1. Development and Testing Safety Improvement in Primary Care 1 and 2

2. Aims To enable 50 Primary Care teams to:
Identify and reduce harm to patients
2. Improve reliability of care for patients
On High Risk Medications
With Heart Failure
3.Develop safety Culture
4.Involve Patients in QI

3. ‘Look at areas of major clinical risk to patients as
they move across the health system.’
Medication Reconciliation
Results Handling
Communication after outpatient clinics

4. The Tools Collaborative Bundles Patient Involvement Trigger Tools
Safety Climate

5. Knowledge
Topics
Tools
What to spread?
How to spread?

6. Model for Improvement

7. Care Bundle
A care bundle is a set of interventions that, when used together, significantly improve patient outcomes.

9. Peter Provonost (ITU physician at Johns Hopkins Hospital, Baltimore, Maryland )
Simple message:
‘Evidence Based practice…
Culture Change…
Measurement of change…’

10. 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

11. ‘An intervention to decrease catheter-related bloodstream infections in the ICU’ Pronovost P, et al. (December 2006) N. Engl. J. Med. 355 (26): 2725–32.

12. ‘CLABs are not an inevitable product of complex ICU care but the result of highly variable
and therefore unreliable care delivery that predisposes to infection.’

13. Central line infection rate (per thousand line days)
92% reduction
2.34
0.18 13

14. What is a Bundle? Simple tool Combination of measures
Regularly repeated
Measure of reliability of process
Highlight areas for improvement
Rapid and easy
Collection by clerical staff

15. What is a care bundle? Key Requirements for Care Bundles
4 or 5 elements
Across Patients Journey
Creates teamwork
Mixture easy and hard
All or nothing

16. What is a Bundle?
Aim to ensure patients receive optimum care at every contact
Structured way of improving processes of care to deliver enhanced patient safety and clinical outcomes

17. Bundle vs Audit
Bundle - data collection tool to sample whether optimum care is being delivered
Audit – identifies whether individual measures are being implemented

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

19. Workstream 1 DMARD Bundle
Only those prescribed Methotrexate or Azathioprine
Full Blood Count in the last 6 weeks
Action from abnormal results recorded
Documented review of blood tests prior to issue of last prescription
Ever had pneumococcal vaccine
Documented the patient has been asked about side effects fo their medication at their last blood test
Compliance with full bundle (i.e. all of above)

20. Data Entry

21. Example of Data

22. Composite Tayside
* A new patient measure to be added in June will change the nature of the data with the composite likely to decrease initially.

23. Achievement – Wave 1 Wave 1& 2 Achievements
Patient Measure introduced July2011
All the improvements we have shown you so far have contributed to the results on the graph for both wave 1 & 2 practices. There was s brief spell with the introduction of a new patient measure where results fell for Wave 1 practices but they have identified where they need to improve and have climbed back up the ladder to be in line with Wave 2 practices. 23

24. Its about what you do with the data…….24

25. Like What? Practice meeting Notice board Process mapping Ask patients
Try changing something….
Measure the effect.

26. 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 26

27. 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

28. Side Effects
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) 28

29. Protocols
“The main success is tightening up our protocols. In particular our pre-initiation checklist works well and ensures everyone has everything done before starting DMARDs.”
“Also monitoring seems to be safer - consistently giving only 1/12 Rx on 1 repeat ensures no-one can get script if not being monitored.”
Another practice highlighted said “the main success ………………
The pre-initiation checklist is shown below. 29

30. Reliable systems
“The practice team are more aware of the need to adopt "failsafe" systems rather than assume 100% adherence to systems”
Another practice provided the following quote. 30

31. Small Tests of Change Engagement/Educating Patients/System changes
Staff Education / Changes to systems
Inviting patients by phone
Sending information leaflets indicating the importance to attend.
Notes on repeat prescriptions
Stop on Prescription until patient attends
Restriction on time interval for repeat prescription.
Reinforce recall system
Providing information regarding side effects
Demonstration of Vision Guideline at staff meetings.
Staff asked to add text “DMARD” or “NPT” to patient file.
Ensure GPs (including Registrars, locums) are aware of how they deal with DMARD results and new
Implementation of a DMARDS Checklist
Education of all clinical staff dealing with hospital recommendations to ensure that Azathioprine and Methotrexate is not commenced until 14 days after pneumococcal vaccination.

