Education

and Training

Technical Series on Safer Primary Care

Education and Training: Technical Series on Safer Primary Care
ISBN 978-92-4-151160-5

© World Health Organization 2016

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-
ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial
purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should
be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO
logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent
Creative Commons licence. If you create a translation of this work, you should add the following disclaimer
along with the suggested citation: “This translation was not created by the World Health Organization
(WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition
shall be the binding and authentic edition”.
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the
mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/
rules).

Suggested citation. Education and Training: Technical Series on Safer Primary Care. Geneva: World Health
Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO.
Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit
requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as
tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse
and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any
third-party-owned component in the work rests solely with the user.
General disclaimers. The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status
of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not
yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned.
Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or
implied. The responsibility for the interpretation and use of the material lies with the reader. In no event
shall WHO be liable for damages arising from its use.
Contents

Preface 1

1 Introduction 3
1.1 Scope 3
1.2 Approach 3

2 Education and training 4

3 Types of education 5
3.1 Pre-service education 5
3.2 In-service education 5

4 Key issues 7
4.1 Limited pre-service education 7
4.2 Limited education about safety 7
4.3 Limited targeted training 7
4.4 Limited evidence about approaches 8

5 Potential solutions 9
5.1 Practical approaches 9
5.2 Content 9
5.3 Integrating safety education 11
5.4 Infrastructure support 12
5.5 Monitoring outcomes 13

6 Practical next steps 15

7 Concluding remarks 18

Contributors 24

References 26
Preface

Safer Primary Care

Health services throughout the world strive to provide care to people when they
are unwell and assist them to stay well. Primary care services are increasingly at
the heart of integrated people-centred health care in many countries. They provide
an entry point into the health system, ongoing care coordination and a person-
focused approach for people and their families. Accessible and safe primary care
is essential to achieving universal health coverage and to supporting the United
Nations Sustainable Development Goals, which prioritize healthy lives and promote
well-being for all.

Health services work hard to provide safe and high quality care, but sometimes
people are inadvertently harmed. Unsafe health care has been recognized as a
global challenge and much has been done to understand the causes, consequences
and potential solutions to this problem. However, the majority of this work up to
now has focused on hospital care and there is, as a result, far less understanding
about what can be done to improve safety in primary care.

Provision of safe primary care is a priority. Understanding the magnitude and nature
of harm in primary care is important because most health care is now offered in this
setting. Every day, millions of people across the world use primary care services.
Therefore, the potential and necessity to reduce harm is very considerable. Good
primary care may lead to fewer avoidable hospitalizations, but unsafe primary care
can cause avoidable illness and injury, leading to unnecessary hospitalizations,
and in some cases, disability and even death.

Implementing system changes and practices are crucial to improve safety at all
levels of health care. Recognizing the paucity of accessible information on primary
care, World Health Organization (WHO) set up a Safer Primary Care Expert Working
Group. The Working Group reviewed the literature, prioritized areas in need of
further research and compiled a set of nine monographs which cover selected
priority technical topics. WHO is publishing this technical series to make the work of
these distinguished experts available to everyone with an interest in Safer Primary
Care.

The aim of this technical series is to provide a compendium of information on

key issues that can impact safety in the provision of primary health care. It does
not propose a “one-size-fits-all” approach, as primary care is organized in different
ways across countries and also often in different ways within a given country.
There can be a mix of larger primary care or group services with shared resources
and small services with few staff and resources. Some countries have primary
care services operating within strong national support systems, while in other
countries it consists mainly of independent private practices that are not linked

1
 preface

or well-coordinated. The approach to improving safety in primary care, therefore,

needs to consider applicability in each country and care setting.

This technical series covers the following topics:

Patients
n Patient engagement

Health workforce
n Education and training
n Human factors

Care processes
n Administrative errors
n Diagnostic errors
n Medication errors
n Multimorbidity

n Transitions of care

Tools and technology

n Electronic tools

WHO is committed to tackling the challenges of patient safety in primary care, and
is looking at practical ways to address them. It is our hope that this technical series
of monographs will make a valuable and timely contribution to the planning and
delivery of safer primary care services in all WHO Member States.

2
1 Introduction

1.1 Scope
The health workforce is an essential component of safer primary care. To provide
safe, high quality primary care, necessary educational qualifications, good training
and ongoing professional development are paramount.

There is an increasing recognition of the importance of improving safety, but health

care education may lag behind. Health care workers do their best to provide safe
care, but they need the skills and resources to identify risk and reduce harm. This
is why it is important to take a systematic approach to providing education about
improving safety in primary care.

This monograph describes key characteristics for consideration by the World

Health Organization (WHO) Member States to support safer primary care when
developing or reviewing the education and training of health care workers.

After outlining the approach taken to compile information, the monograph describes
why examining provider education is important. It then identifies key issues that
may hinder education and offers potential solutions with examples of content that
could be included in the curricula of education courses. The term “education” is
used throughout to include education and training. The term “provider” is used to
mean various categories of health care workers.

1.2 Approach
To compile information for this monograph, WHO sought the advice of experts
in the field recommended by the Safer Primary Care Expert Working Group and
reviewed relevant research, the published literature and educational curricula.

International experts in delivering safe primary care provided feedback, examples

of strategies that have worked well around the world and practical suggestions
about potential priorities for countries for improving the safety of primary care
services.

3
2 Education and training

There are many reasons why it is essential to examine education when striving for
safer primary care. Key reasons include:
n providing education about the core principles of primary care to all health care
providers creates a foundation of values upon which to develop a positive safety
culture;
n having an adequate and well-trained primary care health workforce is essential
for providing safe, high quality care;
n educating the workforce about safety skills has the potential to further improve
patient outcomes.

