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Medicines Breakthrough
Collaborative 1Wednesday 4
November 2015
A Quality Improvement Approach to Patient Safety in Medicines OptimisationAnna BurhouseDirector of QualityWest of England AHSN
WHAT IS QUALITY IMPROVEMENT SCIENCE?
At present, the evidence is clear that healthcare is not always safe and can lead to poor patient experience and outcomes. At the same time, the economic downturn means an end to year-on-year financial increases. Healthcare services are being challenged to respond to this not through indiscriminate cuts, but by improving efficiency, driving up quality and reducing levels of harm.’
The Health Foundation 2014
The Triple Aim
PopulationHealth
Experienceof Care
Per CapitaCost
Don Berwick 2015
Aims for Improvement
• No Needless Deaths• No Needless Pain or
Suffering• No Unwanted Waits• No Helplessness• No Waste
……For Anyone
• Safety• Effectiveness• Patient-centeredness• Timeliness• Efficiency• Equity
“The First Law of Improvement”
Every system is perfectly designed to achieve exactly the results it gets.
Building Reliable Systems
• Design needs to be woven into working practices, with repeated cycles of adaptation, small steps.
• Find what works, adapt or abandon what does not.• When you know what works on a small scale, look to
implement more widely.• Ask the people who are on the receiving end of care
whether the new methods result in good care.• Open culture, flat hierarchies, challenge is not a threat
but a source of new ideas and improvement
Complexity and Reliability
Aim: “90% compliance with Antibiotic
Received Within One Hour” (4 step process)Probability of on-time successful
completion at each step
Steps 90.00% 99.00% 99.90% 99.99% 99.999%
1 90.00% 99.00% 99.90% 99.99% 99.999%
2 81.00% 98.01% 99.80% 99.98% 99.998%
4 65.61% 96.06% 99.60% 99.96% 99.996%
8 43.05% 92.27% 99.20% 99.92% 99.992%
16 18.53% 85.15% 98.41% 99.84% 99.984%
32 3.43% 72.50% 96.85% 99.68% 99.968%
64 0.12% 52.56% 93.80% 99.36% 99.936%
128 0.00% 27.63% 87.98% 98.73% 99.872%
If the reliability of each step is 90% then the
overall reliability for the 4 steps together is only
65.61% (.90^4=.6561)
How does the complexity of your process
affect reliability?
Diagnosis
Correct antibiotic chosen
Correct prescription
available
Antibiotic given within right time
scale
• ThroughPut Yield (TPY), is defined as the number of units coming out of a process divided by the number of units going into that process over a specified period of time.[1] Only good units with no rework are counted as coming out of an individual process.
• Also related, "first time yield" (FTY) is simply the number of good units produced divided by the number of total units going into the process. First time yield considers only what went into a process step and what went out, while FPY adds the consideration of rework
FIRST PASS YIELD – no rework possible, opportunity missed
• 100 units enter A and 90 leave as good parts. The FTY for process A is 90/100 = .9000
• 90 units go into B and 81 leave as good parts. The FTY for process B is 81/90 = .8889
• 81 units go into C and 73 leave as good parts. The FTY for C is 73/81 = .90
• 73 units got into D and 64 leave as good parts. The FTY for D is 64/73 = .87
• 64 units go into E and 58 leave as good parts 58/64 =.90
• 53 units go into process F 48 leave as good parts 48/53 =0.9
BUT
• The total first time yield is equal to FTYofA * FTYofB * FTYofC * FTYofD or .9000 * .8889 * .90 * .90 = .65
reference - Wikipedia 2/10/14
Reducing Variation
Old Methodology
• Design and them implementation.• Audit, followed by change, followed by audit• Audit time consuming, complex and difficult• Audit of paperwork rather than whether care is better.• Extremely slow process, taking design cycles into years
rather than days
Changing our approach
No action taken here
Reject defectives
Better Quality Worse
Old Way(Quality Assurance)
Requirement,Specification or
Threshold
Action taken on all occurrences
Better Quality Worse
Source: Robert Lloyd, Ph.D
New Way(Quality Improvement
The Three Faces of Performance Measurement
Aspect Improvement Accountability ResearchAim Improvement of care
(efficiency & effectiveness)
Comparison, choice, reassurance, motivation
for change
New knowledge(efficacy)
Methods:• Test Observability Test observable
No test, evaluate current performance Test blinded or controlled
• Bias Accept consistent bias Measure and adjust to reduce bias
Design to eliminate bias
• Sample Size “Just enough” data, small sequential samples
Obtain 100% of available, relevant data
“Just in case” data
• Flexibility of Hypothesis
Flexible hypotheses, changes as learning
takes placeNo hypothesis
Fixed hypothesis(null hypothesis)
• Testing Strategy Sequential tests No tests One large test• Determining if a change is an improvement
Analytic Statistics(statistical process
control) Run & Control charts
No change focus(maybe compute a
percent change or rank order the results)
Enumerative Statistics(t-test, F-test, chi square, p-values)
• Confidentiality of the data
Data used only by those involved with improvement
Data available for public consumption and
review
Research subjects’ identities protected
Knowledge Base for Continual Improvement
Knowledge for Improvement ▪ Systems▪ Variation▪ Psychology▪ Improvement techniques
Continual Improvement
Subject andDiscipline Knowledge
+
Adapted from Don Berwick 2015
• Appreciation of a system• Understanding of Variation• Theory of knowledge• Psychology
(adapted from Langley et al)
The Science of Improvement
THE MODEL FOR IMPROVEMENT: PLAN, DO, STUDY, ACT
When you combine the 3 questions with
the…
PDSA cycle, you get…
Source: The Improvement Guide p. 10
…the Model for
Improvement.
