Improving the safety of High Risk Medications Experience so far…… Neil Houston Berny Welch Louise Black

Aims Learn about approaches to measurement of the high risk medication care bundles Learn various tools to support practices to make improvements and achieve reliability Share experiences, challenges and successes.

Over to you . . . Get a partner – preferably someone you don’t know very well Stand back to back with your partner Without looking change one physical thing, about your appearance Turn around and face partner WHAT HAS CHANGED!!! 2 mins – icebreaker exercise – Jo Matthews 4

Do it again How was it for you ?

Some change is easy Some change is hard to see the effect of - study it More and Bigger changes can be uncomfortable Ok that’s enough ….

“Education, education, education” Tony Blair 1997 “It’s the economy, stupid” Bill Clinton 1991 No politician has yet said: “Data, data, data” “It’s the data, stupid”

Process and outcome measures……

New rules – concentrate on process Process measures are collected in a practice or unit - those results can give the team the needed success If process becomes highly reliable the outcome will follow as long as it is connected to science Outcome measures will most likely lag behind process measures Leaders should tend to focus on outcome while individual teams should be held responsible for process reliability 9

If you focus on reliable processes the outcomes will follow …..

Practice Feedback There is magic in graphs… There is magic in graphs. The profile of a curve reveals in a flash a whole situation – the life history of an epidemic, a panic or an era of prosperity. The curve informs the mind, awakens the imagination, convinces…. Henry D Hubbard, 1939

Automatic Data Extraction Blessing or missing a trick?

Bundle Compliance

GGC Primary Care DMARDS Bundle Compliance Alexa Wall, NHS Lanarkshire Rachel Bruce, NHS Greater Glasgow and Clyde

Aggregation National Solution Lothian – QUIDs Glasgow excel Lanquip Others??

Getting Practices to reflect on data and do something with it Not in the bottom drawer Data on the notice board Practice meetings PDSAs Reflection sheets

Please use this form to carry out an internal review of your anticoagulation bundle data What did your bundle data show? Please explain any improvement work you have carried out What challenges have you faced? How might you further improve your data or practice systems? What else might you change? Interface challenges - highlight any interface areas for improvement Need support or guidance to make changes in your practice?

SEA feedback Combined feedback from mid year reflection and SEAs,

Improvements Phone protocol for INR results Teach back Leaflets KIS Interface – dx letter Dawn email

Learning from each other Knowledge website – worth a trawl!

Forth Valley Templates Info leaflets Warfarin Warfarin guidance

Tayside – Vision guidance and templates Credit Card sized patient information leaflets were developed and tested as an aid to informing patients about the blood tests and side effects. As a result of focus groups/trigger tool with patients and carers in Year 1 one practice developed and tested a results card. (Muirhead) 24

PDSA - Improve Compliance of Patients Attending Monthly Blood Monitoring Ensure patients prescribed Methotrexate or Azathoprine attend a monthly review for blood monitoring Patients complying by attending blood monitoring will increase Using a variety of engagement methods Patients engaging 5 Stop repeat prescription until they attend 4 Restrict the amount of repeat prescription available to them to encourage attendance 3 Put a note on patients repeat prescription 2 Send information stating reasons for why it is important to attend 1 Invite patients who have failed to comply by telephone 25

Fife Frequently asked questions Warfarin Care Bundle Question 1: How many patients do I need to review each month? Answer: 10 patients randomly chosen from your warfarin patients. Question 2: Is there a web based recording tool? No. The recording tool is available on the website but you need to save it to your computer and make sure it is backed up. http://www.knowledge.scot.nhs.uk/spsp-pc/health-boards/nhs-fife.aspx

Tayside Vision Guideline In the initial phase of the project extensive consultation took place with secondary care consultants (rheumatology, dermatology and gastroenterology) along with secondary care pharmacy. This assisted with the revision and standardisation of the guidelines for DMARD monitoring. These guidelines are now included as a weblink in the Primary Care ‘Vision’ software, so they are always available to practices in their most up to date form. This vision guideline has also encouraged consistency of recording any monitoring, actions taken and information provided to patients. It was adopted by many of the Tayside practices but did require some awareness raising to ensure all staff were singing to the same hymn sheet. Many of the other changes made by practices utilised the VISION system as you can see from those that are to follow. 27

How can we help practices make improvements Process Mapping made easy

Video Process mapping

Questions? Comments?

