 Hello everybody, and a very warm welcome to the latest in this series of Wonka webinars. Today the topic is quality and safety, and it will be led by Dr Pilar Astier, Chair of Wonka's Working Party on Quality and Safety and Family Medicine. She's put together a great panel who you'll meet as we go along, but I'd like to offer a special Wonka welcome to Dr Neelam Dingra from WHO headquarters in Geneva. Neelam is head of the Patient Safety Flagship within WHO's Integrated Health Service Division, and is a great supporter of Wonka and Family Medicine. Neelam, your most welcome. As usual, we'll also be monitoring your questions and comments on both Zoom and Facebook, and we hope that there'll be time for Anastav Dahl to pose at least some of those to the panelists. But without further ado, let me pass over to our Wonka President, Dr Donald Lee, for his opening remarks. Good day. Good morning. Good afternoon. Good evening. Welcome to the seventh Wonka webinar. We just celebrated World Family Doctor Day, and I thank Family Doctors for sharing the burden of dealing with this COVID-19 global epidemic. Family Doctors are continuing with their massively increased workload, but I'm proud of the level of support and collegiality displayed within and across our member organizations and from region to region. Family Doctors all around the world disseminate scientific advice, clinical updates, reflective messages, and professional support through their social media links and connections. The Wonka webinar is a platform for all of you to share experiences, relay information, and to keep in touch with each other regularly, like family members urging courage, offering mutual support in these extraordinary times. Next please. Patient safety is the cornerstone of high quality healthcare. Quality in healthcare and safe care mean best health outcomes that are possible, given the available circumstances and resources consistent with patient-centered care. The provision of quality healthcare in a safe environment should be universally available to all people, especially during challenging times, which we are facing, combating COVID-19. Tonight we have a panel of distinguished speakers who will identify quality and patient safety issues to improve primary care delivery during the COVID-19 crisis. It will cover a wide range of topics, so without further ado, may I pass on to Pila, who will introduce the panelists. Thank you, Dr. Lee. A very warm welcome to Warwell attendees today's quality and safety in family medicine Wonka webinar. I am Pila Rastier, Spanish family doctor and the chair of the Wonka World Working Party on Quality and Safety in Family Medicine. First, I would like to thank Wonka World for their extraordinary support to make this webinar possible today. Next slide, please. Second, I'm delighted to introduce these wonderful team of family doctors from all over the Wonka regions. They are going to share with you in about three minutes. It's one, some key messages of their knowledge and expertise on quality and patient safety issues in primary care, while the COVID-19 pandemic. Next slide, please. We are going to talk about six quality and safety challenges, team organization, safe use of medications, telemedicine, professional health, community and public health issues. And finally, some practical issues on quality management. Thank you very much all panelists for the effort to be brief and concise. We have prepared an appetizer together for you with the aim to go on learning and improving so that we can all build an excellent and safe primary care even in crisis situations. And given the floor to Dr. Enes Tatbal, President-elect Wonka World, thank you very much, Anna, for your commitment and quality and safety in family medicine. I'd like to ask you live warm greetings from Norway to everyone. The COVID pandemic works as a magnifying glass. Strengths and weaknesses of our healthcare systems become more visible. It provides us with an opportunity to identify where we can improve in all the domains of family medicine, if being clinical practice, teaching, research or advocacy. Next slide, please. Family doctors continue to do what we always do, provide care to our populations in accordance with the core values of our specialty. The values which unite us despite global differences in how our services are set up and delivered. We provide continuous comprehensive and personal care at first point of contact. That is our common denominator and our common point of departure, looking at improvement of health care quality. Next slide. What changes are we going through as we speak? Personal centered medicine used to mean face to face contact using body language and physical contact as important tools in diagnosing and treating disease, in comforting people in crisis and alleviating pain. Now we need to take preventive measures and reduce physical contact, often looking into the eyes of our patients through a shield or on a screen. For our patients, it means that there is a risk of being left without hermetic if you're old and sick. Patients with chronic disease are reluctant to come to the doctor's office in care of being infected. In previous webinars, we have also learned how mental health issues are increasing during the pandemic. And so is the risk of family violence. Digital diagnostic tools are flooding the market to the systems but also frustration for patients as well as physicians. That is the environment in which family doctors now look for ways to improve equality and safety. And as always, we need to take not only the doctor's perspective, but also that of the patients and of the policy makers to work back from the field and that way help them to make good decisions. Next slide. But without listening to people, no health care quality improvement is possible. So we will listen to you participants in the audience. During a series of short presentation, we invite you to share questions and observations. We have Jose Miguel Bueno Ortiz and Laura Cronangla from Spain monitoring the chat and Ruth Wilson from Canada, the Facebook feed. After the presentations, they will convey questions from you to the panelists. Enjoy the presentations and give us feedback please. It's now my privilege to welcome David Moores. David, the screen is all yours. Next slide, I guess. Good morning, or good day, Wonka colleagues. Canada is the second largest country by land size in the world. But we are only 36 million people. One might say that we are more naturally socially distanced than many other countries. In general, we are 13 publicly funded, but privately delivered health systems, much like the NHS England, NHS Scotland, NHS Wales and Northern Ireland. Co payments and bankruptcies as a result of out of pocket expenses are not issues that Canadians have to endure. Next slide. Some 25 years ago, our British colleagues characterized a significant event as any event thought by anyone on the team, to which we would add including patients and their families be significant in the care or conduct of the practice. Although often bad, it's sometimes more we can learn from the bad than the good or the good than the bad. This is next slide. This is a quote from our nurse at the McEwen University Health Centre, where we look after over 9,000 people. And although the leadership team we're looked to for comfort, we the leadership team look to our team for comfort as well. Next slide. So I'm going to give you three significant events that may resonate. The first relates to a system, the Alberta Health Services developed a contingency plan to close the practice. It was seen as another outpatient clinic in need of closure. But we developed a contingency plan to accommodate this other practice of 5,200 people. Next slide. This is a personal issue. The people on the right have given their permission. The elderly woman is Marge, who's been in my practice for 25 years. Across Canada, seniors in nursing homes have died at significant rates. We don't want mom to go through what has happened in Quebec or Ontario. So we do virtual visits for this woman. But it can only be done because of our team. Next slide. And