriculum statements of direct relevance to patient safety are:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

QAST1.1

Use effective communication, active listening skills, self awareness and self reflection to assess external and internal influences to help reduce hazards to patient safety.

QAST1.2

Use patient communication skills to acknowledge the experience that patients bring to their care, such as their knowledge about their symptoms and treatments.

QAST1.3

During communication and patient management, recognise that patients can take an active role in patient safety, sometimes helping to detect errors and adverse events, which may alert doctors to the presence of risk.

QAST1.4

Acknowledge patient concerns and complaints about treatments and the general practice when promoting patient safety.

QAST1.5

Use effective skills to discuss adverse events with patients and peers that aim to identify causes and prevent recurrence.

2. Applied professional knowledge and skills

QAST2.1

Understand the Quality Framework for Australian General Practice and implementation strategies in the general practice setting.

QAST2.2

Understand that changes in the person (eg. change in cognitive state), the patient healthcare context (eg. the emergence of new diseases) and in the nature of clinical care (eg. advances in technology) all create changes that may increase the likelihood of harm to patients. This requires ongoing vigilance to minimise the impact of these changes on clinical care.

QAST2.3

Apply knowledge of the impact of human factors, such as the role of cognitive overload and resilience, in order to maximise the safety of patients.

QAST2.4

Apply knowledge and use processes to ensure that the correct patient receives the correct treatment or procedure in the general practice setting and that they are compatible with those used in the acute health setting.

QAST2.5

Recognise and manage adverse outcomes including adverse events and near misses in patient care.

QAST2.6

Understand the characteristics of effective teams and the skills needed to develop and sustain these teams are a core element of ensuring a systemic approach to patient safety and quality improvement.

QAST2.7

Apply knowledge and skills in the identification of the causes of near misses and adverse events to reduce risk of harm that reflects the Australian general practice setting.

QAST2.8

Apply skills and knowledge necessary to undertake both quality assurance and quality improvement activities that include reducing the risk of adverse events.

3. Population health and the context of general practice

QAST3.1

Understand the local, regional and national factors that affect quality improvement in the general practice setting.

QAST3.2

Know the epidemiology of harm and error, eg. common causes of harm and how this can focus attention on the most effective interventions for reducing risk of harm to patients.

QAST3.3

Identify factors that affect the capacity of patients to engage in reducing risk of harm so that care and patient safety measures can be tailored accordingly. For example, legal competence of patients and their views of medical care and the authority of doctors.

QAST3.4

Use a range of ways to explain risk to assist the difficulty that patients may have when trying to understand the magnitude, likelihood and impact of the risks they face in their healthcare. This includes adapting risk explanations to people from culturally and linguistically diverse backgrounds.

QAST3.5

Understand how general practice advocacy at a health system level helps protect the safety of patients, eg. by alerting manufacturers to design limitations (eg. poor packaging) or by ensuring that the health system is not a barrier to patient safety (eg. the impact of workforce numbers on safe general practice care).

4. Professional and ethical role

QAST4.1

Apply legal and ethical requirements for obtaining informed consent from patients and carers, including the impact and implications of competence in decision making, and to advance decision making (including advance care planning and health directives).

QAST4.2

Provide feedback on performance to all members of the general practice team to help maintain the safety of patients including engaging with peers, team members and other providers about issues such as competence. Undertake steps to protect patients from related factors that may cause harm.

QAST4.3

Understand how the principles of natural justice and procedural fairness can help when investigating patient safety issues.

QAST4.4

Seek feedback from patients, general practice peers and team members and act on this feedback to help promote a safer patient environment.

QAST4.5

Document processes and procedures such as triage arrangements and quality improvement processes that help promote patient safety.

QAST4.6

Undertake quality assurance and quality improvement activities which reduce the likelihood of harm to patients.

5. Organisational and legal dimensions

QAST5.1

Understand that systems based approaches to health that focus on quality and safety is likely to produce a safer health care environment, thus complementing the person based approach.

QAST5.2

Understand the implementation of the Quality Framework for Australian General Practice into the general practice setting.

QAST5.3

Communicate effectively with members of the general practice team to ensure continuity of information to optimise patient care and protect patient safety.

QAST5.4

Engage with members of the general practice team in briefings before, and where necessary, debriefings after procedures with which team members assist.

QAST5.5

Accurately record clinical encounters with patients to ensure the continuity of safe, high quality patient care, and to help resolve any adverse outcomes.

QAST5.6

Understand that the development of an open, transparent, supportive and just culture within the general practice setting is regarded as the foundation of safety for patients and members of the healthcare team.

QAST5.7

Facilitate teamwork and demonstrate both leadership and the ability to take direction and work within teams when necessary.

QAST5.8

Report on incidents including lapses in safety, slips, errors, mistakes, adverse events and near misses within the practice.

QAST5.9

Assist the cultivation of meaningful and timely ways of reporting and acting on incident reports.

