1. Inspiring Change Leading Innovation to challenge the past and deliver
quality outcomes for the future
Supported by:

2. Welcome & Introduction
Sheelin McKeagney
Community Pharmacist
Chair of the Pharmacy Forum NI
Supported by:

3. The Quality Jigsaw Rebalancing Premises Standard
Clinical Assurance
Premises Standard
Rebalancing
Error Reporting Standard

4. New Community Pharmacy Contract
Anticipated in 2017/18 - Endorsed by Minister O’Neill Jan 2017
Target - New contractual arrangements in place by 31st Mar 2017
Delayed due to the current political situation
Significant amount of progress made since pre-negotiations began in Oct
CPNI and HSCB currently pressing ahead with an ambitious programme of service development work
Quality and outcomes will underpin the new contract

5. Rebalancing Medicines Legislation and Pharmacy Regulation Programme Board
Reviews relevant pharmacy legislation and regulation to ensure it:
Provides safety for users of pharmacy services
Reduces any unnecessary legislation
Allows innovation and development of pharmacy practice

6. Rebalancing Programme Components
Review of dispensing errors legislation
Enabling registered pharmacy standards and related matters
Review of hospital pharmacy regulation, including in respect to dispensing errors
Review of pharmacy owner, superintendent and responsible pharmacist arrangements
Review of pharmacist supervision

7. Rebalancing – Community Pharmacy Headlines
Proposals have been prepared for:
a defence to the criminal sanction for inadvertent dispensing errors
clarity around the roles and responsibilities of owners, superintendents and responsible pharmacist arrangements
Work has been commenced on
Review of pharmacist supervision

8. Professional Standards For Reporting

10. Outcome Based Premises Standards
Initiated by government as part of ‘Enabling Excellence’
The aim is to have ‘outcome driven’ standard
Autonomy given to owners and superintendents to run businesses to safe and quality outcomes
Promoting innovation in practice
Incorporating support premises other that pharmacies

11. Outcome Based Premises Standards
Key enablers:
a) Governance arrangements to manage risk
b) Working arrangements including skill mix and use of staff
c) Working environments including premises, equipment and facilities
Enabling oversight of the full range of service provision from pharmacies
Evidence based quality assurance building on existing standards but not prescriptive to one size fits all

12. Quality Assurance & Clinical Governance
Rolled out in Aug Consists of an annual assurance declaration and visit to pharmacies over a 3 yr. period
The aim and purpose - Monitor compliance with aspects of Pharmaceutical Services Regulations (NI) 1997, Terms of Service, service specifications, related professional standards and best practice
Developed by HSCB & CPNI
Patient safety is a component of the visit protocol
Involves - Discussion on processes for recording medicine incidents and near-misses and
Also, how practice is reviewed in light of an incident or patient safety communication

13. Quality Assurance & Clinical Governance
The Community Pharmacy Clinical Governance Framework is currently being developed by HSCB and CPNI
Implementation will require a change in current Terms of Service through an agreed process.
It is proposed that a risk management programme is included in the framework
This would incorporate systems for recording and reviewing incidents within the pharmacy
Sharing learning with pharmacies in the same chain, as well as anonymous reporting to HSCB

14. This Evening…
Challenge
Learning
Making a change

15. Learning from Experience
Dr Brenda Bradley
Pharmacy Lead, HSCB
I work as a pharmacist in the HSCB and one of our main roles is to consider mechanisms to improve patient safety in the area of medicines management, from both a CP and GP perspective. One of the main ways we do this is to consider safer systems and consider possible processes and mechanisms to reduce the risk of adverse incidents occurring in the first place.