finally, we wanted you to know that despite our best efforts at screening people, we sometimes are at risk as well as our patients. This was a memo and from our team, and the upside of this was we need to ensure people know that we will look after them no matter what. And now I turn it over to my colleague, Professor Shabir Moussa. Hi, everyone. Thanks. Thanks, David. I'm really pleased to be here on behalf of Wonka Africa. I think that as a family physician in Africa, a lot of the requirement to be able to develop quality and safety is going to be about how do we reorganize care? And I think just to start by showing you what's going on in Africa, you can see the two hot spots is Egypt and South Africa. And the way in which cases are going slowly, they're becoming much more exponential. So what is happening in the US now that South America could very easily become what is happening in Africa. Next. I think in South Africa as the hotspot, I just need to share some quick background. I think we have a seriously inequitable health care system with almost the same amount being spent by 16% of the population as 84% of the population, the rest of the population gets from the public service. Private health care practitioners as the private primal care are actually very marginal, only having about 67% of the spend in private sector. So it's really a very private hospital dominated sector. We have mostly the public service in health districts under provincial control. So it's really not very decentralized. And I as a public health practitioner, public family physician work in that space with really very poor capacity available. Next. So in South Africa, the trajectory of COVID has been not quite the same as the rest of the country, the rest of the world. As you can see, there was an inflection point, which happened in our country with a very dramatic lockdown, which has been one of the more stronger in the country. Yet, I think we're still not getting ahead of the curve in the sense that it's growing, growing slowly. So if you go to the next slide, you'll see next, you'll see that in fact, as projections go in South Africa, that we're expecting, you know, projections of up to 1.2 million infections, we expect at least with least in a sort of ballpark of 45,000 deaths. These projections, everyone qualifies them by saying, while they depend on how the, the, you know, disease, you know, sort of evolves over the next few weeks. But this is clearly in everyone's language as this is going to exceed our capacity, as you can see by the ICU beds by enormous numbers. So if you go to the next slide, I'm going to share with you a little bit of how team reorganization has occurred in one district. So you can see how 10 is in fact a very small geographic space in the population of 57 million, which as you can see on the right is about 15 million. And right at the middle of halting is the city in which I live, which is called Johannesburg. And in Johannesburg, there are seven sub districts. And you can see the sub district D is Soweto. It is almost a third of the population of Johannesburg. And in that, I provide clinical governance supervision in the 29 facilities in there. I also am linked to the University of Frankfurtstrand. But I provide direct care to patients in a practice in one of five community centers in that region in a space called Shea Weller Community Practice, where a population of about 30,000 that I work as a team to provide. So next, what we have found in terms of the public service generally is that we have lots of people coming to very few facilities with very poor physical distancing. And as you can see in that picture, it makes for a very anxious situation where staff get very anxious. They don't often have good PPE, they don't manage those cues very well. And in fact, as a result, they've tried to reduce services, which is a real problem for our long term health. Next. So in terms of how we address that initially in the public service in Halting, the health service said, you know, we basically are going to go around and find contacts of people we've identified, usually at hospitals or by virtue of them being picked up in the private sector. And so it was a very strong public health orientation that stopped at a sub district level on paper almost. And at clinics, we said that this is not going to address the problem because everyone walking in with a cough and a cold, despite the travel history could potentially have COVID. So we set up a process at the facility itself. And essentially saying that we need to reorganize the facility to cater to dealing with COVID patients in what we call a temperature test clinic, reaching out to the community and trying to establish how we can work with as a partner with the community in education, but also the community of work is going out and finding patients as well as educating in terms of protection. And then we thought we would link up with the sub district effort, both in terms of supporting the facility as well as integrate with this public health approach. We used a similar thing to similar idea with the private GPs to provide them some advice next. But if you look at it, we basically set up, you know, trying to get work with team three sort of zones, trying to manage the queue outside with physical distancing, getting a single point of entry, some sanitation, and then a very simple screening with community of workers that try to decide, you know, with a few questions that we screen with, do these patients have any symptoms? And if they do, then they go into an area we call orange, usually something that will be set up as a chest clinic. And then the rest of the service would continue. And this was a way in which we would manage, you know, the staff patients as well as continue the services and increase the testing next. So it has been quite challenged. It has worked quite well in certain spaces. And as you can see, it takes a lot of paint, with tape and the like, but these resources are challenged. Go next. So in terms of next, in terms of progress, we've set up about seven, seven facilities, 11 facilities, and these have been the large community of centers across the city. But our challenges remain if we are going to scale it up and cover all 130 facilities across the city, we need testing arrangements to be clarified materials, staff to be aligned to the purpose, and other things like that. So this has been a focus of our training in the last few weeks. Thanks. So with that, I think, you know, there's some resources we put out as well to guide the community and, you know, the other team members. And this is available to our partners become quite a powerful way to manage the process. So with that, let me hand over, I'm not sure whether David will take it on, but thank you very much. That's the team that's produced it. But let's hand over to Neelam. Perhaps you can share your insights. Thank you, Neelam. Good afternoon, everyone. Could I have the next slide, please? So I'm going to speak about the WHO Global Patient Safety Challenge as an initiative, particularly on medication without harm, and the tools which WHO has developed to address medication associated harm. Next slide, please. WHO has launched the challenge of selecting a topic which poses a major and significant health risk to patients. And these challenges have been to implement proper intervention in a specified area. So so far, WHO has issued three challenges to the global community. The first challenge was on clean care is safe care, and which actually brought the five moments of hand hygiene, which is very, very familiar to all of you. And this actually is extremely important in current scenario for promoting hand hygiene university. Next slide. The second challenge was launched to address the unsafe surgical practices, and it was called a safe surgery, safe lives. And it led to development of a surgical safety checklist to create some sort of tool which could help a surges around the world to have a structured approach to surgery. And this also has been extremely successful challenge. Next slide. In 2017, WHO launched their third challenge, which is the