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Alastair Carmichael
Primary Care Pharmacy Consultant
Quote from Dispensing Doctors Association Guide to Dispensing 2019:
“If we want to retain the ability to provide the dispensing services that our patients value so highly, then it is essential that those services are of the highest quality”
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But, what is “Quality”? Feels valuable?
Getting something for your money?
Reliable product or service?
Safe method of operation?
Feels better than the “economy” version?
Often costs more?
Differentiates a product or service from its competitors?
Developing Quality, Efficiency, Safety
Examine the details of the Dispensary Services Quality Scheme
Looking at how you can help develop the above 3 key elements of your dispensary service
There will be….
Practical tasks within your groups
Sharing different experiences and knowledge
DSQS – What is it? Dispensary Services Quality Scheme Compiling of: Team Competencies CPD SOPS DRUMS Clinical Audit Optimum resource level Serious and untoward incident monitoring &
reporting
DSQS – What’s worth to your practice?
£2.58 per “active” dispensing patient per year.
Large practice with 10,000 dispensing patients = £25,800!
DSQS / Quality What parts of DSQS can help our practices build real
quality?
- Valuable
- Reliable
- Maintain safety
- Differentiates your services from your competitor
DSQS – What is it? Dispensary Services Quality Scheme
Compiling of:
Competencies
CPD
SOPS
DRUMS
Clinical Audit
Optimum resource level
Serious and untoward incidents
Standard Operating Procedures:
Standard Operating Procedures: Why do we have them?
Who writes them?
Who is responsible for ensuring they work?
Who reviews them?
Standard Operating Procedures:
Why do we have them?
- Primarily - safety
Who writes them?
- Anyone who performs the processes
Who is responsible for ensuring they work?
- The team manager & Everyone!
Who reviews them?
- Anyone in reality
SOP’s – Let’s write one! Key elements needed:
• Objectives – what are we trying to achieve?
• Scope – what area does this cover?
• Responsibilities – who is responsible for carrying out these procedures and who is responsible for ensuring it happens?
• Process steps – in as much detail as logically necessary
• Date of preparation & review – imperative!
• Signatures – those responsible & those using
SOP Titles:
Issuing of repeat prescription
Registering a supply of a CD to a patient
Receipt and destruction of patient returned CD’s
Any other suggestions?
Review of SOP’s Minimum every 12 months or when a change has been
necessary due to change in legislation or perhaps review of a error?
Who is responsible for the review?
What can you do to help the team maintain a credible, safe & useful set of processes?
Developing Quality: DRUM’s
Dispensary Review of the Use of Medicines
Not a clinical review, but a practical review
Does not necessarily need a confidential room to carry them out – a discreet area.
Dispensary team perfectly placed to gather information that your clinicians would never hear
Good feedback and recording essential
Developing Quality: DRUM’s
Questions on DRUM template:
- Are the medicines working?
- Do you remember to take them as prescribed
- Do you suffer from any side effects?
- Can you read and understand the labels?
- Can you open the container?
- Do you have a problem using devices?
Developing Quality: DRUM’s
Questions on DRUM template:
- What type of questions are all these?
Developing Quality: DRUM’s
Are the medicines working?
= Yes or No?
Softer approach: Do you think your medicines are working?
- Allows patient to consider response?
- Uses the word “your” to pass ownership to the patient
- Who knows if medicines are working really?
- Based on symptom control?
Output from DRUMS?
Are they targeted at any particular patient group? Eg Asthmatics?
Are the results reviewed or compiled by anyone?
Could the output for the reviews be shared with your prescribing team in order to improve patient care?
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Developing Quality: Clinical Audit Big increase in concern and interest from NHS England
Regional & Area teams
Some practices have had money withheld due to audits not being acceptable!