17. The headlines that appeared regarding the Elizabeth Lee case……

18. Extent of dispensing incidents
A study conducted in Manchester1 found that dispensing incidents occur at a rate of 26 per 10,000 dispensed items
22 ‘near misses’ and 4 dispensing errors
In NI in 2016/17, approx 41.5 million items were dispensed
107,900 incidents per year
91,300 near misses
16,600 dispensing errors
1 Ashcroft D et al. Pharmacoepidemiology and Drug Safety 2005; 14:

19. What are we doing in Northern Ireland?
Community Pharmacy Assurance Framework (visits started August 2016)
Patient safety is a component of the visit protocol
Discussion on processes for recording and reviewing medicine incidents and near- misses
An anonymised record of an incident and/or near miss is also viewed.
Focus on beta blocker SAI learning
Community Pharmacy Clinical Governance Framework
Currently being developed by HSCB and CPNI
Likely that a risk management programme will be included in the framework
systems for recording and reviewing incidents
sharing learning with pharmacies in the same chain
anonymous reporting to HSCB.
Both to try to reduce the incidence of errors and share learning with the aim of making practice safer

20. How to Report an Adverse Incident

21. Reported Adverse Incidents Community Pharmacy 1st April 2015 - 31st March 2017
Total reported incidents:
925
Anonymous
645
Identified Community Pharmacy
280
Administration or supply of a medicine from a clinical area 2
Advice 1
Medication error during the prescription process 6
Monitoring or follow up of medicine use
Other medication error 66
Preparation of medicines / dispensing in pharmacy
847
Supply or use of Over The Counter medicines

22. 847 Incidents: Preparation of medicines / dispensing in pharmacy

23. Prevented/No harm incidents
Why report?
Death 1
Severe 0s
Heinrich, an engineer in the 1940s found that for every one very serious incident e.g. death, when this was investigated further he found that there were tens of similar incidents causing severe harm, hundreds of similar incidents causing only minor or moderate harm and thousands of similar incidents where no harm was caused or where the incident was prevented. If we had known about all the minor incidents, perhaps the severe one could have been prevented. This illustrates the importance of reporting – even of minor and no harm incidents.
Minor – Moderate
00s
Prevented/No harm incidents
000s

24. Why report an Adverse Incident?
Learn from incidents
Identify trends
Share knowledge across practices
Prevent reoccurrence.
Learning Culture – NOT Blame Culture !

25. A real life story… Consider the following issues:
What sort of drug was being used
The role of the patient
Checks carried out before administration of the drug
How the incident was managed
Learning from previous similar events
How does what you see relate to community pharmacy?
Obviously a complete tragedy and very hard to watch in parts
There are a lot of analogies with some of the SAIs we have seen in the HSCB and shared learning on, including the recent beta blocker SAI:
High risk drug where there was a lack of familiarity - often high risk drugs are prescribed for dispensing in CPs
Learning:
- Staff training
Awareness raising e.g. high risk medicines poster
The role of the patient
Patient wasn’t given any info and neither was wife. In this case, it wouldn’t have made a difference but often in CP, pt can be used as the last check
Checks carried out before administration of the drug
None – nurses involved but no query, even though the dose required 14 vials.
Learning – get a double check where possible, large no of doses should be a trigger to check again
How the incident was managed
Poorly – Trust not keen to engage with the family – you can see the effect this had. Encourage you to work with the family if make an error
Learning from previous similar events
NPSA alert sent with little effect. See same with beta blocker – Eliz Lee case, learning from our own beta blocker

26. In conclusion Purpose of tonight:
Learn from experience – both your own and those of others
Challenge how you and your staff currently work – don’t be complacent - think differently
Consider the full range of options open to you – small and large
Do something different – make some changes!

