clinical programme groups name of cpg: programme group (p&mm cpg) · 2012. 10. 29. · plan....

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Clinical Programme Groups 2012 – 13 Quality & Safety (Q&S) Monitoring

Report Template

Name of CPG:

Pharmacy and Medicines Management Clinical Programme Group (P&MM CPG)

Names and role of individual responsible for this report:

Julie Smith, Associate Chief of Staff Nursing Louise Howard-Baker Clinical Director

Date of report:

1st November 2012

1. Strategies and Plans

1.1 Please provide an outline of CPG strategies, plans and priorities The P&MM CPG overarching strategy is in the BCUHB Our 5 year Plan. The priorities are agreed annually with Tiers 3, 4 and 5 Senior Managers and with the Executive Director. Locality working and targeting chronic disease management and high impact interventions specifically, respiratory, mental health, chronic pain; Support for the review of care plans for people on 10 or more medicines and/or people on complex medication.

• All localities have an identified lead pharmacist. • Targeted medication reviews make up part of the Quality and Safety element of the

Local enhanced Service for Medicines Management Implementation of a BCUHB prescribing formulary across primary and secondary care

• BNF Chapters 1,2,3,4,6 are complete with a number of others being progressed. • Wound Dressing Formulary has been approved by DTG and is about to be

launched. Extension of automation (vending machines) into acute medicine, general ward areas:

• Automated medicines cabinets have been installed in EDs and Medical Assessment Units.

• Further funding has been received from WG to increase the number of vending machines.

Roll-out e-discharge prescribing on an all North Wales basis.

• Testing continues at Cardiff and Vale; roll out depends on the Clinical Portal being in place in BCUHB.

• Late and in some cases absence of discharge and medication summaries continue to cause problems for patients.

Implementation of the P&MM CPG aseptics strategy across BCUHB, in consultation with other CPGs, including cancer services and radiopharmacy.

• Upgrade of YGC • Review of radiopharmacy, chemotherapy, over-labelling, CIVAS, TPN.

BCUHB Quality & Safety Committee 1.11.12 Item 12/114

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We will identify specific innovations in medicines management for analysis e.g. mental health Monitoring of non-medical prescribing to ensure sound, robust governance and adherence to formulary. Assurance that Pharmacists and associated staff, particularly in a community based setting, are supported and equipped to promote healthy lifestyles, e.g. alcohol awareness campaigns, smoking cessation, obesity reduction, to improve the health of the population and reduce demand on health services. In addition to the key themes, there are also the BCUHB 5 year commitments around Organisational Development and Governance and Informatics for all CPGs: Making it Safe CPG structures: The two CPG performance groups are the Finance and Performance (meets monthly) and the Board (meets bimonthly). Reporting to these groups are the following:

• Pharmacy and Medicines Management Quality and Safety Group • Drugs and Therapeutics Group (DTG) • Medicines Policies and Procedures Sub-Group • Controlled Drugs Local Intelligence Network • BRAG Group • Wound and Dressing Sub-Group • Safe Medication Steering Group • Safe Medication Practice Groups x3 • NICE and AWMSG Guidance Group (NAGG) • Clinical Economy Group (CEG) • Medicines Management Nurses Strategy Group • Non-medical Prescribing Steering Group

1000 Lives+

• Medicines Management – high risk medicines • Medicines Reconciliation

Medication Incidents and Prescribing Errors

• Collation of medication incidents • Collection of pharmacist contributions to care for All Wales Intervention Database

(AWID) Development and review of Patient Group Directions NPSA and MHRA alert handling and implementation Medicines Policy & Code of Practice Education, Training and Research and Development

• Education and Training Lead • SIFT posts • Medicines Management Nursing posts • Research and Development Local Research Forums


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Making it Better See CPG priorities for community strategy, population health, e-discharge, automation and aseptic services. Making it Sound Corporate Governance in relation to NICE Accountable Officer Regulations Making it Work Deliver a balanced Budget

• Service Improvement • Inter-CPG working • Address sickness absence • Local Enhanced Service for Medicines Management • Skill mix • Delivery of Community Pharmacy Contract

Making it Happen

• Implement Strategy • Communication Strategy

1.2 Please outline how, in the development of the above plans, your CPG has

ensured a patient centred approach that has patient safety and safeguarding as a priority

The vast majority of the delivery plan for P & MM CPG is dedicated to patients safety, by driving clinical effectiveness. The LES for Medicines Management for primary care incorporates both elements. Pharmacists are involved in the production of care pathways ensuring that appropriate guidance is used. In addition:

• There is a patient representative member on the CPG Board. • Pharmacists collect data on their ‘contributions to care’. This data can highlight

where there may be particular problems with prescribing or administration. E. g. the absence of enoxaparin in a patient at high risk of developing hospital acquired thrombosis.

