Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Frequently Asked Questions
1. How do I get leadership buy-in?
Leaders play an important role in an improvement program by reinforcing the importance of the program to the organization’s mission and providing technical support for the work.
Engaging your organization’s leaders is the first step for any quality improvement project. The Guide includes several materials to help you convey the importance of engagement to improve your practice’s safety, including an infographic and training materials.
Key approaches for engaging leadership include:
- Making a strong case for change. Use the infographic or training slides to inform leaders about the risks to patient safety in primary care settings and how patient and family engagement strategies can improve patient safety and quality of care outcomes. For example, engaging patients and families can help reduce emergency department visits and hospital readmissions, as well as improving patient health outcomes.
- Presenting data. Use data to demonstrate the expected impact of the interventions on patient, clinician, and practice-level data, including costs to help establish a return on investment.
- Identifying a clinical champion.
- Keeping your leaders informed. It is critical to keep your leaders informed with regular briefings of the impact of the initiative on the practice.
2. How do I convince clinicians to participate?
Engaging a clinician champion for your improvement activities is a good way to enhance clinician participation. Identify one or two clinicians who may be willing to pilot test the activity with their patients, and have them share their experiences with others during staff meetings or huddles.
3. Which interventions should I select?
Mapping your quality improvement activities to your organizational priorities is an important first step. The list below can help you complete this step.
- Select Be Prepared To Be Engaged if you want to ensure that your patients ask you any questions they have and communicate their concerns and health goals to you. This intervention can help make office visits more efficient and reduce followup calls.
- Select Create a Safe Medicine List Together if you have many patients with multiple medications or you have committed to helping patients with medication management. This intervention can help you conduct medication reconciliation based on a complete and accurate list of medications, meet national patient safety goals, and improve patient outcomes.
- Select Teach-Back if you want to ensure that your patients understand what you tell them, including instructions such as how to take care of themselves at home, how to take their medications, how to use devices, and what additional procedures or care they need. This intervention can help make sure your patients leave your office knowing what they need to know and do.
- Select Warm Handoff Plus if you have handoffs within your practice, but they are currently done via the electronic health record or a paper note. This intervention can help improve communication between team members and with the patient and family.
4. How do I get started with implementation?
Start with the Implementation Quick Start Guide. This short guide will give you the steps to take and the decisions to make to design your implementation.
5. Our practice is short staffed. This isn’t a good time to implement something new.
Time in primary care, or the lack of it, is a major barrier to improvement activities. If you are short staffed or if there are other significant production pressures within your practice, you are not alone. Lack of time seems to be a perpetual issue in primary care. Consider starting small. Begin with one or two clinician teams to work out any process challenges. The best tests of change are small, incremental steps. This approach will increase the chance of success and sustainability of the activity within your practice setting.
6. We have a lot of staff turnover. How can I sustain the strategy with staff turnover?
Staff turnover can be very disruptive to improvement programs and processes. It is important that when you plan your implementation, you communicate with and educate all staff members so that they know their roles. Integrate the strategy into onboarding activities for new employees and consider succession planning. This approach will help support long-term sustainability of the intervention, reduce the disruption of staff turnover, and build a more resilient team.
7. How can I reinforce use of the strategies?
You can reinforce the use of the strategies by:
- Using daily huddles or regular meetings to allow your team to share experiences with the strategies, ask questions, and highlight safety issues detected using the strategies.
- Posting visual aids to provide a daily reminder to your team. These might be small posters or sticky notes near computers or telephones. You can also provide stickers to put on badges.
- Providing feedback to team members using the strategy.
- Identifying team members who are successfully using the strategy and asking them to be peer coaches.
- Sharing positive patient feedback.
1. How can I get patients to use the Be Prepared Note Sheet?
Provide the sheet to the patient along with a pen and explain its use. Try to avoid providing the sheet along with the other previsit paperwork so that it doesn’t become just another form in a pile of forms. All team members should reinforce the use of the sheet. The front desk can introduce it, whoever rooms the patient can ask whether the patient has filled it out or needs help filling it out, and the clinician can request to review it to set the visit agenda.
2. What if my patient doesn’t want to write anything down?
Explain that the sheet is optional, and the patient doesn’t have to write anything down. Ask the patient to think about what he or she wants to talk about and any questions to ask. Using the sheet can be a reminder for the patient and can also help the healthcare team understand and plan for whatever the patient wants to discuss.
3. What if my patient can’t write (or can’t write in English)?
Offer to help the patient. Ask the patient questions such as “What do you want to make sure you talk about today? What questions do you have? Do you have any health goals today? Maybe you want to sleep better or quit smoking or better control your high blood pressure?” Offer to write down the patient’s answers as he or she talks.
4. What if I don’t have time to cover everything a patient has written down?
The sheet should help you prioritize with the patient the concerns and questions to discuss during the visit. If there are more issues than can be discussed in the scheduled visit time, you can recommend that the patient schedule another visit to specifically discuss the additional issues or you can provide referrals (e.g., to a dietitian) or educational resources.
