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PrISMS Collaborative
Intervention Bundle (October 2016)
Developed and tested by our collaborative GP practice teams
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Contents
Foreword ................................................................................................................................................. 4
Overview ................................................................................................................................................. 5
What is an intervention bundle? ............................................................................................................ 5
Introduction ............................................................................................................................................ 6
Interventions ........................................................................................................................................... 7
Applying the interventions...................................................................................................................... 7
1. Protected GP Review Time.............................................................................................................. 8
2. Electronic Monitoring of Patients ................................................................................................. 10
3. Raising Awareness......................................................................................................................... 12
3a. Raising Staff Awareness ........................................................................................................ 12
3b. Raising Patient Awareness .................................................................................................... 14
4. Hard Stops in the System .............................................................................................................. 16
5. Gold Standard Framework ............................................................................................................ 17
6. Medicine Safety Huddles .............................................................................................................. 18
7. Training Package for Locum Staff.................................................................................................. 19
Other ideas for change: ........................................................................................................................ 20
Appendix ............................................................................................................................................... 21
Getting Started on Haelo Hub ........................................................................................................... 21
PrISMS Practice Contact Details ........................................................................................................ 22
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Foreword
Over the last 12 months, we have seen the PrISMS Collaborative GP practice teams test many innovative ideas and change systems to improve the safety of medicines prescribed by primary care in Salford. We have witnessed the hard work and commitment that has been required from both the practice staff and the dedicated faculty of experts behind the scenes. We are aiming for the collaborative practices to have 95% of their patients on higher risk medicines (Non-Steroidal Anti Inflammatory Drugs, Methotrexate and Amiodarone) to have optimised medicines care by the end of 2016. In order to achieve this aim we need to further test the interventions developed across all the practices in the collaborative. The launch of this intervention bundle marks an exciting point in our improvement journey, with seven tools designed, tried and tested by you on a small scale to improve the quality of prescribing of our higher risk medicines and reduce the potential risks from their use.
We know there will be more lessons to learn as testing scales up, it is important to remember that understanding what doesn’t work is as important as learning what does. Continuing to develop and further refine these interventions over time is also important. We look forward to working with you further to support the ongoing development of this bundle, which we hope to spread widely across GP practices in Salford in the coming year.
Francine Thorpe
Director of Quality & Innovation
NHS Salford Clinical Commissioning Group
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Overview
The PrISMS collaborative launched in September 2015. Since then, teams have been
working hard to develop and test changes in order to make a positive impact on the care
delivered to patients.
The practices that have been taking part in the collaborative and who are working together
to test new ways of working are:
Clarendon Medical Practice, Langworthy Medical Centre, Blackfriars Medical Practice,
Mosslands Medical Practice, Pendleton Medical Centre, Salford Health Matters, St Andrews
Medical Practice 2 and St Andrews Medical Practice 3.
We would like to thank all of these teams for their hard work and commitment.
The collaborative has been utilising the Model for Improvement (see
figure 1) as a framework for testing new interventions and making
changes in their areas.
The Model for Improvement is a simple, but effective too for
accelerating improvement.
The model has two parts:
Three fundamental questions
The Plan-Do-Study-Act (PDSA) cycle to test and implement
changes
The PDSA cycle provides structure to each test of change to help
determine if the change is an improvement.
Reference: Langley GL, Nolan KM, Nolan TW, Norman CL, Provost, LP. The Improvement
Guide: A Practical Approach to Enhancing Organizational Performance.
What is an intervention bundle?
An intervention bundle is a group of interventions which, when adopted and applied will
address a particular problem. This bundle has been developed to assist teams to improve
their processes for ensuring the safety of patients on high risk medicines. Many of these
interventions interlink and will be most effective when they are combined together as a
bundle rather than when they are used individually.
Figure 1
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Introduction
PrISMS (Practices Improving the Safety of Medicines in Salford) is a Breakthrough Series
Collaborative designed to improve medication safety in primary care in Salford. The work
has been commissioned by Salford Clinical Commissioning Group (CCG) and delivered jointly
by the CCG and Haelo (Salford’s innovation and improvement science centre). Eight Salford
based practices have signed up to take part in this programme of work, with the aim that
95% of patients on high risk medicines (NSAIDS, Methotrexate and Amiodarone) will have
optimised medicines care by October 2016.