• Medication incidents are monitored and acted on; incidents with a common cause or drug will be taken to Safe Medication Practice Groups, which are multidisciplinary to find a solution in order to prevent recurrence.

• MHRA product recalls and safety notices are handled via Datix to ensure rapid resolution and closure, thereby safeguarding patients.

• NPSA patient safety alert for the safe use of insulin and adult patient’s insulin passport has had a patient representative member.

• The three hospital pharmacy departments are actively promoting the Discharge Medication Use Review (DMR) scheme being offered by community pharmacies, eligible to offer this advanced service under their contract. The DMR has been designed to offer a reconciliation service to patient to ensure that they continue to take their medicines as intended on discharge and do not take medicines that were discontinued or changed.


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2. Performance

2.1 Please outline how the CPG ensures that it has the right systems and processes in place to deliver, from a patient / service user perspective, efficient, clinically effective, timely and safe services, which are based on sound evidence, and delivered by caring and competent staff.

In secondary care the CPG believes that, taking into account the size of its workforce, professional constraints and the volume of work in the hospitals that it has the right systems and processes. It continues to work with the medical and surgical teams to ensure that there is effective communication, particularly around discharge, as failure to do so often results in delay. In primary care, small and dedicated teams support GP practices with their prescribing, identifying problem areas and supporting practices to address them. They communicate changes directly to patients, mainly by letter, but will see patients when required. Please also:

a) describe how the CPG measures clinical performance and patient outcomes, providing a report for each of the service areas / types being provided (this should be whole system – ie community and hospital, where appropriate)

The CPG monitors a number of key performance indicators which include prescription turnaround times, intrathecal doses prepared, medicines reconciled within 24 hours of admission, AWMSG prescribing indicators, prescribing interventions in secondary care. The CPG monitors the outcomes from some of the Community Pharmacy enhanced services for outcomes e.g. smoking cessation quit rates. EHC supplies, supervision rates for methadone and subutex. The WG also requires community pharmacy to report back to CPGs on the number of interventions that have been undertaken during public health campaigns

b) identify any variations in performance across North Wales,

particularly concerns regarding quality and safety

Prescribing data is used to highlight variation in both GP practice and hospital prescribing, and can be used to draw attention to individual prescribing behaviour e.g. for excessive prescribing of controlled drugs, hypnotics and anxiolytics.

c) identify any challenges or areas for development

Areas for development include aseptic manufacturing. Steps have already been taken to rationalise what is made on each site e.g. adult and paediatric insulin syringes are manufactured at YGC and YWM respectively. There is further scope to develop this concept. Hospital discharge remains an area for development. The lack of timely communication to GPs is consistently highlighted as a problem, and although YG


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and YWM have electronic discharge systems, YGC still uses paper, with all the associated problems of legibility and accuracy of transcribing the prescription. There remains some variation in how the public health campaigns are delivered across BCUHB. Some community pharmacies have been recruited to becomes ‘healthy living pharmacies’ whereby counter staff are trained to deliver brief interventions to high risk groups e. g immunisation to new mothers. 2.2 Please describe how the CPG ensures that decisions are based upon valid,

accurate, complete and timely data and information The CPG uses a cascade system for MHRA drug alerts and recalls. The on-call pharmacists have a Blackberry, registered with the MHRA, which means that urgent alerts can be acted on immediately. All alerts are logged onto Datix and actions taken are reported directly onto the system. Dissemination of prescribing messages to primary care contractors may be by newsletter or by email for urgent message. All information is checked for accuracy by the Assistant Medical Director for accuracy. 2.3 Please describe the 1000 lives plus work being done

a) Which work-streams, and at what stage for each Antipsychotic prescribing in dementia, which was the medicines management mini-collaborative, has been moved into the dementia work stream. One of the mental health pharmacists has been working with the dementia team in two nursing homes in Colwyn Bay. Training for care home staff has been developed and is in the process of being accredited at Bangor University. A spread plan has been developed. Medicines reconciliation continues in the three acute hospitals. The data is collected and is monitored as a KPI for the CPG. The rate of unreconciled medicines remains at approximately 22-25%. This is accounted for by patients admitted out of hours and at weekends and while access to GP medication records is not possible, and community pharmacies are closed it is not possible to improve this rate. Other work streams are included in the LES for Medicines Management , and GPs sign up to do one or two for the financial year. They include:

