1. Safer Medicines Outcomes on Transfer Home
SMOOTH
Safer Medicines Outcomes on Transfer Home
CLINICAL LEAD Sanjoy Nand
SMOOTH TEAM Team Lead: Rebecca Lawn
Sonia Varma, Ahmed Marmoush
PROJECT SUPPORT Doreen Liow, Nazanin Falconer
Karla Rika-Heke, Maika Veikune
Ian Kaihe-Wetting, Truc Nguyen
20,000 Days Ian Hutchby, Monique Davies

2. Safer Medicines Outcomes on Transfer to Home (Discharge Medicines Management)
SMOOTH’s Aim:
2-3% reduction in readmissions associated with medication related problems
by providing 90% of high risk adult medical and surgical patients with a
medication management service at discharge and during the immediate post
discharge period (7 days)
Collaborative 20,000 days campaign
Using a risk predicative tool to determine patients at highest risk of medication related harm

3. SMOOTH Driver Diagram -

4. Why SMOOTH?
Medication management support at the discharge phase has been adhoc – resulting in inaccurate and incomplete information being provided to patients and primary care providers resulting in suboptimal medicines use
Patients often don’t understand the changes made, some are unaware of the importance of taking medicines or what the new medicines are for which results in inappropriate disease management, adverse drug events and readmissions
Evidence suggests that pharmacist interventions at discharge and pharmacist led follow up of discharges (care integration) results in lower rates of readmission
The intervention improves patient care when transitioning from hospital to home, optimises medicines use, integrates care and improves overall patient safety

5. ART Tool

6. SMOOTH Change Packages
Secondary Drivers
Change Ideas Tested
Evidence of Improvement
Identify target population
Use ART Tool vs referral process by clinical pharmacist to identify patients.
ART tool adopted as captured 70% of patients identified by clinical pharmacist as needing SMOOTH services.
Discharge Planning Process
Notification process for discharge to be implemented
Initially SMOOTH patients reviewed and assessed on admission and again at discharge. The average time spent on each patient found to be 3 hours – too long. Process modified to provide service when notified of discharge only, reduced time per patient to average 1 hr
Implementation of GDD on wards has improved workflow, more idea of when patients for discharge
Magnets introduced – improved profile of SMOOTH
SMOOTH sentence in discharge summary to be entered by clinical pharmacists
ART access provided to nurses

7. SMOOTH Change Packages
Secondary Drivers
Change Ideas Tested
Evidence of Improvement
Discharge care package and medication processes
Medication reconciliation at discharge to prevent errors and ensure accuracy of information communicated to patient and primary care providers.
Tailored patient education
Interventions package provided.
Data collection form created to capture key measurements and standardised process. Refined over time to improve efficiency of data collection
Electronic version created to eliminate process of data entry proved too time consuming
Use of laptops to ensure access to computers for SMOOTH pharmacist at time of discharge allowing services to be provided in a timely manner.
Patient questionnaires developed – obstacles in collection of patient experience data, process currently being refined
Communication and follow up
Communication of information to other health professionals
Communication with patient, family or care givers if medication not collected or reason to follow up. Time consuming process.

8. SMOOTH Measures Summary
Total number of patients seen each day is recorded on a work list. This enables us to measure how close we are to achieving our aim
A care package was created to formalise the medication management services the SMOOTH team provides
A data collection form is utilised to document the number of discrepancies or errors prevented. Each error is then graded using a standardised approach
Additionally, the services each patient receives at discharge and during the immediate post discharge period is documented on the data collection form, using a tick box approach

9. SMOOTH Implementation
Implementation Areas
Changes to Support Implementation
PDSA cycles
Standardisation
1.Standard Criteria to determine which patients seen i.e. high risk as determined by the ART tool
2. Standard process checklist for seeing pts at discharge
1. Asked for referrals by pharmacist, checked ART score, found 70% of referrals were HR as defined by ART. Decided ART tool was valid way to select patients
2.Test process for seeing patients at discharge (see other pharmacists)
Documentation
1. Job descriptions for pharmacists involved in process
2. Standard data collection form
1.Test description of a care integration pharmacist
2.Devolop and test data collection form against project measures
Training
1.Training other pharmacists to support implementation of change eg, SMOOTH sentence, notification of discharge
2.Doctors information at medical handovers
3.Nurses for use of ART tool
1.Test whether the inputting of SMOOTH sentence increases number of patients seen
2. Medical staff awareness of SMOOTH service
3.Test whether nurse use of ART tool increases notification to SMOOTH team
Measurement
1. Number of patients seen at discharge
2. Monitoring number of errors and types of errors
3, Patient experience
1. Ensure adequate number of patients seen
2. Test whether EDS contains errors
3. Patient feedback sought at point of admission and at point of discharge
Resourcing
1. Pharmacist resource
2. Modify hours to capture more patients
3. Laptop purchases
1.Currently adequately resourced for Medicine. Will PDSA resources when roll out to surgical. Will assess alternate model for service delivery in Surgery.
2. Review hours to determine if need for extended hours within current resource
3.Laptops improved workflow for SMOOTH pharmacist
Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

10. SMOOTH Highlights
Rapid development and implementation of the SMOOTH change package
Multiple system refinements: Development of a standardised discharge process and care package of interventions with clinical pharmacy
Implementation of a formal process for notification of discharges organisation wide
Collaboration with other health professionals: recognition from medical staff about the need for medication management at discharge interface and acknowledgment of the quality of clinical and patient centred services provided by SMOOTH team
Collaboration with quality improvements personnel and valuable learning from each other to test change packages and ideas
Key learning: Small, inexpensive tests of change via PDSA cycles can provide valuable return in overall learning. Failure can provide successful learning .

11. SMOOTH Lowlights Difficulty capturing meaningful patient feedback
Slow uptake with the notification of the discharges resulting in very low numbers for SMOOTH
Reliance on various methods for notification of discharges – not a self sustained process - workflow not consistent
Time constraints impacting delivery of services
Limitations with capturing 90% of high risk patients discharged .

12. Variation in processes
Currently data is collected consistently due to standardisation of the collection form
Some variation is noted in provision of service and interventions as these services are time dependent and reliant on early notification of the discharge. These variations can be measured by capturing the time of notification vs the number of interventions provided per patient
Variation in provision of services provided across different populations due to language barriers and time restraints. These variations can be measured by comparing the number of interventions provided per patient vs the ethnicity of the patient
Variation in recording information on the EDS by individual SMOOTH pharmacists. These variations can be measured by retrospectively auditing 20 EDS for information recorded .

13. SMOOTH Achievements to date
Change package provided to 385 general medical patients.

14. SMOOTH Results so far… From 133 errors - using epifany grading systems
Grade all errors based on actual outcome – but where the patient did not receive a dose grade on most likely outcome if patient had received a dose:
5 -An error that resulted in SERIOUS/CATASTROPHIC HARM to patient.
4- An error that resulted in MAJOR HARM to patient. Major harm is that requiring increased hospital stay or significant morbidity.
3- An error that resulted in MODERATE HARM to patient. Moderate harm is that requiring treatment with another drug OR cancellation/postponement of treatment.
2- An error that resulted in MINOR HARM to patient. Minor harm is that requiring minor (non-drug) treatment or treatment change.
1- No harm or only minor harm – not requiring “treatment”

15. SMOOTH Achievements to date
Out of 365 who received the care package ~35% (133) had at least one error identified on the discharge summary