medication without harm challenge. And we have provided a framework of four domains under which we are urging countries and partners to take action. And these are patients and the public healthcare professionals, medicines as products, and the systems and practices of medication. Next slide. This challenge was launched in 2017 at the second global ministerial summit on patient safety. And this has ultimate objective to reduce, reduce avoidable harm related to medications up by 50% over the period of next five years. Next please. As part of this challenge, WHO has developed several tools and guidance to support countries and work with partners to implement the challenge. And one of the most important challenge tool we have developed is a campaign toolkit, in which we have given a campaign of for patients as well as for healthcare professionals. No check and ask before you take it and no check and ask before you give it. And this has been very, very effective. And I would urge all the members of Onca to implement this campaign in their health facilities. Next slide. In addition, WHO has also developed a patient engagement and empowerment tool, the five movements for medication safety, starting taking, adding, reviewing and stopping, which is stars in English as an Imonic. And this primarily gives questions, which the patients should ask their healthcare professionals and doctors to engage with them and to understand about the medication and what, how should they make sure that medication practices and the use they're following escape. Next please. And this tool is also available as the mobile application, WHO MedSafe. Next please. As a couple of other resources, the WHO has developed for medication safety or patient safety solutions for localized sound-like medication, control of concentrated electrolyte solution, and also assuring medication accuracy and transition in care. And another initiative of high five projects also develop several tools related to medication reconciliation. Next please. The WHO has urged countries to prioritize three key action areas. Action on these will significantly reduce medication-related harm. And these are transitions of care, highly situation and polypharmacy. Next please. So hand over to Pilar now. Thank you very much, Nilan. Well, regarding WHO key actions on medication without harm challenge, we can consider the COVID-19 pandemic is a high risk situation because there is a lack of evidence regarding treatments. There is a big change on the way we visit patients and there is a high impact on the community. Next please. Regarding a safe use of medication in primary care, there is no specific therapy approved until now for mild to moderate COVID-19 patients. Nevertheless, hydroxychloroquine, chloroquine and isotromethine that are the quite common in primary care might cause harm and we should be aware about this harm. Next please. There is no current scientific evidence on the effectiveness of other support treatments for COVID-19 mild to moderate patients. In relations to anticoagulants, they use is oriented to prophylaxis of thrombolism. Bronchodillators have no routine role for the management of COVID-19. Corticosteroids are not recommended for viral pneumonia. And regarding NSAIDS, we do not have confirmatory clinical data until now. Next please. So when a COVID-19 patient is discharged from hospital, we as family doctors are in chair of their follow-up. There are some issues we have to talk about in our practices for a safe use of medication, which treatment to maintain after discharge and for how many days and recognize COVID-19 side effect after discharge, planning complementarities to control side effects due to treatments and is there a need for palliative care as well. Next slide please. We should not forget a safe use of medication for chronic conditions. Many patients take several medications. Family doctors should be aware with regard to the accessibility of medications and ensure safety medication intake by answering any questions that may arise with patients and caregivers. Next please. Some tips. A stay home message for your surgeries. Agreeing on common recommendations for the treatment of COVID patients in the team. Ensuring a safe medication using at least five letters when searching for a medication in an electronic system considered to support patients, families and informed caregivers on a safe use of medication. Be aware of pharmacovigilance issues during pandemic. Do not forget to report to the reporting on learning system on patient safety any issue regarding medications including COVID-19. Next please. Finally, keep updated on a safe use of medication as scientific evidence is evolving very fast during this pandemic. Thank you for your attention and I'm giving the floor to Dr. Neelan Dengrege. Thank you Pilar. Next please. So Pilar and I would like to conclude this session on safe use of medications by saying patient safety comes first when using medications. Next please. And we urge all of you to join us in achieving medication without harm. More information about the this challenge as well as the WHO patient safety flagship and different initiatives is available on the WHO website under health topic patient safety. Thank you very much for this opportunity and I hand over to Professor Donald Lee now. Thank you. I'm sure everyone would agree there's been a lot of use of internet medicine, tendering medicine and so forth so we'll spend the next few minutes talking about safety and quality issues. Next please. Advances in technology can impact on quality and safety provision of online health care providing solutions to present difficulties and challenges. But it can also create further legal, ethical and social concerns. Technology can provide solutions by aiding doctors in making better diagnosis at a distance and have proven valuable during the COVID-19 epidemic. Next please. The medical profession will need to consider how they can best adapt to internet practices using technology, policy and legislation and consumer education to adequately protect the patient. Any adaptation, however, should not lower the established medical standards and hence put patients at potential risk. Next please. The global risk to the health and well-being of everyone they take the ethical codes of conduct and regulatory frameworks need to be constantly reviewed and updated not only to address online medical practitioners, but also other players that facilitate this commercial activity. Appropriate ethical guideline and regulation should be aimed at technologists, delivery specialists and financial institution credit in the stream of online medical commerce. Next please. The need to protect consumers from potential harmful consequences of online consultation should be a core principle guiding the conduct of all commercial entities. Perhaps the only way forward into the future is for more international consensus, cooperation and agreement to establish global ethical and regulatory standards for online medical practice to safeguard medical practitioners and recipients of medical advice and treatment. So now the chair of Wonka E-Health, Dr. Pramantha Prasad Kapta will continue our presentation. Pramantha. Thank you, Dodal. I'm going to speak on benefits and challenges in the implementation of telemedicine E-Health related to COVID-19. Next slide, please. The primary care physicians are working tirelessly in the front lines at ground zero. Next slide, please. Next slide, please. So I'm going to start with some case scenarios in which we can use telemedicine like a patient with mild respiratory symptoms need evaluation, but has been told not to go to the emergency room. Second scenario, a provider has been quarantined due to COVID-19, but can continue to see patients from their home via virtual visits. The third scenario, a patient with severe symptoms of COVID-19 is hospitalized and needs a speciality consult with an infectious disease doctor in a remote location. Those are the scenario where most of the telemedicine is benefited when it is used. Next slide, please. So we can use telemedicine to prevent overcrowding in emergency