Implementing the Scottish Patient Safety Programme in Primary Care
Dr Stuart CummingGP and Associate Medical
Director Primary CareNHS Forth Valley March 2014
The wider context
Phased Approach
Stage 1
General Medical Services
Prototype and Testing 2010- 12
Launched March 2013
Stage 2
Pharmacy and Nursing
Proto-typing and testing from late 2013
Stage 3
Dentistry and Optometry
Exploratory work late 2014
Our aimAll NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.
Sept 201382% of all 1000 Scottish practices (100% of all Forth Valley practices) engaged in at least one high risk area of the Scottish Patient Safety Programme in Primary Care including Care Bundles and Trigger Tools
3 workstream aims
Safety culture
95% of practices undertaking Safety Climate Surveys, by April 2014
95% of practices undertaking Trigger Tool reviews, by April 2014.
Safer medicines
95% of practices implement systems for reliable prescribing and monitoring of high risk medications, by 2016.
95% of practices have safe and reliable systems for medicines reconciliation following discharge, by 2016.
Safety at the interface
95 % of practices have safe and reliable systems for handling written communication received from external sources, by 2016.
95% of health boards and practices have safe and reliable systems for results handling, by 2016.
• Two elements included in the GP Contract QOF:–Trigger tool –Safety climate survey
• 14 NHS boards implementing Enhanced Services incorporating bundle elements of programme –warfarin, –DMARDs, and –medicines reconciliation
Focus in the first year
Trigger Tools• >3 consultations in 7 days• Repeat medicine discontinuation• Drug allergy noted• OOH/A&E attendance• Hospital admission
Anticoagulants and DMARDs• INR>5• Hb <10 or WCC <3.5• AST/ALT >150• eGFR drop by >5
• Systematic review of records and Significant Event Analysis (SEA)
Methodology – Collaborative within a Collaborative
Protected Learning TimeNational Learning
SessionsNHS Board Learning
Sessions
Collaborative Interactive Workshops (Awareness raising) October- December 2012
Learning Session 1 14-15 March 2013
Local Learning Session 1May-August 2013 (half or whole day)
Learning Session 2 5-6 November 2013
Local Learning Session 2November 2013- March 2014
Where are we now? NHS Forth Valley
• Initial Piloting – 11 practices• Communication, awareness raising, learning events• Develop local expertise, support, programme management and
leadership• Prioritised by Board and within QI plan
Roll out to all Practices through Enhanced Services from 2012
2012/14 Warfarin and DMARDs – all practices
2013/14 High Risk Co – prescribing
2014/15 Medication Reconciliation
CREATE - engaged staff – positive feedback
Practice and system-wide improvement …….
Impact on DMARD prescribing Methotrexate 2.5MG TABS AS % OF ALL ORAL RX :
Forth Valley OTHER HBS
Impact on Warfarin INR control in Forth Valley
INR< 1.5 and > 5.0
All INR Requested By Practice: May to Oct 2013
INRs out of range FV 2012-2013
2012 2013
INRs < 1.5 7.9% 6.2%
INRs > 5 1.6% 1.9%
DAWN practices. INRs within range 2012-2013
2012 2013
INRs +/- 0.5Benchmark 50%
53.3% 55.75%
INRs +/- 0.75Benchmark 80%
71.6% 70.45%
Reducing High Risk Prescribing
NSAIDs
• Adverse reactions to medication cause:
– 5 -17% of admissions linked to – 4% of hospital bed capacity – 70% preventable
5% of prescriptions contain an error Adverse Event rate 1- 2% Consultations
“Absolute number of those harmed may be just as large or greater than secondary care” Health Foundation 2011
To Err is Human 1999Howard et al Br J pharmacology 2006
Zhang et al BMJ 2009Howard et al qshc 2003
Reducing High Risk Prescribing
Target Areas• Patients age ≥ 65 years on triple whammy combination.
(ACE/ARB + diuretic + NSAID)
*80% risk of hospitalisation with renal problems in 30 days• Patients age ≥ 65 years prescribed an NSAID without
gastroprotection• Current anticoagulant user prescribed an NSAID without
gastroprotection.