27. Seeing Things Differently and Seeing Different Things
Dorothy McKee

28. Who am I? A management and leadership consultant
Passion for learning and development
Interest in how businesses can learn from psychology
Value of challenge

29. Aims of the Presentation Aims of the Presentation
To challenge thinking on our perceptions
To illustrate how the way we see things affects decision making
To consider the competitive advantage in seeing things differently

30. Latest Thinking on Learning and Personal Change
That we filter out negative experiences and the opportunity to learn from them
The importance of focus and mindfulness
That we can change the way our brains are wired

31. Change and the Brain Change and the Brain
Old dogma: Brain hardwired by experiences in childhood
New research: Neuroplasticity
‘Mind’s ability to change the brain
Change thought process and perspectives
Old dogma: Brain hardwired by experiences in childhood
New research: Neuroplasticity
‘Mind’s ability to change the brain’
Change thought process and perspectives

32. Change and the Brain Re-label negative thoughts
Reattribute them to something else
Refocus on new behaviours
Re-evaluate the new behaviours as better than the old ones
Relabel: The first step is to relabel a given thought, feeling, or behaviour as something else. An unwanted thought could be relabelled "false message" or "brain glitch." This amounts to training yourself to clearly recognize and identify what is real and what isn’t, refusing to be tricked by your own thoughts. You step back and say, “This is just my brain sending me a false message
2. Reattribute: The second step answers the question, “Why do these thoughts coming back?” The answer is that the brain is misfiring, stuck in gear, creating mental noise, and sending false messages.
3. Refocus: The third step is where the toughest work is, because it’s the actual changing of behaviour. You have to do another behaviour instead of the old one. Having recognized the problem for what it is and why it’s occurring, you now have to replace the old behaviour with new things to do. This is where the change in brain chemistry occurs, because you are creating new patterns, new mindsets. By refusing to be misled by the old messages, by understanding they aren’t what they tell you they are, your mind is now the one in charge of your brain.
This is basically like shifting the gears of your car manually. “The automatic transmission isn’t working, so you manually override it,”
4. Revalue: It all comes together in the fourth step, which is the natural outcome of the first three. With a consistent way to replace the old behaviour with the new, you begin to see old patterns as simple distractions. You devalue them as being completely worthless. Eventually the old thoughts begin to fade in intensity, the brain works better, and the automatic transmission in the brain begins to start working properly.

33. Learning to see Things from Different Perspectives
Realising that things may not always be as they seem
Being able to learn from failure
Being open to challenge
Not being risk averse
Use the example of the thinking from NLP to demonstrate how we hold mental models about things that may not always be correct. We only draw representations of the world and not the world itself
The picture of the rabbit to show how our brain immediately interprets information that looks close to the image our view of the world may not always be correct
We need to be able to question some of the concepts we hold about the world we all view the world through certain lenses and this is why in terms of innovation it is important to surround your self with people who think differently .
Alastair Campbell in his book Winners notes how innovation is about constantly questioning what you are doing and asking is there a better way.
Woody Allen “ if you are not failing now and then it’s a sign you are not doing anything innovative.
Mattew Syed notes the importance of facilitating the association of diverse ideas and bringing people together with dissent an d criticism.
Example of Lynda Gratton and Tata Steel which has a “Dare to Try Initiative” that recognises attempts to create a major attempts to create a major innovation that failed to get the desired results.

34. Use the example of the thinking from NLP to demonstrate how we make maps things that may not always be correct they may be a rough guide to the landscape.
We only draw representations of the world and not the world itself . THE MAP IS NOT THE TERRITORY.
We need to be able to question some of the concepts we hold about the world we all view the world through certain lenses and this is why in terms of innovation it is important to surround your self with people who think differently .

35. A Rabbit or a Duck?
Hint: the duck is looking left, the rabbit is looking right Important to realise that things may not always be as they seem
The picture of the rabbit to show how our brain immediately interprets information that looks close to the image our view of the world may not always be correct
We need to be able to question some of the concepts we hold about the world we all view the world through certain lenses and this is why in terms of innovation it is important to surround your self with people who think differently .

