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Improving Patient Safety in Primary Care NHS Forth Valley 204/15 Neil Houston Clinical Lead,

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Presentation on theme: "Improving Patient Safety in Primary Care NHS Forth Valley 204/15 Neil Houston Clinical Lead,"— Presentation transcript:

1 Improving Patient Safety in Primary Care NHS Forth Valley 204/15 Neil Houston Clinical Lead,

2 Session Aims Review the safety work in Primary care in the last 12 months including: Improvements in safety of prescribing of NSAIDS Prescribing and monitoring of Warfarin and DMARDS Review use of Safety climate survey and trigger tool - Learn about the safety programme in 2014/15 which includes: Reliable medication reconciliation after discharge Appropriate use of antipsychotics in elderly patients Involving patients in making care safer

3 Session Aims What are we trying to achieve?Where have we got to?What are our next steps?

4 Our Ambition To reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting.

5 Our Aim All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.

6 3 workstreams Safety Culture Safer medicines Safety at the interface

7 Focus in 2013/14 Trigger Tool Reviews (twice per annum) Safety Climate Survey (once per annum) National Warfarin, DMARDS Local

8 What are we trying to achieve?Where have we got to?What are our next steps?

9 Health Board areas of focus Warfarin NHS Ayrshire & Arran NHS Borders NHS Dumfries & Galloway NHS Fife NHS Forth Valley NHS Grampian NHS Highland NHS Lothian DMARDS NHS Forth Valley NHS Lanarkshire NHS Tayside Medication Reconciliation NHS Ayrshire & Arran NHS Greater Glasgow and Clyde NHS Lothian NHS Orkney NHS Shetland NHS Western Isles

10 Progress towards our aims 83% of all Scottish practices engaged in improving reliability of one high risk area 819 practices across Scotland currently collecting data and making improvements

11 All 57 FV practices signed up to Local Enhanced Service contracts using care bundle methodology for Near Patient Testing and Anti-coagulation in 2013/14 80% FV aggregate anticoagulation bundle compliance 56 (98.2%) of FV practices participated in the climate survey with 881 (89.8%) responses across practice staff 55 (96.5%) of practices participated in trigger tools reviews 36 practices undertook Significant Event Analysis around anticoagulation and NPT medications practice participants at FV Patient Safety Learning Session Key Achievements

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13 Anticoagulation Compliance No of practicesPrescribingINR duration Patient Advice Within 7 days Written EducationOverall Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

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15 Efficiency!

16 MTX 2.5MG TABS AS % OF ALL ORAL RX : FV VS OTHER HBS

17 safety culture 95% of practices undertaking Trigger Tool Reviews and Safety Climate Survey, by April 2014 Workstream Aims

18 Progress towards our aims 90% of all practices in Scotland completed the Safety Climate Survey, by April 2014

19 NSAID prescribing Impact Latest data Oct – Dec 2013 Patients age ≥ 65 years on triple whammy combination. (ACE/ARB + diuretic + NSAID) Reduced by 31% Patients age ≥ 65 years prescribed an NSAID without gastroprotection Reduced by 33% Current anticoagulant user prescribed an NSAID without gastroprotection. Reduced by 55%

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24 What are we trying to achieve?Where have we got to?What are our next steps?

25 Our Aim All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.

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29 Safety Programme Safe and Reliable Medicines Reconciliation after discharge Safe and Reliable antipsychotics in elderly patients with dementia Significant safety issues that occur at discharge using an SEA form Activity to involve patients in safety improvement work Climate Survey and Trigger Tool

30 More than 40% of medication errors result from inadequate reconciliation in handoffs during admission, transfer and discharge of patients. 20% of these were believed to result in harm. Institute of Medicine’s Preventing Medication Errors,

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32 Medication Reconciliation

33 Med Reconciliation after discharge - CQC Unreliable at admission Inaccurate and delayed at discharge, Unreliable systems in place in primary care for updating 17% of practices delegation of the responsibility for medicines reconciliation to managerial or clerical staff. ‘Managing patients medicines after discharge from hospital’ October 2009.