QAST5.10

Report errors appropriately to organisations outside the practice such as medical indemnity insurers, companies for equipment failures, and agencies such as adverse drug reporting authorities.

QAST5.11

Understand general practice legal obligations (including those relating to medical indemnity insurers), especially in the context of the discussion of adverse events.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

QASLM1.1

Describe internal cues and thought processes that might facilitate or impede the patient-doctor relationship.

QASLM1.2

Identify factors that contribute to distracting the GP during patient care tasks.

QASLM1.3

Outline occasions when a patient might contribute to maintaining the safety of care.

2. Applied professional knowledge and skills

QASLM2.1

Define a near miss and adverse event.

QASLM2.2

Outline characteristics of effective teams.

QASLM2.3

List common factors that are causes of error in medical practice.

QASLM2.4

Outline the concept of quality healthcare and strategies for improvement.

3. Population health and the context of general practice

QASLM3.1

Describe common forms of harm to patients in medical practice.

QASLM3.2

List examples of factors that may impede a patient making a realistic assessment of their risk.

4. Professional and ethical role

QASLM4.1

Describe the elements of valid consent.

QASLM4.2

Describe factors that would facilitate discussion of patient safety among peers.

QASLM4.3

Describe the concept of 'professional boundaries'.

QASLM4.4

Describe the symptoms of stress and fatigue and apply these to the workplace.

5. Organisational and legal dimensions

QASLM5.1

Describe a clinician's patient safety related legal obligations to their medical registration board and medical indemnity insurer.

QASLM5.2

Outline the difference between a 'person based' and a 'systems based' approach to patient safety.

QASLM5.3

Discuss the implementation of quality improvement of healthcare systems.

Prevocational doctor

1. Communication skills and patient-doctor relationship

QASLP1.1

Describe internal cues that occur during a clinician's interactions with patients.

QASLP1.2

Distinguish patient related factors that are likely to impede effective communication.

QASLP1.3

Differentiate between an effective handover of clinical care from an ineffective handover.

2. Applied professional knowledge and skills

QASLP2.1

Differentiate between a near miss and an adverse event.

QASLP2.2

Explain why the distinction between near misses and adverse events is important.

QASLP2.3

Distinguish between effective leadership and the ability to take direction and work within teams when necessary.

QASLP2.4

Outline quality improvement settings within your current workplace setting.

3. Population health and the context of general practice

QASLP3.1

Describe common causes of harm to patients in hospital and how this may differ from the general practice setting.

4. Professional and ethical role

QASLP4.1

Distinguish between appropriate and inappropriate boundaries in patient relationships.

QASLP4.2

Outline ways of gaining feedback from patients in the general practice setting.

QASLP4.3

Describe how to give constructive feedback on performance to other members of the team.

QASLP4.4

Outline the principles of natural justice and procedural fairness.

5. Organisational and legal dimensions

QASLP5.1

Differentiate between a just and unjust culture.

QASLP5.2

Describe examples of a positive contribution to creating a 'safety culture' and their application to the current workplace.

QASLP5.3

Identify the symptoms of stress and fatigue and apply these to the workplace.

QASLP5.4

Outline quality assurance processes and how these apply in the hospital setting.

Vocational registrar

1. Communication skills and patient-doctor relationship

QASLV1.1

Demonstrate effective communication in the patient-doctor relationship.

QASLV1.2

Explain effective ways to manage complaints by patients.

QASLV1.3

Demonstrate effective strategies to raise concerns with a colleague about a lapse in safety.

QASLV1.4

Explain the issues involved in discussing an adverse event with patients.

2. Applied professional knowledge and skills

QASLV2.1

Outline the Quality Framework for Australian General Practice and strategies for implementation in the general practice setting.

QASLV2.2

Complete a structured and systematic analysis of the causes of a near miss or adverse event.

QASLV2.3

Arrange a quality improvement activity focused on improving practice processes.

3. Population health and the context of general practice

QASLV3.1

Outline the relevant laws relating to competence in decision making for minors and for adults.

QASLV3.2

Show how the magnitude, likelihood and impact of risk can be explained to patients with poor literacy skills.

QASLV3.3

Outline the regulatory framework for quality improvement in the general practice setting.

4. Professional and ethical role

QASLV4.1

Describe processes for maintaining appropriate boundaries in patient-doctor relationships.

QASLV4.2

Apply the concept of procedural fairness to a complaint about a colleague.

QASLV4.3

Explain the ethical issues that arise in a discussion about an adverse event caused in another health setting.

QASLV4.4

Describe the role of clinical governance and clinical leadership in quality improvement measures including patient safety.

5. Organisational and legal dimensions

QASLV5.1

Describe the human factors of risk and provide a range of safeguards in the general practice setting which protect against these.

QASLV5.2

Explain how safeguards to patient safety operate within the systems of the practice.

QASLV5.3

Demonstrate effective recording of clinical encounters with patients.

QASLV5.4

Identify and modify organisational risks to patient safety.

