1. Using PRIMIS tools for quality improvement

2. Myth buster
PINCER is pharmacist-led information technology intervention for reducing clinically important errors in general practice prescribing (PINCER)
PINCER is not a clinical audit and it is not a reactive alert tool used to periodically identify patients at risk so that remedial action can be taken.
PINCER should not be time consuming for general practice (on average 60 patients per practice were identified in the East Midlands PINCER 3 study, only 50% needed an intervention)
PINCER does not need to be ran on a monthly basis – clinical audit and findings from the initial study suggest 6 month review to capture improvement and/or new patient incidents
The PINCER audit tool will remain stable over the next 12 months despite changes to general practice systems and coding structures
PRIMIS are the technical authors of PINCER (clinical and technical specifications remain the intellectual property of the UoN), no other provider of ‘PINCER’ indicators have been validated against the official evidence based set

3. The PINCER Intervention
Pharmacist-led IT-based intervention to reduce rates of clinically important errors in medicines management in general practices
Conducting searches on GP clinical systems to identify patients at risk from common and important prescribing errors
Pharmacists (trained in the PINCER approach) working with general practices to develop an action plan to correct and prevent potentially hazardous prescribing
PINCER is another one of those acronyms that describe what this intervention is about.
Pharmacist-led IT-based intervention to reduce rates of clinically important errors in medicines management in general practices
Broadly speaking there are three core components to the PINCER intervention
A search is run on the GP clinical system to identify patients at risk of some common and important prescribing errors. Currently this involves using tools provided by PRIMIS
Primary care pharmacists employed by the CCG to work in the practice and have been trained in the PINCER approach review the identified cases from the search. The pharmacist work out the probable causes behind each case by applying RCA.
These results are feedback to the practice using academic detailing where necessary.
Then working with the practice action plans are created to identify both the immediate risk and changes to the systems and processes required to prevent the error from reoccurring. The pharmacist then continue to work with the practice to implement these actions.
This quality improvement cycle is repeated after around 6 months which creates additional information to monitor change in comparison with other participating practices and CCGs.
Pharmacists (and pharmacy technicians) working with and supporting general practice staff to implement the action plan

4. Information governance assurances
PRIMIS is not involved in the collection of patient identifiable data
PRIMIS does not share data with the pharmaceutical industry or other commercial organisations
Practices can choose to submit practice level data to PRIMIS for the online comparative analysis service (CHART Online) – data collection agreements exist – the practice controls access
Use of practice data is governed by our Security and Confidentiality of Practice Data Policy
Anyone wishing to use PRIMIS tools must register as a member of the PRIMIS Hub - use of that data is governed by our Privacy Policy
PRIMIS is certified to BSI ISO 9001 and BSI ISO/IEC and achieved compliance with the NHS IG Toolkit
CHART Online is a secure, central database storage facility located at PRIMIS on a University of Nottingham server. The results are displayed via a web browser.
For the majority of our quality improvement tools practices submit aggregate data to CHART Online. However, in some situations one-line-per-patient de-identified data may be required to allow greater depth of analysis (in such instances practices are asked to complete a Data Sharing Agreement [DSA] before they are able to upload data, outlining the purpose of the data collection activity and permissions to view the data).
Using PRIMIS tools for quality improvement_V th October 2017

5. What we will cover Identifying the need for change Planning the change
Reflection and evaluation
By involving the people who will either be involved in making the change happen or will be affected by the change, it can become a much easier, smoother process. Some of the tools we will examine in the workshop today will be useful when consulting and motivating these key people.
We will examine a selection of tools and techniques but this is not an exhaustive list, there are many more tools out there that you can research and use.
The tools we will examine today have been separated into 3 categories:
Those that help to identify the need for change
Those that help you plan the change
And those that help with the reflection and evaluation process
MGCHG_Ppt_V March 2014

6. Change management is….
…a structured approach to moving individuals, teams, and organisations from the current state to a new state
Activity – get learners to describe what they think change management is….
After deciding what needs to be changed and how it will be achieved, the process of implementation needs to be considered. Where possible, any change should ideally be planned and managed from the outset to the point at which the expected outcome is achieved.
If we look at the definition of management it can be summarised as:
those (individuals or groups) who manage
a talent or skill for organisation, efficiency, accomplishment, tact, ingenuity, persuasiveness or negotiation
supervision or direction
to organise the activities of (a person or group of people)
to persuade (a person) to do something or to persuade (a person) towards some objective
If we refer back to the definition of change outlined earlier in the lesson (and link this with the definition above) change management can be defined as:
a structured approach to moving individuals, teams, and organisations from the current state to a new state
To achieve the transition an individual or group of individuals will normally be responsible for leading and facilitating the process from beginning to end. Implementing the change and achieving the required outcome will often have an impact on other people outside the group/individual responsible for leading and facilitating the change. If change is implemented using a structured framework, it is possible to break the change down into smaller stages or tasks that are easier to manage. It is also useful to have a few methods in mind as to how to achieve it.
MGCHG_Ppt_V March 2014