34 Discrepancies between the hospital discharge prescription and drugs subsequently prescribed to the patient. Discrepancies found in 43% of patients. Of drugs newly prescribed by the hospital, 28% were either not continued or altered dose Where suggested a change in dose, the dose was not changed by the GP practice in 35% of cases. But it is an active process by GP – the hospital may not be right! UK study (Avery et al) 2012

35 Margaret story

36 Where do thing go wrong with medicines when a patient is discharged?

37 “In God we trust. All others bring data.” W. E. Deming

38 Medicines Reconciliation Audit 10 of the following patients per month: Patients who have been discharged from an acute medical admission and Patients over 75 years of age who have been discharged from an inpatient stay from anywhere

39 Medication Reconciliation Measures- National 1) Has Electronic Discharge Document ( IDL) been received by a clinician on the day of receipt. 2) Has medicines reconciliation on occurred within 2 working days of the IDL being received by the GP. 3) It is documented that any changes to the medication from their pre admission prescription have been recorded in the clinical record ? 4) It is documented that any changes to the medication have been discussed with the patient or their representative within 7 days of receipt? 5) Have all the above measures have been met (composite).

40 Medicines Reconciliation Bundle Forth Valley 2014 / 15 1.Has the immediate discharge document (IDL) been forwarded to a clinician on the day of receipt? 2.Has medicine reconciliation occurred within 7 days of the IDL being received by the practice? 3.Is it documented that any changes to the medication following reconciliation have been updated in EMIS within 7 days of the IDL being received by the practice? 4.Is it documented that any *significant changes to medications have been discussed with the patient or their representative if appropriate within 7 days of the IDL being received by the practice? *significant changes include a repeat medication being started or stopped or alteration in dose 5.All measures have been met

41 The truth will set you free…… But first it will piss you off !

42 Help Provided Guidance Data collection Identifying patients Templates

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44 Codes and their meaning -- ?! Read CodeTerm Display on template and record 18HE2 Discharged from inpatient care IDL received and workflowed 28B318Medication reconciliation 367Is Advice to continue with drug treatment No changes to drug treatment 8B3RDrug therapy discontinued 8B3A3 New medication commenced 8B316Medication changedMedication dose altered 8B314Medication review doneMedication record updated 48B3S0 Post hospital discharge medication reconciliation with pt Medication discussed with patient or carer 8BIo Drug directions adequate and appropriate Not appropriate / necessary to discuss with patient / carer 671G0Medication discussed with pharmacist And/ or practice admin staff

45 Information appears clearly in EMIS consultation history

46 If templates are used coded information can be searched

47 GP IT site templates/fv-enhanced-service/http://staffnet.fv.scot.nhs.uk/index.php/a-z/gp-it-support/emis/emis- templates/fv-enhanced-service/

48 NHS Ayrshire & Arran’s Experience John Freestone – GP Clinical lead East and South Ayrshire

49 What have we done so far? Local Enhanced Service Medicine reconciliation Warfarin management Patient safety SEAs Reconciliation of addiction medication Local collaborative meetings 47 out of 55 practices taking part

50 Medicines Reconciliation Audit 10 of the following patients per month: Patients who have been discharged from an acute medical admission, and Patients over 75 years of age who have been discharged from an inpatient stay from anywhere 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 discussed with the patient or their representative? Are all the above measures met?

51 Medicines Reconciliation Compliance with bundle – May 2013 Compliance with bundle – Feb 2014

52 Medicines Reconciliation – how did we improve? Data and feedback – so practices knew if they were improving Local collaborative – sharing systems and learning Attempting to institute a whole systems approach

53 Data and Feedback

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55 Collaborative Meetings 1 launch day and then 3 half day meetings in localities Attended by GP, manager and practice nurse Discuss progress, patient stories, QI tools Small group work Review results – benchmarking Discuss systems Discuss SEAs Feedback with commitment to change Systems employed - variable Newsletter with summary of learning and sharing of resources

56 Patient Story – Mr D (84) Admitted with chest pain PMH –Angina –Atrial fibrillation Discharge diagnosis: Acute Coronary Syndrome Medication on IDL - angina meds changed –Nicorandil added –Bisoprolol seemed to be stopped Medicines reconciled

57 Patient Story – Mr D (84) Patient phoned –Unsure of meds - daughter deals with them –Patient asked to get daughter to phone 2 weeks later – house visit request short of breath Pulse 120 irreg, signs of LVF Admitted - Bisoprolol restarted

58 Patient Story – Mr D (84) SEA – unnecessary admission. Discussed with consultant. Error on IDL Not picked up by practice system due to patient confusion about medications Change to practice system

59 Positive SEAs Potential errors picked up early by new systems IDLs often questioned Communication between practice, patient, carer and pharmacist better