Actions• Review data• Do searches• Review patients • Redo searches after 6 months • Submit numbers
Proportion of Patients aged 65 years or over currently prescribed
an NSAID who do not have co-prescribed PPI Gastroprotection
Impact - early days latest data June – Sept 2013
• Patients age ≥ 65 years on triple whammy combination. (ACE/ARB + diuretic + NSAID)
Reduced by 13%
• Patients age ≥ 65 years prescribed an NSAID without gastroprotection
Reduced by 16%
• Current anticoagulant user prescribed an NSAID without gastroprotection.
Reduced by 62%
Medicine ReconciliationOver 40% of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer and discharge of patients. Of these errors, 20% were believed to result in harm
….Institute of Medicine’s Preventing Medication Errors
Issues
•Unreliable medication reconciliation at admission.
•Inaccurate and delayed medication history at discharge
•Unreliable Primary Care systems for reviewing discharge prescriptions and updating repeats accurately
•Delegation of the responsibility for medicines reconciliation to managerial or clerical staff.
•43% discrepancies between the hospital discharge communication and those subsequently prescribed to the patient. (Avery et al) 2012
Medicines Reconciliation BundleWhole System Working Project Practices will carry bundle data collection on medicine reconciliation on a random 10 patients a month that have
(a)been discharged form an acute medical admission, or (b)patient aged over 75, who have been discharged from any inpatient stay
• Measure1- Has the immediate discharge document (IDD) been workflowed on the day of receipt?
• Measure2- Has medicine reconciliation occurred within 5 days of the IDD being workflowed by GP/Pharmacist?
• Measure 3- Is it documented that any changes to the medications have been actioned?
• Measure 4- Is it documented that any changes to the medications have been discussed with the patient or their representative if appropriate?
• Measure 5- All measures have been met
……Supported by work in acute sector
FALKIRK
EARLY YEARS COLLABORATIVE
WHAT IS THE EYC?• The World’s first national multi-agency
quality improvement programme
• Based on the improvement science and collaborative approach used in infection control
SMALL SCALE TESTS
http://youtu.be/_ZcUM-_7kEE
TESTING• After watching the EYC animation:
– How much do you know about the EYC?
– How effectively does the animation explain the purpose of the EYC?
FALKIRK TESTS• 80-85% of woman being booked for ante-natal
services by 12 weeks gestationTester Health Maternity Services - Val Arbuckle, Elaine Ronald, Kirsty
MacInnes (Sister/Neonatal midwives)
Test aim To have 80% pregnant women booked for ante-natal services by 12wks gestation.
Change(s) made:
1. Developed poster highlighting maternity booking line & sent to GP
2. Cards in pharmacies next to pregnancy tests3. Posters sent to nurseries and family centres
Results
80% goal exceeded when questioning 10 patients Highlighted issues with phone booking line, raised with Serco
to ensure phone being manned/ call backs Raised to 85% and up scaled to include all attending
appointments Number of woman accessing maternity services direct has
increased, expectant mothers being seen earlier.Next Steps
Test being scaled up to continually monitor number of all Pregnant woman accessing service <12 weeks gestation
04/03/2013 Develop poster & send to GP
18/03/2013 Cards in pharmacies
25/03/2013 Posters to nurseries and family centres
15/04/2013 Ask if seen poster/card
13/05/2013 Ac phone
20/05/2013 Add in vitamins
15/08/2013 50% left message and received call back
31/01/2014
Upscale: No longer based on 10 people, now based on figures of electronic figures on monthly bases collected for the previous month.
FALKIRK TESTS• 130 requests received for Psychology of
Parenting ProgrammeTester Education Services – Beverley Isdale (Development Officer/PoPP - Programme manager)
Test aim Psychology of Parenting Programme – To monitor the number of PoPP requests and take steps to increase awareness if uptake is low.
Change(s) made:
1. Presentations delivered at various professional meetings2. Posters and leaflets distributed to Nurseries, health practices
and librariesResults
Number of referrals/requests increased and therefore more groups ran allowing more parents the opportunity to participate.
Better outcome for children/families dealing with behavioural issues.