DSQS requirement to carry out one clinical audit within the dispensary each year
Aim is to seek ways to improve patient care and outcomes
Systematic review of care against a given standard/best practice, which may lead to implementing change
Audit should only be possible to be conducted by a Dispensing Practice and not a Prescribing-Only Practice
Patient surveys are not an acceptable audit
Developing Quality: Clinical Audit Advice from DDA and NHS England:
Define what is going to be measured against a guideline or accepted best practice standard
Audit should involve the whole team
Set the dates for when data will be collected
Establish what is the patient sample or group
Gather the data and compare against the agreed standards
Review where improvements could be made to improve performance
Set dates to re-audit in the same methodology
Review the new results to see what happened
The Audit Cycle:
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Examples of Clinical Audit: Use of BG testing strips by your type 2 diabetic pts – do
they use according to guidelines? The taking of bisphosphonates (Alendronic, Ibandronic) –
do your pts follow the instructions? Asthmatic children aged 5-15 – do they use a spacer device
with their steroid inhaler? Patients taking long term steroids – have they got a suitable
card with their current dose details? Repeat script ordering turnaround? Warfarin Methotrexate
Are we actually doing what we thought we were doing?
Examples of Clinical Audit: Key elements of a good audit:
1. Measureable criteria, which are known by clinicians/ healthcare professionals
2. Defined pt group – gender, age range etc
3. Defined pt number
4. Be prepared to fail, learn and change
Group Exercise: Write a clinical audit plan Key elements: 1. What are the established criteria you are measuring
against? 2. What sample of pts are you targeting? 3. Over what time frame are you carrying the audit out
for? 4. How are you going to record your results? 5. How are you going to share these with your clinical
team? 6. What changes are you going to make before re-
auditing?
Clinical Audit Plan: Alendronic Acid Criteria: Alendronic Acid 70mg should be taken once a week
only, 30 minutes at least before food whilst standing or sitting upright; washed down with a full glass of water.
Establish how many patients are taking this medication correctly Patient group: Both sexes, all ages? Patient numbers: Just 20? Review with patients as they collect their repeats? Open question: “Can you tell me how and when you take this
medication?” Grade feedback – 100% to 0% correct? Easy to review data and feedback? Action needed – Improved counselling? Written information? Re-audit – same group or different group??
Clinical Governance for the Dispensary: - “Clinical governance can be defined as a
framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will f lourish.”
- What does this really mean for your dispensary?
Clinical Governance for the Dispensary: Safeguarding high standards in dispensing
Create the right environment
Constantly measure your performance and safety
Create a reporting mechanism so that all errors however they have occurred are reported.
Review these errors on a regular, open basis and ensure learning
Defining Errors: Different definitions, but they will happen
Near Miss – an error which was identified, which had the potential to cause harm or danger, but was prevented from doing so.
Significant Event – an error in patient care which reached the patient/ affected the patient, although the effect or harm is not quantified.
Defining Errors in Dispensary:
Recommendation:
- Near Misses – all errors that were identified during the prescription and dispensing process, that did not reach the patient, and were able to be rectified
- Significant Event – any error regardless of outcome which reached the patient – ie: the error breached the SOP’s in place to protect the patient
Defining Errors in Dispensary: Near Miss Recording:
- Have simple recording available to all team members at all times – either on the PC desktop system; or paper copy on workbench
- Detail exactly what happened, including names of meds, pt ID numbers if need be
- Record team members involved
- Collate weekly; review daily/weekly
- Have team briefings to discuss and learn
- Take action if necessary with SOP’s
Defining Errors in Dispensary:
Near Miss Recording:
- Team should feel comfortable to record any errors, and all team members must comply.
- Similar or frequent errors may establish training need or process failure
- High level of recording is good practice
- Disciplinary action should not be involved in this process, unless training has failed to improve performance
Defining Errors in Dispensary:
Significant Events:
- Any error that reaches the patient (in dispensary terms) no matter if medication has been taken
- Your practice should have a standard process of reporting and recording
- Inform your CCG in accordance with good local practice
- Review any SE’s in line with Near Miss Records
- A lack of SE reporting is as worrying as an excess!
Developing Quality in your Dispensary
Can you add quality to your dispensary?
Could you develop ways to improve the efficiency of your dispensary to improve patient care?
Can you ensure your dispensary operations are as safe as they can be?
Developing Quality in your Dispensary – 3 Key Learnings:
Anyone in the team can write an SOP!
Use your DRUMS to help improve patient care
Start on your dispensary audit as soon as possible in order that you can re-audit before end March next year.