60 Systems

61 Medicines reconciliation - template Screen shot of Johns template

62 Whole System Working Developing links with IT Secondary care Pharmacy

63 Interface Issues Review of IDLs from Crosshouse Hospital 2012 Quality and accuracy of IDLs HEPMA – electronic discharges Access to Key Information Summary Induction training Audit of IDLs

64 Medicines reconciliation - successes Improvement to systems Sharing of ideas between GPs Development of links between practices Development of links between leads and other areas of health care Identification of “local champions” “I don’t think it is difficult [medicines reconciliation]. It takes a bit more work but it’s what we should be doing after all.” North Ayrshire GP

65 Medicines reconciliation – challenges Buy in by GPs – “problem is with secondary care not with us” Workload issues in GP Problem with systems Patients with cognitive impairment Patients who are not aware of the changes made in hospital Carers Blister packs Interface issues including the quality of Immediate discharge letters

66 Future SPSP LES 2014 Continue medicines reconciliation Option of enhanced SEA Re-launch and learning sets Closer working between patient safety leads in primary and secondary care

67 NHS GG&C Reflections from 13/14 Q1: does the meds rec work improve patient safety? 86% Yes 5% No 9% possibly Q2: does the meds rec work improve practice processes? 76% Yes 5% No 9% formalised existing process Q3: did you use your data to make improvements? 62% Yes 24% No 14% made improvements but not specifically from the data

68 Reflections from 13/14 LES practices so far (n=21) Main +ve Time: less calls/queries from patient standard process reduces time spent rectifying error better organisation/reduced frustration better practice communication Patients really like it Main –ve Time: chasing secondary care more admin work trying to contact patients identifying cohort

69 Questions?

70 A possible way to improve your systems Process mapping made easy!

71 What about secondary care?

72 SEAs Practices will highlight to the Board significant safety issues that occur at discharge using an SEA form.

73 Process for recording Quick Easy Links to appraisal – submit and save Takes account of SAER policy Allows links to M & M in other departments Emerging themes – newsletter and risk register

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76 Questions?

77 A Scottish Government CEL A strategic plan medicines reconciliation across the single system Admission Goals 95% compliance with medicines reconciliation within 24 hours of admission Discharge Goals 95% compliance with medicines reconciliation on discharge 95% of patients have an accurate medicines list on the Interim Discharge Letter (IDL) Patient demographics documented Allergy status on discharge documented Changes from admission medicines documented to include changes, discontinuations and new medicines started

78 Medicines Reconciliation and patient safety– Acute Care Scott Hill Lead Pharmacist Acute Services

79 Medicines reconciliation Medicines most common healthcare intervention Inadequate medicines reconciliation accounts for up to 20% of adverse drug events and 46% of all medication errors amongst hospital in patients (Roizic 2001)

80 Safer Use of Medicines SGHD/CMO (2013) 18 Key messages Provides national definition, goals, measures and recommended practice statements Patient centred approach Clinical leadership and champions Monitoring of goals

81 Measurement Goal - 95 % compliance with medicines reconciliation within 24 hours of admission Month October 2013 November 2013 December 2013 January 2014February 2014 March 2014 Demographic s 90%95% 100% 94% Allergy status 60%65%85%100%87%94% Two or more sources 35%70%85%73%93%75% Plan for each medicine 30%55%60%84%93%75% Accurate list of medicines 65%85%80%84%80%75% Med. Rec. in 24 hours (all 5 of above) 10%20%45%63%60%50%

82 Improve patient safety by strengthening the contribution of pharmacists to : Improve the reliability medication reconciliation when patients are discharged from hospital Deliver reliable processes underpinning the safe prescribing monitoring dispensing and administering of high risk medications Improve the safety culture of pharmacy teams in the community Pharmacy in Primary Care – Our Aims

83 HIS will support 3 health boards to participate in a collaborative (June 14 – June 16) Each NHS board will recruit - Pharmacy clinical lead, 8 pharmacy teams, section of the acute sector and 2 GP practices Pharmacy Teams will attend National and Local Learning Sessions run by the participating boards. After attending a learning event and learning about the Model for Improvement pharmacy teams will: –Implement a care bundle for medicines reconciliation high risk medicines, ie Warfarin, Lithium, Methotrexate –Carry out a safety climate survey

84 Coming soon – Involving Community Pharmacy in making care safer Med rec andf high risk medicines Communication of IDL Testing work begins late 2015 Hopefully Fv involved – need 2 interested practices

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86 What about the others Warfarin and NPT 2 data collections per year £200 per practice in ES