Total number of requests: 130
Next Steps
Scale up programme to include more groups
0
5
10
15
20
25
15/07/13 15/08/13 15/09/13 15/10/13 15/11/13 15/12/13 15/01/14 15/02/14
Num
ber o
f Re
ques
tsPoPP Requests Per Week
Date Annotation02/09/13 Presentation to HT meeting09/09/13 Presentation SW team managers14/10/13 Presentation to HV team meeting21/10/13
Graeme cluster connecting with parents EPS
11/11/13 Facilitators Bo’ness18/11/13
Facilitators Denny / presentation to EYPIP
25/11/13 Facilitators Falkirk High02/12/13 EYO twilight EPS10/02/14 EY conference EPS
FALKIRK TESTS• 4 Leadership Walkrounds UndertakenTester Education Services - Elaine Costello (Acting Head of Service
(Individual and Additional Support)/Service Manager (Co-ordinated Children’s Services)
Test aim To highlight the importance of and increase the number of EYC leadership walkrounds.
Change(s) made:
Walkrounds highlighted at leadership meetings Walkround schedule created to encourage leaders to sign up
Results
Practitioners feel valued Barriers highlighted and actions taken forward Role for leadership Opportunity for senior members of staff to see the fantastic
work being done at practitioner level in Falkirk/Forth Valley Number of Walkrounds undertaken: 4
Next Steps
Maternity Services Walkround planned for April Leadership sign-up sheet produced
** planned
FALKIRK TESTS• Health Visitor increased attendance at 27-30
month reviews from 43% to 100%Tester Health – Karen Miller (Health Visitor)
Test aim To improve the attendance rates at 27-30 month reviews
Change(s) made:
1. Karen introduced a phone call into the process in order to agree a suitable time and date with the parent/carer
Results
The appointment date/time agreed was convenient for the parent/carer rather than the previous appointment by post which they had no choice over.
The parent/carer could completed the questionnaire in advance and therefore were not stressed during the appointment and could answer more fully/honestly
Attendance rates have increased from 43% to 100%
Next Steps
Continue to monitor attendance rates Scale up within practice
Goal
0
10
20
30
40
50
60
70
80
90
100
28.08.13
25.09.13
23.10.13
20.11.13
16.12.13
16.01.14
16.02.14
% A
tten
ding
App
oint
men
ts
27-30 Month Assessment - Attendance at Appointments
IntroducedPhone Call
Child Unwell
Prescribing Management in Primary Care:
From strategy to operational delivery
Fiona Allan
Primary Care Pharmacist
April 2014
Context – scale of prescribing
• NHS FV population ~ 300,000
• Health Centres: 56 (mixture of urban and rural centres)
• Primary Care spend on drugs in 2013 > £51M
• 50% of practices have annual prescribing budgets of > £1M
Context – scale of prescribing support
• Office based strategic team • Lead Pharmacist (1 WTE)
• Prescribing Adviser (0.6 WTE)
• Prescribing Support Pharmacy Technicians (2 WTE)
• Administrator (0.8 WTE)
• GP Practice-based team• Primary Care Pharmacists (X WTE)
• Primary Care Pharmacy Technicians (X WTE)
• Spend to save….dietician input to review ONS
Challenges & Opportunities:Variation in Prescribing Costs
across Scottish HBs
Challenges & Opportunities:Variation in Prescribing Costs
across FV Practices
• HB Average Cost/Patient = £168
• Range from £126 to £196
Practice Ref Practice Cost Per Patient (June 13)
A £196.53B £194.35C £194.04D £185.21E £184.58F £183.19G £183.08H £182.77I £181.92J £181.66 …… ……O £154.69P £154.60Q £152.99R £151.75S £151.16T £146.14U £145.86V £141.31X £130.53Y £127.09Z £126.39
HB Average £168.45
Data to support strategic planning
• PRISMS: PRescribing Information SysteM for Scotland• Online system: Data available on every prescription
dispensed in Primary Care
• 2-3 months in arrears • Identifiable to HB, Practice, Prescriber level• Down to individual products• Useful for identifying variance (volume and
cost)/possible areas requiring prescribing review; evaluation of impact of change
From identifying variance to change
• Variance data discussed at PEG
• Local expert agreement/support secured for change
• Local implementation plan/protocol developed, hooked to local work strands & reinforced by local formulary messages/information bulletins (see later slide – frameworks/incentives)
• PCP/PCT engagement with practices
• Implementation at practice level
• Evaluation of change
PRISMS shows FV HB is an outlier for an particular topic
Triptorelin Items per 1000 patients May 2009 - May 2012 FV vs OHB & Scotland
0
0.1
0.2
0.3
0.4
0.5
0.6
Item
s /
1000
Pat
ien
ts
NHS AYRSHIRE & ARRAN NHS BORDERS NHS DUMFRIES & GALLOWAY NHS FIFE
NHS FORTH VALLEY NHS GRAMPIAN NHS GREATER GLASGOW & CLYDE NHS HIGHLAND
NHS LANARKSHIRE NHS LOTHIAN NHS TAYSIDE Scotland
Best practice is agreed and outlined in a local prescribing protocol
Strategic messages embedded with electronic formulary/local prescribing
bulletins
GP agreement/participation in change secured
• PCP/T discussion/sign up
• Hook to local initiatives– GP Contract/QOF
• Points/£ allocated to medicines management targets
– Prescribing Incentive Scheme (PIS)• Practices set a cost per patient (CPP) target (achievement of
target = retention of a proportion of savings)
– PPPP• Practices with continuing high CPP excluded from PIS• Support in the form of protected time/facilitation
PRISMS supports HB level evaluation of success
Summary: What has worked for us
in achieving prescribing change?