Figure 2
The above driver diagram was developed for the programme and articulates the
collaborative theory for change and how the collaborative practices will achieve the aim.
The practice teams identified small tests of change in areas they believed would lead to
improvements. The interventions that follow are the result of the work carried out by those
teams.
You have already taken the first steps towards improving the safety of patients in your care
by taking part in this collaborative. The next step is to apply the interventions listed in this
document to support the testing of large scale change. By working with your colleagues
across the collaborative and developing new standards you can make a real difference to
medicines safety, and begin to drive wider change in Salford.
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Interventions
This intervention bundle has been created to help support the scale up and spread of seven
key interventions that have been tested in individual practices. We believe that if applied
correctly, these will help to improve medicines safety for patients:
Protected GP Review Time
Electronic Monitoring of Patients
Raising Awareness
Hard Stops in the System
Gold Standard Framework
Medicine Safety Huddles
Training Packages for Locum Staff
Applying the interventions
We would like you to apply all appropriate interventions in your practice. For some practices
this will be more than others depending on what systems you already have in place. It is
advised to take each new intervention and test it on a small scale to start with in order to
allow staff and teams a chance to experience and understand how the intervention works.
This will also allow you to make small changes and adaptions to the intervention, to suit
your local environments, as we recognise every system is slightly different.
This should be achieved by rapidly testing and applying the interventions on ‘one patient’,
‘one day’, ‘next shift’ etc...
As your staff and team’s confidence increases; begin to apply and standardise the
intervention within your practice and daily working systems.
You may wish to collect some local process data to track and monitor the reliability of the
interventions as they are being applied.
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1. Protected GP Review Time
It is important to allow GPs enough time to review patient discharge summaries to lower the risk of
harmful drug interactions. This intervention forms part of the ‘Monitoring Systems’ driver.
What is protected GP review time?
This intervention sets aside time each day for GPs to review all relevant discharge
summaries received during the previous day. This commonly only pertains to discharge
summaries that contain changes to a patient’s medication. In this time GPs would review
the patients notes and requirements, make follow up calls to the patient and other medical
professionals as required.
What has testing shown?
This intervention can be tested in various ways depending on which works best for your
particular practice.
One of the practices testing this intervention, Clarendon Medical Practice, has multiple sites.
This allows them to assign the GP working in the quieter surgery 30 minutes per day to
review all medicines reconciliation letters that have been received during the previous day.
However, it is possible to consider assigning a specific room in the surgery where this can
take place.
Mosslands Medical Practice used their Vision appointment system to allocate time as an
‘acute medicine’ slot, i.e. the slot is not a face to face patient appointment but a time slot
for a GP to check medicines reconciliation changes for a particular patient and contact the
patient if needed.
Figure 3
This chart shows that Clarendon Medical Practice has
seen a positive increase in the proportion of patients
where significant changes to medications have been
discussed with them or their representative within 5
working days of the IDL (Immediate Discharge Letter)
being received by the practice (Medicines Reconciliation
Measure 4).
If the next data point is continues on this trend for
another month we will see positive statistical change.
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How should protected GP review time be tested?
In order to test this change we would like you to:
Discuss with your colleagues which option for protected GP review time will work
best at your practice i.e. a set time in a quiet area for one GP each day, an
appointment system or a combination of both.
Decide which GP should conduct the review process each day.
Ascertain how long the GP will need to complete the mean amount of discharge
summaries.
Identify a place for the GP to undertake this work (if applicable).
Block out appointment sessions in the GP worklist on the required day (if applicable).
Identify the daily administration staff that will review and sort the discharge
summaries.
Collect data on the testing process (optional).
Gather feedback from staff.
Make any changes to the process as necessary.
Top Tips
Make sure each referral has already been checked and coded by a member of the
administration team and that only those which require a clinical action are assigned
to a GP.
On Mondays it may be worth splitting the discharge summaries between two GPs or
blocking out extra time for the GP who is assigned to the task as they will need to
work through all the summaries received over the weekend.
When organising the GP review time, it is important to think about how to ensure
that this time is truly protected and how to allow the GP to work on this intervention
uninterrupted.
When creating the appointment slot it is important to ensure the information
required to review the patients is easy to find. This can be done by creating a list of
patients to be reviewed within the booked appointment slot, enabling the GPs to
locate the patients directly within Docman.
GPs should document their actions on screen after reviewing the medications; this
means the surgery will always have an audit of what has been done with the
medications.