7. Managing change in general practice
Change necessitated by circumstances is acceptable in general practice Often evidence is not available for required change Change based on fashion is less acceptable than that based on sound evidence Imposed change is more acceptable if it is expressed in terms of outcome rather than detailed behaviour The positive way to deal with imposed change is to create a sense of ownership of the change within the practice
Scott and Marinker (1993), in the BMJ publication Change and Teamwork in Primary Care, conclude that:
Undertaking an audit can provide evidence of the need for a change in the way that a practice manages patient information. An audit can raise dissatisfaction about the quality of patient information and create an incentive for change, specifically if the outcome is linked to improvement in patient or business management. Using data as a springboard for action is more effective than simply suggesting that a change needs to take place.
Scott and Marinker (1993), Change and Teamwork in Primary Care (BMJ)
MGCHG_Ppt_V March 2014

8. Where to start? What Who How Why
What do we want to achieve with this change?
Who is affected by the change and how will they react?
If you are involved in leading or supporting a change, understanding the need for change and the process needed can be simplified by asking the following questions:
What – what do you want to achieve with this change?
Who – who is affected, who will implement and who is responsible? Will it be the same person for the whole process?
Why – why do we need to change
How – how can we achieve the change, do we need help will we need to use external resources such as training or people with specific knowledge.
The responses to these questions should start to inform and shape the change as well as identify some of the key tasks and indicators that can be used to develop an action plan to achieve the expected outcomes.
How much
can we achieve ourselves and what do we need help with?
Why do we
need to change?
MGCHG_Ppt_V March 2014

9. The PINCER Intervention in practice
Run PINCER audits
RCA
Meet with practice
Action
planning
Implementation
PINCER intervention can only be done in collaboration with a practice. The practice should own the interventions and changes to process that the searches highlight so that it does not become the pharmacist’s responsibility.
The PINCER intervention needs some initial time investment so that the PINCER and the searches can be explained to the practice. Practice managers can be invaluable along the process for organising meetings, getting paper work signed off for the University and freeing up staff to work on changes in systems.
It is important to have the key people at any feedback event e.g. clinical meeting where a variety of staff are present. Essential to feedback on positive changes made as well and good results.
The feedback event creates good discussion around personal practice and opportunity to educate. During the discussions and planning it is important to remain focussed on the processes in place and not the person.
Action plan – PINCER can be done as a whole but it is more usual to do as small chunks.
It is essential to have named people involved in the workstream which can include admin staff and nurses as well as a GP lead. (PINCER is very good CPD for GPs due to the evidence and audit cycle)
Implementation can vary from specific patient intervention, changes in read code creating/changing a practice system.

10. PINCER 3
Eleven specific audits developed by PRIMIS in partnership with the University of Nottingham which allows GP practices to easily interrogate their clinical data and identify patients who are potentially at risk of harm through prescribing errors or inadequate drug monitoring.
Can reduce unnecessary and inappropriate treatment and hospital admissions
Supports the NICE ‘Medicines Optimisation Clinical Guidelines’ published in March 2015
Provides multi-dimensional data from patient to practice, local and national levels
Identifies patients who may not have received the necessary monitoring or investigations and require a medication review

11. OUTCOME: GI BLEED
Query 1: In a patient aged ≥65 years prescription of an oral NSAID without co-prescription of an ulcer-healing drug
Query 2: Prescription of an oral NSAID, without co-prescription of an ulcer-healing drug, to a patient with a history of peptic ulceration
Query 3: Prescription of an antiplatelet drug to a patient with previous peptic ulcer or GI bleed without co-prescription of an ulcer-healing drug
Query 4: Prescription of warfarin or a New oral anti-coagulant (NOAC) and an antiplatelet in combination without co-prescription of an ulcer-healing drug
Query 5: Prescription of warfarin or NOAC in combination with an oral NSAID 
Query 6: Prescription of aspirin in combination with another antiplatelet drug without co-prescription of an ulcer-healing drug

12. OUTCOME: EXACERBATION OF ASTHMA
Query 1: Prescription of a non-selective beta-blocker to a patient with asthma
Query 2: Prescription of a long-acting beta-2 agonist inhaler (excluding combination products containing inhaled corticosteroid) to a patient with asthma who is not also prescribed an inhaled corticosteroid
OUTCOME: HEART FAILURE
Query 1: Prescription of an oral NSAID to a patient with heart failure
OUTCOME: STROKE
Query 1: Prescription of antipsychotics for >6weeks in a patient aged ≥65 years with dementia but not psychosis
OUTCOME: KIDNEY INJURY
Query 1: Prescription of an oral NSAID to a patient with chronic renal failure with an eGFR <45