32. Bundles – Good: Every two weeks we review 5 pts via Bundle
Time - 15mins
Like the graphs – see improving…
We display ours on staff notice-boards for feedback with annotation
Quick action to problems i.e non-attenders, pneumococcal vaccine, PDSA etc
Raised awareness
Drive changes, PDSAs.
How do we change behaviour of patients?

33. What about other bundles
What about other bundles? Medication Reconciliation Warfarin Pressure Ulcers

34. NHS Tayside Accurate Patient Medication Lists within Practices
Primary Drivers
Perform Medicines Reconciliation receipt of discharge script
Ensure changes to medications are recorded within patient record
Ensure changes to medications are communicated to patient
Secondary Drivers
Develop Standard Operating Procedure for “Medicines Reconciliation”
Develop Tools to support Medicines Reconciliation within participating practices
Obtain read code to record medicines reconciliation occurring
Obtain read code to record action taken on changes with medications
Encourage patient involvement from participating practices
Develop education materials re patient medication lists
Obtain read code to record discussion re discharge medications with patient
AIM:
95% of patient medication records are accurate within the practice system following discharge from hospital by June 2012 within participating practices.
Measures:
Has the Immediate Discharge Document been workflowed on the day of receipt?
Has medicines reconciliation (see full definition in guidance document) occurred within 2 working days of the Immediate Discharge Document being workflowed to the GP/Pharmacist
Is it documented that any changes to the medications have been acted upon?
Is it documented that any changes to the medications have been discussed with the patient or their representative?
Are all the above measures met?
Outcome Measure:
Accuracy at admission of medication lists from each participating practice at 3 monthly intervals following implementation of the bundle. 34

35. Medication Reconciliation Measures
Has the Immediate Discharge Document been workflowed on the day of receipt?
Has medicines reconciliation occurred within 2 working days of the Immediate Discharge Document being workflowed to the GP/Pharmacist
Is it documented that any changes to the medications have been acted upon?
Is it documented that any changes to the medications have been discussed with the patient or their representative?

36. Utilising I.T.
Implementation of READ Codes for Medicines Reconciliation
Development of Guideline/Macros on Clinical System 36

37. Practice Protocol
For the purpose of this protocol the practice defines Medicines Reconciliation as:
“The process of obtaining an up-to-date and accurate medication list that has been compared with the most recently available information and has documented any discrepancies, changes, deletions or additions resulting in a complete list of medication accurately communicated”
(Institute for Healthcare Improvement,

38. Tayside Picture 38

39. Spread NHS Greater Glasgow & Clyde Lanarkshire Lothian
Interest from practices at recent SIPC ‘celebration’ event

40. Meds rec data – NHS Greater Glasgow and Clyde

41. Warfarin 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 6 months?*
Overall compliance out of 5

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

43. 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.

44. Primary Care Prevention of Pressure Ulcers Inclusion Patients visited by the District Nurse Exclusions One off visits by the District Nurse Process Measure ( Care Bundle) Patients on district nursing caseload will have a waterlow pressure ulcer risk assessment undertaken on the first visit and an assessment and score recorded on CNIS. If found to be at risk (waterlow > 10) a SSKIN care plan will be completed to reflect the level of risk identified from the risk assessment and will include a positioning and repositioning regime. Patients will be reassessed at each visit and if there is any change in physical or mental health a repeat risk assessment will be undertaken and recorded. Outcome Measures Number of days between no new pressure ulcers found on patients on district nurse case load. Number of new pressure ulcers developed in the district nurse case load in the last month. The safety cross will be used to inform the above outcome measures 55

45. “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”

46. Improvements Optimised care Guidance/ Templates
Blood monitoring /Recalls
Reduced variation
Patient Education and Self management
More efficient
Less Stress!

47. Questions?

48. Patient Involvement

49. Patient Involvement Education about drugs Self management
Process mapping
Questionnaires
Practice Focus Groups
Feedback

50. Patients Responsive enthusiastic patients appreciate being Involved
“The main learning was that they appreciate being involved in their own care”
“Barriers have just been ourselves”