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2. Electronic Monitoring of Patients
The EMIS Web and Vision practice systems have many features that make it easier to monitor
patients on high risk drugs in order to help prevent harm. This intervention forms part of the ‘Safe
and Reliable Prescribing’ driver.
What does this mean?
Introducing monitoring systems for patients can help ensure that patients on high risk
medications are dealt with by all systems in a consistent manner. Blackfriars Medical
Practice tested this intervention and focused on patients who are prescribed Methotrexate
and used forms or templates built into their EMIS Web clinical system. The form has a
number of sections that staff need to complete when initiating a patient on Methotrexate
or when taking blood from these patients. Some of these sections cannot be advanced until
the required action has taken place creating a ‘hard stop’ in the system. Please note: there is
also a similar form available for the Vision system.
When should these forms be completed?
These templates should be used by a GP or clinical pharmacist when a patient is newly
started on a DMARD or newly joins the practice and is taking a DMARD. When it is time for
a patient’s DMARD blood test, the nursing staff and/or HCA should use the DMARD blood
sample template.
Further details of these forms and a guidance document are available to download from the
PrISMS Intervention Bundle section of Haelo Hub. If you do not have access to Haelo Hub,
please contact the team at [email protected]
What has testing shown?
According to baseline data collected by the test site, only 1 out of 6 GPs were able to locate
all information relevant to Methotrexate patients in a timely manner. However, after testing
of the new template this was increased to 6 out of 6 GPs. This is a clear improvement and
should serve to increase the reliability of Methotrexate prescribing
Figure 4
This chart shows that Blackfriars Medical Practice has
seen an increase in the proportion of patients that have
ever received or declined a pneumococcal vaccine
(Methotrexate Bundle Measure 4).
This measure has shown a percentage change of 200.3%
from a median value of 33.3% to 100%, the change
occurred after version 1 of the EMIS Web template was
introduced in April 2016.
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How should electronic monitoring be tested in your practice?
In order to test this intervention we would like you to:
Download and install the initiation and blood test templates on to your practice
clinical system.
Raise awareness of the templates with all clinical staff and explain how to use them.
Use the initiation template once for all patients on Methotrexate and then any
future patients that are prescribed Methotrexate.
Use the blood test template when taking bloods.
Collect data on the testing process - this can be done using the SMASH dashboard by
checking the number of patients who are being prescribed Methotrexate with a FBC
and LFT and obsevng how this changes over time.
Gather feedback from staff.
Make any changes to the process as necessary.
Top Tips
Make sure that practice policy is updated to add the DMARD initiation
form/template at the start of a patient’s prescription on Methotrexate, otherwise
information about shared care will not be captured.
Make sure that staff filling in the template do not input the follow up date as
‘today’s date’; an incorrect date will lead to patients not being monitored correctly.
Use the Methotrexate questionnaire (available to download from the PrISMS
Intervention Bundle section of Haelo Hub) to help convince any team members that
change will result in improvement by following these steps.
Run baseline tests with GPs, ANPs and Practice Nurses to ascertain how many
can find the relevant information on Methotrexate patient notes (use the
questionnaire in part 1 of the appendix for this data collection).
Record how long this takes each person.
Repeat these tests after trialling the DMARD templates for 2 weeks.
Feedback the results to staff.
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3. Raising Awareness
One of the most important things we can do to improve a system is raise awareness of any
problems. There are multiple ways to do this and they all form part of the ‘Safe and Reliable
Prescribing’ driver.
How do I raise awareness in my practice?
There are various ways that you can raise awareness of high risk drug combinations and
patients who are susceptible to harm. This could be as simple as sending email reminders,
to adding pop up alerts on your practice system or distributing leaflets. The main methods
that have been tested by the PrISMS practices are outlined below; some of these may be
less applicable for your practice than others however, they have all proven to be effective.
3a. Raising Staff Awareness
Alerts
Vision allows users to add yellow alert boxes on patient records that pop up when high
risk drug combinations are prescribed. Langworthy Medical Centre tested this
intervention and below is an example of what the pop-up box looks like on their system.
The process for adding these yellow boxes is very simple. Click Add in the menu bar at
top of screen then click on Reminder. A pop-up box will appear and once this is
completed the sticker will appear in the corner of the screen.
Figure 5
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Appointments
The Vision appointment system can be used to book an ‘acute medicine’ slot where the GP
can check over a particular patient record, make any changes and contact the patient if needed.