13. Root cause analysis Identifying the need for change
Planning the change
Reflection and evaluation
Root cause analysis

14. What is Root Cause Analysis?
Is the identification of the ‘vital few’ causes that have a material impact on the outputs of a process
Analysis is used to identify areas for change and to develop recommendations which deliver safer care for patients.
This is about you finding out more about the practice you are working with
How do they currently do things and why they do them

15. Neglect and wilful misconduct are a rare source of harm
Person centred
System centred
Problem
Careless individuals
Poor design
Focus
Blame
System
Solution
Remove individual
Change system
Improving the reliability and safety of healthcare systems is a critical task

16. How can we identify the underlying system failures which contribute to an adverse event or near miss?
Need to identify the root cause. This is a factor:
which significantly contributes to an adverse event
if resolved will eradicate, or significantly contribute to the resolution of, the identified problem to which it is attached
Undertake a root cause analysis (RCA)
structured investigation that aims to identify the true cause(s) of a problem, and the actions necessary to eliminate it (Anderson & Fagerhaug 2000)

17. Applying the principles of RCA
Action 1
Identify incident
CHART and PINCER 2
Gather information
Fishbone & 5 whys 3
Identify and prioritise problems 4
Explore problems
Practice meeting 5
Identify quality and safety improvement 6
Implement action plan and share learning
Action plan and lessons learnt
RCA : Structured investigation that focuses on systems, not individuals
Use computer searches to identify near misses:
Prescribing Safety Indicators
Gather information:
Results of computer searches
Medical record review
Guidelines, policies & procedures
Audit data
Brainstorming session to identify problems
Involve all relevant practice staff
Identify key contributory factors/underlying reasons for potentially hazardous prescribing
Prioritise problems
Type of problem
Size of problem
Individual patients
Review medication
Request blood tests
Alter prescriptions
System changes
Add computer alerts
Develop new working practices
Educate practice staff
Explore problems identified in step 3
Which factors are most important?
How can these be addressed?
Identify improvements/action plan
Engage relevant staff members
Discuss/brainstorm possible solutions
Identify key contacts and assign tasks
Agree timescales
Agree monitoring & review process

19. Think about how you would apply the principles of root cause analysis when delivering the PINCER intervention
You have identified 5 people in one practice that are prescribed an antipsychotic for more than six weeks in patients without a read code of psychosis. All have been prescribed in dementia and none of them have entries mentioning the drug in the notes in the last three months

20. Conducting a good practice meeting
Identifying the need for change
Planning the change
Reflection and evaluation
Conducting a good practice meeting

21. Resistance to change Resistance is a resource Communication is key
You can change the change
Objections can be valid
Acknowledging history reduces resistance
In some instances, where individuals feel threatened and lost by changes happening to or around them, their natural response is to reject and resist change. This usually occurs if they feel negatively about the general experience of change, both past and present, or do not understand why the change is required. They will find a number of reasons to declare the change unnecessary and unworkable, with the hopes of putting a stop to the change. They will often be vocal about their resistance, but the resistance can also be shown through actions (or lack of action) and body language. Not all resistance to change should be considered negative. In their article 'Decoding Resistance to Change' Jeffrey D Ford and Laurie W Ford suggest it is important to note the following (click on the boxes below to reveal more information):
Resistance is a resource – It is possible to use resistance to change as a resource. It is an important form of feedback and may influence a better way of achieving the desired outcomes.
Communication is key – people will resist change if they are not communicated with at the right time.
You can change the change – If necessary, change the change. Those that are resisting the change might be able to identify the pitfalls within the action plan or improve the plan as they are closed to the operational activities.
Objections can be valid – listening to objections and using the skills that already exist within the team to facilitate the change increases ownership and buy-in.
Acknowledging history reduces resistance – Be aware of history and failed promises, especially those aligned with rewards. If past promises related to previous changes were made and not kept, it is likely that there will be scepticism and disenchantment. If old promises can be acknowledged, even if only by way of an apology, respect for those leading the change and for the process can be established.
MGCHG_Ppt_V March 2014