Continuing professional development

1. Communication skills and patient-doctor relationship

QASLC1.1

Demonstrate the ability to modify communication processes about risks and benefits for the individual context of each patient.

QASLC1.2

Create checklists for briefing and debriefing for new or uncommon procedures.

QASLC1.3

Formulate ways to explain new technologies or treatments to patients.

2. Applied professional knowledge and skills

QASLC2.1

Assess areas where clinical competence diminishes and create safeguards against harm to patients.

QASLC2.2

Modify plans to accommodate cognitive overload, fatigue and stress in the practice team.

QASLC2.3

Create opportunities to recognise and reward quality initiatives in the practice setting.

3. Population health and the context of general practice

QASLC3.1

Document the reporting of lapses in quality to external agencies, such as medical indemnity insurers and post-marketing surveillance bodies such as the Therapeutics Goods Administration and Australian Drug Reactions Advisory Committee.

QASLC3.2

Monitor trends in near misses and adverse events in the general practice setting.

QASLC3.3

Modify processes in line with advances in the evidence of effective clinical practice.

4. Professional and ethical role

QASLC4.1

Plan clinical discussions with peers in order to learn from ongoing practice.

QASLC4.2

Integrate patient feedback into ongoing professional development.

QASLC4.3

Maintain clinical competencies through continuing professional development and quality improvement activities.

5. Organisational and legal dimensions

QASLC5.1

Integrate enhanced safeguards for patients into the organisational processes of the general practice.

QASLC5.2

Integrate contingency planning into general practice planning.

QASLC5.3

Assess risk in the practice setting on a consistent basis.

QASLC5.4

Describe, where appropriate, the quality improvement measures within the practice.

QASLC5.5

Outline regulatory frameworks that govern quality improvement within the general practice setting.

References

  1. WONCA working party on quality and safety in family medicine. Quality and safety in family medicine. WONCA; 2011. Available at www.globalfamilydoctor.com/aboutWonca/working_groups/quality_ass/wonca_qualityassurance.asp?refurl=wg.
  2. World Health Organization. The conceptual framework for the international classification for patient safety. Version 1.1. Final technical report. Geneva; 2009. Available at www.who.int/patientsafety/implementation/taxonomy/icps_download/en.
  3. The Royal Australian College of General Practitioners. A quality framework for Australian general practice. Melbourne: The RACGP; 2005. Available at www.racgp.org.au/qualityframework.
  4. The Royal Australian College of General Practitioners. Standards for general practices 4th edn. Melbourne: The RACGP; 2010. Available at www.racgp.org.au/standards.
  5. Kidd MR, Beilby JJ, Farmer EA, Jackson CL, Trumble SC. General practice education and training: past experiences, current issues and future challenges. Med J Aust;194(11):S53–4.
  6. World Health Organization. Conceptual Framework for the International Classification for Patient Safety. Geneva. World Health Organization. Version 1.1 2009 www.who.int/patientsafety/taxonomy/icps_full_report.pdf.
  7. The Royal Australian College of General Practitioners. Patient safety initiatives. Melbourne: The RACGP; 2010. Available at www.racgp.org.au/safety.
  8. Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 2003;20(3):231–6.
  9. Bent S, Padula A, Avins AL. Brief communication: Better ways to question patients about adverse medical events. Annals of Internal Medicine 2006;144(4):257–61.
  10. Britt H, Miller GC, Steven ID, Howarth GC, Nicholson PA, Bhasale AL, et al. Collecting data on potentially harmful events: a method for monitoring incidents in general practice. Fam Pract 1997;14(2):101–6.
  11. Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care 2004;13(Suppl 2):ii28–33.
  12. Rosser W, Dovey S, Bordman R, White D, Crighton E, Drummond N. Medical errors in primary care: results of an international study of family practice. Can Fam Physician 2005;51(3):386–7.
  13. Vincent CA, Coulter A. Patient safety: What about the patient? Quality and Safety in Health Care 2002;11(1):76–80.
  14. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care 2004;13(Suppl 1):i85–i90.
  15. Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994;343(8913):1609–13.
  16. Espin S, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Qual Saf Health Care 2006;15(3):165–70.
  17. Reason J. Human error: models and management. BMJ 2000;320(7237):768–70.
  18. Flin R, Maran N. Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care 2004;13(Suppl 1):i80–4.
  19. Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, et al. Adverse drug events in ambulatory care. N Engl J Med 2003;348(16):1556–64.
  20. Nicholson D, Hersh W, Gandhi TK, Weingart SN, Bates DW. Medication errors: Not just a few "bad apples". J Clin Outcomes Manag 2006;13(2):114–5.
  21. Australian Council for Safety and Quality in Health Care. National Patient Safety Education Framework. 2005. Available at www.health.gov.au/internet/safety/publishing.nsf/Content/C06811AD746228E9CA2571C600835DBB/$File/framework0705.pdf.
  22. Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003;12(Suppl 2):ii17–23.

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