Presentation on theme: "Improving Patient Safety in Primary Care"— Presentation transcript:
1Improving Patient Safety in Primary Care NHS Forth Valley 204/15Neil HoustonClinical Lead,
2Session AimsReview the safety work in Primary care in the last 12 months including:Improvements in safety of prescribing of NSAIDSPrescribing and monitoring of Warfarin and DMARDSReview use of Safety climate survey and trigger tool -Learn about the safety programme in 2014/15 which includes:Reliable medication reconciliation after dischargeAppropriate use of antipsychotics in elderly patientsInvolving patients in making care safer
3Session Aims What are we trying to achieve? Where have we got to? What are our next steps?
4Our AmbitionTo reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting.The programme ambition and aim support the Scottish Government’s Quality Strategy of safe, effective person-centred care. Primary care is a priority for the Scottish Government and will continue to be so.
5Our AimAll 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.
6Safety at the interface 3 workstreamsSafety CultureSafer medicinesSafety at the interfaceHow we going to achieve our aims -
7Focus in 2013/14NationalTrigger Tool Reviews (twice per annum)Safety Climate Survey (once per annum)LocalWarfarin,DMARDSAt this stage need to make reference to fact most people focusing this year on National areas and that these are supported within a contractual framework.
8What are we trying to achieve? Where have we got to?What are our next steps?
9Health Board areas of focus WarfarinNHS Ayrshire & ArranNHS BordersNHS Dumfries & GallowayNHS FifeNHS Forth ValleyNHS GrampianNHS HighlandNHS LothianMedication ReconciliationNHS Ayrshire & ArranNHS Greater Glasgow and ClydeNHS LothianNHS OrkneyNHS ShetlandNHS Western IslesDMARDSNHS Forth ValleyNHS LanarkshireNHS Tayside
10Progress towards our aims 83% of all Scottish practices engaged in improving reliability of one high risk area819 practices across Scotland currentlycollecting data and making improvements
11Key AchievementsAll 57 FV practices signed up to Local Enhanced Service contracts using care bundle methodology for Near Patient Testing andAnti-coagulation in 2013/1480% FV aggregate anticoagulation bundle compliance56 (98.2%) of FV practices participated in the climate survey with 881 (89.8%) responses across practice staff55 (96.5%) of practices participated in trigger tools reviews36 practices undertook Significant Event Analysis around anticoagulation and NPT medications100 + practice participants at FV Patient Safety Learning Session
13Anticoagulation Compliance No of practicesPrescribingINR durationPatient AdviceWithin 7 daysWritten EducationOverallApr43100.096.499.894.985.678.8May3899.794.799.283.977.1Jun3797.695.485.178.4Jul97.198.795.887.682.9Aug97.595.387.380.6Sep3597.899.490.884.2Oct4799.398.598.990.186.8Nov4699.198.094.484.477.3Dec4498.694.286.780.4Jan4599.595.788.883.6Feb98.896.989.886.0Mar4099.096.289.785.4
16MTX 2.5MG TABS AS % OF ALL ORAL RX : FV VS OTHER HBS
17Workstream Aimssafety culture95% of practices undertaking Trigger Tool Reviews and Safety Climate Survey, by April 2014Individual boards have currently collating their Trigger Tool data and we heard some great examples of learning from trigger tool reviews this morning. In achieving our aim for the SCS – we’ve got to . . .
18Progress towards our aims 90% of all practices in Scotlandcompleted the Safety Climate Survey,by April 201490% - this is a massive achievement – think they should all give themselves round of applause.
19NSAID 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 gastroprotectionReduced by 33%Current anticoagulant user prescribed an NSAID without gastroprotection.Reduced by 55%
24What are we trying to achieve? Where have we got to?What are our next steps?
25Our AimAll 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.So when do we move to a new area . . .