22. Overcome resistance Awareness and education
Participation and negotiation
Produce and share an action plan
Identify key personnel and responsibilities
Most resistance is usually based on a personal understanding of what the proposed change means and is a specific phase experienced through the transition stages of personal behaviour. Bearing this in mind, there are several techniques and practices that can be used to overcome resistance to change such as the following (click on the boxes below to reveal more information):
Awareness and education – One of the most common techniques in overcoming resistance to change is education, but in the informal sense. Involve those who will be affected by the change, address their concerns and explain the planned changes. By involving staff from the outset, they will be more aware of the rationale behind the decision to change and are more likely to process it quicker.
Participation and negotiation – Involve the team(s) affected in designed and developing the change – participation and being able to influence the process leads to ownership.
Produce and share and action plan – Have a clear and achievable action plan that is accessible to everyone involved with or affected by the change. Listen to feedback about the action plan and be prepared to change it if necessary.
Identify key personnel and responsibilities – People know who they need to speak to if they have ideas, concerns and comments about the change or the plan.
MGCHG_Ppt_V March 2014

23. Engagement meeting Foster key relationships (PM, lead GP)
Outlining the project
Defining your role – what you will and won’t do
Updating morbidity codes and test results?
Intervening with at risk patients
Improving systems to prevent future problems
Providing regular feedback

24. Identifying the need for change
Define the vision of where you want to be
Identifying driving forces and resisting forces (force field analysis)
Recognise the potential hazards of taking a ‘no change’ option (doom scenario)
Define best practice
Carry out SWOT analysis
MGCHG_Ppt_V March 2014

25. The PINCER Intervention in practice
Run PINCER audits
RCA
Meet with practice
Action
planning
Implementation
PINCER intervention can only be done in collaboration with a practice. The practice should own the interventions and changes to process that the searches highlight so that it does not become the pharmacist’s responsibility.
The PINCER intervention needs some initial time investment so that the PINCER and the searches can be explained to the practice. Practice managers can be invaluable along the process for organising meetings, getting paper work signed off for the University and freeing up staff to work on changes in systems.
It is important to have the key people at any feedback event e.g. clinical meeting where a variety of staff are present. Essential to feedback on positive changes made as well and good results.
The feedback event creates good discussion around personal practice and opportunity to educate. During the discussions and planning it is important to remain focussed on the processes in place and not the person.
Action plan – PINCER can be done as a whole but it is more usual to do as small chunks.
It is essential to have named people involved in the workstream which can include admin staff and nurses as well as a GP lead. (PINCER is very good CPD for GPs due to the evidence and audit cycle)
Implementation can vary from specific patient intervention, changes in read code creating/changing a practice system.

26. Feedback meeting Present the data Discuss your findings (RCA)
Reach agreement on actions to be taken and by whom

27. Effective communication
Be specific Have clear reasons and benefits of change Be honest Communication style – be creative Manage any issues as they occur Review progress – does this meet the vision Two-way communication
Based on the Change Management Toolkit: Navigating Change in the NHS (produced by NHS Connecting for Health):
Be specific – specify the change and identify who will be affected by it. Make sure people are aware of and can understand the change.
Have clear reasons and benefits of change – share background information. Explain why the change has come about and highlight the benefits. Are the reasons financial, organisational or political? Explanation can help with engagement. Explain how individuals or groups will benefit.
Be honest – about the risks and benefits. The change will affect some more than others. If people are aware of this from the outset they are able to process and manage both the good and bad effects that the change might bring about. There will also be less opportunity for rumours to develop.
Communication style (be creative) – use different mediums and formats to communicate. Be creative, but don’t lose the message. Use technology for example, blogs, sound bites, notice boards, diagrams, update sessions and newsletters. Perhaps include a ‘right to reply’. Make sure you can communicate with everyone. Give them an opportunity to ask questions (anonymously if necessary), if they are unsure of anything that has been communicated. Repeat messages to ensure information has been shared at every opportunity.
Manage any issues as they occur – try to anticipate and manage problems. Do not put issues to one side. Deal with them as they arise and manage them appropriately. Let people know what has been done to resolve them.
Review progress – does this meet the vision? – make sure people know what the successful change will look like. Celebrate moving towards the goal and vision. Let people know when key milestones have been achieved. Acknowledge (and perhaps reward) those that have contributed. Communicate any changes to the original plan.
Two-way communication – open up channels of communication. Give people an opportunity to be involved through discussion and exchange. Ask for feedback and suggestions. Listen to any resistance and work with those affected by the change to solve problems and issues. They might have better solutions. This will keep people engaged as they will be able to contribute if they want to.
Without good, effective communication change will be difficult to monitor and manage. There is likely to be increased resistance and limited success. It may also take a longer time to achieve the overall change and vision.
We will look at the importance of communication when we discover some of the change management tools later in the session.
MGCHG_Ppt_V March 2014