Primary care is guided by eight core principles: access or first-contact care;

comprehensiveness; continuity of care; coordination; prevention; family orientation;
community orientation; and person-centredness (1). WHO has identified that
applying these principles is key to providing high quality health care globally (2).
Ensuring that the core characteristics of primary care are included in the education
process of all health care workers will help to build a health care culture where
safety and quality are valued because they are central to patient well-being.

Efforts to improve safety must include educating the workforce. The composition
of the primary care workforce varies substantially by setting. However, regardless
of the structure of the primary care workforce, pre-service and in-service education
enhances the safety and quality of care by ensuring that individuals are well
prepared to perform their required duties, thereby reducing errors due to gaps in
knowledge or skills.

4
3 Types of education

This section briefly outlines various types of education for providers and why they
are important. It is important to review what type of education is available and
identify any gaps in provision.

The main types of education that may support safer primary care include:
n undergraduate and postgraduate pre-service education for trainee providers;
n in-service education programmes for practising providers;
n patient education and awareness raising.

This monograph covers the education of providers, but it acknowledges that the
education and awareness raising of patients as key members of care teams are
equally important.

3.1 Pre-service education

Pre-service education for professionals occurs before they are qualified as health
care providers. The safety of primary care can be strengthened by ensuring good
quality pre-service education in technical skills, preventive care, diagnostics,
therapeutics and palliative care.

Infusing primary care principles into pre-service education for all health professionals
would provide a shared cultural background and promote a coordinated team-
based approach toward achieving safety for all. Interactions with trained primary
care providers early in pre-service education would give exposure to trainees and
allow for on-the-job training in a conducive learning environment.

Equally important are postgraduate level education courses and training

programmes, including those leading to a qualification as a specialist in primary
care. In some areas, basic primary care services are delivered without a postgraduate
trained primary care specialist. However, educating a cadre of postgraduate level
trained specialists, such as family doctors, should be seen as essential to provide
the advanced diagnostic and assessment services needed in primary care.

3.2 In-service training

Professional development through in-service training is another way to build and
maintain high quality primary care. For health systems that have yet to develop
a robust specialty workforce in primary care, in-service training can be targeted
towards upskilling or retraining existing health professionals to provide the health
system with competent primary care providers.

5
 types of education

Continuing professional development programmes can help to maintain

competency in a wide range of skills and ensure familiarity with the latest guidelines
and evidence-based initiatives. In-service training also has the benefit of teaching
techniques that may be immediately relevant to providers, meaning that they can
make changes to their practice straight away.

Adult learning principles suggest that it is important to offer incentives, both

financial and professional, to providers already in practice in order to encourage
them to take part in in-service training. Incentives might include a qualification
equivalent to a specialty degree, an increase in monetary compensation upon
completion of the programme or the ability to maintain a license to practice.

Upskilling programmes may be more successful if implemented in settings as

close as possible to the trainees’ existing place of work so as to limit geographic
barriers and encourage retention in rural and remote areas. Running programmes
in close proximity to the trainees also increases the likelihood that the training will
reflect and address the issues most commonly encountered in local practice.

Training a local team in safe primary care practice, although resource intensive, is
highly effective. Practicing emergency response together as a primary care team
instils confidence in the team members and creates a positive safety culture.

6
4 Key issues

There are a number of issues and challenges facing authorities involved in planning
for education for safer primary care. Key issues to consider include:
n variations in the level of education providers have before beginning clinical
practice;
n insufficient inclusion of safety topics into pre-service curricula;
n limited education about safety specifically targeting primary care;
n limited evidence about the most effective educational techniques.

This section describes these issues and challenges and the following section
considers potential solutions.

4.1 Limited pre-service education

In an absolute sense, patient safety is most compromised when patients lack basic
access to a competent primary care provider. In some settings, health workers at
grassroots level may not have received adequate clinical training before entering
service and perhaps none specific to primary care. This may mean that they are at
higher risk of unfavourable patient outcomes. These issues are compounded when
providers are placed in remote settings with little access to learning resources.

4.2 Limited education about safety

The process and duration of education for health care workers varies widely
depending on the level of professional qualification and health system setting.
Regardless of the length of training, safety education remains largely absent from
pre-service education in many settings. For instance, a survey of 125 medical
schools in one high-income country found that only 10% had safety content in
elective or required courses and only half of recently published medical textbook
editions contained safety information (3).

4.3 Limited targeted training

There is also a lack of training about improving safety that specifically targets the
primary care context. Even when health systems provide education to improve
safety, it often has a general focus or an emphasis on the hospital context. The
most common evidence-based medicine approaches for safety in primary care
depend on narrow research, offer only marginal gains when applied in practice or
do not account for the multimorbidity commonly seen in primary care (4).

7
 key issues

Safety improvement strategies developed in academia may not result in a change

in clinical practice (5,6). There is even a danger of introducing new harms by using
protocol-driven approaches rather than respecting the judgement of clinicians (7).
Therefore, educational initiatives need to explicitly address these challenges in
translating improvement initiatives to the primary care setting.

4.4 Limited evidence about approaches

Another issue is that there is limited evidence about which educational approaches
are most effective in the pre-service and in-service settings. A review of professional
curricula for safety education found that a variety of methods have been used to
teach safety skills. These include lectures, workshops, objective structured clinical
examinations, “standardized” patients, simulation exercises, root cause analysis,
quality assurance projects and other interactive learning methods (8). However,
there is limited evidence about which of these methods is the most successful
or how outcomes vary depending on the type of learner or setting. This is true in
general and is a particular issue in primary care (9).

Most research related to educational interventions for improving safety suggests

that education improves knowledge and attitudes, but this may not necessarily
translate into improvements in clinical outcomes (10-12).

8
5 Potential solutions

There are a number of strategies that may help address the issues related to
education about safer primary care. These include:
n using practical educational approaches;
n developing educational content targeted at primary care;
n integrating safety education early into pre-service curricula;
n ensuring that an infrastructure is in place to support education;
n monitoring the impact of educational initiatives.