A Modelfor Learning and
Change
Bayes’ Simple Rule
Thanks to Bob Lloyd for this slide
“By updating our initial belief about something with objective new information, we get a new and
improved belief.”
Rev. Thomas Bayes(1701-1761)
Changes that Result in
Improvement
HunchesTheories
Ideas
A P
DS
A P
DS
AP
DS
A P
DS DATA
Learning over Time
Repeated Uses of the Cycle
Develop approaches to improve glycemic
control
Proactive glycemic control an integral part
of system
A PS D
APS
D
A PS D
D SP A
DATA
D SP A
Cycle 1: Develop system to track Hbalc levels for diabetic population
Cycle 2: Establish protocol for HbAlc routine measurements
Cycle 3: Collaborative planning or control levels
Cycle 4: Set target levels for HbAlc levels
Cycle 5: Implement protocol with all staff
Learning over Time
Improving Management of Population – Diabetic Blood Sugar Levels
Detail D
esign
A P
S D
AP
SD
A P
S D
D S
P A
A P
S D
AP
SD
A P
S D
D S
P A
A P
S D
AP
SD
A P
S D
D S
P A
A P
S D
AP
SD
A P
S D
D S
P A
Self CareSupport
Delivery SystemDesign
Decision Support
Clinical Information
Systems
Using Multiple “Ramps” over time:
Chronic Disease Care
A Collaborative Approach
• Do you know how good you are?
• Do you know where you stand relative to the best?
• Do you know where the variation exists?
• Do you know the rate of improvement over time?
The Breakthrough Series
National AHSN MO patient
safety collaborative
People support what they help to create: microsystems
“The most important single change in the NHS… would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end…”
Don Berwick
Diabetes Digital Coach
Elizabeth Dymond Deputy Director of Enterprise West of England AHSN
AHSN’s Mission
• Building a culture of collaboration and partnerships
• Speeding up adoption of innovation into practice
• Creating wealth through co-development testing and early evaluation and spread of new products and services
Driving Innovation by making the NHS a Lead Customer
Challenge led approach
AHSN Challenges R4H
National scene
“We want to see patients and carers involved in decisions about their care, receiving appropriate structured education to support self-management, having more control and managing their own health, care and treatment.” Act for Diabetes 2014 NHS England
Provide staff and patients with access to high-quality tools for structuring and recording care-planning and shared decision-making. Kings Fund 2014
The NHS Five Year Forward View committed to developing a National Diabetes Prevention Programme. A delivery group from NHS England, Public Health England and Diabetes UK is currently leading the design of the programme.
Challenge Process
• Members work together
• Define an unmet need
Challenge Definition
• Challenge is published
• Companies respond
Challenge Launch • Best solutions
picked• Lead
Customers• Projects up to
£50KReview
• Evaluation• Learning shared• Next steps
Go - live
Soft Start Innovation
Content slide heading
Clinical Commissioning Groups
Bath and North East Somerset
Bristol
Gloucestershire
North Somerset
South Gloucestershire
Swindon
Wiltshire
• “By working with the AHSNH we would be able to access technologies and providers that otherwise we would not be aware of but neither would we have the internal resource to procure.” (South Gloucestershire CCG)
• “Together we are leading on redesigning the clinical pathway for our patients with Diabetes and are consequently very interested in this project.” (BANES CCG)
• “I was interested to read about the diabetes mobile and web based work in the West of England AHSN newsletter. We would be keen to be involved in testing and evaluation of products if you are looking for this.” (North Somerset CCG)
Opportunities for company applicants
Your innovative product will be used & evaluated in a real world setting.
