1. Proctor’s Implementation Outcomes
Quality Improvement tools to improve the safe use of high risk medicines – a theory based evaluation
Abstract submission:
Background
The Scottish Patient Safety Programme - Pharmacy in Primary Care (SPSP-PPC) collaborative is a Quality Improvement (QI) initiative striving to improve patient safety within community pharmacy. One element of the collaborative has involved implementation of High Risk Medicine (HRM) Care Bundles (CBs) which focused on non-steroidal anti-inflammatories and warfarin. These were implemented in 27 pharmacies across four NHS regions by applying the Institute of Healthcare Improvements’ “Breakthrough Series Collaborative Model”. This study reports on (1) implementation of the HRM CBs and (2) application of the collaborative model.
Methods
Mixed-method evaluation involved questionnaires, semi-structured interviews, case studies, process mapping and documentary evidence. Analysis was informed by two theoretical frameworks: the Kirkpatrick Model to investigate impact of training delivered; and Proctor’s Taxonomy of Implementation Outcomes to understand the factors influencing implementation.
Results
The evaluation involved approximately 187 participants. The collaborative model was rated positively, provided networking opportunities and motivation to engage, yet further consideration of learning needs and how best to deliver the QI approach at scale requires attention. The CBs were considered acceptable, appropriate, feasible and compatible within community pharmacy practice. Adoption of QI methods was variable and risks to sustainability included lack of whole-team involvement in CB delivery. Significant variation of the CBs between NHS regions existed; posing challenges for further implementation, such as equality of patient care.
Conclusion
The findings demonstrate capacity for community pharmacy to deliver safety-focused initiatives within a collaborative. Application of frameworks helped develop key recommendations informing strategic decision-making. Key issues are being taken forward through consolidation and further testing of the CBs, and resource development to facilitate whole-team engagement.
Ms Natalie Weir1, Mrs Emma D. Corcoran1, Dr Rosemary Newham1, Prof Anne Watson2, Dr Paul Bowie2, Prof Marion Bennie1.
1Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.
2NHS Education for Scotland, 2 Central Quay, 89 Hydepark Street, Glasgow, UK.
Background
Results
The Scottish Patient Safety Programme – Pharmacy in Primary Care (SPSP-PPC) collaborative aimed to improve patient safety within community pharmacy.
This involved using a collaborative model1 with structured learning events in-between action periods, and training community pharmacy staff on Quality Improvement (QI) tools (e.g. Plan-Do-Study-Act cycles).
High risk medicine interventions known as Care Bundles (CBs) were designed and implemented. These focused on non-steroidal anti-inflammatory drugs (NSAIDs) and warfarin.
The CBs were implemented in 27 pharmacies and 2 dispensing doctors across four NHS regions.
187 individuals participated in the evaluation.
Kirkpatrick Model
Findings
Reaction
Positive engagement with collaborative.
Reported increase in knowledge and application of knowledge.
Training viewed positively but work pressure issues limited use of training materials.
Learning
Understanding and knowledge of QI tools and programme elements was low at baseline but increased sharply and was sustained over the 2 year programme.
Behaviour
Dissemination of learning to pharmacy staff who did not attend learning events was lacking.
CB delivery often conducted by the Pharmacist/Manager.
Have you checked that the patient is concordant with taking their NSAID?
Have you checked if the patient is experiencing adverse drug reactions or side effects?
Figure 2. Analysis of collaborative model by applying the Kirkpatrick Model
Proctor’s Implementation Outcomes
Findings
 Acceptability
Staff understanding and acceptance of the CBs maintained over time in part through local solutions to implementation.
Adoption
Pharmacy sites adopted the CBs with confidence.
Appropriate-ness
CBs were appropriate within community pharmacy for safe and reliable patient care.
Better alignment with other national services suggested.
Feasibility
Data reporting onerous, but delivering the CBs was feasible.
Fidelity
Delivering the CBs was often the pharmacist’s responsibility, with limited wider team involvement.
Variation of the CBs between NHS regions posed challenges for wider implementation.
Penetration
Awareness and understanding of the CBs was variable which affected who in the pharmacy team was involved.
Sustainability
CBs were compatible with pre-existing pharmacy activities and sustained for 2 years.
Pharmacy staff willing to continue delivering the CBs.
Has gastro-protection been prescribed for high risk patients?
For patients identified as taking other high risk drugs, has this risk been highlighted to the prescriber?
If the prescriber was contacted, was the resulting review communicated back to the pharmacy?
Has this change been discussed by the pharmacist with the patient/carer?
Figure 1. Example NSAIDs CB
Aim
The aim of this study was to evaluate the (1) application of the collaborative model and QI learning and (2) implementation of the CBs.
Methods
A two-year, mixed-method evaluation was informed by two theoretical frameworks:
the Kirkpatrick Model2 to investigate impact of training delivered.
Proctors Implementation Outcomes3 to understand the factors influencing CB implementation.
Methods included questionnaires, interviews, focus groups, on-site visits, and field work.
Figure 3. Analysis of implementation by applying Proctor’s Implementation Outcomes
Conclusions
Findings demonstrated capacity for community pharmacies to deliver safety focused initiatives using a collaborative model.
The CBs’ continue to develop, with key issues taken forward through consolidation and testing of the CBs.
Ongoing focus is on whole-team engagement with the CBs.
Acknowledgments
We would like to thank all participants for their input, The Health Foundation who funded this work (Award Reference Number: 7271), and all members of the SPSP-PPC Steering Group.
References
Institute of Healthcare Improvement. The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. Innovation Series, (2003).
Kirkpatrick DL. Techniques for evaluation training programs. Journal of the American Society of Training Directors. 1959;13:21-6.
Proctor E, Silmere H, Raghavan R et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and policy in mental health. 2011;38(2):65-76.