Engagement of Engagement of Key Stakeholders Key Stakeholders
PRESCRIBING EFFICIENCIESGROUP (PEG)
CRITICAL SUCCESS FACTORS
Clear Strategy Leadership Benchmarking
Capacity todeliver
(spend to save)
Robust Financeand Prescribing
Data
GP IncentiveScheme
GoodCommunication
and feedback
Identify and workwith outliers
Prescription for Excellence
Gail Caldwell Pharmacy Director
April 2014
Working towards the SG 2020 Vision
“Everyone is able to live longer and healthier lives at home or homely setting”
• Integrated health and social care• Focus on prevention, anticipation and self management• Community care, day case treatment the norm• Highest standards of quality and safety• Person at the centre• Prevent hospital (re)admissions• People get back home/community asap
Prescription for Excellence
• Supporting patients to achieve intended outcome of treatment
• Cooperation with patient and wider health and social care team
• Integral part of local initiatives
• Profession working together to support patient at any point in their care
Vision in Prescription for Excellence
• Increase clinical capacity in primary care• All patients receive pharmaceutical care from
clinical pharmacist independent prescriber• Medical practitioners maintain overall
responsibility for diagnosis• Not solely relying on delivery from a pharmacy,
release clinical capability on an equitable basis through new innovative models which facilitate professional independence
2023
Joe in 2023
• Supported to self-manage, using technology
• Complex specialist medicine, hospital pharmacists collaborate to deliver home pharmaceutical care, homecare
• Hospital at home clinical pharmacy services
Pharmacy in 2023
• Efficient and cost effective pharmacy network
• Dispensing NHS prescriptions and other aspects of NHS Pharmaceutical Services that are best delivered from registered pharmacy
• Fully released clinical capability of pharmacist
• Dispensing managed by pharmacy technicians
• Harnessed new technology e.g. robotics
Lisa, NHS Pharmaceutical Care in 2023
• Increase clinical capacity in primary care team
• Professional independence• Working in collaborative
partnerships, accredited clinical pharmacist independent prescriber (general practice clinical pharmacist)
• Allocated patient case load, patient registration with “named pharmacist”, NHS FV Performers List
• Equitable access: distributed models from GP practices, domiciliary, telehealth, clusters (group practices)
NHS Board in 2023• Professional and clinical
leadership• Based on local need, PCSP
describes how FV plans, provides and delivers pharmaceutical care and medicines to local community, including clusters of pharmacists
• Pharmaceutical care provided by pharmacist, complements and supports dispensing GP practices
• NHS framework and standards for pharmaceutical care for care homes, care at home, drug and alcohol
Infrastructure in 2023
• Governance to support safe delivery of pharmaceutical care
• Patient level risk assessment, identify those benefit most from NHS Pharmaceutical Care
• Share information, maximise ehealth solutions
• Workforce fit for purpose and meets service needs
Conclusion
• Prescription for Excellence aspirational plan for future of pharmacy profession
• Initial focus, pharmacists deliver pharmaceutical care patient clinics (service and financial plans by end March)
• Local work commenced on Pharmacy 2020 vision
• Wider engagement, agree priorities in local context