Introducing a Patient Safety Programme Dr Gordon Black NHS Lothian Clinical Lead SIPC Project

The NHS Lothian experience with Warfarin Brief Background How well do we manage Warfarin at the moment? The SIPC warfarin journey Where next?

Safety Improvement in Primary Care 1 (SIPC 1)

Aims To enable 80 Primary Care teams to: Identify and reduce risk and harm to patients Improve reliability of care for patients On High Risk Medications With Heart Failure

NHS Lothian took on the Warfarin workstream Care Bundles Trigger Tools Climate Survey Patient Involvement PDSA’s Process Mapping Collaborative learning NHS Lothian took on the Warfarin workstream

Can we do better with warfarin management? Warfarin is the second most common cause of adverse drug events in emergency departments Incidence of major bleeding in patients prescribed warfarin ranged from 0% to 16%, and the incidence of fatal bleeding was 0% to 2.9%.

Warfarin Video Could this happen in your practice?

What is ‘normal’ practice Worksheet 1 activity

Measuring Outcome for the project We were able to get INR results for all practices in NHS Lothian from the labs We decided to look at results ‘outwith’ an expected range <1.5 & >5

How well are we doing in NHS Lothian? ‘All’ GP practices Results <1.5 & >5

SIPC Project Can we do any better? Care Bundles ) Trigger Tools ) Climate Survey ) Patient Involvement ) PDSA’s ) Process Mapping ) Collaborative learning ) Overall aim was to reduce INR results above 5 by 30%

Practice Recruitment

Care Bundle Development Bundles of care 4 or 5 elements Across Patients Journey Creates teamwork Mixture easy and hard All or nothing

Care Bundle Development Reviewed literature / guidelines Discussed with colleagues Spoke to ‘Bundle experts’ from IHI Spoke to patients

Patient Involvement 1. Lothian wide focus group 2. Practice specific focus groups

Patient Involvement Lothian Wide Patient Focus Group – 20th August 2010 What would you change? Once diagnosed, info on foods/ diet/ over-counter drugs which may affect INR. Someone specific to sit down and give all the info and make sure patient understands. Annual check-up.

Warfarin Bundle v1 Elements Is the target INR recorded in patient’s notes INR is taken within 7 days of planned repeat INR Last INR recorded in yellow book Face to face education recorded every 3 months

Warfarin Bundle v1 How well do you think you would do? What elements would challenge your practice?

Warfarin Bundle Weekly Data Collection Tool

Data Entry Charts

Bundle Feedback Not challenging enough Target INR always recorded Yellow book wasn’t always applicable (if patients preferred their diaries, or the practice uses an online system such as INR Star) No consistence with prescribing and interval for follow up appointment.

Warfarin Bundle v2 Needed to increase the level of challenge- Listened to practices Patient focus groups Review of literature

Warfarin New Bundle Is there evidence that the last advice re warfarin dosing given to patient followed current Lothian Guidance/ INR Star/ RAT? Is there evidence that the last advice re the interval for blood testing given to patient followed current Lothian Guidance/ INR Star/ RAT? Has patient been taking the advised dose since last blood test? INR is taken within 7 days of planned repeat INR?* Face to face education recorded every 3 months?* Overall compliance out of 5

Warfarin New Bundle Is there evidence that the last advice re warfarin dosing given to patient followed current Lothian Guidance/ INR Star/ RAT? Is there evidence that the last advice re the interval for blood testing given to patient followed current Lothian Guidance/ INR Star/ RAT? How do you decide what dose of warfarin a patient needs and when they should return – if you asked one of your partners would they do the same?

INR Blood Tests Dalkeith Medical Practice Dr Richard Conlan Kevin Lawrie (Practice Manager) Hazel Thomson (Practice Nurse)

Can you improve efficiency? Dec-10 – Dalkeith introduced the RAT system Aug-11 – Dalkeith started the SIPC project Test per patient before RAT = 2.2 average Test per patient after RAT = 1.4 average Saving = almost 100 appointments per month

Craigmillar Medical Practice Our Experience Craigmillar Medical Practice

Our Experience Bundle changed to make it more relevant for the practices. HCA collects the information for the last three. GP then goes through records and collects information for the first two. Generally all the bundles score highly. Most difficult is face to face education every three months.

Warfarin Bundle Data Collection Tool Bundle Composite Patient 1 Overall Compliance Y N No. out of 5 Is there evidence that the last advice re warfarin dosing given to patient followed current Lothian Guidance/ INR Star/ RAT? Is there evidence that the last advice re the interval for blood testing given to patient followed current Lothian Guidance/ INR Star/ RAT? Has patient been taking the advised dose since last blood test? INR is taken within 7 days of planned repeat INR? Face to face education recorded every 3 months? Overall compliance with bundle (i.e. total number of patients who achieved ALL 5 composites) __ / 5 1. Is there evidence that the last advice re warfarin dosing given to patient followed current Lothian Guidance/ INR Star/ RAT? 2. Is there evidence that the last advice re the interval for blood testing given to patient followed current Lothian Guidance/ INR Star/ RAT? 3. Has patient been taking the advised dose since last blood test? Check with the patient that they have actually taken the correct dose. 4. INR is taken within 7 days of planned repeat INR. The planned date and actual date of next INR test must have been recorded. 5. Face to face education recorded every 3 months? This must include advice, questionnaires, leaflets etc.