5.1 Practical approaches

Designing core training around the actual primary workplace setting helps primary
care providers learn the practical skills needed for the competent day-to-day
management of patients.

Health care workers may also be likely to gain new knowledge using applied
methods, such as case discussions, practical simulations and learning from
reflecting on real-life examples. These practical approaches could be incorporated
into any educational initiatives.

Patient safety themes need to be reinforced through various methods recurring in

the curriculum, with opportunities for trainees to learn to get and give feedback on
safe practices.

5.2 Content
Diagnosis, prescribing, communication and organizational change are the key
areas associated with harm in primary care (13). This may vary across countries
and areas. Based on expert feedback, WHO has stratified the main causes of safety
issues in primary care according to the country income level (Box 1). It is important
to develop educational systems to address the issues that are most relevant to the
national or local context.

9
 potential solutions

Box 1. Main causes of safety incidents in primary care (14)

Low-income settings
n Counterfeit drugs

n Errors when performing clinical tasks due to inadequate

knowledge or skills
n High workload
n Poor communication between health workers and patients

Middle-income settings
n Poor communication between health workers and patients

n Counterfeit drugs
n Errors when performing clinical tasks due to lack of
knowledge or skills
n Gaps in systems management, such as human resources
n Information technology and tools

High-income settings
n Poor communication between health workers and patients

n Errors in diagnostic imaging

n Gaps in systems management, such as human resources
n Errors from information technology and tools
n Low staff morale

Education should focus on issues that have the greatest burden of harm. Diagnostic
and clinical task errors are common in most health systems, so there is a need for all
primary care workers to have a comprehensive, quality education about these aspects.

In systems with higher levels of communication errors and issues with information
technology or tools, there is a need to educate leaders and managers to restructure
health systems and develop a broader culture of safety.

WHO Multi-professional Patient Safety Curriculum Guide suggests that 11 topics

about safety should be included in all health care education (Box 2).

In addition, education could focus on building leadership that recognizes the

importance of patient safety and creates an environment where individuals can
report errors to facilitate learning and prevent recurrence without fear of retribution.

Other key topic areas may include culture, handoffs and transitions and workforce
safety, such as strategies to prevent burnout and increase resilience. Worker safety
and adequate working conditions may be the preconditions to patient safety.

Many organizations have made their curricula or tools available online (16-19).

10
 potential solutions

Box 2. Eleven patient safety topics for inclusion in education (15)

1. What is patient safety?

2. Why applying human factors is important for patient safety
3. Understanding systems and the effect of complexity of
care
4. Being an effective team player
5. Learning from errors to prevent harm
6. Understanding and managing clinical risk
7. Using quality improvement methods to improve care
8. Engaging with patients and caregivers
9. Infection prevention and control
10. Patient safety and invasive procedures
11. Improving medication safety

5.3 Integrating safety education

As well as considering how education is provided and what type of content to cover,
it is also important to think about when education on safety should be provided.
Early compulsory pre-service education, as well as in-service education, is needed
to close the safety gap. This education is important for all professional disciplines,
not only doctors.

There is little evidence that education programmes focused on improving processes

for people with particular conditions result in improved patient outcomes,
particularly at a population level. Instead, it may be preferable to teach general
safety principles that can be tailored to a variety of clinical settings and a range of
health problems.

Pre-service education may be specific to an individual professional discipline, such

as nursing, medicine or pharmacy, but safety concepts should be introduced early
in the curriculum for all.

In some settings, much of the pre-service education involves practical learning

using a hierarchical apprenticeship model. Therefore, it is also important to
consider the role of clinical supervision and the curriculum that may help shape
ideas about safety behaviour. Supervision offers an opportunity to model good
safety processes in practice. Providing effective clinical rotations with high quality
supervision, role modelling and feedback may be core to improving safety (20).

Discipline-specific in-service education can help to build a uniform base of general

knowledge while emphasizing safety topics that are relevant to the specific
profession. However, in-service education should also take into account the team-
based nature of primary care, which requires disciplines to work together to
coordinate care. Studies suggest that multi-professional, inter-professional team-

11
 potential solutions

based education about safety can improve practice in primary care (21). Whilst
workers may initially feel uncomfortable learning alongside other disciplines,
multidisciplinary learning helps workers consider patient safety within the context
of teamwork (22). Multi-professional education could contain basic elements
relevant to all involved disciplines, such as information sharing, recording risk
assessments and handover procedures.

For pre-service and in-service education to be effective, the learning environment

must be open and accepting of identifying and discussing errors.

Creating a more open learning environment can be achieved in a number of ways,

such as:
n supporting providers to lead by example and preparing them to discuss their
own errors;
n scheduling regular discussions to review errors and near misses designed not
to blame, rather to reward those who bring forward issues for the group to learn
from;
n recognizing that communication between health care providers is a critical
element of patient safety. In addition to ensuring that practitioners are educated
to have effective communication skills with patients, they also need education to
ensure effective communication between practitioners of the same and different
professional disciplines. This can be done by role modelling and communication
skills’ assessments;
n providing education about handling uncertainty, which is prevalent in primary
care.

5.4 Infrastructure support

As with any intervention intended to bring about change, using an integrated,
system-based approach provides the best opportunity for sustainable improvement.
Incorporating both primary care training and safety training into the health care
education system is an important step towards building ongoing sustainability and
ensuring a future workforce competent in these areas. Health systems may need
to develop more robust ways to support the implementation of safety principles
because educational programmes alone will not be sufficient to provide safer
primary care.

A whole systems approach is needed. A system-wide commitment to establishing

and supporting primary care as a foundation for health systems is needed to ensure
adequate training, resources and incentives for high quality care at the grassroots
level.

Professional societies within primary care could show a commitment to patient

safety by developing patient safety curricula, disseminating information at
professional conferences, recognizing patient safety in guidelines and standards,
advocating for adequate human and financial resources and establishing broader
safety reporting mechanisms (23).