• Anticoagulation • Chronic Heart Failure • Atrial Fibrillation • Amiodarone • Antipsychotic prescribing • Antibiotic Stewardship • NSAIDs

b) Is data being submitted against the 1000 lives plus measures

The antipsychotic data is no longer part of the medicines management work stream. Practices are holding their own data, but it will be used at the yearend as part of their evidence for the quality component of the LES for Medicines Management.


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c) Is there a spread-plan for each work-stream

There is a spread plan for antipsychotic prescribing in dementia and two localities, Conwy and Wrexham South are spreading the heart failure work stream.

d) How is the implementation of these plans being monitored and recorded

The heart failure spread is being monitored as part of the Locality Leadership Team work plan. The dementia spread is part of the Dementia Plan

2.4 Please provide a statement of assurance on the implementation of NICE and relevant professional guidance

a) Implementation, compliance and audit against NICE and other relevant guidelines

P&MM CPG plays a key part in the implementation of NICE and relevant professional guidance:

• Annual Horizon scanning to consider the impact of future NICE guidance for BCUHB

• CPG Membership of the NAGG group consists of the CoS, Clinical Director and Locality Lead pharmacist

• NICE and associated guidance is included in the annual LES for medicines management.

• BCUHB NICE monies are held by P & MM CPG and allocated to other CPGs during the financial year.

b) Compliance with NPSA, MHRA and other relevant alert notices

• P & MM CPG manage the MHRA alerts via the Datix system and the reports

are posted on the intranet: http://howis.wales.nhs.uk/sitesplus/861/page/47631

• NPSA alerts are handled by the patient safety leads pharmacists. They are dealt with either by a multidisciplinary task and finish group or at the Safe Medication Practice Groups. There are six outstanding alerts although most of the recommendations have been implemented.

2.5 How does the CPG develop and monitor its Quality Improvement and audit plan?

A pharmacist lead has been identified who is responsible for maintaining a register of audits undertaken by P&MM CPG. The primary care annual audits are decided on during the development of the LES for MM and consultation takes place with PCSU and the LMC. They generally cover NICE technology appraisal guidance or clinical guidelines. Audits are developed as and when patient safety alerts are received by the CPG. Diploma pharmacists have to undertake audit as part of their syllabus.

a) Please outline relevant strategic learning from audit


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An annual audit conducted of prescribing errors within the Cancer CPG demonstrated that doses were not being adjusted according to patient blood results and that rescue treatment was not being prescribed in many cases. As a result, the Chemotherapy Lead has asked the oncology pharmacists to take a zero tolerance stance to prescribing errors and that all prescriptions are returned to the prescriber.

b) Please describe the findings and main actions for the following

audits:

i. Consent ii. Capacity Act iii. Deprivation of Liberty

P&MM does not take part in these audits.

2.6 Patient Experience and User Involvement. Please outline the results of

patient surveys, with progress made on actions agreed as a result. Picker Institute survey results highlighted gaps in patient counselling at discharge. Patients did not consider that they were given enough information about side effects etc. Prior to this, most discharge information was given by nursing staff. A change in working structures within the pharmacy at the Maelor meant that pharmacy technician ward teams could be developed, giving then more access to patients at the point of discharge. The East team repeated the survey and found an improvement in patient satisfaction. In the west, a bilingual Medicines Information service is available for patients. A recent survey demonstrated that patients were happy with the service, were given the opportunity to speak Welsh and that advice was given in a language that was easy to understand and they would use the service again.

