1. Safety in Practice Learning Session 3 PHO and Facilitator: WPHO – Andrew Jones Team members: Kirsty Laws, Allie Waretini, Mel Lanz, James Recordon Silverdale Medical

2. Safety in Practice Medication Reconciliation Aim: - To ensure that all medication lists are updated in a timely manner after hospital discharge, and patients followed up by phone or in person if indicated. - To standardise procedure in our large practice. We chose this audit as a means to first assess, and then improve, the Secondary to Primary Care interface for our patients on multiple medications. These are mostly, but not all, frail elderly.

3. Safety in Practice Change Ideas - Set expectations within practice by discussion/progress reports at Clinical Meetings. -Share individual cases of benefit/harm to patients relating to medication reconciliation (or lack of) -Task reminders to individual practitioners where medrec not completed -Audit by provider with name-and-shame (fortunately didn’t have to go this far!)

4. Safety in Practice Change Package Change TestedOutcome / Evidence of Improvement All the above approaches were used simultaneously. Owing to the small number of cases each month it was not viable to break the data down further. Moderate improvement in individual measures especially patient contact, demonstrated on monthly data collection. Change of targets during the year made comparison difficult.

5. Safety in Practice Prescribing audit cycle RNZCGP audit of long-term prescribing was used to identify problems in regular medication lists and/or prescribing. We found excellent accuracy and compliance on most aspects. Recording of use of complementary/alternative medications was infrequent, and difficult to identify even when recorded. After brainstorming at the practice meeting, we will use the Medical Warnings tab in MedTech to record these, in the “note” field, so they will be visible whenever a new prescription is written.

6. Safety in Practice Measures Summary We are now measuring: -Viewing of discharge summary within 7 days of receipt -Updating of medication list within 7 days of receipt -Contact made with patient (if appropriate) within 7 days of discharge. -Time from discharge to receipt of summary (this remains at 0 days for around 90%, with a small number markedly delayed, up to 3 weeks after discharge)

7. Safety in Practice Achievements to date Do you have an -agreed aim – all discharge handling achieves 100% on current measures -a change package – continue reporting to monthly meetings -measurement plan – continue audit of 10 patients at least 3-monthly to avoid slippage. Do people on your team know what their responsibilities are and what is expected of them? – much improved What has changed and what difference have the changes made? Main change has been awareness of the better continuity achieved with consistent process (any doctor or nurse seeing a patient can be confident the meds list is up to date – although we still check the discharge summary when the next script is written). Highlighting changes as “prescribed externally” enhances this.

8. Safety in Practice Further learning Completed the trigger tool for 25 patients over 75 on multiple long-term medications. Significant harms were found for 3 patients. 1 related to anticoagulation and another to non-anticoagulation! (This is also the story of my daily professional life) Difficulties with anticoagulation had also been a recurring theme with our medrec patients. On this basis another team member is now undertaking an audit of all patients discharged on warfarin or dabigatran.

9. Safety in Practice Any other achievements? We do feel we already had a strong quality improvement focus in the practice. Participating in this programme helped to reinforce it, and to bring in new ideas. Silverdale Medical was formed by the amalgamation of 2 existing practices at the beginning of 2013, and working towards a shared goal helped to unify the team, and to achieve the standardisation of process that is needed for safety, especially in a large organisation. The latest Patient Satisfaction Survey results were very gratifying!

10. Safety in Practice Highlights and Lowlights Lowlights – early problems with the audit measures were frustrating and demoralising. Now fixed and much more usable. With MedRec, which is a Secondary/Primary transition issue, it would have been good to have more input and action on problems from the DHB. No good us reading a summary promptly, if it arrived 3 weeks late. Highlights - New ideas, contact with other practices, understanding how our challenges compare with those of other practices and differing enrolled populations. Learning from this audit fed into ideas for further CQI activities. Future – with so many practices working together, could we get some real information on clinical outcomes? Maybe publishable?