A mixed-methods study of the implementation of the Trigger Review Method in general medical practice

Introduction : There is now compelling evidence that a significant minority of patients suffer preventable iatrogenic harm during their interactions with health care, including in UK general practice. While our understanding of the extent of the problem and the contributing factors continues to increase, it remains incomplete. Further patient safety research is therefore urgently required, particularly to develop, test and successfully implement effective improvement strategies, methods and tools. Of the main approaches currently available for improving patient safety, the general practice Trigger Review Method (TRM) is of particular interest and the main focus of this study. The TRM is, quite simply, a structured way to rapidly screen samples of random electronic patient records for undetected patient safety incidents (PSIs). It is essentially an adaptation of clinical record review, with the same underlying principles of learning from error and improving care. Development of the TRM commenced in 2007 in Scottish general practice, with subsequent testing in The Health Foundation-funded Safety and Improvement in Primary Care (SIPC) programme. In 2013, the TRM was included as one of the three core components of the Scottish Government’s Patient Safety Programme for Primary Care (SPSP-PC). Scottish general practices were also financially incentivised through the Quality and Outcomes Framework (QOF) to routinely apply the TRM and report their findings. However, despite the increasing and national interest in the TRM, many unanswered questions remained: what is its potential value, how acceptable and feasible is it and to what extent (if any) will, or should, it become part of routine general practice? The aims of this study were therefore to: (i) describe the patient safety perceptions of general practice clinicians and staff; (ii) determine the usefulness of the TRM; (iii) explain how the TRM worked; and (iv) identify the main factors that facilitated or hindered its implementation. Methods: This study has a mixed-methods design. It was undertaken in the West of Scotland region in two NHS Health Boards: Greater Glasgow and Clyde (GGC) and Ayrshire and Arran (A&A). Convenience samples of 12 general practice teams and 25 GP Specialty Trainees (GPST) were recruited. Data were collected through: semi-structured interviews (n=62) with a range of general practice clinicians and staff; and cross-sectional trigger reviews of selected electronic patient records. Normalisation Process Theory (NPT) underpinned all stages of the research. NPT is a socio-technical, middle-range theory about the ‘work’ people do collectively and as individuals to implement and sustain complex health care interventions such as the TRM. The majority of the qualitative data were analyzed thematically and a NPT framework was applied to the remaining data. Quantitative data were analysed using recognised statistical tests. Results: A total of 47 primary care clinicians reviewed 1659 electronic patient records and detected 216 PSIs. A substantial minority of these were considered to have led to moderate or more substantial harm (29.2%), while the majority (54.8%) were rated as being preventable or potentially preventable. The most common type of PSI related to ‘medication’ (40.7%) and the most commonly implicated drug was Warfarin. The participants reported considering or undertaking specific improvement actions during and after approximately two thirds of trigger reviews. The most common action was ‘feedback to colleagues’. More specific actions included: undertaking significant event analyses (SEAs) and clinical audits, designing or redesigning practice protocols and including their findings in their appraisal documentation. The vast majority of participants identified four main factors as being particularly important for the successful implementation of the TRM, and by extension its potential normalisation. The first and most important factor was provision of adequate resources and protected time to conduct trigger reviews. The second factor was whether senior leaders in the practice teams, the government and professional bodies practically demonstrated their support for the TRM through, for example, contextually integrating it into existing general practice processes. The third and fourth factors related to the characteristics of participants. Successful implementation required knowledgeable clinicians to remain engaged with the TRM, and to perceive it as useful, acceptable and feasible – which the vast majority of participants were, and did. Discussion: This study is the first known attempt to investigate how the TRM is implemented and perceived from the perspective of general practice clinicians and staff. The main findings are that most participants experienced the method as acceptable, feasible and useful. It is clear that the TRM is uncovering important patient safety concerns and also driving improvements in related care systems and processes at the individual practice level. The implication is that this is making significant and demonstrable differences to patient care, while impacting positively on local safety culture. On the evidence presented, normalisation of the TRM in general practice can therefore be recommended. However, while the usefulness of an intervention is an important factor in determining whether it is normalised or not, the study findings also clearly indicate – consistent with the international literature – that there are other factors that are at least equally important for normalisation. At the time of writing, there are no formal mandates or financial incentives for general practice clinicians or teams to perform regular trigger reviews. It therefore seems likely that normalisation of the TRM in Scottish general practice will be gradual and piecemeal, if it happens at all. Nevertheless, the lessons learnt from this study can be incorporated in the ongoing efforts to further improve the safety of care in general medical practice. In particular, researchers and policy makers should pro-actively identify and address the main factors that are known to facilitate or hinder the implementation of improvement initiatives; the existing knowledge and ‘engagement’ of clinicians should be recognised and harnessed; and the lessons learnt from PSIs should be more widely disseminated