department, urgent care clinics, and primary care clinics. We can use teleconcentration as a triage. We can address the ongoing healthcare needs of patients with chronic illness to reduce in-person clinical visits. And we can use telemedicine can bring speciality care services to patients being cared for in areas without access to such care, both domestically and internationally. Next slide, please. So there are the fourth challenges. Those are administrative engagement where there are the issue of financial conditions we are going to pay. There is the physician engagement where every country has its own laws, policy, ethics, the e-prescriptions law, and multi-judicial license service. Then there is infrastructure engagement where there is issues like connectivity issues like board ban, training of staffs, hardware agonistics, and sustainability engagement where reimbursement by payers. Next slide, please. So those are the actions we can take to expand telemedicine availability during the COVID-19 pandemic. So where we can lose privacy regulation, like most of the countries like India, Japan, South Korea, and many more other countries had already its restrictions on telemedicine and mobile health to treat COVID-19 patients remotely. We can allow phone visits to call if I ask telemedicine. We can allow clinicians to practice across state lines. We can allow patients to access service from their homes and waiving the need for pre-existing relationship. Next slide, please. So I will conclude by saying that telehealth is bridging the gap between people, physicians, and health systems, enabling everyone, especially symptomatic patients, to stay at home and communicate with physicians through virtual channels, helping to reduce the spread of the virus to mass population and the medical staff on the front line. Thank you. Thank you for listening. I'll hand over to you, Harris, now. Thank you very much, Pramendra, for the introduction. My name is Harsley Zidakis. And I would like to talk to you about the digital health assessment framework that Wonka has recently introduced. The evaluation of digital health application is becoming increasingly important to improve their quality, to ensure patient safety, and to strengthen public and professional trust. Wonka can play a pivotal role in developing a certification program, ensuring the services, technology, organization and implications of the product and provider meet specific standards, our values and principles. So driven by our guiding principles, we performed research, from desk research on topics which may be important for the assessment of digital solutions from the perspective of family doctors. And an initial set of topics was created, was gathered and clustered into level thematic domains, reflecting in 112 in 112 item questionnaire. We then run a pilot together with the Pingan good doctor company and in order to assess the and judge the conformity according to the standards that we said. Now, this framework includes 11 domains of evaluation ranging from user aspects to healthcare system and ethical matters. The ratings are translated in outcomes along three dimensions, the comprehensiveness of the services provided, the scalability to other settings, countries and healthcare systems and the validity and availability of evidence, such as cost effectiveness. Traffic light style, rating method is employed to judge the three dimensions as an indication for the level of conformity with the Wonka standards per dimension. So we will be further developing the assessment framework with the help of the E-Health Party and other partners. Now, it is my pleasure to introduce to you Dr. Andrei Rosford and Professor Amani Havi, who will be leading the next session of our webinar. Thank you. Thank you very much, Harris. And good afternoon, everybody from Ireland. Quality of care. Well, what is quality of care? Let's remind ourselves. There are many definitions to quality of care and I've listed some of the dimensions here. Since COVID began, we've been all very busy with clinical risk management and focusing on quality and safety in patient care. But COVID has put a fresh emphasis on the dimension of clinician health and safety at work. Management of work related risks for healthcare workers. And we all hear the stories of colleagues with serious illness, COVID related illness and indeed many have died. It reminds us of the Dublin Declaration on Patient Safety from 2017 at the Equip Conference, which states clearly that healthy doctors are needed for safe patient care. So in this section on professional health, I will discuss personal protection and protection of the team. And Amanda will discuss protecting patients and professional organizational safety issues. So here we aim to give you just a taster presentation of a future full webinar on this topic. Next slide, Harris, please. Courage is the first of human qualities because it is the quality which determines the others. And that's a very profound statement from Aristotle and very relevant to us now. We've all witnessed the widespread public appreciation being expressed by the public in recent months. For the dedication and for the brave healthcare workers doing their jobs all over the world, dealing with uncertainty and with serious risk of contracting the virus themselves and also spreading it to loved ones. That appreciation has also been for everyone working in family medicine, where more than 80 percent of the infection is managed. This quotation tells us if we're going to be caring and compassionate, if we're going to diagnose and give expert advice during COVID, we need to be courageous and resilient. And this lighthouse is a symbol of that courage, standing strong against the waves that crash into us, but also shining out a light to help and support people in difficulty. It's a symbol of safety. Next slide, please, Harris. Personal protection from infection is key in 2020 medicine. With many people asymptomatic, this can also be a real dilemma. We've been postponing or avoiding procedures that are risky. We've been using PPE for face to face care and using added protection for our staff. Really important in these stressful busy times of telemedicine, not to neglect our basic physiological needs of water, food and sleep. Psychological health and well-being is so important for patients as well as for family medicine staff. And the experts tell us that this will be even more important in the future, as there is an increasing incidence of patients with anxiety and post-traumatic stress disorder following their own experiences of COVID. Remember, these are our patients too. It looks like the model of the COVID pandemic is more of a marathon than a sprint. And of course, family doctors are resilient, but these are unusual circumstances. We know that education and training can help develop resilience while meaning full purpose and values and a good social network can help to nurture it. My college, the ICGP for example, has been supporting GPs through COVID by coordinating latest expert data and guidance and distributing it through email notifications in the website and webinars. One of these streams has been self-care, bulletins for GPs and advice on sickness absence and returning to work has also been coordinated, because many clinicians in family medicine have their own illnesses and may be taking medication, for example, that may reduce immunity of those health care work to infections. And I think the key message here is GP care for GPs and for practice staff is vital. Next slide, please. Thank you. I think we need to acknowledge when we're talking about protecting the practice team that many GPs are solo GP single-handed right across the world in both rural and urban settings. And these GPs have particular risks of professional isolation and potential burnout. COVID is very challenging for them and so is teamwork. But like all of us in group practices and solo general practice, we need to be innovative and we need to coordinate tasks with other members of staff and indeed with other practices nearby or virtually with other practices that are more distant to us. We