1. Introduction to the DMARDS Care Bundle
Simon Randfield, NHS Forth Valley
Deirdre Cameron, NHS Tayside
Lynsey McCloy, NHS Forth Valley

2. Aims of session Introduce the DMARDs Care Bundle
Discuss measures, operational definitions and rationale.
Discuss data collection process and frequency
Discuss ways to involve patients
Share resources, challenges and learning

3. An Introduction to DMARD bundles

4. Bundles vs Audits? Can’t always count everything every time
Volume may be too high, but high volume is an opportunity to sample
Take 5 or 10 notes and check if actions done
Less work, but more often
Firstly - why to sample rather than study the whole? 4

5. Whole is better than the sum of its parts
Reliable Care - Care Bundles
4 or 5 elements of care
All or nothing
Whole is better than the sum of its parts
Evidence based
Across Patients Journey
Creates teamwork
Done reliably
Small frequent samples 5

6. All or nothing measures
‘Care bundles’ are all or nothing measures
The % of patients who achieve ALL individual measures/get all appropriate care
Appropriate when:
Each element is important in its own right
Patient outcome is improved by ALL measured care being received (the whole is greater than the sum of the parts)
Each element should be necessary every time
Secondly, the concept of composite measures “all or nothing” = reliable care 6

7. Across Patients Journey
Reliable Care - Care Bundles
4 or 5 elements of care
All or nothing
Whole is better than the sum of its parts
Evidence based
Across Patients Journey
Creates teamwork
Done reliably
Small frequent samples
What evidence have we used to form the bundles? 7

8. DMARDs Care Bundle
Appropriate tests are carried out in correct timescale?
Has there been a full blood count in the past 12 weeks (AZA) 8 weeks (MTX) as per local guidance?
Appropriate action taken and documented for any abnormal results in previous 12 weeks?
If any abnormal results in previous 12 weeks [WBC<4, neutrophils<2, platelets < 150, ALT > x2 normal upper limit (>60)] has action been recorded in the consultation record?
Blood tests reviewed prior to prescription?
Is there a documented review of blood tests prior to issue of last prescription?
Appropriate immunisation?
Has the patient ever had pneumococcal vaccine?
Patient asked about any side effects following last time blood was taken?
Have all the above measures been met?
Bundle measures have been tested and tweaked in SIPC project over 2 years and 3 HBs

9. DMARD Bundle Appropriate tests are carried out in correct time scale
Measure: Has there been a full blood count in the past 12 weeks (AZA) or 8 weeks (MTX) as per local guidance
BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists
Local guidance should be followed where available
Different boards will have different guidelines eg Tayside FBC 6 weekly and local guidelines may not exist

10. DMARD Bundle
Appropriate action are taken and documented for any abnormal results in previous 12 weeks
Measure: If any significantly abnormal results occurred in the previous 12 weeks has action been recorded in the consultation record? (ref appendix 1)
Need clear definitions of abnormal test results
BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists
Local guidance should be followed where available

11. Guidelines Multiple specialists initiate these medications
Multiple guidelines available (eg BAD, BSR)
An agreement!

12. Local Guidelines
A challenge is the number of specialists involved in these drugs , locally and also through tertiary care services

13. DMARD Bundle Blood tests are reviewed prior to prescription  
Blood tests are reviewed prior to prescription
Measure: Is there a documented review of blood tests prior to issue of the last prescription?
No patient should receive a repeat prescription if the monitoring has been inadequate.
Good practice

14. DMARD Bundle Appropriate immunisation
Measure: Has the patient ever had a pneumococcal vaccine?
Rheumatology Local Policy, Good practice
“across the patient journey”
Across the patient journey- preventative care important too

15. DMARD Bundle Side effects
Measure: Is it documented that the patient was asked about any new or recent side effects the last time blood was taken for drug monitoring?
Recognising the importance of Patient Involvement
as per Quality Strategy, The Health Foundation – Closing the Gap

16. Reliable Care - Care Bundles
4 or 5 elements of care
All or nothing
Whole is better than the sum of its parts
Evidence based
Across Patients Journey
Creates teamwork
Done reliably
Small frequent samples
Multidisciplinary- most practices will need to use doctors, nurse/phlebotomist, and admin to achieve the bundles 16