3. Workforce

3.1 Please describe how the CPG ensures that the workforce is appropriately selected, trained and responsive to the needs of the service, ensuring that professional standards, registration/revalidation/indemnity requirements and safeguarding arrangements are maintained

New assistants and pre-registration technicians have to undergo numeracy and literacy tests prior to interview. NLIAH provides annual funding to the tune of 50% to train new technicians (6), pre-registration pharmacists (9) and diploma pharmacists (9) to ensure that pharmacists are trained to a high standard. The CPG works with Universities and HEIs to ensure that the programmes meet the Health Board’s requirements. All new starters’ qualifications are verified and pharmacist and technician registration status checked. GPhC registration is checked annually and registration renewal receipts are collected from pharmacists and technicians. GPhC also now send lists of the names of pharmacists and technicians whose names have been removed from the register.


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3.2 Please describe staff experience within the CPG, include staff numbers,

sickness absence, bank, locum and overtime activity. P&MM CPG has a low turnover of staff and below average sickness absence (Cumulative total at Aug 12 was 3.97%). There are 320.75 wte staff in the CPG. There are four band 2 bank ATOs in Ysbyty Gwynedd on zero hour contracts, but no locums or overtime activity. On-call, weekend and late night working hours are taken back as TOIL, as agreed. 3.3 Please describe how the CPG ensures that there is an ethos of continual

quality improvement and regular methods of updating the workforce in the skills and competencies needed to demonstrate quality improvement throughout the organisation

• P & MM CPG recruits newly qualified pharmacists to a 2 year diploma

programme, run by Cardiff University.

• Pharmacists and technicians are required by the GPhC to record their CPD on-line.

• Lunchtime educational sessions are held in the acute hospital sites, with

speakers ranging from members of CPG staff, consultants or visiting clinicians. Pharmacy staff attend Grand Rounds.

• The CPG has a funded post to deliver National Prescribing Centre

therapeutics training to pharmacists and technicians working in GP practices and specialist nurses.

• SIFT funding has been used to appoint pharmacists in all three acute

hospitals to support medical undergraduate training. This is done in conjunction with the deanery and coordinated by a Tier 6 education and training lead pharmacist.

• CPG Medicines Management nurses deliver training to nurses on the

administration of medicines. • There is a rolling Quality Improvement Programme designed to increase the

P & MM skills in improvement methodology by applying the model to local projects.

3.4 Please provide a statement of assurance on how the CPG promotes team

working, collaboration and partnership working to provide the best possible outcomes for its citizens.

P and M CPG works collaboratively with other CPGs, Health Boards and localities to influence medicines management practice across the Health Board to ensure best use of resources and patient safety.

• The Tiers 4 (Clinical Directors), 5 and 6 managers all have ‘B’ roles designed to promote collaboration and the spread of good practice across the organisation. Tier 4: Patient Safety, Locality Working, Service Modernisation


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Tier 5: Patient Safety, Localities, Hospital Operations Tier 6: PCSM, SSD, CYP, W, MH, Cancer CPGs, Education and Training, Medicines Governance, Formulary, Patient Safety

• Pharmacists and technicians are working in GP practices across the Health Board.

• There are nominated pharmacists for each of the localities

• The CoS and ACoSOps for P & MM CPG co-chaired the Inter CPG meetings.

4. Governance

4.1 Please provide an assurance statement on how the CPG ensures proper governance and risk management performance

The CPG has an effective internal governance and risk management framework in place. This statement is supported by both the CPG hierarchy and the committee structure. Examples from the Finance and Performance Management Group

• Monitoring the CPG financial position and capital programme; determination of key financial assumptions to underpin the 12/13 CPG budget. Review of CIP updates

• Review of the CPG risk register and escalation of identified high level risks. • Review and monitoring of the CPG key performance indicators • Review of monthly workforce intelligence dashboard • Review of sickness absence data • Receive reports from Quality and Safety Sub-group

Examples from the P & MM CPG Quality and Safety Group Meeting

• Completion and Monitoring of Standards for Health • Receive reports from Health and Safety Sub-group • Service User Experience and Information • Receive updates from Corporate Sub-Groups (CESC, Infection Control,

Equality and Governance, PTR, Information Governance. • Update of the CPG risk register] • Mandatory Training • Incident and Complaint review

Examples from the CPG Board

• Patient Safety Update, include 1000 Lives • Primary Care & Community Implementation Update • Community Pharmacy contract update • Performance Report • Workforce and OD report • Financial Report • Service development report


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• Drug and Therapeutics update • CPG Update

4.2 Healthcare Standards for Wales. Please provide a summary report on the

standards reviewed

• The P & MM CPG is responsible for the BCUHB corporate standard 15, Medicines Management. This went to Star Chamber in August. The standard achieved an average score of 3 and an action plan is being developed.