12
 potential solutions

Accreditation programmes could be established to assess the quality of primary

care training and assure adherence to recognized international standards. The
World Organization of Family Doctors (WONCA) has developed standards and a
checklist for assessing primary care education programmes based upon standards
from the World Federation of Medical Education (24).

Professional organizations could develop a consensus about a core set of

competencies relevant to safety. Patient safety topics could be included in
examinations as a requirement for certification in medical professions. This would
help to ensure that professionals possess the necessary knowledge and skills
to practice safely as well as fostering a culture of safer primary care (25). Some
organizations have online courses and resource materials for supporting providers
to become certified in patient safety (26).

5.5 Monitoring outcomes

It is important to put in place systems and indicators to measure the effectiveness
of education. This would help to understand which educational approaches are
most effective and their impact on patient outcomes over time.

As well as helping to monitor improvement, measurement can serve as a catalyst

for change. Providing practitioners with the skills to measure safety and quality
offers the opportunity for providers to lead change through continuous quality
improvement.

However, developing accurate and effective methods to measure the overall quality
of primary care and specific aspects of patient safety can be challenging and it
is important to be realistic. It will likely take years to see changes in population-
based outcomes resulting from comprehensive primary care education. Process
and output indicators, such as the number of providers trained, may be useful
intermediate measures of improvement, but information needs to be collected for
a purpose and not seen as a “tick box” exercise.

Examples of potential indicators that could be tracked at each organization or at

national level over time include:
n number of patient safety incidents reported;
n number of professionals of different cadres trained in patient safety;
n number of patient safety educational workshops provided;
n proportion of staff receiving continuing safety training in the last year;
n change in performance on patient safety knowledge tests;
n change in patient safety culture questionnaire.

Outcome measures focused on particular conditions could be used, but this runs
the risk of over-emphasizing specific conditions rather than general safety principles
and can distort the focus on comprehensive care that is so essential in primary
care settings. It may be more relevant to observe and score training participants to
measure changes in clinical practice.

13
6 Practical next steps

Educating and training the health workforce is a key foundation for improving
the safety of primary care. Strategies that WHO Member States could consider
prioritizing to build sufficient health workforce capacity for improving safety in
primary care include:

1. Recognizing the infrastructure needed to support education

n identifying safer primary care as a goal in national strategic plans to ensure that
decision-makers allocate resources for education;
n building leadership capacity in safety through engaging those at governance
level, encouraging external accreditation and incorporating safety elements in
regulatory and licensing requirements;
n linking safer primary care with existing donor initiatives to secure more
resources;
n linking with professional societies, networks, patient organizations and other
key stakeholders to emphasize the importance of education in patient safety.

2. Developing education specifically about safety in primary care

n making education about safety in primary care mandatory and part of assessment
procedures;
n drawing on existing curricula about patient safety in primary care and adapting
using locally-relevant examples;
n incorporating a wide range of topics in safety education, such as human factors,
leadership, intra- and inter-professional communication, incident reporting, how
to measure safety and quality in primary care, and how to learn from errors;
n providing education about quality improvement approaches so that workers
are not only able to identify incidents, but also know how to minimize them in
the future. This may include education about reminder systems, clinical audits,
outreach visits and continuous quality improvement;
n providing generalist education that can be adapted to many contexts rather than
disease-specific interventions;
n starting training in safety early, preferably at the pre-service phase, where there
is better opportunity to capture whole cohorts and lay solid foundations.

3. Thinking creatively about how to provide education

n educating workers using a mix of pre-service and in-service education. General
training in safety could be provided for all workers with more specific training
targeted as needed;

14
 practical next steps

n offering practical education, perhaps in a workplace context, by using direct

observation, feedback, videos and rotations;
n providing opportunities to learn about and practice safer primary care in a local,
team-based setting;
n evaluating the effectiveness of different education methods;
n monitoring improvements in learner and patient outcomes so that changes in
practices and patient safety can be tracked over time;
n giving incentives for providers to take part in education, such as protected
learning time, financial support and certificates.

4. Developing trainers and educational resources

n accrediting courses and learners;
n sharing resources between smaller and larger organizations so that all can
access expertise and educational materials;
n developing shared resources, such as educational tools and measures, and
drawing on existing online materials;
n increasing opportunities for supervision and role modelling;
n identifying champions for patient safety in primary care and training them as
trainers to support peer-to-peer learning;
n developing links with international bodies to help implement best practices;
n providing platforms where primary care services and providers can celebrate
success and share ideas.

5. Widening the range of professionals trained

n ensuring that an appropriate number of primary care workers of different
disciplines are educated, such as healthcare assistants, nurses, doctors and
administrative support roles;
n educating all health professions about the principles of primary care to build
shared understanding;
n offering opportunities for inter-professional team education;
n developing training at different levels to lower the initial hurdle for the majority
and allow those interested to continue learning at higher levels;
n educating providers about the patient’s role in improving safety because patients
are key members of care teams.

Countries have varying levels of resources and it is recognized that increasing the
number of primary care providers, whether fully trained or not, is of primacy to
some. Far more people are harmed on a global scale by lack of access to primary
care than are actively harmed by the provision of services within primary care
clinics. In low- and middle-income settings, the focus of education might be on
building a cadre of sufficiently resourced primary care centres staffed with health
care teams competent in the provision of primary care services. This means that
safety principles should be incorporated as early as possible in the education

15
 practical next steps

of all providers. The focus should not be only on those who may eventually
work in primary care, because the workforce is fluid and people move between
organizations and roles.

Safer primary care is a need for health care systems in countries across the world.
All providers in all health care systems have the potential to make errors. It is
critical to educate providers to expect errors and to know how to deal with them
appropriately. Providers need to be able to recognize errors, learn from them and
work towards system changes to prevent future occurrences. To achieve this, the
learning environment for both trainees and practitioners must be open to ensure
that it is safe and acceptable to discuss errors.