Table Discussion What have you done in your board to Facilitate practice data collection? Promote practice reflection on the data and improvement? What could you now go and try ?

Feedback Any other things to look out for when shopping??

Re focus Re energise

Outcome measures Reduced Admissions Reduced readmissions < 30 days Improved safety culture Better INR Control

Outcome Measures Warfarin % of INRs per practice/board less than 1.5 and more than 5 per practice % of INRS per practice/board over 8 per practice Numbers of days since last INR>8 in practice ? % of INRS which were: Within +/- 0.5 of target (BSH suggested minimum standard 50%) Within +/- 0.75 of target (BSH suggested minimum standard 75%)

Data held at board level Lab data Computer assisted software data ? Others NHS Forth Valley approach - a work in progress

FV %INR <1.5 and >5/total INRs by practice Why do we think this is necessary? 55 pts admitted in FV in 2010 primarily due to overanticoagulation (underestimate) There is a wide variation- these figures are from FV jan- march 2012 37

Aggregated data - INRs out of range FV 2012-2013 7.9% 6.2% INRs > 5 1.6% 1.9%

Computer assisted software info DAWN 39

DAWN practices +/- 0.75 target INR

% Dawn INR+/- 0.75 2012 71.6% 2013 70.45% DAWN +/- 0.75 Benchmark 80%

Benchmark 50% % Dawn INRs +/- 0.5 2012 vs 2013 DAWN +/- 0.5 2012 53.3% 55.75% DAWN +/- 0.5 Benchmark 50%

INR within 0.5 and 0.75 (DAWN)

Note missing practices –cant tie up names and practice numbers and skew due to low freq practices (which might use health centres as well as own practice Average 14.2 44

FV total INRs by month 2011-12 2012-13 Marginal improvement on a background of change –more pts on warfarin )AF guidelines, QOF) 2011-12 2012-13 45

Methotrexate Outcome measure % of prescriptions of Methotrexate, per board, which are for 2.5 mgs

Escape the RAT race with NHS Grampian Dr Berny Welsh Mrs Louise Black

Warfarin High Risk medication Complex patients Polypharmacy Frail Elderly

INR control outcome data Why? Intuitively appealing as measure of how reliable and safe practice warfarin service is. Why should practices share data with us? Own data to use for improvement Healthy competition

Recruiting practices Personal contacts Practice pharmacists Early adopters CHSCP meeting

RAT system – monthly report (now have 6 months of data!) PCT report Prepare Run Copy & Paste into email Send

Number of INRs (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L  203 159 189 195 192 198 170 276 211 246 224 231 Number of INRs within 0.5 of target (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L  119  97  94 120 109 126  95 137 111 145 128 132 Number of INRs > 0.5 of target (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   35  24  30  29  41  37  32  61  38  52  38  37

Number of INRs < 0.5 of target (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   49  38  65  46  42  35  43  78  62  49  58  62 Number of INRs within 0.75 of target (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L  144 117 126 149 123 148 120 183 142 183 158 170 Number of INRs > 0.75 of target (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   25  16  20  21  31  24  24  49  31  36  31  30

Number of INRs < 0.75 of target (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   34  26  43  25  38  26  26  44  38  27  35  31 Number of INRs > 5 (Active patients) (A=Oct 2012 - L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L    2   0   0   2   4   1   2   6   3   2   4   1

Voila! You’ve got useful outcome data 

Using your data in practice Print, display and share on Patient Safety Board Use this to have discussions in practice Plan improvement steps if required What are you going to do with it

Successes and challenges Early days What sense ownership by practices? Growing number practices participating

Questions?

Group Discussion What are you currently doing with outcome data? What might you do differently with your data/support to practices? How will you progress this in your HB and at your next learning session? What can you share?