29Safety ProgrammeSafe and Reliable Medicines Reconciliation after dischargeSafe and Reliable antipsychotics in elderly patients with dementiaSignificant safety issues that occur at discharge using an SEA formActivity to involve patients in safety improvement workClimate Survey and Trigger Tool
30More 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,
32Medication Reconciliation This is the type of discharge letter that some practices still receive when a patient comes out of hospital and it makes it very difficult to reconciel those medications accuratelyFailure to reconcile the medications after dischareg has been shown to lead to increase readmissions
33Med Reconciliation after discharge - CQC Unreliable at admissionInaccurate and delayed at discharge,Unreliable systems in place in primary care for updating17% of practices delegation of the responsibility for medicines reconciliation to managerial or clerical staff.‘Managing patients medicines after discharge from hospital’ October 2009.Its easy to blame the hospital but work done by the Care Quality Comission revealed that altho med rec is done poorly at admission and that discharge letters are often inaccurate and delayed at discharge practices do not have reliable systems in place for reconciling the meds when the patient comes home
34Discrepancies 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 doseWhere 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
36Where do thing go wrong with medicines when a patient is discharged?
37“In God we trust. All others bring data.” W. E. Deming37
38Medicines Reconciliation Audit 10 of the following patients per month:Patients who have been discharged from an acute medical admissionandPatients over 75 years of age who have been discharged from an inpatient stay from anywhere
39Medication 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).
40Medicines 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 dose5.All measures have been met
41The truth will set you free…… But first it will piss you off !
44Codes and their meaning --?! Read CodeTermDisplay on template and record18HE2Discharged from inpatient careIDL received and workflowed28B318Medication reconciliation367IsAdvice to continue with drug treatmentNo changes to drug treatment8B3RDrug therapy discontinued8B3A3New medication commenced8B316Medication changedMedication dose altered8B314Medication review doneMedication record updated48B3S0Post hospital discharge medication reconciliation with ptMedication discussed with patient or carer8BIoDrug directions adequate and appropriateNot appropriate / necessary to discuss with patient / carer671G0Medication discussed with pharmacistAnd/ or practice admin staff
45Information appears clearly in EMIS consultation history
46If templates are used coded information can be searched
48NHS Ayrshire & Arran’s Experience John Freestone – GP Clinical lead East and South Ayrshire
49What have we done so far? Local Enhanced Service Medicine reconciliationWarfarin managementPatient safety SEAsReconciliation of addiction medicationLocal collaborative meetings47 out of 55 practices taking part
50Medicines Reconciliation Audit 10 of the following patients per month:Patients who have been discharged from an acute medical admission, andPatients over 75 years of age who have been discharged from an inpatient stay from anywhereHas 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?
51Medicines Reconciliation Compliance with bundle – May Compliance with bundle – Feb 2014
52Medicines Reconciliation – how did we improve? Data and feedback – so practices knew if they were improvingLocal collaborative – sharing systems and learningAttempting to institute a whole systems approach
55Collaborative Meetings 1 launch day and then 3 half day meetings in localitiesAttended by GP, manager and practice nurseDiscuss progress, patient stories, QI toolsSmall group workReview results – benchmarkingDiscuss systemsDiscuss SEAsFeedback with commitment to changeSystems employed - variableNewsletter with summary of learning and sharing of resources
56Patient Story – Mr D (84) Admitted with chest pain PMH Angina Atrial fibrillationDischarge diagnosis: Acute Coronary SyndromeMedication on IDL - angina meds changedNicorandil addedBisoprolol seemed to be stoppedMedicines reconciledPatient story that illustrates some of these challenges and successes
57Patient Story – Mr D (84) Patient phoned Unsure of meds - daughter deals with themPatient asked to get daughter to phone2 weeks later – house visit request short of breathPulse 120 irreg, signs of LVFAdmitted - Bisoprolol restartedPatient story that illustrates some of these challenges and successes
58Patient Story – Mr D (84)SEA – unnecessary admission. Discussed with consultant.Error on IDLNot picked up by practice system due to patient confusion about medicationsChange to practice systemHow record carers and how record contact themUsed stories like these to allow practices to reflect on their systems
59Positive SEAs Potential errors picked up early by new systems IDLs often questionedCommunication between practice, patient, carer and pharmacist better