can look to sharing on call, covering each other for absences or for fatigue when we may need to take time out and look at developing a shared rotor for keeping each other up to date from reliable sources and managing the information overload that's coming our way. It's OK to be worried. It's OK to ask. And if we can include everybody in the practice team in clear briefings, know who to go to for decisions and coordination and look at workload distribution and risk stratification has to happen for staff as we do for patients so that the least vulnerable staff do the do the most face to face. So I'll just finish with call your family doctor and let's remember World Family Doctor Day 2020, we are on the front line. And at this point I'd like to hand you over to Amanda Hanne. Thank you, Andre. Greetings, everybody. And some of what I'm going to say is more like a summary at this stage, because some of the points have been made already. But. One of the big things that we've had to pay attention to in every country is how to protect the patients from uncertain risk. And in the UK and England where I work, of course, general practices have stayed open. And of course, it's been an absolute priority to maintain patient access to health care. But in the initial phase of the covid crisis, we've altered how we do consultations so that all our patients are being triaged by phone before they have any possible face to face contact. Sometimes as time has gone on, we've already started using online request forms. We are using a software called Footfall, where if people can fill in the reasons why they want the contact, how to give the contact, what they're expecting when they can be called back. Then by the time I'm looking at that as the GP, a lot of them have already been answered by other people. And that's very simple, a synchronous way of putting in that first request. Then we can proceed to phone video consultation, emailing, sending photos in if it's a rash or something like this. And this is helping us really to get the message to people, don't come down to the clinic first. If they do come to the front door, the front door is shut. And as Shabir was saying, we have screening and temperature checks, and we're only allowing people in who we've already agreed can come down or if we're absolutely sure that they are safe to come in. In addition, in terms of protecting patients, as with most countries, the UK spend a lot of energy on risk stratification. And we have a group called Shielded. If people don't know about that, they can look on the NHS website who are the most vulnerable. And there's been a lot of clinical discussion about that group, because, you know, some people who are older, very fit, but ages of fact to some people, younger chemotherapy patients, dialysis patients, you know, and this group are being very restricted in their access. And again, as practice, we've had to think, well, for them, you know, how do we keep in touch with them? We're making more proactive calls. We're also saying if we need home visits, you know, we will go in full PPA and we will have to do that for those people because they are the most vulnerable. And finally, we've seen a big real organization in the clinics across the different cities or different regions in England, like Shabir was describing in Johannesburg, where we've got some areas that are called hot hubs, not necessarily the hospital, but a clinic with enough space, entrances, protected areas, full PPA to see patients who may have COVID before they are sent to the hospital and cold clinics so that there are also places where we think as much as possible, patients won't have been contacted and staff won't get contacted by the time they actually come face to face. So these are some of the ways we've adapted and we think that some of these will continue. Next slide, please. The other thing is we've had to think very hard as Wonka member organizations like me and the Royal College of GPs and my colleagues about what we can offer our colleagues, our members, their staff, their patients. We've also set up a lot of resources. A lot of energy has gone into these e-learning hubs and they are open to view at the moment. So please, if you want to see the kinds of things we've been doing, well-being, clinical advice, protection advice, have a look at the college resource hub. The college has really been advocating as well. In primary care, we didn't get the testing and the PPE straight away that we should have done. There was a big national debate about that and our leaders in the college have been really strong in advocating for what the members and their clinics and their staff need. We've been trying to help with the challenges, the workforce, training people up quickly, helping people who have returned to practice to help with the COVID practice, get going quickly and working closely with other stakeholders, particularly public health, particularly the other professional bodies, so that we've got a collective overview and a collective interface with government without being inefficient because everybody is working really hard and we don't want to have 17 conversations where one will do. And again, we're hoping that those partnerships will help us as we move forward. We're already talking about recovery from this phase and reconstruction, although as somebody said, you know, it's going to be a marathon, it's not just a sprint. So that ongoing collaboration, I think, has been really important. Thank you very much. I will now hand over to Jacqueline Ponzo and Patricia for the questions around community. Sorry. Hello, everybody. I'm from Brazil. I will talk with Jacqueline about the main challenge of community intervention in the context of COVID-19. Next slide, please. We base it in three main access. The first one, surveillance, not only for the new cases of COVID, but also other complex cases that are under our responsibilities, like chronic conditions or patients with some mental health issues. The second access, communication, because quality of information is essential at this time of many uncertainties that we are living in. And the third one, solidarity networks, essential to support social weakness in this moment. Next slide. Bringing correct information and fighting fake news are part of the community approach at this time. You can use social media flyers, WhatsApp angels, podcasts on community radios, very common here in Latin America. The content of the information should range from health information, hygienic, to information about epidemic numbers in the community. Here in Brazil, communication about local numbers is being essential for us to be able to convince the population of big communities how the importance on what is the big importance of the social isolation. Next, please. Another another important point is the increase of domestic violence, mainly against women, due to intense family life. So it's essential that primary health care professional be aware of this problem. Here in Brazil, the community health workers, in addition to active searching for from searching for people with respiratory symptoms, are taking a careful look at one and signs of regarded violence. To deal with this problem, we need to active social support networks in the community. The elderly is also a population at risk for COVID and therefore they need help with their daily activities, such as food, groceries, or Portuguese medicines. They also need help to chat and talk with friends and family using social media. So the health care team must connect them with solidarity networks. In addition, it's important to be aware of signs of loneliness and increase risk of suicide and to seek support in the community itself. COVID brings a new challenge to primary health care and like making shared decision or delivering difficult news from distance. So we we as professional primary health care professionals, we must learn new skills mainly related to patient communication mediated by new technology. Next slide please. Another important is community mental health. It's demand is increasing now. There is a lot of fear and stress due to confinement