What is a Care Bundle? How can we use them to make our systems safer and more reliable ? The aim of this session is to introduce the concept of care bundles and how they drive improvement , The session should cover: What are they How they work - sharing the experience from SIPC To highlight the care bundle practices will be using and the rationale for it Highlight the frequency and sample size of data collection Demonstrate the data collection process

3 Questions? In General Practice do we accept that care could be improved? If so, can we change our current practice? Can we use Care Bundles to help us? Ask the audience is there an acceptance than care could be made reliable? If so how do we do that and can a care bundle act as a catalyst to make improvements?

Care Bundle A care bundle is a set of interventions that, when used together, significantly improve patient outcomes. Care bundle definition Interventions need to be done together and it is this consistency that leads to significant improvements

How do we know how well are we doing in General Practice? Enhanced services GMS Core QOF QOF QP Immunisation Targets Formulary Adherence Prescribing targets There are already a number of different quality initiatives in Scottish General Practice – highlight the positive effects these initiatives have on care GP Appraisal Clinical Audit Revalidation Patient Satisfaction

Bundles ensure that every person gets reliable, consistent care every time

What is a care bundle? 4 or 5 elements of care Evidence based Across Patients Journey Creates teamwork Done reliably All or nothing Small frequent samples This slide outlines the elements which make up a care bundle 6

QoF Data Looked at 9 practices which provided QOF data on particular QOF indicators Then looked at an overall composite measure of the indicators Combining QOF data with the care bundle approach may provide a more meaningful measure of quality in general practice Carl de Wet, John McKay and Paul Bowie Research was carried out on 9 practices in Scotland – researchers looked at their QOF data to see how reliable the care they were providing was

QOF Data - CKD Chronic kidney disease (CKD) The % of patients on the CKD register: CKD3 whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less CKD5 with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE – I) or angiotensin receptor blocker (ARB) CKD6 whose notes have a record of a urine albumin: creatinine ratio (or protein: creatinine ratio) test in the previous 15 months They looked at whether the QOF indicators were achieved - for example the CKD indicators above

Outcomes Chronic kidney disease (CKD) Threshold (min-max %) Average for all 9 practices (%) CKD3 40-70 76.9 CKD5 40-80 98.8 CKD6 89.2 Overall Composite 100% Although individual QOF measures would indicate that patients with diabetes receive reliable care and many practices achieve near to maximum points, the data can be misleading about how consistent our care is

Outcomes 69 Chronic kidney disease (CKD) Threshold (min-max %) Average for all 9 practices (%) CKD3 40-70 76.9 CKD5 40-80 98.8 CKD6 89.2 Overall Composite 100% 69 When we look at which patient receive all the interventions – the composite - we are less reliable

QOF Data - Stroke Stroke/TIA The percentage of patients with: STROKE6 a history of TIA or stroke in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 or less STROKE8 TIA or stroke whose last measured total cholesterol (measured in the previous 15 months) is 5 mmol/l or less STROKE10 TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March STROKE12 with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded) The same picture occurs in the management of most patients with a chronic disease

Outcomes Stroke / TIA Threshold (min – max %) Average for all 9 practices (%) STR 6 40-70 91.5 STR 8 40-60 86.7 STR 10 40-85 93.7 STR 12 40-90 96.6 Overall Composite 100%

Outcomes 74.1 Stroke / TIA Threshold (min – max %) Average for all 9 practices (%) STR 6 40-70 91.5 STR 8 40-60 86.7 STR 10 40-85 93.7 STR 12 40-90 96.6 Overall Composite 100% 74.1

Reliable Care?? 38% of patients with Type 1 Diabetes receive 9 key interventions NICE 2008/9 The sample above was from a small group of practices but these findings are replicated nationally as illustrated by these figures

Can Care Bundles make a difference?

At this point you may wish to show delegates the Peter Pronovost clip, showing how care bundles can make a difference – the link for this video is available on the knowledge website

(ITU physician at Johns Hopkins Hospital, Baltimore, Maryland) Peter Provonost (ITU physician at Johns Hopkins Hospital, Baltimore, Maryland) Simple message: Checklist –evidence based Improved culture Measurement ‘Retool’ = PDSA This slide reinforces the messages of the clip Key interventions need to be reliably implemented and measured, which leads to improvement using PDSAs

Peter Provonost’s Care Bundle A simple 5 item checklist protocol would greatly reduce infections when inserting a central venous catheter Doctors should: Wash their hands with soap. Clean the patient’s skin with chlorhexidine antiseptic. Put sterile drapes over the entire patient. Wear a sterile mask, hat, gown and gloves. Put a sterile dressing over the catheter site. The checklist, or bundle, can be very simple

But can lead to dramatic results such as a huge reduction in central line infections demonstrated above These results have been replicated in Scottish hospitals

Do Care Bundles work in Primary care?

Introduced a Care Bundle Reviewed literature / guidelines Discussed with colleagues Spoke to ‘Bundle experts’ from IHI Spoke to patients Piloted the Care Bundle All care bundles tested throughout the pilot work were developed using this process

Bundle Compliance This shows how practices in Lothian made their care more reliable by implementing the warfarin care bundle

Practice Manager Experience (video clip) You may wish to show delegates the Practice Manager video clip, which highlights how implementing the warfarin bundle acted as a catalyst to improving practice systems and care – this video is available on the HIS website

Can you improve efficiency? Dec-10 – Dalkeith introduced the RAT system Aug-11 – Dalkeith started the SIPC project In some practices it led to fewer INR blood tests being carried out as variation reduced Test per patient before RAT = 2.2 average Test per patient after RAT = 1.4 average Saving = almost 100 appointments per month

SIPC Evaluation Successes of bundles More systematic approaches to processes, e.g monitoring/repeat prescriptions Better documentation Better communication of results Less Variation Proactive Educated patients Less stress Increased confidence in roles Following evaluation of the pilot work, practices highlighted the following successes and positive impact of the bundles

Sharing Successes, Challenges and Resources Some of our Challenges: Time Competing priorities Negative attitudes Understanding of tools and methods Struggling practices need support Some of the challenges identified are highlighted on this slide

SIPC Evaluation Successes “they are straight forward, it is not too complicated” “it is a simple tool that highlights if there is a drop (in care) and why, it is visual because you can print it off” “the main strength is when you see them improving, it encourages you and motivates you”

“The care bundle was useful because it identified gaps” SIPC Evaluation “The care bundle was useful because it identified gaps” “You can see week by week, month by month, whether or not you are showing any improvement, we seem to be improving and that’s good” This highlights the benefits of regular data collection and using the data to drive and reinforce improvements 28

Any Questions?