Education is essential, but not sufficient alone to improve safety in primary care.
Other monographs in this technical series consider some of the other aspects of
systems design that are crucial for safer primary care.

16
7 Concluding remarks

Primary care services are at the heart of health care in many countries. They provide
an entry point into the health system and directly impact on people’s well-being
and their use of other health care resources. Unsafe or ineffective primary care may
increase morbidity and preventable mortality and may lead to the unnecessary use
of scarce hospital and specialist resources. Thus, improving safety in primary care
is essential when striving to ensure universal health coverage and the sustainability
of health care. Safer primary care is fundamental to the United Nations Sustainable
Development Goals, particularly to ensure healthy lives and promote well-being
for all at every age.

Understanding the magnitude and nature of harm in primary care is important

because a significant proportion of health care is offered in this setting, yet there
is little clarity about the most effective ways to address safety issues at this level.

This monograph summarizes the evidence and experience in building sufficient

health workforce through ongoing education and training in order to improve
patient safety in primary care. However, interventions to implement strategies for
appropriate education and training would need to be implemented in conjunction
with other important aspects covered in this series.

The Technical Series on Safer Primary Care addresses selected key areas that WHO
Member States could prioritize, according to local needs. This section summarizes
the key messages from all of the monographs and provides a list of 10 key actions
that are likely to have the most impact on improving safety in primary care. Links
to online toolkits and manuals are also referenced in order to provide practical
suggestions for countries and organizations committed to moving forward this
agenda.

1. Set local priorities

Countries and regions differ and a strategy that works well in one area may not
transfer well to another. Similarly, issues in need of improvement in some regions
may not be a priority for others. In seeking to improve safety in primary care,
countries could use local information about their safety issues to identify key
priorities at the national or regional level. Priority setting could be accomplished by
drawing on input from patients and professionals, sourcing local statistics on safety
issues and comparing key themes from the literature with local circumstances (27).

Checklists are also available to help identify potential patient safety issues such as
environmental risks in primary care services (28).

One practical way to move forward is creating mechanisms for bringing together
key stakeholders to consider the local information available and develop strategic
and operational plans for improving safety in primary care. Communicating

17
 concluding remarks

proposed priorities widely and amending them based on feedback from health
care professionals and patients would help to obtain their buy-in, as well as raise
awareness of the importance of improving patient safety in primary care.

Regular measurement of safety related performance indicators could be considered

as one of the priorities. Policy-makers can use measurements to help identify local
issues where performance is suboptimal and then evaluate different types of
interventions for improvements. Priorities could be reviewed every few years to
ensure that they remain in line with local needs and good practice.

2. Take a wider systems approach to improving safety

Although the series has described specific technical areas, each monograph
refers to interlinkages with other areas. Focusing on improving just one factor
may not have a large or sustainable impact on patient safety overall. It may be
important to simultaneously improve communication with patients, train health
care professionals and introduce new tools to support more streamlined care.

Taking a systems approach to safer primary care means looking at how different
components relate to one another and considering various factors which could
influence safety. These include factors such as workforce availability and capability.

A practical systems level initiative is to focus on increased communication and

coordination across different types of care including primary, secondary and also
social care. This may include strengthening technical systems for sharing records
and communicating what is happening.

It is also important to build relationships between care professionals. At a policy

level, this may involve considering how to develop supportive infrastructure, such
as having a directory of services to help build networks of professionals and align
resources. If hospital, primary care and social care professionals are able to meet
and discuss safety issues, this could foster supportive relationships and increase
understanding of each other’s roles. Regional forums or meetings could be set up
so that professionals from different organizations can get to know each other and
share their successes and challenges in improving patient safety.

Manuals and reference lists are available with further ideas for improving
coordination and reducing fragmentation across systems (29,30).

3. Communicate the importance of safety in primary care

Policy-makers, health care professionals, patients and families may not always be
aware that there are important safety issues to consider in primary care. Raising
awareness of this as a priority area will help stakeholders to understand why safety
in primary care is essential to improve people’s well-being and for safeguarding
scarce health care resources.

Serious consequences due to the lack of safety in primary care, particularity relating
to poor transitions of care between primary and other levels, and administrative,
diagnostic and medication errors could be highlighted to raise awareness on the
need to improve patient safety in primary care.

18
 concluding remarks

Practical ways to increase awareness include incorporating safety-related

information into the training of health professionals, communicating effectively to
professionals and patients through channels that would be most appropriate for
them and spreading key messages through media campaigns. A communications
plan could be developed in tandem with local priority setting discussed earlier.

4. Focus on building a positive safety culture

Effective leadership and supportive culture are essential for improving safety in
primary care.This means creating an environment where professionals and patients
feel able to speak up about safety issues that they are concerned about, without
fear of blame or retribution. It means promoting an environment where people
want to report risks and safety incidents in order to learn from them and reduce
their recurrence, and where incidents are seen as caused largely by system failures
rather than individuals. This also includes the importance of having feedback
mechanisms in place to explain any improvements made after safety issues have
been raised. Promoting transparency is key to building a strong safety culture.

A number of tools are available describing approaches to support the development

and measurement of a positive safety culture (31,32).

Practical steps that could be taken to strengthen safety culture include: leadership
walkrounds, whereby senior managerial and clinical leaders “walk the floor” (in
this case, leaders visiting clinics and speaking with staff and patients about what
is working well and not so well); starting team meetings with a patient story; using
reflective practice to focus on safety issues, such as audits and having mechanisms
for reporting safety issues, such as through regular team meetings. Such approaches
may need to be adapted for use in smaller primary care clinics. Regardless of the
specific method, the focus should be on raising awareness, encouraging safety
discussions and taking concrete follow-up actions to build a safety culture.

5. Strengthen ways of measuring and monitoring patient safety

It is important to measure and monitor patient safety improvements over time.
This may include having clear definitions of patient safety incidents and indicators
to be measured annually, setting up national or local incident reporting systems
where data is compiled regularly, or using tools to assess patient experiences and
measure improvements in patient safety.