61Medicines reconciliation - template Screen shot of Johns template
62Whole System WorkingDeveloping links withITSecondary carePharmacy
63Review of IDLs from Interface Issues Crosshouse Hospital 2012 Quality and accuracy of IDLsHEPMA – electronic dischargesAccess to Key Information SummaryInduction trainingAudit of IDLs
64Medicines reconciliation - successes Improvement to systemsSharing of ideas between GPsDevelopment of links between practicesDevelopment of links between leads and other areas of health careIdentification 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
65Medicines reconciliation – challenges Buy in by GPs – “problem is with secondary care not with us”Workload issues in GPProblem with systemsPatients with cognitive impairmentPatients who are not aware of the changes madein hospitalCarersBlister packsInterface issues including the quality of Immediate discharge letters
66Future SPSP LES 2014 Continue medicines reconciliation Option of enhanced SEARe-launch and learning setsCloser working between patient safety leads in primary and secondary care
67NHS GG&C Reflections from 13/14 Q1: does the meds rec work improve patient safety?86% Yes % No % possiblyQ2: does the meds rec work improve practice processes?76% Yes % No % formalised existing processQ3: did you use your data to make improvements?62% Yes % No % made improvements but not specifically from the data
68Reflections from 13/14 LES practices so far (n=21) Main +veTime: less calls/queries from patientstandard process reduces time spent rectifying errorbetter organisation/reduced frustrationbetter practice communicationPatients really like itMain –veTime: chasing secondary caremore admin worktrying to contact patientsidentifying cohort
77A Scottish Government CEL A strategic plan medicines reconciliation across the single system Admission Goals95% compliance with medicines reconciliation within 24 hours of admissionDischarge Goals95% compliance with medicines reconciliation on discharge95% of patients have an accurate medicines list on the Interim Discharge Letter (IDL)Patient demographics documentedAllergy status on discharge documentedChanges from admission medicines documented to include changes, discontinuations and new medicines started
78Medicines Reconciliation and patient safety– Acute Care Scott HillLead Pharmacist Acute Services
79Medicines reconciliation Medicines most common healthcare interventionInadequate medicines reconciliation accounts for up to 20% of adverse drug events and 46% of all medication errors amongst hospital in patients (Roizic 2001)
80Safer Use of Medicines SGHD/CMO (2013) 18 Key messages Provides national definition, goals, measures and recommended practice statementsPatient centred approachClinical leadership and championsMonitoring of goals
81MeasurementGoal - 95 % compliance with medicines reconciliation within 24 hours of admissionMonthOctober 2013November 2013December 2013January 2014February 2014March 2014Demographics90%95%100%94%Allergy status60%65%85%87%Two or more sources35%70%73%93%75%Plan for each medicine30%55%84%Accurate list of medicines80%Med. Rec. in 24 hours (all 5 of above)10%20%45%63%50%
82Pharmacy in Primary Care – Our Aims Improve patient safety by strengthening the contribution of pharmacists to :Improve the reliability medication reconciliation when patients are discharged from hospitalDeliver reliable processes underpinning the safe prescribing monitoring dispensing and administering of high risk medicationsImprove the safety culture of pharmacy teams in the community
83Implement a care bundle for medicines reconciliation 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 practicesPharmacy 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 formedicines reconciliationhigh risk medicines, ie Warfarin, Lithium, MethotrexateCarry out a safety climate surveyTimeframe –Received applications from 7 health boards – shortlisting this weekInterviews taking place on 27th May and successful boards will commence in June 2014.
84Coming soon –Involving Community Pharmacy in making care saferMed rec andf high risk medicinesCommunication of IDLTesting work begins late 2015Hopefully Fv involved – need 2 interested practices
862 data collections per year What about the othersWarfarin and NPT2 data collections per year£200 per practice in ES
87Safety ProgrammeSafe and Reliable Medicines Reconciliation after dischargeSafe and Reliable antipsychotics in elderly patients with dementiaSignificant safety issues that occur at discharge using an SEA formActivity to involve patients in safety improvement workTwo half day patient safety learning sets within existing PLT (eg CREATE)Climate Survey and Trigger Tool
94FV Safety Climate 2014 Dr Simon Randfield What does safety climate mean?FV Safety Climate Dr Simon Randfield
95The way things are done around here Safety Culture“ Individual and group values, attitudes, perceptions and patterns of behavior that determine their commitment to safety management”The way things are done around hereNHS Education for Scotland 2010It’s a snap shot of an organisations safety culture- the way things are done around here – when no ones watching….