and uncertainties about life. In addition, many families will have to deal with the death of loved ones with insignificant financial laws and many are also essential workers like drivers, supermarkets, workers, cleaning personnel. Therefore, teams must be prepared and offer alternative for remote mental health care. Next slide please. Last but not least for us is the issue of social isolation in suitable places, especially in our countries or in countries that have many areas with high population density. So it is difficult to do social isolation in such communities. In this sense, building partnership with the social assistance secretariat to provide adequate place for centralized isolation of mild case of COVID is an alternative and it's being used in several countries with good evidence. It's also necessary to offer masks and alcohol gel to people who are unable to buy it. And that's very common. Next slide. Thank you very much. I would like to introduce the next speakers, Risha Roberts and Gina Usta. Perfect. Gina, you can go on. Hello. Great thanks, everyone. I'm sorry. The connection is so poor. I'm not able to go on video. First slide please. There's no doubt that COVID-19 pandemic has pushed the healthcare system and even the patients in services to deliver services in very unfamiliar way. And the patients and healthcare providers were both unprepared in this new system. The telemedicine lacks essential aspects of patient evaluation and this is why it may be considered a bit to be substandard. Like for example, we cannot do a physical exam. We're not able to access the, we're not able to notice the non-verbal views. And even in the private sector, the healthcare team is not available. It got disconnected because of the lockdown and the network has to be rebuilt. Next slide please. Even in many places, electronic health records is not available. When taking a history using the telemedicine, many times we have to rely on the patient's understanding of their diseases. On what they're called medications, his name are. And even the lab results, they are being recorded from memory and most probably they may be inaccurate. Even the scans that are being sent on web or on internet, they are, they may be poorly done and therefore you cannot see the results pretty well. Many people are also relying on paper records. This is why the patients file is not or the documentation is poorly done sometimes as because of the lockdown. You have to write it on a piece of paper and then you have to wait till you are able to access the patient's file and then record them on the paper. Many people are now with physicians are now using Google Docs to store online the medical encounters. But that creates a major concern on safety of the information being stored there. Next please. This medical encounter rely on two senses, the vision and the auditory. The auditory is not the auscultation. It is basically what we listen when we take the patient's history. And these also have some limitations. When I'm looking at the patient using my screen, I wonder whether he has jaundice or he is pale. Is this lesion that he's showing me skin lesion is elevated or is it flat? Is it populated or is it hard? Sometimes the diagnostic steps are not always accessible because of the lockdown. People may not go there either because of lockdown or they are afraid of getting COVID. And even the financial situation many times may not allow them to go and request and or to blood tests. Therefore, we are also on patient-generated data. They have to take their own blood pressure. They have to take their own dextrose which or temperature which raises concern about the appropriateness of the doses and the reasonability of the decisions we are taking. In addition, we have to operate with guidelines that have been done not using for normal days when we were not using telemedicine. And we wonder whether these guidelines to apply in these times when telemedicine is being used. And maybe a good thing to do is to start having developing guidelines and algorithms. This is something that probably we can work on with WUNCA. Now, one more thing that may affect the safety and the quality of the encounter is basically the privacy. In lockdown, how much can we make sure that the patient is private? Is we're having a private encounter with the patient? To what extent can we ask intimate questions? Questions like about family violence? Definitely we cannot. Next, please. And there are still places where we are doing face-to-face medical encounters. Now, the face-to-face medical encounters are limited to urgent cases and usually it is by appointment. There is phone triaging to rule out the possibility of COVID and access the urgency, accuracy of phone triaging is variable. Even with COVID is suspected, the sensitivity and specificity of the available test is variable. And therefore it is something to be considered whether the patient who is presenting with a negative COVID test to what extent they are definitely negative. There is always the possibility of false negatives. There are also some clinics who cannot comply or commit to provide preventive measures in addition to there is sometimes inconsistency on how preventive measures are to be done. And this poses problems for hygiene and increase the chance of infectivity. Now, I leave for the floor to Dr. Rich. Thank you, Janan. And thank you, Harris. It probably feels like we've all been drinking from a fire hose today. And so my job in wrapping up is to try to bring this all together in a practical way that we can use in our practices. Donald Lee reminded us at the beginning of the Wonka definition of quality. And in fact, the working party put together a book a few years ago that gives lots of examples of different approaches to quality and quality improvement strategies. Next slide, please. And one helpful way to think about this conceptually is to perhaps use the model developed by Professor Donah Badian. And what he described were three kinds of measures or attributes to health care. One is structural measures, process measures, and outcomes measures. And they are all interrelated. And I'll go through some examples of those with the next slide. So when you look at structural measures, it's assessing a practice's capacity or systems to provide high quality care. So for instance, we cannot provide high quality care in an environment where patients with COVID are presenting without having adequate personal protective equipment for us and for the patients. And yet, how do we do that? Well, one strategy from Japan is called Kanban. And it's a very clever way of keeping up your inventory so you know if there's a mask that you need it will be there. Is the facility safe? Do we have a way of separating unwell from other patients? One single-handed family doctor outside of Melbourne built a new clinic. And one door was for people with symptoms like COVID. And the other door was for everybody else. And the door for the people was COVID symptoms. And this was back when he was doing it for SARS when he built it. Basically went into an airlock and into a waiting area that was a negative pressure area. So again, there are lots of clever ways to make sure our facilities do as good as they can for us. The next slide talks about process measures. And that's focusing on actually how the care is provided. And so for instance with regard to COVID, how many of us are keeping track of how many patients we have that are receiving testing for either the SARS virus with nasal pharyngeal swabs or blood antibody tests and how many of those convert positive? What proportion of our patients are vulnerable and maybe need more active outreach instead of waiting for them to call us or to log on to do an electronic visit? Are we reaching out to them? Next slide, please. And outcomes measures, undoubtedly the most important attracts what our interventions do in the health status of our patients. And so in, for instance, you could measure how many patients die of COVID-19 in your practice. It's always struck me as ironic that with all the many things we measure in health care, we very rarely measure