28. SWOT analysis Strengths Weaknesses Opportunities Threats
What is it?/Why is it useful?/Purpose
The SWOT analysis is a tool that will enable a team to identify their Strengths and Weaknesses, and examine any Opportunities or Threats they face. SWOT can help uncover opportunities that can be taken advantage of and by understanding any weaknesses eliminate threats that would otherwise disrupt any changes.
How is it used?
 A successfully conducted SWOT involves identifying the following:
Strengths are attributes of the organisation that are helpful to the achievement of the objective.
Weaknesses are attributes of the organisation that are harmful to the achievement of the objective.
Opportunities are external conditions that are helpful to the achievement of the objective.
Threats are external conditions that are harmful to the achievement of the objective.
The things an organisation does particularly well (strengths) or badly (weaknesses) at present;
The factors that in the future may give the organisation potential to grow and increase efficiency or may make its position weaker (threats). Opportunities and threats normally arise from changes in the environment, but sometimes have their origin inside the organisation – for example, if key machinery or people, functioning very effectively at present, are likely to break down or retire in a few years’ time, that is a threat.
LC Note: Example of tool in use in appendix of handbook – p21
MGCHG_Ppt_V March 2014

29. What would you consider?
Prescription of aspirin in combination with another antiplatelet drug without co-prescription of an ulcer-healing drug
Number of patients =8
Most have a fixed term for the second antiplatelet
Second antiplatelet has always been started in hospital

30. 2 antiplatelets
Process for addition
Who adds to repeat and do they know to consider gastro-protection
Feedback to hospital
Stop dates for antiplatelets to directions
Review dates for PPI to directions
Education – prescriber and patient
Use of computer system and software available

31. What would you consider?
Prescription of an oral NSAID, without co-prescription of an ulcer-healing drug, to a patient with a history of peptic ulceration
Number of patients =8
5 of which have a PPI on repeat but have not collected regularly enough to be adherent

32. NSAID and non-adherence to PPI
Process for identifying non-adherence in the practice
Medication review
Repeat issue by reception team
Education of the patient
Clear directions on the medication
What to do if PPI declined

33. Action planning Identifying the need for change Planning the change
Reflection and evaluation
Action planning

34. Action planning MGCHG_Ppt_V3.0 28 March 2014
There are a few slides on Action Planning
Action planning can be seen as a cycle. The cycle is continuous: once the first cycle is complete it is repeated once the effectiveness of the action plan has been assessed and suitable changes made. When implementing an action plan in real life, it is possible that stages will overlap and the objectives may even change. As a result, the action plan should be re-visited frequently and updated to reflect any such changes. Before you start If you are planning to implement a change within an organisation, it is a useful starting point to ensure you are clear about what you are working towards or trying to achieve. It is also beneficial to identify and understand any problems that could prevent a successful outcome. Any problems identified should be incorporated into the overall aim but they should be rephrased to be reflective of the positive outcome you are trying to reach. An action plan should contain:
a statement of what must be achieved/the objective
the steps/activities involved to reach this objective
who is responsible for each step/activity
time schedule
identification of any resources that are needed to complete the step/activity
Where am I now and where do I want to be – think about some of the tools we explored in ‘Unfreezing’ such as Vision Box and Best Practice.
MGCHG_Ppt_V March 2014

35. MoSCoW Must Do Should Do Could Do Won’t Do
Once the objective has been decided upon, all of the people who will be affected by the change should be involved in developing the detail of the action plan. The more informed and involved people are, the more likely they are to be positive about working towards achieving the desired outcome. They will also need to understand exactly what is required of them, so this is a good opportunity to consult people and ensure they are clear about individual activities and how it affects them. How do I get there? What do we need to do to reach our objective? This is where all the essential individual activities need to be identified that will help you achieve your objective. The best way to make progress is to break down the tasks into small steps and then identify the actions needed for each step. There may be several goals that need to be achieved and each one will need to be broken down into a list of tasks. Be aware that many plans fail because tasks appear too difficult to achieve, so be realistic. Small manageable steps are best. Suggested technique: If you are involving everyone in the development of your action plan, then get together and discuss the strategies you might use to reach the goal. Use flipchart paper and pens and have everyone contribute their ideas. Once complete, pull all the ideas together and assess the pros and cons of each suggestion. Consider the cost, resource implications and timing of each suggestion. The aim is to come to a mutual agreement on the best way forward. Collate the list of suggestions and consider the pros and cons
Consider the cost, resource implications and timing of each suggestion
Start by prioritising what can be done straight away
Identify the biggest obstacle and put extra steps in place to combat this
Check that nothing has been missed
Identify the end point for each step so you know when something can be marked as completed
What is it?/Why is it useful?/Purpose
This is a prioritisation tool. A key component of effective planning is that you deliver the most important features first
How is it used?
This is a particularly useful tool in order to reach agreement within the group. Ask the group to identify their ‘musts’ and ‘shoulds’. They should be focusing on their ‘musts’ – they can always come back to the others in the future.
Features that absolutely have to be done are categorised as Must. If any of these features are not done, the project will be considered a failure.
Features that are important to the success of the project, but are not absolute musts (they have a workaround or will not cause the project to fail) are categorised as Should.
Features that are nice to have but are not core features are categorised as Could.
Features that are not going to be implemented this time are marked as Won’t.
Why mention ‘won’t do’ at all? There are two reasons. One is that feature priorities can change as the project goes on. These features could have started as Should and been re-prioritized to Wont, and they may be re-prioritized back again. The second is that these features are a starting point for the second version or next implementation.
LC Note: Example of tool in use in appendix of handbook – p23
MGCHG_Ppt_V March 2014