Using checklists in individual practices can both improve the quality of care and
act as a structured form of record keeping. A number of examples of checklists to
improve safety monitoring are available (33).

Data quality is fundamental to measuring improvements in patient safety. If accurate

and comprehensive medical records are not kept, then errors and omissions are
more likely to occur. As health systems mature, clinical governance processes tend
to strengthen. This includes having processes for managing risks and identifying
strategies for improvement.

19
 concluding remarks

A number of tools are available to measure and monitor different aspects of safety
in primary care and countries could examine what is currently available and adapt
materials based on local priorities (34,35).

6. Strengthen the use of electronic tools

The adoption of electronic tools will be critical to improving safety in many ways.
Examples include the use of electronic health records for more accurate and
complete patient records; timely and reliable sharing of health data; supporting
the diagnosis, monitoring and management of diseases and conditions; effecting
behaviour change and reduction of health risk, and empowering and engaging
patients and families in their own care. eHealth can help structure communication
between professionals in a way that reduces errors and improves coordination. It
can reduce unnecessary consultations and hospitalizations and improve access to
knowledge about health conditions and their management for both professionals
and patients. However, to achieve their full potential, electronic tools need to be
integrated with other parts of service delivery and adapted to the local context.

It takes time and resources to implement electronic tools, and requires the capacity
to use and maintain them. It is therefore important to be strategic and to understand
the foundations and design of systems in order to ensure the best return on
investment. Linking the implementation of electronic tools in local settings to a
national eHealth strategy is essential as it provides the foundation, justification
and support needed to go forward in a coordinated way.

Irrespective of the status of the health system, it is important to strengthen the

use of electronic systems to improve patient safety. For some countries, this may
involve the introduction of electronic health records to replace paper records.
For others, it may mean having integrated electronic systems between primary
care and hospital and social care, or making the tools easier for professionals and
patients to use. Countries could draw on lessons learned from other countries
about implementing electronic health records, including the challenges faced and
how these were overcome, and what best practices could be applicable to their
own setting.

7. Involve patients and family members

Empowering and encouraging patients to speak up, for example when something
does not seem right or when a symptom is inadequately explained, can be
fundamental to improving patient safety. Family members play a key role as
advocates and informal carers and therefore supporting and educating them can
help to improve safety.

Proactive engagement of patients and families can help to accelerate the

implementation of health care safety initiatives. When systems open themselves
up to patients rather than being reactive, this is likely to improve system efficiency
and the quality of care.

A number of tools have been evaluated to enhance patient and family involvement
and awareness, including those with limited or low literacy skills (36-39).

20
 concluding remarks

8. Strengthen workforce capacity and capability to improve safety

There is a need to strengthen the primary care workforce in many settings by
training a large pool of generalist workers, including doctors, nurses and those
with supporting roles.

Strengthening the workforce also involves focusing on recruitment and retention,

including taking steps to enhance the physical and physiological safety of health
care workers. Professional burnout, fatigue and stress can all adversely affect
patient safety.

The education and training of health care professionals to manage and minimize
potential risks and harm that can occur in primary care are central to improving
safety at all levels of care. This includes providing training on patient safety for
students (including students who may not be training to work in primary care to
ensure understanding across the different care pathways), multidisciplinary and
inter-professional education, as well as continuing professional development. A
number of free training course materials are available to help with this (40-42).
As a further step, consideration could be given to making involvement in safety
and quality improvement a requirement for ongoing training and professional
licensure.

In addition to formal education, informal approaches could also be applied to

build the capacity of health workforce to improve safety. This may include holding
regional meetings and coaching sessions to review patient safety incidents and
areas for improvement, and holding small team meetings to upskill staff.

9. Focus on those at higher risk of safety incidents

Some people are at greater risk of safety incidents in primary care. These include
children, older people, those living in residential care or nursing homes and people
with multiple health conditions. People with simultaneous mental health and
physical health issues are also at increased risk of safety incidents.

Focusing on groups at higher risk may improve the quality and safety of care by
providing more personalized care and ensuring smoother transitions between and
within services. For instance, upskilling professionals in how to identify and treat
depression may have an impact given the high rate of adverse events among those
with combined mental and physical health issues.

Across the world, most systems were not designed to care for people with multiple
health conditions. Systems may thus need to focus more on what can be done
to improve care for people with multiple conditions, including whether social
interventions would be more worthwhile than increasing medicalization.

A number of guidelines and toolkits suggest practical steps to better support people
at higher risk of safety incidents (43-47).

21
 concluding remarks

10. Celebrate successes and share learning with others

Local teams, regions and countries should celebrate their successes and share
learning with others. Hearing what has worked well can spark ideas in others and
help to continue the momentum towards safer primary care.

Ongoing research plays a key role in identifying what works best to improve safety
and how to implement best practices and success stories across diverse care
settings. Although the technical series has drawn together a wide range of evidence
and expertise, it has also highlighted a number of gaps about what works best
to improve patient safety in the primary care context. By continuing to promote
learning through research, and publishing and disseminating findings, countries
could contribute to knowledge in this area.