deaths in a family doctor's office. And that's because it tends to be a relatively low frequency event. But it's hard to know if we're doing better or worse without keeping track of some data. And not everything is about COVID. We're going to have patients who delay or deferred care that will down the road be developing strokes or heart attacks because of blood pressures and uncontrolled. And so we need to keep all of this in mind as we juggle these many things. Next slide, please. So where do we start? Well, you can get ideas about where you might want to focus your efforts to improve and measure your quality from things like patient complaints. If patients are not showing up in your practice because they're afraid or because they don't like sitting next to somebody that's coughing, that's important to listen to and to try to make changes. You can do it by asking your staff and keeping a registry in your staff of the things that patients are presenting with. There are many, many guidelines out. There are probably too many, frankly. The number of periodicals and other writings on COVID have been overwhelming in these last four months with something like 100,000 articles now in the peer reviewed literature. So it's very hard to keep up and the guidelines keep changing about every 15 minutes anyway. You wear a mask, you not wear a mask. And our job as family doctors is do the best we can to stay current and more importantly perhaps to reassure our patients that we're going to be there for them even as what the truth seems to be may shift as time as more information comes in. And then of course we also have policy makers or those that pay for care and they have their own requirements about what quality projects we should be working on and what measurements we should be using. There's a global one of PHCPI which is primary healthcare performance indicators. It involves WHO, Gates Foundation, others. They're developing a list of numerous indicators. But what I'm going to say to you at the next slide is you got to pick one. You can develop 5,611 different indicators of your quality and you're going to accomplish nothing. So I'm going to say it a second time. Pick one if you're going to start to take this seriously and improve your quality. Next slide please. And when you do identify that one thing that you want to work on to better understand how am I doing and how can I do better? There's from industrial engineering and statistics there are models like the plan do study act model. I'm sure many of you have been exposed to this but it's a fairly straightforward way of getting your practice organized working as a team to identify and then remedy problems in the practice. And I would encourage you to listen in on the webinar sessions that we're going to be doing in the future where we'll get into all of these in greater depth. We don't have time to do fishbone diagrams or Delphi techniques or anything like that today. Next slide. And so I'm going to leave you with this one slide and say for the third time, pick one thing. Our days are a blur of patience that we're seeing both in person and increasingly and sometimes mostly electronically but we still take care of people one at a time. And by that we also then take care of their families one at a time, which means that we're taking care of our communities one at a time. And consequently with all the world's family doctors taking care of the world altogether. And sometimes I think that gets lost as we get so focused on incubation periods and transmission rates and all the other things that are certainly important but we still have more people around the world dying of things like violence and malnutrition and heart disease and on and on and on. And so COVID is certainly very important. As family doctors, we understand fully that it's not the only thing we do or even the only thing that's important. So with that, I'd like to hand off to Dr. Anna Stavdell, our Wonka President-Elect. Thank you very much, Rich. And thank you for such brilliant presentations and lots of information. We will not check out the input from our audience and I'm calling Spain. Are you ready to convey a question to our panelists and we will do it this way. You will address one of the panelists with the question. If the rest of you panelists want to reply or respond to the question, give me a sign. So I will make sure you will have the floor or the screen afterwards. So Jose, there. And do you have a question for one of the panelists? Yes, we... Can you hear me? Yes. Well, some of our webinar participants are worried because of the care we neglect to patients who are afraid of catching coronavirus and do not come to the health center or to our practice. So what do you think we should do and how could we organize our agenda in terms of time to try to contact those who are ill? We know them and they are not coming. Okay, so who do you think would be the first one to respond to this question? Could be David Muiz, please. David Muiz. We can't hear you. No, you must unmute yourself. Thank you. Can you hear me? Yes. My apologies. I was about to say, could you repeat the question? But I think what we've discovered in the McEwen University Health Center is despite our initial straining and so on, there appears to be a message that we don't want to see you. We're in the last couple of weeks, we're toying with changing that message. We want to see you. The question is how and the question is how to protect you because the public is afraid of coming to hospitals and doctors and health centers and so on. But we will work towards this issue. So we have actually capitalized on the virtual visit as our colleague mentioned, the very notion that people are more available. We've had patients in our practice say to us after COVID-19 has settled, will you continue to provide this extraordinary service? Any other panelists who have ideas to share with the audience as a response to this question? We can allow one more response to this question before we come on. If I might, Anna, one of the things that I think is very exciting as I talk to friends and colleagues around the world is family medicine is so, of necessity is so innovative. And I'm seeing things that people are sending me, everything from drive-up service in your car to change in the way that you approach home visits, sometimes doing the home visit outside the home and through the window to one doctor in Michigan was talking about he's used his electronic record system to track people that have not come in that should have and they're actually doing active outreach with daily phone calls if necessary. So I think the genius of family doctoring is that we figure out a way to make it work and to stay connected to people. That's our challenge and it's not an easy one but it's also probably what we do better than any. Did I see your hand, Patricia? Did I see your hand? No? I think Mirella, sorry, Anna, for hijacking the conversation with Mirella. Oh, yeah, there you are. Yeah, I saw, yeah. Hi, and you touched on it already, Richard, but as we sort of move into more looking after our chronic disease management patients, the two T's, teams and technology, if you have it. And that's sort of what we've started doing at our four clinics is having team members reach out to those vulnerable patients. Having lists created by the EMR automatically of the patients that haven't been in, the ones with uncontrolled hypertension and A1Cs that haven't been done in so long. And then the team members can reach out, start that outreach with a little bit, take as much work away from the physician as we can so that the physician can do the more important stuff. Thank you very much. Ruth, how are you doing on Facebook? Any questions for the panelists? It's wonderful to see the number of family doctors from around the world who've signed on to Facebook and many of them are expressing appreciation for the webinar, realizing that as many have said, it's just a small taste of the issues that we might discuss. I'm gonna ask Pilar, our leader, one question, which has been posted. What's a good example or some of the best examples of following