36. Responsibility charting
GPs
Practice Manager
District Nurses
Practice Nurses
Computer Operator
Reception
Patients
Install computerised appointments system A R I S
Enter hospital discharge summaries onto computer C --
Attend clinical coding training
Audit data quality levels
The next step when creating an action plan is to identify who is responsible for each step. Consider the experience, skills and confidence needed for each task in order to select the best person. Also, consider whether that person has the time/capacity to complete that task. If there is a selection of people to choose from, you may also want to consider who is the most willing (either because it is linked to their role or they are keen to learn a new skill). It should be made clear that some tasks may require input from several people even though an individual may be identified as making sure the task is completed. Finally, someone should be identified as being responsible for making sure all the steps happen (ie overseeing the project).
What is it?/Why is it useful?/Purpose
This chart is used in order to plan who needs to be involved in each stage of the change process and to what level. Used this way, the responsibility chart ensures that people’s time isn’t wasted by attending meetings/discussions where they are not really required.
How
Identify who is responsible for each step of an action plan. Consider the experience, skills and confidence needed for each task in order to select the best person. Also, consider whether that person has the time/capacity to complete that task. Some tasks may require input from several people even though an individual may be identified as making sure the task is completed.
A responsibility chart allows individuals to be identified as RASCI = Responsible (R), Accountable (A), Supporting (S), Consulted (C) or Informed (I).
Only those people identified as ‘responsible’ would normally be included on the main action plan.
The responsibility chart should be used in conjunction with main action plan to give further detail regarding the involvement of other people.
MGCHG_Ppt_V March 2014

37. S M A R T Specific Measurable Achievable Relevant Timely
Be precise about what you want to achieve
Quantify your objectives. How will you know you have achieved what you set out to achieve
For an objective to motivate people, it should be challenging but not impossible or too difficult
Is it going to improve your situation? List the benefits that would be achieved by putting this plan into practice
Give a time frame for achieving the objectives
An example of a SMART objective might be: To have 80% of practices within a PCT accredited as ‘paperlight’ within the next 12 months. This objective is SMART because: It is specific - it states an achievement level (80%), a time frame (12 months) and gives a clear action: practices to be accredited paperlight, not just working towards paperlight practice
It is measurable - it states an achievement level (80%) and a time frame (12 months), allowing progress to be measured. It will be obvious whether the objective has therefore been achieved (or not)
It is achievable - as the achievement level (80%) and time frame (12 months) are realistic, this results in an achievable objective
It is relevant - the objective is linked to the aims of the organisation that is working towards achieving this objective. It is not an unrelated or low priority objective
It is timely - the time frame has been specified and it is realistic but not long lasting. There is a specific end point to work towards which will help give momentum to the plan
MGCHG_Ppt_V March 2014

38. Avoid failure!
Planning too much too soon. Remember that small manageable chunks are best
Lack of detail or vague steps without definition of the tasks involved
Not involving people who have been identified to complete tasks
Lack of resources (or poor resource planning)
Poor time planning resulting in unrealistic deadlines

39. Action planning Actions Person Responsible Start Date
Expected Completion Date
Resources
Actual Completion Date
Step 1. Identify budget available for new scanner
Practice Manager
Anna Smith
3rd March
5th March
12 month practice financial plan
4th March
Step 2. Identify the requirements of the new scanner to assist with purchasing the correct model
Admin Manager
Jenny Williams
6th March
Time to consult admin staff,
Access to the 12 month I.T plan
Step 3. Research available scanner models to meet budget and specification needed
I.T Manager
John Croft
13th March
Internet access
Budget details
Specification requirements
Time for research
14th March
Flexibility It is important to build in flexibility for effective planning. Consider several different ways of achieving the objective so, that if one method turns out to be ineffective, there is an alternative that can be considered. Also, try to anticipate any problems that might occur before they actually do so that they can also be planned for. Resources The next step is to identify the resources that will be needed to put the plan into action. Examine each step and list the resources needed. Consider people, time, space, equipment and transport etc and (if required) how much each of these will cost. Time and people are two of the most important resources: achievement of the objective would be impossible without these. Compile the action plan
You should now have all the information that you need to compile your action plan. The design of the plan is up to you so long as it is clear, not open to misinterpretation and contains all the information needed. See below for an example of an effective action plan. Remember, action plans should ideally be used in conjunction with a responsibility chart and a Gantt chart, as these give more information than is contained on the action plan in relation to responsibility and time scheduling. Final check
Finally, review the action plan on paper to check for any gaps. These must be addressed immediately and the plan updated. Ensure everyone has sight of the action plan and has the opportunity to ask questions or raise any issues.
MGCHG_Ppt_V March 2014