22
Contributors

Leadership group
Aziz Sheikh David Westfall Bates
University of Edinburgh Harvard University
Edinburgh, United Kingdom Boston, United States of America

Liam Donaldson Edward Kelley

WHO Envoy for Patient Safety World Health Organization
World Health Organization Geneva, Switzerland
Geneva, Switzerland
Itziar Larizgoitia
Neelam Dhingra-Kumar World Health Organization
World Health Organization Geneva, Switzerland
Geneva, Switzerland

Project coordination and editorial support

Sukhmeet Singh Panesar Debra de Silva
Baylor College of Medicine The Evidence Centre
Houston, United States of America London, United Kingdom

Chris Singh
The Evidence Centre
Wellington, New Zealand

Authors
Jeff Markuns Shannon Barkley
Boston University Baylor College of Medicine
Boston, United States of America Houston, United States of America

Other contributors
Alexander Carter Elzerie de Jager
Health Economist World Health Organization
London, United Kingdom Geneva, Switzerland

Jan de Maeseneer Tejal Gandhi

Ghent University National Patient Safety Foundation
Ghent, Belgium Boston, United States of America

23
 contributors

Nalika Gunawardena Katherine Hayes

University of Colombo World Health Organization
Colombo, Sri Lanka Geneva, Switzerland

Amanda Howe Arnoldas Jurgutis

University of East Anglia Klaipeda University
Norwich, United Kingdom Klaipeda, Lithuania

Michael Kidd Wendy Madigosky

Flinders University University of Colorado
Adelaide, Australia Boulder, United States of America

Edward Mann Elias Mossialos

World Health Organization London School of Economics and
Geneva, Switzerland Political Science
London, United Kingdom
Chow Mun Hong
SingHealth Polyclinics Paul Shekelle
Singapore, Singapore West Lost Angeles Veterans Affair
Medical Centre
Ranjit Singh Los Angeles, United States of America
The State University of New York
Albany, United States of America Rafla Tej Dellagi
Ministère de la Santé
Allyn Walsh Tunis, Tunisia
McMaster University
Hamilton, Canada Ruth Wilson
Queen’s University
Josephine Zvemusi Chiware Kingston, Canada
Ministry of Health and Child Care
Harare, Zimbabwe

24
References

1 Kidd MR. The contribution of family medicine to improving health systems: a

guidebook from the World Organization of Family Doctors. 2nd ed. London:
Radcliffe, 2013.

2 Primary health care: now more than ever. In: World Health Report 2008. Geneva:
World Health Organization, 2008.

3 Kane JM, Brannen M, Kern E. Impact of patient safety mandates on medical

education in the United States. J Patient Saf. 2008;4:93-7.

4 Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in

crisis? BMJ. 2014;348:g3725.

5 Trietsch J, van Steenkiste B, Hobma S, Frericks A, Grol R, Metsemakers J, et.

The challenge of transferring an implementation strategy from academia to
the field: a process evaluation of local quality improvement collaboratives in
Dutch primary care using the normalization process theory. J Eval Clin Pract.
2014;20(6):1162-71.

6 Vachon B, Désorcy B, Camirand M, Rodrigue J, Quesnel L, Guimond C et al.

Engaging primary care practitioners in quality improvement: making explicit
the program theory of an interprofessional education intervention. BMC Health
Serv Res. 2013;13:106.

7 Greenhalgh T. Unsafety. Br J Gen Pract. 2013;63(607):95.

8 Kiersma ME, Plake KS, Darbishire PL. Patient safety instruction in US health
professions education. Am J Pharm Educ. 2011;75(8):162.

9 Nie Y, Li L, Duan Y, Chen P, Barraclough BH, Zhang M, et al. Patient safety

education for undergraduate medical students: a systematic review. BMC Med
Educ. 2011;11(1):33.

10 Boonyasai RT, Windish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB.
Effectiveness of teaching quality improvement to clinicians: a systematic
review. JAMA. 2007;298(9):1023-37.

11 Batalden P, Davidoff F. Teaching quality improvement: the devil is in the details.

JAMA. 2007;298(9):1059-61.

12 Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T. Changing and
sustaining medical students’ knowledge, skills, and attitudes about patient
safety and medical fallibility. Acad Med. 2006;81(1):94-101.

13 Wilson T, Sheikh A. Enhancing public safety in primary care. BMJ. 2002;

324(7337):584-7.

25
 references

14 Cresswell KM, Panesar SS, Salvilla SA, Carson-Stevens A, Larizgoitia I,

Donaldson LJ et al. Global research priorities to better understand the burden
of iatrogenic harm in primary care: an international Delphi exercise. PLoS Med.
2013;10(11):e1001554.

15 Patient safety curriculum guide: multi-professional edition. Geneva: World

Health Organization; 2011.

16 Open School. Cambridge, MA: Institute for Healthcare Improvement; 2014

(http://www.ihi.org/education/ihiopenschool/Pages/default.aspx, accessed 19
September 2016).

17 US Department of Health and Human Services. Patient Safety Network. Patient

Safety Primers. Rockville, MD: Agency for Healthcare Research and Quality
(https://psnet.ahrq.gov/primers, accessed 19 September 2016).

18 Australian Patient Safety Education Framework. 2005 (http://www.

safetyandquality.gov.au/wp-content/uploads/2012/06/National-Patient-Safety-
Education-Framework-2005.pdf, accessed 19 September 2016).

19 Teaching for Quality. Washington, DC: Association of American Medical Colleges;

2015 (https://www.aamc.org/initiatives/cei/te4q/, accessed 19 September 2016).

20 Cresswell,K, Howe A, Steven A, Smith P, Ashcroft D, Fairhurst K, et al. Patient

safety in healthcare preregistration educational curricula: multiple case study-
based investigations of eight medicine, nursing, pharmacy and physiotherapy
university courses. BMJ Qual Saf. 2013;22(10):843-54.

21 Slater BL, Lawton R, Armitage G, Bibby J, Wright J. Training and action for
patient safety: embedding interprofessional education for patient safety within
an improvement methodology. J Contin Educ Health Prof. 2012;32(2):80-9.

22 Anderson E, Thorpe L, Heney D, Petersen S. Medical students benefit

from learning about patient safety in an interprofessional team. Med Educ.
2009;43(6):542-52.

23 Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a better health
system. Washington DC: National Academy Press; 2000.

24 WONCA global standards for postgraduate family medicine education. World

Organization of Family Doctors; 2013 (http://www.globalfamilydoctor.com/
site/DefaultSite/filesystem/documents/Groups/Education/WONCA%20ME%20
stds_edit%20for%20web_250714.pdf, accessed 19 September 2016).

