1. Improving the safety of High Risk Medications Experience so far……
Neil Houston
Berny Welch
Louise Black

2. Aims
Learn about approaches to measurement of the high risk medication care bundles
Learn various tools to support practices to make improvements and achieve reliability
Share experiences, challenges and successes.

4. Over to you . . .
Get a partner – preferably someone you don’t know very well
Stand back to back with your partner
Without looking change one physical thing, about your appearance
Turn around and face partner
WHAT HAS CHANGED!!!
2 mins – icebreaker exercise – Jo Matthews 4

5. Do it again How was it for you ?

6. Some change is easy
Some change is hard to see the effect of - study it
More and Bigger changes can be uncomfortable
Ok that’s enough ….

7. “Education, education, education”
Tony Blair 1997
“It’s the economy, stupid”
Bill Clinton 1991
No politician has yet said:
“Data, data, data”
“It’s the data, stupid”

8. Process and outcome measures……

9. New rules – concentrate on process
Process measures are collected in a practice or unit - those results can give the team the needed success
If process becomes highly reliable the outcome will follow as long as it is connected to science
Outcome measures will most likely lag behind process measures
Leaders should tend to focus on outcome while individual teams should be held responsible for process reliability 9

10. If you focus on reliable processes the outcomes will follow …..

11. Practice Feedback There is magic in graphs…
There is magic in graphs. The profile of a curve reveals in a flash a whole situation – the life history of an epidemic, a panic or an era of prosperity. The curve informs the mind, awakens the imagination, convinces….
Henry D Hubbard, 1939

13. Automatic Data Extraction Blessing or missing a trick?

15. Bundle Compliance

16. GGC Primary Care DMARDS Bundle Compliance
Alexa Wall, NHS Lanarkshire
Rachel Bruce, NHS Greater Glasgow and Clyde

17. Aggregation
National Solution
Lothian – QUIDs
Glasgow excel
Lanquip
Others??

18. Getting Practices to reflect on data and do something with it
Not in the bottom drawer
Data on the notice board
Practice meetings
PDSAs
Reflection sheets

19. Please use this form to carry out an internal review of your anticoagulation bundle data
What did your bundle data show?
Please explain any improvement work you have carried out
What challenges have you faced?
How might you further improve your data or practice systems?
What else might you change?
Interface challenges - highlight any interface areas for improvement
Need support or guidance to make changes in your practice?

20. SEA feedback
Combined feedback from mid year reflection and SEAs,

21. Improvements
Phone protocol for INR results Teach back Leaflets KIS Interface – dx letter Dawn

22. Learning from each other Knowledge website – worth a trawl!

23. Forth Valley
Templates
Info leaflets Warfarin
Warfarin guidance

24. Tayside – Vision guidance and templates
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) 24

25. 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 25

26. Fife Frequently asked questions Warfarin Care Bundle
Question 1: How many patients do I need to review each month?
Answer:
10 patients randomly chosen from your warfarin patients.
Question 2: Is there a web based recording tool?
No. The recording tool is available on the website but you need to save it to your computer and make sure it is backed up.

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. How can we help practices make improvements Process Mapping made easy

29. Video Process mapping

30. Questions? Comments?

31. Table Discussion
What have you done in your board to
Facilitate practice data collection?
Promote practice reflection on the data and improvement? What could you now go and try ?

32. Feedback Any other things to look out for when shopping??

33. Re focus
Re energise

34. Outcome measures Reduced Admissions Reduced readmissions < 30 days
Improved safety culture
Better INR Control

35. Outcome Measures Warfarin
% of INRs per practice/board less than 1.5 and more than 5 per practice
% of INRS per practice/board over 8 per practice
Numbers of days since last INR>8 in practice ?
% of INRS which were:
Within +/- 0.5 of target (BSH suggested minimum standard 50%)
Within +/ of target (BSH suggested minimum standard 75%)

36. Data held at board level
Lab data
Computer assisted software data
? Others
NHS Forth Valley approach - a work in progress

37. FV %INR <1.5 and >5/total INRs by practice
Why do we think this is necessary?
55 pts admitted in FV in primarily due to overanticoagulation (underestimate)
There is a wide variation- these figures are from FV jan- march 2012 37

38. Aggregated data - INRs out of range FV 2012-2013
7.9%
6.2%
INRs > 5
1.6%
1.9%

39. Computer assisted software info DAWN39

40. DAWN practices +/- 0.75 target INR

41. % Dawn INR+/- 0.75
2012
71.6%
2013
70.45%
DAWN +/- 0.75
Benchmark 80%

42. Benchmark 50% % Dawn INRs +/- 0.5 2012 vs 2013 DAWN +/- 0.5 2012 53.3%
55.75%
DAWN +/- 0.5
Benchmark 50%

43. INR within 0.5 and 0.75 (DAWN)

44. Note missing practices –cant tie up names and practice numbers and
skew due to low freq practices (which might use health centres as well as own practice
Average 14.2 44

45. FV total INRs by month 2011-12 2012-13
Marginal improvement on a background of change –more pts on warfarin )AF guidelines, QOF) 45

46. Methotrexate Outcome measure
% of prescriptions of Methotrexate, per board, which are for 2.5 mgs

48. Escape the RAT race with NHS Grampian
Dr Berny Welsh
Mrs Louise Black

50. Warfarin High Risk medication Complex patients Polypharmacy
Frail Elderly

51. INR control outcome data
Why? Intuitively appealing as measure of how reliable and safe practice warfarin service is.
Why should practices share data with us?
Own data to use for improvement
Healthy competition

52. Recruiting practices Personal contacts Practice pharmacists
Early adopters
CHSCP meeting

53. RAT system – monthly report (now have 6 months of data!)
PCT report
Prepare
Run
Copy & Paste into
Send

54. Number of INRs (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L  
Number of INRs within 0.5 of target (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L  119  97   
Number of INRs > 0.5 of target (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   35  24  30  29  41  37  32  61  38  52  38  37

55. Number of INRs < 0.5 of target (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   49  38  65  46  42  35  43  78  62  49  58  62
Number of INRs within 0.75 of target (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L  
Number of INRs > 0.75 of target (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   25  16  20  21  31  24  24  49  31  36  31  30

56. Number of INRs < 0.75 of target (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L   34  26  43  25  38  26  26  44  38  27  35  31
Number of INRs > 5 (Active patients) (A=Oct L=Sep 2013)    A   B   C   D   E   F   G   H   I   J   K   L    2   0   0   2   4   1   2   6   3   2   4   1

62. Voila!
You’ve got useful outcome data 

63. Using your data in practice
Print, display and share on Patient Safety Board
Use this to have discussions in practice
Plan improvement steps if required
What are you going to do with it

64. Successes and challenges
Early days
What sense ownership by practices?
Growing number practices participating

65. Questions?

67. Group Discussion
What are you currently doing with outcome data?
What might you do differently with your data/support to practices?
How will you progress this in your HB and at your next learning session?
What can you share?