This also fits into the Protected GP Review Time intervention.
Mosslands Medical Practice tested this intervention by colour coding their appointment
slots as shown in the figure below, however you are welcome to test your own system.
Figure 6
Information Leaflets
One practice testing this intervention created information leaflets reminding GPs to
prescribe gastro-protective medicine alongside NSAIDS in patients over the age of 65.
These leaflets were pinned up on notice boards and given to GPs to display in their
rooms. An example of the leaflet designed by Salford Health Matters is available to
download from the PrISMS Intervention Bundle section of Haelo Hub; you may use this
leaflet in your practice or design your own.
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3b. Raising Patient Awareness
Methotrexate Booklet
Salford Health Matters have been using a Methotrexate booklet (available to order here
http://pcse.england.nhs.uk/orders/), which provides patients with a comprehensive
guide to the drug helping to ensure that patients understand the medication that they
are on and why it is important to take the correct dosage. An electronic version of this
booklet can be downloaded from the PrISMS Intervention Bundle section of Haelo Hub.
Figure 7
Side effects on medication boxes
Clearly stating the side effects of medications in a location that patients are more likely
to notice can help to increase medicines adherence it can also raise a patient’s
awareness of how their medicines may interact with each other.
Salford Health Matters have made relevant information for patients visible on the front
of their prescriptions bags. This includes dosage information, blood testing frequency,
red flags and side effects of the medication.
An example of the prescription dosage instructions are available to download from the
PrISMS Intervention Bundle section of Haelo Hub.
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How should I test raising awareness?
In order to test this intervention we would like you to:
Discuss with your colleagues which option for raising awareness you would like to
work on first; bear in mind that you can test more than one method at a time.
Edit any leaflets or templates provided ensuring that they align with your practice
standards.
Share these interventions with your practice staff.
Collect data on the testing process (optional).
Gather feedback from staff.
Make any changes to the process as necessary.
Top Tip
Know your clinical system, read your Vision / EMIS Web handbook to see what
reminders and alerts you can use and do some online research.
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4. Hard Stops in the System
A ‘hard stop’ is a point in the system that states that unless a predefined action has been
completed, the process can progress no further. It enables us to ensure that we are reliably
applying key elements of our processes. This intervention forms a part of the ‘Safe and
Reliable Prescribing’ driver.
What hard stops are being tested?
Mosslands Medical Practice created a hard stop in the repeat prescription process for those
patients who are prescribed Methotrexate and have undergone blood tests in the hospital.
If the blood tests have not been received back from the hospital a repeat prescription
cannot be issued. This stops Methotrexate from being prescribed when there is no
assurance that continuation is indicated.
How should hard stops be implemented?
In order to test this intervention we would like you to:
Change methotrexate prescribing from ‘repeat’ to ‘acute’; meaning that a clinician
will need to sanction each prescription.
Collect data on the testing process - this can be done using the SMASH dashboard by
checking the number of patients who are being prescribed Methotrexate with a FBC
and LFT and see how this changes over time.
Gather feedback from staff.
Make any changes to the process as necessary.
Top Tips
This intervention can be used for other high risk drugs such as Warfarin or Tramadol.
This may not be applicable for all patients so needs to be tried on a case-by-case
basis.
This can be added to a GPs list of tasks on the practice system.
Ensure the work is shared between practice staff and it is made visible through the
Vision or EMIS Web appointments system.
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5. Gold Standard Framework
The Gold Standards Framework (GSF) relates to patients approaching the end of their lives.
For more information see the website (http://www.goldstandardsframework.org.uk/).
What is being done?
While testing this intervention, Clarendon Medical Practice have amended some of their
policies regarding patients approaching their end of life. For example, this practice’s policy
requires 48 hours’ notice for prescription changes to be made. However, it has been
modified for GSF patients; who now have their prescriptions changed on the day, as their
medication needs change more rapidly than those of other patients.
How should this be implemented?
In order to test this intervention we would like you to:
Create a list of patients who are on the Gold Standards Framework.
Create an alert on their patient record that advises staff that this patient is a GSF
patient (this also links in with intervention 3a Raising Staff Awareness).
Amend the template letter (available to download from the PrISMS Intervention
Bundle section of Haelo Hub) and send it to GSF patients.
Collect data on the testing process (optional).
Gather feedback from staff.
Make any changes to the process as necessary.