40. Take action! Avoid failure Monitor progress Evaluate
It is now time to put the plan into action. Constantly check progress against the action plan and update it as often as is required. Keep in regular contact with those responsible for getting activities done. Avoiding Failure Listed below are some common reasons why action plans fail. Consider these before putting a plan into action:
planning too much too soon. Remember that small manageable chunks are best
lack of detail or vague steps without definition of the tasks involved
not involving people who have been identified to complete tasks
lack of resources (or poor resource planning)
poor time planning resulting in unrealistic deadlines
Monitoring Progress Constantly check progress against the action plan and update it as often as is required. Consider the following questions: is progress being made?
what problems have been/are being encountered?
what can be done to provide support?
what achievements need acknowledgement?
are resources being efficiently and effectively used?
Meet with staff members regularly to review progress and provide support and feedback. Monitoring is a continuous function; it helps to identify problems, successes and allows lessons to be learned from mistakes. Monitoring progress regularly increases the likelihood of achieving objectives on time and with success. End of Cycle Evaluation If you think you'll be trying to achieve a similar goal again, revise the action plan based on lessons learned and start the cycle again. Don’t forget to consider what went well in addition to the problems encountered.
MGCHG_Ppt_V March 2014

41. Lessons learned report
What is it?/Why is it useful?/Purpose
 Very rarely is a change introduced in exactly the way it was visualised at its inception. Some alterations are made along the way due to circumstances, opportunities that arise during the change or other developments both internal and external are introduced.  The purpose of the Lessons Learned Report is to bring together any lessons learned during the project that can be usefully applied to other projects.
As a minimum, lessons learned should be captured at the end of each stage of the project. At the close of the project it is completed and prepared for dissemination.
It should include the following:-
  Which management and specialist/quality processes went well/went badly/were lacking
Assessment of the techniques and tools used
A description of any abnormal events that resulted in a deviation from the plan
Recommendations for future enhancement
The Lessons Learned Report should be viewed as information that can be shared (although sometimes areas may have to be kept confidential) 
More information about ‘lessons learned’ is available online - particularly at the OGC website. Ref: Office of Government Commerce (OGC.gov.uk) (accessed January 2010) & Managing Successful Projects with PRINCE2, HMSO
MGCHG_Ppt_V March 2014

42. Tips for success
Keep people informed Don’t rely on messages being cascaded Monitor progress Celebrate successes along the way Communicate clearly and positively
As we’ve seen many of the key skills needed in change management are those relating to communication and effective planning
To be effective when implementing change, we must be able to listen and listen actively i.e. to restate, reflect, clarify without interrogating and encourage the speaker.
Here are some tips for success… [read slide]
MGCHG_Ppt_V March 2014

43. Summary
This work provides a real opportunity to improve patient safety in your general practice
The indicators provide a “litmus test” into the practice prescribing
Demonstrating success will, however, be more of a challenge
Key issues include:
involving all members of the practice
taking a systems approach to patient safety
agreeing on a plan of action and executing this

44. Introduction to quality improvement
Identifying the need for change
Planning the change
Reflection and evaluation
Introduction to quality improvement

45. GP Pharmacists and QI
As experts in medicine and their use, pharmacists play a crucial role in quality improvement programmes The Royal Pharmaceutical Society actively promote the potential benefit that pharmacists can bring to primary care patients particularly in relation to long term condition management By integrating pharmacist skills with those of the rest of the general practice team they can work together to improve patient outcomes and safety PRIMIS tools provide a solid foundation for a quality improvement programme that can be instigated and led by Pharmacists
Refer to document in the image shown (RPS promotes the role of pharmacists in LTC management).
CPPE – Centre for Pharmacy Postgraduate Education
Using PRIMIS tools for quality improvement_V th October 2017