You will submit a quotation rather than a tender as we are looking to evaluate a number of innovative solutions with the costs of each one less than £50,000
You will receive a report on the evaluation which will also be shared with West of England
AHSN members who commission and provide healthcare services across our region with a population of 2.4 million people.
You have the opportunity to develop your products in line with commissioner and provider
requirements.
Increased potential for sales in West of England healthcare providers.
Increased potential for national sales as the 15 AHSNs across England share case studies.
Registration on national portals to receive alerts on further relevant public sector procurement opportunities.
What if ……healthcare records were shared
between the person with diabetes and other people
and services that the person wishes to share
that record with? Viewing, inputting and editing rights
are controlled by the person with diabetes and records are available in
real time.
What if….. services were set up so that
healthcare professionals and patients can email,
text and phone each other?
What if ……services were truly joined up to be person-centric and personalized to account for many
people with diabetes having
another long term condition?
What if ….we can enable every citizen to self-care in their
own way to the benefit of their health,
both physical & mental?
Diabetes
139 per cent more likely to be admitted to hospital with angina 94 per cent more likely to be admitted to hospital with myocardial
infarction 126 per cent more likely to be admitted to hospital with heart failure 63 per cent more likely to be admitted to hospital with a stroke 400 per cent more likely to be admitted to hospital for a major
amputation and 817 per cent more likely to be admitted with a minor amputation
272 per cent more likely to be admitted to hospital for renal replacement therapy (ESKD)
http://www.hscic.gov.uk/nda
mHealth
• ….also known as mobile health, covers medical and public health practice supported by mobile devices
• Mobile phones• Patient monitoring devices• Apps• Wearables• Health information• Medication reminders
Self-Management
99% of diabetes care falls to self-management.
Shared decision making: clinicians and patients working together to
– clarify treatment, management or self-management support goals,
– share information about options and preferred outcomes
to reach mutual agreement on the best course of action
Key Dates 2015
• 23rd June – Launch• 22nd July – Deadline for submissions - 27• 27th July – Prepare shortlist - 19• 31st July – Review panel - 8• 15th Sept – Interviews - 5• 4th Nov – Test Bed submission
Thank you
Next steps• Discussions starting on how this programme
links with MO work• Test Bed decision end Dec 2015• Start Diabetes Digital Coach tools projects
• Thank you
Transfer of Care – Supporting PatientsMartin Littleton, Implementation Manager
Avon Local Pharmaceutical Committee
Supporting Community Pharmacy across Avon
Supporting Community Pharmacy across Avon
Why is it needed?
Supporting Community Pharmacy across Avon
Hospital Discharge Project• At point of discharge from hospital patients are signed
up to the service• Patient information securely transferred to the chosen
pharmacy• Pharmacy accesses data on PharmOutcomes
– Includes an attached TTA letter• Pharmacy contacts the patients
– Medication review– Review of new medicines where appropriate– Ensure the patient is clear about their condition and how to
administer their medicines
Supporting Community Pharmacy across Avon
Proof of concept
• The technology of PharmOutcomes would work for this service
• Pharmacies would contact patients• Patients would be receptive to the service• Demonstrated outcomes (small scale)
Supporting Community Pharmacy across Avon
Patients are benefiting
Supporting Community Pharmacy across Avon
Outcomes Are Better
• Mid July patient discharged and not seen in pharmacy• Patient re-admitted. Discharge in September and pharmacy
followed up• Patient not been discharged through service since
Patient not intervened
with
• Patient went in with one medication and came out with nine• Pharmacist spent time explaining and introduced a
compliance aid• Patient now happy
Multiple medication
• GP didn’t want to get involved • Pharmacy contacted hospital and investigated• Diagnosis correct, pharmacist intervened and patient now
happy to take medication
Pharmacist interventio
n with hospital
Supporting Community Pharmacy across Avon
What next?
• Pharmacy contractor engagement and training• Is the payment via an MUR or NMS
sustainable?– Good outcomes achieved without these
• Is there the possibility of a commissioned service…what would this look like?
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