36. Learning from Failure
“ If we are not failing now and then, it is a sign we are not doing anything innovative”.
Woody Allen
Mattew Syed notes how through the process of cognitive dissonance people do not wish to relive failures and or alternatively try to explain it away rather than use them as opportunities to learn. It is as if we have a self-defence mechanism that we use to protect ourselves.
He contrasts the situation where a simple operation went wrong where a problem could have been averted if a consultant had been prepared to take advice from another member of staff to the detailed investigation of the black box that takes place each time there is an air disaster. He points to the fact that senior people often do not want to admit mistakes to themselves.

37. Open to Challenge
The right mind set is about the attitude you take to challenge, and how you use and develop the qualities you have to
maximum effect on meeting that challenge.
It is hard to excel if your mind is in the comfort zone
People often come on my management development programmes because they recognise they wish to be challenged a major source of executive learning is through experiencing dissonant experiences
70% of Executive Learning comes from experience and challenging experiences
20% from developmental relationships
10% from training
Peer learning and the challenge created through action learning is often cited as the most helpful part of leadership development programmes where people focus on real live problems
Senior managers also often report that they often learn most through dealing with difficult life challenges

38. Not Being Risk Averse
“ Leadership requires an experimental mindset- the willingness to work by trial and error –where the community’s reaction at each stage provide the basis for planning future actions” Heifetz
Risk is a critical aspect of entrepreneurship the ability to undertake pioneering ventures
Risk taking involves challenging the status quo and to challenge ambiguity
The issue is that you are often damned if you do and damned if you don’t take a decision and you risk unforeseen consequences.
Example of social services manager who had to make 400,000 worth of cuts from a 2million budget for a transport system for people with disabilities. The cuts demanded a radical approach . The manager considered the options and the risks . Mark decided to talk to the people who used the service and he was able to reach a compromise with the service users who offered to pay a subsided rate the biggest level of opposition came form the minibus drivers there were also political differences over whether the priority should be to modernise services or maintain the rights of the drivers.

39. Change and Complexity …
The sort of dilemma many of you will face on a say to day basis are called wicked problems.
In this model developed by Keith Grint the progression from tame to wicked problems is marked by an increase in uncertainty about the solution and the need for collaboration.
Critical problems are the domain of crisis situations
Tame problems are amenable to rational tools and constitute the domain of management
Wicked problems defy rational analysis and are the domain of leadership
Problems of drug abuse, crime , homelessness, the challenges of the aging population, obesity, mental health issues can change shape as you work on them and often prove contradictory due to the interplay of a number of factors.
Working on the wicked problems requires engaging a range of people and also courage
New strategy for health emphasises the importance of collaborative working and co-production of services

40. “If you cannot change your mind you cannot change anything”.
George Bernard Shaw
Example of Molly’s Pharmacy not just seeing pharmacy as dispensary bring in new customer services in terms of lifestyle and promoting customer health
Development of intolerance testing and own products sports supplements
Now less dependent on the HSE for funding previously was 70% dispensary 30% over the counter now 50% dispensary 50% over the counter
Recognition needed to think bigger to challenge thinking to see things from different perspectives
“All you need is to get just one success”
James Geraghty Molloy’s Pharmacies

41. Inspiring Change Leading Innovation to challenge the past and deliver
quality outcomes for the future
Supported by:

42. Creating Innovation in Community Pharmacy
Medication Safety – An NPA Case Study
Glyn Walduck
Head of Claims
NPA Insurance Ltd

43. Creating Innovation in Community Pharmacy
Medication Safety Officer
Patient Safety Quarterly Report – Quarter 1 (January – March) 2017
patient-safety-quarterly-report-meet-quality-criteria/

44. Creating Innovation in Community Pharmacy
Wrong Drug – Selection errors
Prednisolone and Gliclazide
Methotrexate – lessons learned?

45. Creating Innovation in Community Pharmacy
Right Drug – Wrong Strength
Dexamethasone
PMR s - use them, but with caution, to maintain patient wellbeing!