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6. Medicine Safety Huddles
Regular huddles can improve the communication between members of a team. They can be
used to encourage a culture of openness and honesty. Huddles form a part of the
‘Partnership Working & Leadership’ driver.
What is being done?
St Andrews Medical Centre has been holding staff huddles on three days each week, both in
the morning and in the afternoon. Staff members attend these huddles whenever possible
however all staff are required to attend at least one huddle each week. The huddles last for
around five minutes and provide a forum to discuss medicine safety issues from the week.
How should this be implemented?
In order to test this intervention we would like you to:
Set aside 5 minutes in the morning and 5 minutes in the afternoon 3 days per week.
Commence staff huddles.
Collect data on the testing process (optional).
Gather feedback from staff.
Make any changes to the process as necessary.
Top Tips
Huddles can be vital in increasing staff engagement in your project.
Enable all staff to attend huddles at the time that suits them.
Not all staff have to attend every huddle - consider having different staff at AM and
PM huddles.
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7. Training Package for Locum Staff
Locum staff are a valuable resource within practices however they may not know the
processes and procedures that are integral to medication safety in your practice. Providing
training materials can ensure that all locum staff are fully briefed across all collaborative
practices. This forms a part of the ‘Partnership Working & Leadership’ driver.
What is in the training packages?
While testing this intervention Mosslands Medical Practice created a four page booklet to
be issued to all locum staff on their first day in the practice. The booklet contains the names
and contact details of key staff within the practice (that may be able to help if they have any
queries) along with a brief guide to the Vision practice system and a page outlining the high
risk drugs interactions that the PrISMS collaborative is focussed on (NSAIDs, DMARDs and
Amiodarone). An example of this booklet is available to download from the PrISMS
Intervention Bundle section of Haelo Hub for you to modify and use in your own practice.
How should the training packages be implemented?
In order to test this intervention we would like you to:
Create a Locum staff training package based on the example booklet on Haelo Hub.
Distribute it to all locum staff in your practice as well as new locum staff as they join.
Collect data on the testing process (optional).
Gather feedback from staff.
Make any changes to the process as necessary.
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Other ideas for change:
Consider a daily review of discharge summaries for high risk patients.
Use the SMASH Dashboard for identification of new high risk patients.
Develop a new patient registration process – for example have one day per week for
new patient appointments only.
Map out the processes and systems in your organisation to identify problematic
steps/areas. More information on Process Mapping is available to download from
the PrISMS Intervention Bundle section of Haelo Hub).
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Appendix
Getting Started on Haelo Hub
In order to access the extra content mentioned in this document you will need to have an
account with Haelo Hub, if you do not have access to Haelo Hub, please contact the team at
Once you have an account, Haelo Hub can be accessed by following these steps.
1. First navigate to http://hub.haelo.org.uk/
2. You will then see the login screen shown below, please log in using your username and
password. Your user name should be your firstnamesurname (all lowercase) and your
password will have initially been set up as Haelo. If you are having any issues logging
into Haelo Hub please email the PrISMS team at [email protected]
3. From there click on the PrISMS CCG Collaborative button to access the PrISMS section of Haelo
Hub.
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PrISMS Practice Contact Details
If you would like more information about any of the interventions featured in this document
from the practices that tested them please use the contact details below.
Practice Name Contact Name Role Telephone Number
Blackfriars MP Sameer Butt Practice Manager 0161 819 4792 Sarah Sumner Practice Pharmacist Clarendon MP Janine Elliott Practice Manager 0161 211 7373 Elaine Tidswell Office Supervisor Langworthy MC Dr Maggie McPhillips GP 0161 737 9244 Barbara Slater Practice Manager Mosslands MP Angela Pickering Practice Manager 0161 776 0737 Ann-Marie Kennedy Practice Nurse Pendleton MC Dr Mark Austin GP 0161 211 7420 Sue Wilkinson Practice Manager Salford Health Matters
Robin Green Practice Manager 0161 212 5815
Manjinder Butt Practice Pharmacist St Andrews MP 2 Dr Pete Budden GP 0161 707 5500 Teresa Liu Practice Manager St Andrews MP 3 Dr Mhairi Yates GP 0161 707 5500 Teresa Liu Practice Manager
If you would like more information about the collaborative as a whole please contact either
Tina Dixon at Salford CCG on 0161 212 4836 or the Haelo team at [email protected]
