Areas for improvement in community optometry: flashes and floaters take priority.

PURPOSE: A common response to rising demand for healthcare is to extend the role of health professionals and the range of their service provision. Community optometry in Scotland is a recent example of this. Within this context of innovation and change there are challenges to ensuring quality in optometry practice. The purpose of this research is to establish what the priorities are for practice improvement within community optometry and to start a programme to inform strategies to improve practice. METHODS: A four stage study was conducted: (1) a service-driven topic prioritisation exercise to identify priorities for optometry practice improvement; (2) a review of national and international guidance and UK protocols relating to the identified priority topic; (3) a national theory-based survey identifying current practice and the barriers and facilitators to the target behaviour; and (4) the identification of theory-based intervention options to improve practice. The Behaviour Change Wheel approach to behaviour change intervention development and Theoretical Domains Framework (TDF) provided the underlying theoretical framework. RESULTS: Stakeholders identified 'patients presenting with flashes and floaters' as an important priority for practice improvement. The decision about whether or not to refer patients on to secondary care for further examination is the target behaviour. Guidance for optometrists on this topic is lacking. Six TDF domains were related to the decision about whether or not to refer patients with flashes and floaters to secondary care - 'social influences', 'emotion', 'beliefs about capabilities', 'beliefs about consequences', 'behavioural regulation' and 'reinforcement'. CONCLUSIONS: This study has examined current practice in relation to the management of patients with flashes and floaters, identified the most salient targets for future strategies to improve optometry practice and highlighted what form these strategies may take. It demonstrates the use of a flexible, theory-informed approach, which can be used to engage with stakeholders and professionals to inform the design and development of efforts to improve practice in a variety of healthcare settings.

A national survey of the use of pachymeters by optometrists in Scotland: experience, views and barriers to use.

PURPOSE: Thin central corneal thickness (CCT) is a risk factor for glaucoma. In 2016 all optometry practices in Scotland were provided with pachymeters aiming to improve risk assessment and accuracy of referrals to secondary care. We examined optometrists' experience and views of pachymetry, including perceived barriers to pachymetry in primary care. METHODS: A questionnaire was sent using the REDCap electronic data capture tool to all 1264 optometrists registered with NHS Education for Scotland (NES). The questionnaire evaluated year of qualification, previous pachymetry training, confidence performing and interpreting pachymetry, and perceived indications for and barriers to use. RESULTS: Respondents numbered 418 out of 1264 (33%) optometrists, of whom 56% had previous training in pachymetry. Those that had previous training were significantly more likely to report pachymetry to be useful, with median (inter-quartile range) usefulness score of 86 (71-98) where 0 indicated not at all useful, and 100 extremely useful, vs 76 (58-90), Wilcoxon-Mann-Whitney test, z = -4.67, p < 0.01. There are no valid scales for adjusting intraocular pressure (IOP) using CCT, however 45% of respondents reported using a scale. Optometrists planned to use pachymetry when assessing patients with ocular hypertension or suspected glaucoma. The greatest perceived barrier was the process of decontaminating or cleaning the pachymeter between patients, followed by lack of time and lack of training. CONCLUSIONS: Although the majority of optometrists were interested in performing pachymetry, many lacked confidence in performing and interpreting the results. Forty-one percent of those who reported training in pachymetry still used non-validated scales to convert IOP measurements illustrating the need for further training.

Enhancing the Effectiveness of Significant Event Analysis: Exploring Personal Impact and Applying Systems Thinking in Primary Care.

INTRODUCTION: Significant event analysis (SEA) is well established in many primary care settings but can be poorly implemented. Reasons include the emotional impact on clinicians and limited knowledge of systems thinking in establishing why events happen and formulating improvements. To enhance SEA effectiveness, we developed and tested "guiding tools" based on human factors principles. METHODS: Mixed-methods development of guiding tools (Personal Booklet-to help with emotional demands and apply a human factors analysis at the individual level; Desk Pad-to guide a team-based systems analysis; and a written Report Format) by a multiprofessional "expert" group and testing with Scottish primary care practitioners who submitted completed enhanced SEA reports. Evaluation data were collected through questionnaire, telephone interviews, and thematic analysis of SEA reports. RESULTS: Overall, 149/240 care practitioners tested the guiding tools and submitted completed SEA reports (62.1%). Reported understanding of how to undertake SEA improved postintervention (P < .001), while most agreed that the Personal Booklet was practical (88/123, 71.5%) and relevant to dealing with related emotions (93/123, 75.6%). The Desk Pad tool helped focus the SEA on systems issues (85/123, 69.1%), while most found the Report Format clear (94/123, 76.4%) and would recommend it (88/123, 71.5%). Most SEA reports adopted a systems approach to analyses (125/149, 83.9%), care improvement (74/149, 49.7), or planned actions (42/149, 28.2%). DISCUSSION: Applying human factors principles to SEA potentially enables care teams to gain a systems-based understanding of why things go wrong, which may help with related emotional demands and with more effective learning and improvement.