Rich Roberts' advice and picking one thing? What are some of the innovations in quality that you've heard of or are seeing of people picking one thing to focus on? Thank you very much, Ruth, for your work on the Facebook and thank you for the question. Regarding the COVID pandemic situation, I think primary care doctors will have to make sure we are using medication in a safety way, means as evidence is changing so quickly, we sometimes will have the temptation to do something or to prescribe any drug and we have to have in mind to be aware that medication can cause as well harm. So we have to be quite aware of what are prescribing for patients. So in this COVID pandemic, I will suggest practices to have a safe medication leader, a kind of safe medication leader is to collect the update of medications for the team and then to agree in a consensus in a safe use of medication recommendation along the pandemic. I think in this pandemic, primary care. I'll first remember this one. But before I hand over to Donald, I will, I want to ask a question and that is for Niland from WHO. Again, thank you for joining us and for the cooperation. Can I ask you just what sort of input you have got from this webinar taking back to your work in the WHO? So thank you for this opportunity again. And I think what for me, the whole comprehensive approach to a patient safety and quality has been addressed in this webinar. And particularly going forward with the coronavirus pandemic still evolving in many parts of the world. And till the time there is a vaccine available which is safe and effective, this will change our lives for in the medium and long term to come. So innovative approaches is something which really I think is a very important take home message for me. And also how do we effectively and safely utilize telemedicine in this journey of the patient care. So it's not only about COVID patients as well. It's also about patients who are, who are not accessing the healthcare system as of now to build their confidence into to assure that safety and timeliness of their treatment and make sure that in this time we have different approaches rather than what we have been using using for years so far to have more newer approaches how we can reduce the risk of infection and still provide timely care for patients. Diagnostic safety has emerged as one of the major challenges as well. So I think they are certain so this is another take home for me is diagnostic safety and of course, medication safety. So these are like three or four areas which I think will have major impact on patient safety going forward for both for COVID as well as for non-COVID patients and healthcare workers as well. So while I have the floor and I just want to mention that we also recognize in WHO the interrelationship between health workers and patients and the World Patient Safety Day which is to be marked globally on the 17th of September for 2020 the theme for this day has been selected as health worker safety a priority for patient safety and we are actually asking for speaker for health worker safety as the main call for action to all stakeholders in patient safety. So safe health workers, safe patients is a slogan which we are giving to the world for this World Patient Safety Day because health worker safety is a priority for patient safety. Thank you. I really appreciate it from work aside. I can assure you. Okay, we need to be fair to everyone. So we have that last monitor to convey a question to the panel. Laura, what can you give us from the chat that you have seen as an important issue to address? Thank you Anna. They are asking some people is afraid about now that we are using telemedicine how can we get the patient back to our office? Maybe some of the patients will prefer keep using telemedicine and we will have problems to keep them back to our offices. I was trying to answer that in Spain we use telemedicine for some years before the pandemic and usually we can ask them to come to maybe for a physical examination or just to speak face to face and they usually have no problems about that when you give them the appointment but what is your experience in other countries? I think this question will go to Pamendra as the chair of all the working party of e-Health. Unmute yourself please. Unmute yourself. In my place, like most, I have got lots of patients in my telemedicine consultation but they do come in my OPD also. First, we select some paediatric health centers where we start telemedicine and the person like which healthcare provider in that health center they do physical examination over that they can do that physical examination and with their support we used to treat that patient but sometimes we do call that patient for extra and we need an extra physical examination and investigation to do. Then we call that patient and that patient comes to our OPD. Even if we do consultation and teleconsultation on some patients they do want to come to visit personally also. Thank you. That was a good end of this round. I will now hand over to Donald because you will now round up and maybe you even have a response to the question that was asked. So please Donald, I think it's your view from me. Right, thank you very much panelists and those who have attended. I actually want to respond first of all to Rich who asked for one which actually connects with the digital the question on digital and also coming back. My improvement for quality will be compliance. And that's also connectivity and the continuity of our relations with patients. So how do we achieve that? I think it's the caring attitude during digital consultation whatever and also sometimes proactively calling your patients the long-term ones and this will improve the trusted relation that we build up and that is the most important or valuable relation between family doctors and patients. So I would think that it's the attitude and how you do it's not just a digital message to say, you know, come tomorrow or whatever. Start with how are you? How are things? How's the family? You know, I think the personal touch would be the one and but you use the technology you use the digital technology to help. But anyway, so I would think that, you know improvement is compliance to make sure during these difficult times that our patients comply. Okay, so before I make other closing remarks I think I want to advertise next week, same time. Our webinar will be on research, a very big topic and we're looking forward to see, you know what our coordinators have in mind. I'm sure it'll overrun by three hours if we go on. So anyway, thank you again. So next slide, that's right. So while the response has been magnificent of family doctors globally to the challenge of COVID-19 we should not forget that our patients will continue to have the usual range of illnesses and diseases that require quality and safe care. Some new, some chronic, some easy to treat and others much less so. Many may be ill-defined, some will even be terminal. Next please. So we continue this year as never before to deliver healthcare to our patients in different sometimes innovative ways to meet the demands and restrictions placed on communities for their own safety. As ever, we are the first in and last out professional group serving our patients as best as we can delivering good quality and safe primary healthcare. Our task now is to bring the best of who we are and what we do to a world that is more complex and more confused than any of us would like it to be. May we all proceed with wisdom and grace. Thank you very much everybody. Thank you, Donald, and thanks to all the panel. Please join us again next week if you can for the last in the current series of Wonka webinars as Donald said, focusing on research. Led by Felicity Goodyear-Smith, chair of our research working party, the panel will be discussing some of the studies into COVID-19 that the working party is involved in and also touching on some of its non-COVID activities. Just a reminder that the webinar will be at the earlier time of 100 UTC. So please join us at 100 UTC next Sunday. But for now everybody, thank you again and stay safe.