25 Kachalia A, Johnson JK, Miller S, Brennan T. The incorporation of patient safety

into board certification examinations. Acad Med. 2006;81(4):317-25.

26 Certification board for professionals in patient safety. Boston, MA: National

Patient Safety Foundation; 2016 (http://www.cbpps.org, accessed 19 September
2016).

27 Improving safety in primary care. London: The Health Foundation; 2011; (http://
www.health.org.uk/publication/improving-safety-primary-care, accessed 19
September 2016).

26
 references

28 Primary risk in management services. Cardiff: Public Health Wales; 2015

(http://www.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=73076, accessed 19
September 2016).

29 The improving chronic illness care program. Primary care team guide.
Seattle, WA:The MacColl Center; 2016 (http://www.improvingchroniccare.org/
downloads/reducing_care_fragmentation.pdf accessed 19 September 2016).

30 Care coordination resource list. Beerse: Janssen Pharmaceuticals Inc.; 2014

(http://www.janssenpharmaceuticalsinc.com/sites/default/files/pdf/Care-
coordination-resource-list.pdf accessed 19 September 2016).

31 Seven steps to patient safety. London: National Patient Safety Agency; 2004
(http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-
safety/?entryid45=59787, accessed 19 September 2016).

32 Safety and improvement in primary care. Edinburgh: NHS Education for

Scotland; 2011 (http://www.nes.scot.nhs.uk/media/3437356/Safety-and-
Improvement-Educational%20Resources-A-Toolkit-for%20Safe-Effective-
Person-Centred-Care.pdf, accessed 19 September 2016).

33 Accreditation handbook for ambulatory health care Skokie, IL: Accreditation

Association for Ambulatory Health Care, (http://www.aaahc.org/Global/
Handbooks/2015_Accreditation%20Handbook_FNL_5.22.15.pdf, accessed 19
September 2016).

34 Tools. Cambridge, MA: Institute for Healthcare Improvement; 2016 (http://www.

ihi. org/resources/Pages/Tools/default.aspx, accessed 19 September 2016).

35 Patient safety toolkit. London: Royal College of General Practitioners; (http://

www.rcgp.org.uk/clinical-and-research/toolkits/patient-safety.aspx, accessed
19 September 2016).

36 Partnering with patient and families to enhance safety and quality: a mini toolkit.
Bethesda, MD: Institute for Patient- and Family-Centered Care; 2013 (http://
www. ipfcc.org/tools/Patient-Safety-Toolkit-04.pdf, accessed 19 September
2016).

37 Health literacy toolkit for low-and middle-income countries. New Delhi: World
Health Organization Regional Office for South-East Asia; 2015 (http://www.
searo.who.int/entity/healthpromotion/documents/hl_tookit/en/ accessed 19
September 2016).

38 Health literacy universal precautions toolkit. Rockville, MD: Agency for

Healthcare Research and Quality; 2016 (http://www.ahrq.gov/professionals/
quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html,
accessed 19 September 2016).

39 The Boston Medical Center patient navigation toolkit. Boston, MA; The
AVON Foundation and the National Cancer Institute; (https://nciphub.org/
resources/1600/download/BMC_Patient_Navigation_Toolkit_-_Vol_1.pdf,
accessed 19 September 2016).

27
 references

40 Patient safety research: introductory course (on-line). Geneva: World Health

Organization; 2016 (http://www.who.int/patientsafety/research/online_course/
en/, accessed 19 September 2016).

41 Master in Health Administration. 65+ free online healthcare courses. Davis, CA;
University of California; 2016 (http://mhadegree.org/free-online-healthcare-
courses/, accessed 19 September 2016).

42 Patient safety network. Training catalog. Rockville, MD: Agency for Healthcare
Research and Quality; 2016 (https://psnet.ahrq.gov/pset, accessed 19 September
2016).

43 Age-friendly primary health care centres toolkit. Geneva: World Health

Organization; 2008 (http://www.who.int/ageing/publications/AF_PHC_
Centretoolkit.pdf, accessed 19 September 2016).

44 Patient safety collaborative manual. Hamilton/Mount Gambier/Warrnambool;

Greater Green Triangle/Australian Primary Health Care Research Institute; 2016
(http://www.greaterhealth.org/resources/patient-safety-collaborative-manual,
accessed 19 September 2016).

45 Toolkit for general practice in supporting older people with frailty and achieving
the requirements of the unplanned admissions enhanced (2014). NHS England
South Region; 2014 (http://www.nhsiq.nhs.uk/media/2630779/toolkit_for_
general_practice_in_supporting_older_people.pdf, accessed 19 September
2016).

46 Stay independent falls prevention toolkit for clinicians. Health Quality and Safety
Commission New Zealand; 2015 (http://www.hqsc.govt.nz/our-programmes/
reducing-harm-from-falls/publications-and-resources/publication/2232/,
accessed 19 September 2016).

47 Prevention and control of noncommunicable diseases: guidelines for primary

health care in low-resource settings. Geneva: World Health Organization; 2012
(http://apps.who.int/iris/bitstream/10665/76173/1/9789241548397_eng.pdf,
accessed 19 September 2016).

28
 Technical Series: Safer Primary Care
This monograph on ‘Education and training’ is part of
a technical series of nine monographs which explore
different aspects of safety in primary care services. The
other topics include:

PATIENTS
n Patient engagement

HEALTH WORKFORCE
n Human factors

CARE PROCESSES
n Administrative errors
n Diagnostic errors
n Medication errors
n Multimorbidity
n Transitions of care

TOOLS AND TECHNOLOGY

n Electronic tools

For more information, please contact:

Department of Service Delivery and Safety
World Health Organization
Avenue Appia 20
CH-1211 Geneva 27 Switzerland
Email: patientsafety@who.int
www.who.int/patientsafety
ISBN 978-92-4-151160-5