17. Theres the doc getting a leg up from the nurse… however its usally the pm who decides whats for tea…

18. Reliable Care - Care Bundles
4 or 5 elements of care
All or nothing
Whole is better than the sum of its parts
Evidence based
Across Patients Journey
Creates teamwork
Done reliably
Small frequent samples
Crucial part of the bundle methodology 18

19. DMARD Bundle Composite  
Composite
Have all elements been met for each patient - the ‘all or nothing’ (composite) measure?
Every patient , every intervention, every time

20. No good being consistently crap, or reliably rubbish
No good being consistently crap, or reliably rubbish..its about using the data

21. Small frequent samples
Reliable Care - Care Bundles
4 or 5 elements of care
All or nothing
Whole is better than the sum of its parts
Evidence based
Across Patients Journey
Creates teamwork
Done reliably
Small frequent samples 21

22. DMARD bundle
10 patients on Methotrexate or Azathioprine randomly sampled each calendar month 22

23. Data collection Who? When? How? DMARD Bundle
Ties in with safety climate- better involvement across all of practice improves results.
5 mins asking delegates how will they sell this to their vpractices

24. Who will collect the data?
teamwork

25. How long will it take?
Not Long! 25 25

26. Data Collection Process
and Frequency
We have different mechanisms for data collection and health boards will have the options of:
Using a national web-based data collection tool developed by Healthcare Improvement Scotland
Inputting data into spreadsheets developed for the bundle
Adapt local systems to support data collection
For further information on data collection process is available from the SPSP-PC team.
Dummy national data collection system available to look at during lunch/ coffee breaks

27. DMARDS Collection Template Forth Valley

28. Data Entry Website

29. Run Charts – Example of Data

30. Composite Data Tayside
Patient Measure introduced July2011

31. DMARD bundle
5 mins delegates to consider howq this will be done in their boards? 31

32. Sharing data at board level
Newsletters to all practices
Presentations to Board
Presentations at PLT Sessions/Practice Managers
Submission of Committee Papers
Newsletters – screenshot!, s, collaborative meetings, SEAs, 32

33. Using & Sharing Your Data
Not just about collecting data, but about using it
ITs YOUR data!

34. “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”

35. Reflection Discuss your data What does it show?
What have you done to improve your systems?
What challenges have you faced?
How else might you improve your results/systems?
What can you share? 35

36. Evolution not revolution
Small tests of change The rationale for PDSA comes from systems theory and the concept that systems are made up of interdependent interacting elements and are therefore unpredictable and non-linear: small changes can have large consequences. Short-cycle, small-scale tests, linked to reflection, are seen as helpful because they enable health care teams to learn on the basis of action and its observed effects. The rapid cycle change model calls for sufficient (just enough) data to be collected to know if the change has resulted in an improvement. Changes are tested on a small scale, permitting experimentation and discarding unsuccessful tests. Numerous small cycles of change can successfully accumulate into large effects; for example, an intensive care unit could improve quality by working on a series of cumulative and linked PDSAs in different aspects of care at the same time e.g. respiratory care, medication use, and patient flow (Berwick 1998). In contrast to large-scale approaches, PDSA changes are small (therefore controlling risk and disruption), take minimal time, and require little financial investment with the majority of staff needing little formal training to proceed

38. 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

39. Achievements

40. EMIS template (NPT)
Improvements in data collection. EMIS (FV) and Vision (Tayside)

42. Vision Guideline

43. Moved from Paper-Based Recalls to Electronic Recalls
Utilising I.T.
Moved from Paper-Based Recalls to Electronic Recalls
To ensure continuity during locum cover 1 practice developed this message
A reminder on the clinical system regarding prescribing of medications was added for the clinicians
To ensure GPs check patients bloods prior to Rx re-issue, practices have enforced re-authorisation of one repeat prescription only
These are just some of the examples where IT has helped to improve practice systems:
Before their involvement in the programme, one practice used a paper-based folder to hold information on recalls. Involvement in this programme prompted the practice to update the system, and they now use an electronic system to manage the recalls, which also generates the patient letters.
On practice with single handed GP practice identified issues with the prescribing of DMARDS when the GP was off and a locum was in providing cover.
One practice added this message to the clinical system to prompt to ensure that pneumococcal status is up to date and that there are no contraindications.
Some practices have forced re-authorisation of one repeat prescription only by the GP rather than allowing printing of scripts by admin staff. This prompts GPs to check patients blood results or order these to be undertaken before issuing a prescription.

