1. What is a Care Bundle? How can we use them to make our systems safer and more reliable ?
The aim of this session is to introduce the concept of care bundles and how they drive improvement , The session should cover:
What are they
How they work - sharing the experience from SIPC
To highlight the care bundle practices will be using and the rationale for it
Highlight the frequency and sample size of data collection
Demonstrate the data collection process

2. 3 Questions?
In General Practice do we accept that care could be improved?
If so, can we change our current practice?
Can we use Care Bundles to help us?
Ask the audience is there an acceptance than care could be made reliable?
If so how do we do that and can a care bundle act as a catalyst to make improvements?

3. Care Bundle
A care bundle is a set of interventions that, when used together, significantly improve patient outcomes.
Care bundle definition
Interventions need to be done together and it is this consistency that leads to significant improvements

4. How do we know how well are we doing in General Practice?
Enhanced services
GMS Core
QOF
QOF QP
Immunisation Targets
Formulary Adherence
Prescribing targets
There are already a number of different quality initiatives in Scottish General Practice – highlight the positive effects these initiatives have on care
GP Appraisal
Clinical Audit
Revalidation
Patient Satisfaction

5. Bundles ensure that every person gets reliable, consistent care every time

6. What is a care bundle? 4 or 5 elements of care Evidence based
Across Patients Journey
Creates teamwork
Done reliably
All or nothing
Small frequent samples
This slide outlines the elements which make up a care bundle 6

7. QoF Data
Looked at 9 practices which provided QOF data on particular QOF indicators
Then looked at an overall composite measure of the indicators
Combining QOF data with the care bundle approach may provide a more meaningful measure of quality in general practice
Carl de Wet, John McKay and Paul Bowie
Research was carried out on 9 practices in Scotland – researchers looked at their QOF data to see how reliable the care they were providing was

8. QOF Data - CKD Chronic kidney disease (CKD)
The % of patients on the CKD register:
CKD3
whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less
CKD5
with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE – I) or angiotensin receptor blocker (ARB)
CKD6
whose notes have a record of a urine albumin: creatinine ratio (or protein: creatinine ratio) test in the previous 15 months
They looked at whether the QOF indicators were achieved - for example the CKD indicators above

9. Outcomes Chronic kidney disease (CKD) Threshold (min-max %)
Average for all 9 practices (%)
CKD3
40-70
76.9
CKD5
40-80
98.8
CKD6
89.2
Overall Composite
100%
Although individual QOF measures would indicate that patients with diabetes receive reliable care and many practices achieve near to maximum points, the data can be misleading about how consistent our care is

10. Outcomes 69 Chronic kidney disease (CKD) Threshold (min-max %)
Average for all 9 practices (%)
CKD3
40-70
76.9
CKD5
40-80
98.8
CKD6
89.2
Overall Composite
100% 69
When we look at which patient receive all the interventions – the composite - we are less reliable

11. QOF Data - Stroke Stroke/TIA The percentage of patients with: STROKE6
a history of TIA or stroke in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 or less
STROKE8
TIA or stroke whose last measured total cholesterol (measured in the previous 15 months) is 5 mmol/l or less
STROKE10
TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March
STROKE12
with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded)
The same picture occurs in the management of most patients with a chronic disease

12. Outcomes Stroke / TIA Threshold (min – max %)
Average for all 9 practices (%)
STR 6
40-70
91.5
STR 8
40-60
86.7
STR 10
40-85
93.7
STR 12
40-90
96.6
Overall Composite
100%

13. Outcomes 74.1 Stroke / TIA Threshold (min – max %)
Average for all 9 practices (%)
STR 6
40-70
91.5
STR 8
40-60
86.7
STR 10
40-85
93.7
STR 12
40-90
96.6
Overall Composite
100%
74.1

14. Reliable Care??
38% of patients with Type 1 Diabetes receive 9 key interventions
NICE 2008/9
The sample above was from a small group of practices but these findings are replicated nationally as illustrated by these figures

15. Can Care Bundles make a difference?

16. At this point you may wish to show delegates the Peter Pronovost clip, showing how care bundles can make a difference – the link for this video is available on the knowledge website

17. (ITU physician at Johns Hopkins Hospital, Baltimore, Maryland)
Peter Provonost
(ITU physician at Johns Hopkins Hospital, Baltimore, Maryland)
Simple message:
Checklist –evidence based
Improved culture
Measurement
‘Retool’ = PDSA
This slide reinforces the messages of the clip
Key interventions need to be reliably implemented and measured, which leads to improvement using PDSAs

18. 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.
The checklist, or bundle, can be very simple

19. But can lead to dramatic results such as a huge reduction in central line infections demonstrated above
These results have been replicated in Scottish hospitals

20. Do Care Bundles work in Primary care?

21. Introduced a Care Bundle
Reviewed literature / guidelines
Discussed with colleagues
Spoke to ‘Bundle experts’ from IHI
Spoke to patients
Piloted the Care Bundle
All care bundles tested throughout the pilot work were developed using this process

22. Bundle Compliance
This shows how practices in Lothian made their care more reliable by implementing the warfarin care bundle

23. Practice Manager Experience (video clip)
You may wish to show delegates the Practice Manager video clip, which highlights how implementing the warfarin bundle acted as a catalyst to improving practice systems and care – this video is available on the HIS website

24. Can you improve efficiency?
Dec-10 – Dalkeith introduced the RAT system
Aug-11 – Dalkeith started the SIPC project
In some practices it led to fewer INR blood tests being carried out as variation reduced
Test per patient before RAT = 2.2 average
Test per patient after RAT = 1.4 average
Saving = almost 100 appointments per month

25. SIPC Evaluation Successes of bundles
More systematic approaches to processes, e.g monitoring/repeat prescriptions
Better documentation
Better communication of results
Less Variation
Proactive Educated patients
Less stress
Increased confidence in roles
Following evaluation of the pilot work, practices highlighted the following successes and positive impact of the bundles

26. Sharing Successes, Challenges
and Resources
Some of our Challenges:
Time
Competing priorities
Negative attitudes
Understanding of tools and methods
Struggling practices need support
Some of the challenges identified are highlighted on this slide

27. SIPC Evaluation Successes
“they are straight forward, it is not too complicated”
“it is a simple tool that highlights if there is a drop (in care) and why, it is visual because you can print it off”
“the main strength is when you see them improving, it encourages you and motivates you”

28. “The care bundle was useful because it identified gaps”
SIPC Evaluation
“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”
This highlights the benefits of regular data collection and using the data to drive and reinforce improvements 28

29. Any Questions?