1. We don’t have time to review every patient’s medicines.
We understand that every minute counts within a short primary care visit and creating a medicine list together with the patient may take a little more time. However, the benefits are real. Unsafe medicine practices are a leading cause of death, hospital and emergency department admissions, and poor outcomes from patients taking medicines incorrectly. Engaging patients in creating a complete and accurate medicine list is a first step in medicine safety within primary care.
It is important to start small when initiating the Create a Safe Medicine List Together intervention. Prioritizing patients for a “medicine safety” appointment is one strategy that can help. Patients at greatest risk for medicine-related adverse events include:
- Patients taking five or more medicines. Research shows that up to 57 percent of patients on five or more medicines (called polypharmacy) are at greater risk for adverse drug events.
- Patients who see multiple specialists for their condition.
- Patients taking any one of the “high-harm” medicines. Information on high-alert medicines is available online.
- Patients with recent admissions to the hospital or emergency department. Often the medicines prescribed during a hospital admission are different from what the patient may have been taking at home due to their formularies.
Creating a medicine list annually during the patient’s annual physical or Medicare Wellness Visit is also a good initial strategy.
Ensuring that you know what medicines your patients are taking and that they are taking them correctly is part of professional practice. The Create a Safe Medicine List Together strategy will aid in safe medicine practices and improve confidence with your current medication reconciliation processes.
2. Our medical assistants are not qualified to discuss medicines with patients.
Every practice is different and has different resources. In general, we recommend that a medical assistant (MA) or patient care technician (PCT) work with the patient to get a complete list of what the patient is taking and how he or she is taking it. This step is completed using the medicines brought in and the medicines listed in the electronic health record, and by asking the patient what he or she actually does.
Whoever completes this task does not need to understand all the medicines; he or she is simply capturing the reality of what the patient is doing. The MA or PCT defers any discussion of the medicine or how or why the patient should be taking it to the clinician.
3. How do we get patients to remember to bring in their medicines?
This is a challenge in many practices. You can use the reminder card by handing it out at the prior appointment or mailing it shortly before the appointment. You can add a reminder to bring in medicines to your existing appointment reminder, whether that is a phone call, a robo call, or a text.
One practice added it to their robo call but found they had to add it before the date and time of the appointment because patients were hanging up as soon as they heard the appointment time. Some practices have made specific calls just to remind patients to bring in their medicines, such as the night before a morning appointment and the morning of an afternoon appointment.
4. What if patients don’t want to bring in their medicines?
Explain to those patients the importance of having a complete and accurate medicine list. This is especially effective if the clinician makes the request and provides the explanation.
5. What if patients aren’t comfortable bringing in their medicines (bringing them on public transportation or with them to work before or after their appointment)?
Give those patients the option of using their phone to take pictures of each of their medicines and bringing in their phone. Advise them to include a picture of the label.
6. What if a medicine needs to be refrigerated?
Advise patients with a medicine that needs to be refrigerated to bring the medicine in a thermal tote, such as a lunch bag. They can also take a picture of the label using their phone.
1. What if my patient can’t teach back after several attempts?
If your patient can’t teach back after several attempts, you can try a few options:
- Enlist the help of a family member or friend.
- Ask another member of the healthcare team to explain.
- Take a break or schedule another time to go over the information.
2. What if my patient is offended by being asked to teach back?
When you use teach-back, the emphasis should be on how well you communicated, rather than how well the patient understood. If you frame your teach-back as wanting to make sure you and the patient are on the same page or that you’ve been clear in your explanation, that should help minimize the number of patients who are offended.
3. I don’t have time to do teach-back.
Teach-back may take more time in the beginning. Many clinicians are already using closed- ended questions, such as “Do you have any questions?” or “Do you understand?” Teach-back is just a slight shift to an open-ended question. “Just to make sure we are on the same page, can you describe to me in your own words what you are going to do next?” The additional time it takes for a patient to teach back is made up in reduced phone calls and emails from patients needing clarification, and it results in better patient adherence.
4. Who else can use teach-back besides clinicians?
Teach-back is intended for the clinical encounter, but any member of the care team from the front desk to the medical assistants to the laboratory technicians can use the teach-back method when communicating important information to patients and family. It’s a safety check.
1. This doesn’t work with our workflow. The MA is busy rooming the next patient and doesn’t have time to wait for the clinician.
The Warm Handoff Plus has many advantages to clinical practice, including improving teamwork and communication, as well as reducing the cognitive burden and reliance on the electronic health record for transactional communication. It helps to build relationships and includes the patients and their family members as part of the team.
Patient-centered collaborative communication is the goal with Warm Handoff Plus. Some strategies that might help include:
- Using walkie-talkies to support team coordination, letting both the clinician and the MA know when they are ready and available for a Warm Handoff Plus.
- Huddling at the beginning of the day to review the patients who are scheduled to identify those times where a Warm Handoff Plus is (a) more likely to happen and (b) needed for more complex patients.
- It may not be possible to do a Warm Handoff Plus with every patient every time, so start small. You can use Warm Handoff Plus for the first three or four patients each day or with the first and last patients each day.
In addition, co-locating the care team, when possible, has been shown to support and encourage the adoption of Warm Handoff Plus in practice.