96Adverse Event Causation TechnicalFactors(30-20%)AccidentCausationWhy is it important? Because of role of safety culture on accident causation % of suchHumanFactorsSafetyCultureOperatorBehaviour(70-80%)=+
97Safety Climate- QOFQOF - 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.And why are you here? Well because of 5 qof points of course!
98Progress towards our aims 90% of all practices in Scotlandcompleted the Safety Climate Survey,by April 201490% - this is a massive achievement – think they should all give themselves round of applause.
99Completed numbers in each Health Board April 2014 RegisteredCompletedNot CompletedAll practices% of Practices Registered BoardA&A5456100%96%Borders23221D&G323494%Fife555998%95%FORTH VALLEY57Grampian686358193%84%GG&C249242726197%Highland8310083%Lanarkshire87869699%91%Lothian1151114127Orkney10990%Shetland889%Tayside67Western IslesRegistered of all9148937799192%Completed of all registered21Completed of all practices- excellent buy in across Scotland, a real interest for many to see how this tool might benefit their own practices. Even better in forth valley- HIGHLIGHT FORTH VALLEY FIGURES well done!!
100Forth Valley - Simply the best! In Forth Valley 881 of 981 practice staff took part in the climate surveyWith in practices, uptake varied from 50% to 100%, but only 6 practices achieved less than 80% uptake and 26 achieved 100% uptake
101Using the SafeQuest Safety Climate Survey work in practice? PRACTICE EXPERIENCE… WHO?
102POINTS TO REMEMBER 1 Engage all practice Protected time for staff to complete.AnonymisedNegative questions
105..and the uglyThe blob fish . There were no ugly returns, although some were cursory, and perhaps unlikley to find any benefit from the processes, many were of a high quality and showed remarkable commitment to the process
106Safety Climate Survey - Pros Good for staff moraleCommunicationWork well as a teamInteresting to look at different viewson safety issuesPositive experienceMakes you think about team moreStaff talking to GPsHelp to make positive changesWe found this a particularly useful forum for open discussion within the team.. actually helped us pinpoint areas of specific need…Trouble Shooting TimeGot team thinkingGood insight
107Safety Climate Survey - Cons Communication could be betterUsed PLT -> Chair facilitate GP/PMDidn’t benefit much from itNot that anonymousAge/genderAre things really that bad?Didn’t feel staff would give true responseSmall number of return/survey completedInvolve more Team Members into SEADespite concerns that the process might disturb the hornets nest that lies buried in dome practices, there was very little fallout and NO practices have asked for additional facilitation on the outcomes of their surveys.workloadCan be difficult in a small practiceTime consumingTime loss
109Practice 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.PRACTICE EXPERIENCE… WHO?
111Communication: Forms of communication tasks/ docman/ messages More regular meetings, including adminCommunications bookWhite boardDistribution of agenda and minutes from meetingsShared storage of data (guidelines , etc)Doctors whereabouts and contractibilityDifference between management and non Mx perceptions
119Safety systems: Involving admin in SEAs (admin staff keen) Each member of admin is expected to produce 1 SEA annuallyConcerns re IT communications limitation (MIDIS)
120POINTS TO REMEMBER 2 Time for adequate practice discussion Motivation to address findingsPRACTICE EXPERIENCE… WHO?
121POINTS TO REMEMBER 3 The findings are for your practice teams Don't get too focused on the numbersConcentrate on how you might use the results to drive improvementsIt’s a tool, a snapshotTakes time to changePRACTICE EXPERIENCE… WHO?
122Changes? QOF 2014-15 same format How to make it more useful on repeated use?Confidence limitsFree text optionsadditional questionsconfidential feedback questionnaire asking for further details.
123Climate Survey Learning “a very useful discussion for all”“Embrace the Challenge – its worth it!”