87 Safety Programme Safe and Reliable Medicines Reconciliation after discharge Safe and Reliable antipsychotics in elderly patients with dementia Significant safety issues that occur at discharge using an SEA form Activity to involve patients in safety improvement work Two half day patient safety learning sets within existing PLT (eg CREATE) Climate Survey and Trigger Tool

88 WSW LES Timeline

89 Med Rec Data Entry Sheet

90 Med Rec Paper Data Collection Sheet

91 Med Rec Compliance Run Charts

92 Med Rec Reflection Form

93 Questions?

94 FV Safety Climate 2014 Dr Simon Randfield

95 “ Individual and group values, attitudes, perceptions and patterns of behavior that determine their commitment to safety management” The way things are done around here NHS Education for Scotland 2010 Safety Culture

96 Adverse Event Causation Accident Causation Technical Factors Human Factors Safety Culture Operator Behaviour =+ (30-20%) (70-80%)

97 Safety Climate- QOF QOF - QI002 (now QS008) The practice conducts a safety climate survey with all staff, clinical and non-clinical, using a validated tool, meets to discuss the results, and shares a reflective report on action that arise from this with the NHS Board.

98 Progress towards our aims 90% of all practices in Scotland completed the Safety Climate Survey, by April 2014

99 BoardRegisteredCompleted Not Completed All practicesCompleted % of Practices Registered Board A&A %96% Borders %100% D&G %94% Fife %95% FORTH VALLEY % Grampian %84% GG&C %95% Highland %83% Lanarkshire %91% Lothian %91% Orkney %100% Shetland %89% Tayside % Western Isles %90% Registered of all % Completed of all registered % Completed of all practices % Completed numbers in each Health Board April 2014

100 Forth Valley - Simply the best! In Forth Valley 881 of 981 practice staff took part in the climate survey With in practices, uptake varied from 50% to 100%, but only 6 practices achieved less than 80% uptake and 26 achieved 100% uptake

101 Using the SafeQuest Safety Climate Survey work in practice?

102 POINTS TO REMEMBER 1 Engage all practice Protected time for staff to complete. Anonymised Negative questions

103 The good..

104 The bad..

105 ..and the ugly

106 Safety Climate Survey - Pros Work well as a team Staff talking to GPs Got team thinking Good for staff morale Positive experience We found this a particularly useful forum for open discussion within the team.. actually helped us pinpoint areas of specific need… Interesting to look at different views on safety issues Help to make positive changes Good insight Communication Makes you think about team more Trouble Shooting Time

107 Safety Climate Survey - Cons Used PLT -> Chair facilitate GP/PM Didn’t feel staff would give true response Time loss Didn’t benefit much from it Small number of return/survey completed Time consuming Can be difficult in a small practice Not that anonymous Age/gender Involve more Team Members into SEA Communication could be better Are things really that bad? workload

108 How to use this information?

109 Practice experience - what to do with it ‘Viewpoint – Point of view’ Our experience – the highs and lows. Results – Problems highlighted: Communication, meetings. Areas of improvement: Communications book - a visual reference tool. Admin meetings. G.P. involvement. Open forum - team participation.

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111 Communication: Forms of communication tasks/ docman/ messages More regular meetings, including admin Communications book White board Distribution of agenda and minutes from meetings Shared storage of data (guidelines, etc) Doctors whereabouts and contractibility Difference between management and non Mx perceptions

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113 Workload: “Pace of work leaves little time for planning” Changing staff hours to cover peak times Installation of touch screen arrival system Discussion re doctors sessions

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115 Leadership: Practice vision unclear/ poorly communicated Training for dealing with “problem staff members”

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117 Teamwork: Team building event Better planning of (limited) CREATE PLT Grumble board Staff shadowing

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119 Safety systems: Involving admin in SEAs (admin staff keen) Each member of admin is expected to produce 1 SEA annually Concerns re IT communications limitation (MIDIS)

120 POINTS TO REMEMBER 2 Time for adequate practice discussion Motivation to address findings

121 POINTS TO REMEMBER 3 The findings are for your practice teams Don't get too focused on the numbers Concentrate on how you might use the results to drive improvements It’s a tool, a snapshot Takes time to change

122 Changes? QOF same format How to make it more useful on repeated use? Confidence limits Free text options additional questions confidential feedback questionnaire asking for further details.

123 Climate Survey Learning “a very useful discussion for all” “Embrace the Challenge – its worth it!”

124 Tea and Coffee


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