46. Creating Innovation in Community Pharmacy
Right Patient – Right Drug
The name game! Allcote/Aucote
How to “address” these concerns

47. Creating Innovation in Community Pharmacy
Script – misinterpretation
Trimethoprim 50mg/5ml “take four 5ml spoonfuls twice a day”
Labelled as “take four 20ml spoonfuls twice a day”
Going solo? Take a break – rectify that mistake!

48. Creating Innovation in Community Pharmacy
Transposition of Dispensed Medicines in pharmacy
Trimethoprim 50mg/5ml oral suspension “10ml twice daily” – 60ml prescribed
Methadone 1mg/1ml oral solution 60ml dispensed
Separate the function at the junction!

49. Service Support Pharmacist,
Back to Basics
Kerry Grimes
Clinical Governance &
Service Support Pharmacist,
CPNI

50. A Day in Community Pharmacy

51. Your Patient’s Perspective
How long will I have to wait?
Will I be able to speak to the pharmacist?
Where do I go?
Who can I talk to?
Will they know the answer?
What services are available to me?
Will they be able to help me?
Dispensing, Minor Ailments, Medicines Use Review, Medicines Management, Smoking Cessation…

52. Processes
Your Perspective
Staff
Patient’s Needs
Space
Time

53. CPNI ‘Back to Basics’ Factsheets
Communicating with Patients
Dealing with Complaints
Medicines Use Review (MUR)
Clinical Check and Recording Interventions
Patient Safety Communication
Incident Reporting
Social Media

54. Pharmacy Services Medicines Use Review (MUR)
Supporting over 20,000 patients with long term health conditions to better mange their medicines every year in community pharmacy
Pharmacy Intervention Survey
Over 15 million interventions per year across the community pharmacy network
Over 2.5 million clinical interventions
9 million interventions related to prescription supply
1.3 million public health-related interventions

55. Innovation in Community Pharmacy
Eoghan O’Brien
Community Pharmacist, Portglenone
Nominated Pharmacist, Antrim/Ballymena ICP
Michael Cooper
Community Pharmacist,
Cooper’s Pharmacy, Belfast

56. Demonstrating Innovation

57. Demonstrating Innovation
Outcome:
Front-facing pharmacist improves patient engagement
Accessible service for all our patients e.g. loop induction system
Re-configured layout maximises space and efficiency
Two consultation areas to facilitate more services
More efficient dispensing service…. faster, easier, safer…
Improved communication systems e.g. VoIP
Better facilities for staff
Happier patients… Safer patients…. Satisfied staff….

58. “It is often the simplest of changes that can have the biggest impact”
Lessons Learned
“It is often the simplest of changes that can have the biggest impact”
“Success doesn’t come to you,
you go to it”

59. Demonstrating Innovation
Michael Cooper
Community Pharmacist,
Cooper’s Pharmacy, Belfast

60. Cooper’s Pharmacy Experience
Cooper’s Pharmacy part of local community for over thirty years, opening in 1986
Family owned pharmacy group with four community pharmacies across West Belfast
Five years working in community pharmacy

61. Drivers for Change Changing health landscape To deliver new services
Increasing prescription demands
Fully utilise the pharmacy team
More efficient work flow
Inspired by the way pharmacy has developed in UK and Europe

62. Our Innovative Solution
Robotic System

63. Our Innovative Solution
Design: Robotics influenced the design of the pharmacy. The system encourages a triangular workflow concept: 80-90% of what you are dispensing should be at arm’s reach. 
Safety: Everything is traceable through barcodes and the chances of picking errors is greatly reduced. Workflow and standard operating procedures are all built around the system.
Data Analytics: Delivers reports looking at the pharmacy’s demographics to help identify patients who would benefit from services e.g. patient with diabetes suitable for an MUR.

67. Key Outcomes “Future-proofed” the pharmacy Safer working environment
Optimises use of space and staff skills
Staff engagement
Patient satisfaction
“Change is not an event, it’s a process”
Cheryl James