44. Resources 44

45. Resources 45

46. Patient Involvement 46

47. Patient Involvement
Encourage and support your practice teams to involve patients in their improvement journey. This can include: - Using small tests of change – develop patient educational leaflets in conjunction with patients. - Process mapping and value stream mapping – understanding system from patient perspective. - Patient Feedback – focus groups, questionnaires, make changes using small tests of change and ‘you said, we did’.

48. Focus groups Opportunity to gain feed back in a relaxed environment
Patients meet with others with similar conditions
Opportunity for both praise and positive criticism
Patients appreciated being involved
‘You Said, We Did’ feedback approach after group

49. How are we doing?

50. Feedback What was good about your visit to the practice?
What would you change?
Welcoming from reception and throughout visit
Convenient time
Friendly, pleasant staff
Getting bloods checked re Methotrexate
Reassured that previous bloods had been fine
Able to have blood test at the same time as GP appointment
Not having to come!
Perhaps visit when I have no illness
Weekend appointments: I don’t like to ask for time off just to have a blood test when I am working.

51. Patient Feedback Examples of some of the tools available;
Patient Stories
Interview using prompts to guide the conversation
Digital Patient Stories
Emotional Touchpoints Tool

52. GOING FOR AN APPOINTMENT
Emotional Touchpoints Feedback
GOING FOR AN APPOINTMENT
Irritated
Frustrated
Annoyed
Today the system indicated the GP was on time but I was seen 10minutes later. I didn’t mind as it was quiet and my child was able to run about. I worry about them making a noise.
“Sometimes we have to wait for our appointment too long in the waiting room. I recently made an appointment and waited for 40 minutes to be seen. I was then frustrated, irritated and annoyed I had to make other arrangements with a relative for my child to collected from nursery. This has happened on a number of occasions.”
But I am also grateful that the GP always apologises for the wait.
No-one else would come and say but that would help.

53. Emotional Touchpoints Feedback
If you want to make an appointment to see any Dr I would be confident I could get one. But not if it was a specific one which requires being organised. I would plan ahead as know that it could be an issue if I didn’t
Organised
MAKING AN APPOINTMENT
Personally it would be better if the nurse or the doctor called you with your test results as the system requires you to call them for a telephone appointment. Times can be difficult. It would also be reassuring to know if tests are ok as well as abnormal
RECEIVING TEST RESULTS
Difficult

54. Service user feedback toolkit

55. Feedback from a practice team involved in SIPCs 1
Responsive enthusiastic patients appreciate being involved
“The main learning was that they appreciate being involved in their own care”
“Barriers have just been ourselves”

56. Example of Patient Involvement

57. Example of Patient Involvement Credit Card Leaflet – Side Effects

58. What next?
Discuss in small groups what could be taken forward in your area to involve patients?

59. Thinking ahead
1. What are you going to do in your locality ( IN BOARD GROUPS . table discussion20 MINS). Engagement from 2ry care, Resources, Dates,time lines – ACTION PLAN 59

60. Sharing Successes, Challenges
and Resources
Some of our Challenges:
Time
Competing priorities
Negative attitudes
Understanding of tools and methods
Struggling practices need support

61. Action Plan for your health board

62. Example actions:
Raising awareness of programme locally
Local delivery/ training & protected time to do this?
Who will support delivery/ implementation?
Quality Improvement/Clinical Effectiveness involvement?
Local co-ordination?

63. Every Step is one step Greater to Improving Patient Safety
Every step is a step in the right direction to improving patient safety
And Practices can only be applauded for the good work they have undertaken

64. Whether it be Small or Big
Every contribution is welcome, whether it be big or small