What does our data tell us?

Improving Warfarin Management Driving force was compliance with the bundle. Practices then tried to improve their system: PDSA’s Process Mapping Patient Involvement

Plan, Do, Study, Act

Improve Compliance of Using Guidelines When Treating Warfarin Patients Ensure all GPs and nurses use the Lothian Guidelines when treating patients on warfarin Review of records showing compliance will increase Having guidelines within easy access for use backed up with educational event Practices engaging with process 4 Monitor use of Guideline by developing template for computer system 3 Ensure the Lothian Guidelines are within easy reach for each GP to use 2 Email all doctors stating the importance and set up PLT around it 1 Review in the practice who uses the Lothian Guidelines

Process Map

Patient involvement Each practice was asked to have some Patient Involvement activity. Practice specific focus groups Practice patient questionnaires Simple asking 3 questions Patient involvement with education leaflet

Now what? Bundles helped us understand our system. Bundles raised awareness. Bundles allowed us to make improvements to the system, both for staff and patients.

Bundle Compliance

Does Bundle Compliance = better results?

Does Bundle Compliance = better results?

BUT…… Control chart for INR <1.5 or >5

We do seem to have reduced blood testing! Control chart for mean number of tests per patient per month

What about the Trigger Tool? All practices were trained in the use of the Trigger tool Practices were asked to do the tool every 3 months. Results were collated to learn common themes.

Any thoughts about the use of the Trigger tool?

Experience with the Trigger Tool Doctor Gordon Cameron Milton Surgery, Edinburgh

Initial Apprehension Trigger tool seemed a bit intimidating when we first had it presented to a large group at the study day Much easier to use in practice and after a brief one on one session to get started It’s a really effective tool for reflective analysis on patient safety and other clinical issues Has created a lot of interest from other doctors in the practice as a tool for professional development and for appraisals

Not too time consuming after all Initially seemed like it would take up lots of time to scan the notes and enter the data In practice much quicker than I thought it would be By the second time around I spent only 90 minutes on reviewing 20 sets of notes The absence of triggers sometimes allows quicker scanning BUT – some of the most significant learning experiences were in patients who had NO TRIGGERS

“Dodging bullets ….” No harm actually occurred in this instance so would never have been picked up without trigger tool analysis - events had happened six months before notes were reviewed Patient on warfarin for stable long term AF Co-prescribed aspirin – not intentionally No FBC check in two years Seen with gout (locum doctor) and co-prescribed two different NSAID’s in high dose in the space of ten days No PPI cover given Upward drift of INR during this period to a level just around 4.0 Gout resolved, NSAID’s stopped, INR back to 2.6 …. And were it not for the trigger tool review nobody would have been any the wiser !

Frequent Themes We used the trigger tool in in patients on warfarin Common themes: Missing Read Codes – e.g: Atrial fibrillation not coded in two patients who had it Huge variations in what different doctors thought the “Allergy” codes in GPASS should be used for some only recorded true allergies others recorded all adverse reactions no matter how trivial Practice doing well with Warfarin monitoring but much less well with checking Digoxin levels on a regular basis, checking occasional FBCs.

Trigger Tool vs SEA Significant Event Analysis Can only be used to look at cases where harm has already occurred Needs a lot of writing up Very reliant on the clinician involved feeling able to share Can be threatening Trigger Tool Structured Case notes review Can pick up near miss cases where no actual harm occurred No formal writing up as such Less threatening A more powerful tool for changing personal ways of working

How trigger tool has changed our practice We plan to encourage other partners and doctors in training to use it as part of appraisal Specific changes made in response to things picked up during reviews: Protocol now for recording adverse drug reactions FBC checks at least once a year for all warfarin patients Digoxin levels checked at least once a year Better systems for highlighting possible drug interactions to the doctor who is deciding the next dose of warfarin Much better at coding relevant read codes Closer checking that locums are familiar with practice systems for warfarin patients

Patient Involvement (focus groups) How does it all fit together? PDSA Patient Involvement (focus groups) Labs Data Process Map Care Bundle Trigger Tool

Where next? In NHS Lothian we now have a proposed Locally Enhanced Service to spread the SIPC work across other practices. We have LMC support for the LES. We are currently awaiting a decision for 2012-2013. ? National Patient Safety Programme 2013

What is happening in your Board? To consider before Q & A session: How aware is your board of this agenda What is the current infrastructure to support this What is your board going to do next?