46. Going forward Quality improvement cycle
What are the next steps for your practice? Have you decided?
Recycle and re-audit, this is only the first step in the data quality improvement cycle. You need to do something with the data you have got, and you have made the right moves by feeding back your data to your practice but what are you going to do from here?
There are four key stages associated with high quality clinical audit (see cycle on slide) that allow for the identification of best practice, measurement against criteria, taking action to improve care, and monitoring progress to sustain improvement.
Note that stage 4 includes re-audit. Re-audit should always be part of the initial cycle and not viewed as something that comes after. Re-audit effectively assesses whether the planned changes have been effective.
The cycle may need to be repeated several times to demonstrate that quality of care has improved. This approach to audit is the only way to monitor (and sustain) improvement.
Place emphasis on the fact that clinical audit can be used as a tool to demonstrate reflection and improvement of clinical practice.
ALS_Session3_V /05/16

47. Integrating clinical audit with other quality improvement activity
QOF
Locally Commissioned Services
RightCare inidcators and pathways
CCG Assurance Framework
Revalidation
Raising dissatisfaction
QIPP agenda
CQINN scheme
Pathway and service redesign
Care Quality Commission
Doctors already participate in a range of regional, national and specialist quality improvement activities that gather information about the quality or outcomes of clinical care. Examples are on the slide.
Involvement in these activities may provide opportunity for in-depth clinical audit that can help to fulfil both the requirements of the specific initiative and the audit requirements for GP revalidation.
Developing a culture of ongoing quality improvement activity and incorporating clinical audit into everyday practice will ensure that your surgery provides quality, sustainable, and improving standards of care and meets national requirements without significant additional work.
Planning audit requirements as a practice team and on a frequent basis will provide opportunities to identify where requirements overlap and efforts can be combined. For example one of the quality and productivity (QP) indicators within the Quality and Outcomes Framework involves reducing the emergency admission of patients. If this is transformed into a fully fledged audit based upon standards and a full audit cycle completed, there is no reason why this could not form the basis of an audit for GP revalidation (so long as the GP can prove relevancy to their individual role).
ALS_Session3_V /05/16

48. Aims
Safe
Be as safe for patients in health care facilities as in their home
Effective
Match science, with neither underuse nor overuse of the best available techniques
Patient Centred
Revolve around the patient who should play an active role in making decisions about their own care
Timely
Mean that patients do not experience waits or delays in receiving care and services
Efficient
Be cost effective and reduce/remove waste
Equitable
Disparities in care should be eradicated

49. PLAN DO STUDY ACT PDSA Cycle Plan next steps – action plan!
Implement proposed changes
Repeat cycle - assess effectiveness
Plan the work – which practice/system/ tool?
PLAN DO
STUDY
ACT
The process promotes continual improvement.
The PLAN stage includes gathering data on the current situation and past history.
The DO stage is actually a experiment stage where possible improvements are tested as pilots (on a small scale).
In the STUDY stage the results of those experiments are studied.
And the ACT stage is used to adopt improvements if the experiment found successful methods.
Today is part of the planning stage as you will learn about each of the tools and hopefully therefore decide what it is you might like to plan to achieve within your practice. What is it that you are trying to do? What results do you expect to see?
An important practice (as Deming taught) is to document what improvements are expected in the planning stage. What do you expect to achieve?
Review the results in CHART - what do they mean?
Lessons learnt
Install CHART
Run the MIQUEST data searches
Using PRIMIS tools for quality improvement_V th October 2017

50. does not have to walk on water but…
The change agent
does not have to walk on water but…
should be patient, persistent, honest, trustworthy, reliable, positive, enthusiastic, co-operative, confident (but not arrogant) a good listener, observant (of the feeling and behaviours of others), flexible, resourceful, difficult to intimidate, willing to take risks and accept challenge and be able to handle organisational politics.
And they should have a sense of humour, a sense of perspective and be able to admit ignorance and ask for help when appropriate…”
After a model for implementing the change has been selected, change is most effective if there is someone to lead, manage and implement the change. This could be an individual or a team of people depending on the size and expected impact of the change. They are commonly described as change agents or facilitators. Ideally, change agents should have an affinity with people and understand how change can affect individuals and their environments. They may already work within the organisation or be employed independently.
Change agents are able to recognise the value of people and their contribution to the change process. If people are not consulted and advised appropriately, successful change is much more difficult to achieve. With this in mind, a change agent should be able to engage people using communication skills, interpersonal skills and active listening skills. They should also: be reflective
have the ability to lead
channel and plant ideas
be able to manage reconciliation and resolve conflict
have an awareness of organisational culture and political intelligence
All of the skills, characteristics and abilities attributed to the change agent (whether it is an individual or a group of individuals) play an important role in successful change management, especially that of communication.
Hutton D.W., The Change Agents’ Handbook. (1994)
MGCHG_Ppt_V March 2014

51. Questions
Using PRIMIS tools for quality improvement_V th October 2017