• 64% of the CPG standards have been completed with work ongoing in the remaining standards.

4.3 Learning lessons. How does the CPG ensure that lessons are learned,

shared and monitored?

• Dispensary errors and near misses are monitored and discussed at pharmacy and technician team meetings on a monthly basis. An example is following a number of picking errors involving insulin (similar looking packaging, similar names). This ceased following the introduction of the dispensing robot.

• Primary Care medication incidents detected by pharmacists on admission are reported via Datix for discussion at the PCSU Clinical Management Groups.

• Medication incidents are monitored by the patient safety lead pharmacists for themes and common causes and discussed at the Safe Medication Practice Groups.

4.4 Please provide three examples (from an audit, complaint or a claim) that demonstrate how and what lessons have been learned and shared.

• An audit of the recording of ‘HOSPITAL ONLY’ medication on GP clinical

systems found that in only 48% of cases was a record made of the drug, which is a patient safety issue. As a result, some guidance has been produced for GP practices.

• All wards undertook a safe storage audit which highlighted some problems with drug cupboards which didn’t lock. An action plan was produced and has resulted in the purchase of new drug trolleys for inpatient ward areas.

• From an on the spot concern, raised by a patient following a medication review in his GP practice. The patient’s proton pump inhibitor (PPI) dose was stepped down. However on investigation it was apparent that the person who had undertaken the review had missed the record of Barrett’s oesophagus. It was therefore inappropriate to have reduced the dose of the PPI. As a result, at the time of the incident all primary care staff were reminded of the importance of checking for consultant letters prior to making changes.

4.5 Putting Things Right – Dealing with Concerns

4.5.1 Complaints ( previous 12 month period) a) Number and level (grade) of complaints received


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b) CPG performance in relation to response time targets

i. Trend analysis ii. 2 day acknowledgement by initial grade iii. 30 day final response by initial grade

c) In how many complaints has there been an entitlement to Redress?

d) Ombudsman investigations i. How is the implementation of any resulting actions monitored?

e) What have been the lessons learnt from complaints received?

f) How assured is the CPG that the lessons have been learnt and that action required has been undertaken?

4.5.2 General Incidents (previous 12 month period)

a) Number of general incidents reported b) Trend analysis c) What have been the lessons learnt from incidents? d) How assured is the CPG that the lessons have been learnt

and that action required has been undertaken?

4.5.3 Serious Untoward Incidents (SUIs) and never –events (previous 12 month period)

a) Number and level (grade) of SUIs including those reported to Welsh Government

b) What have been the lessons learnt from these SUIs? c) How assured is the CPG that the lessons have been learnt and

that action required has been undertaken? 4.5.4 Claims

a) Number and type of claims that remain open currently b) Number and type of claims received within previous 12 months c) Are there any recurring themes or trends within the claims

received d) What lessons have been learnt and/or actions taken following the

investigation of a claim? e) What have been the lessons learnt from the claims received? f) How assured is the CPG that the lessons have been learnt and

that action required has been undertaken?

• There have been six formal concerns during the previous 12 months; two were graded at level 3, one at level 2 and three at level 1. One concern graded at level 3 has been entitled to redress

• Acknowledgement of all concerns to all complainants was given within the 2 day time frame, however out of the six concerns received, 2 formal responses were sent from the CPG to the concerns team within the 30 day designated standard, one was reliant on another CPG, one is still open and the other was resolved as a freedom of information request.

• Different issues were identified with all concerns, therefore no key trends identified; however changes in practice have occurred as a result of vigilant checking of TTO’s on discharge from ward areas by registered nurses.


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• Previous identification of trends from informal concerns has resulted in the development of a discharge service in the East, whereby take home medication is prepared by the pharmacy technician from the bedside pod locker and checked by the ward pharmacist. This expedites discharge and reduces waiting times.

• All concerns are discussed at local Quality & Safety CPG groups, ensuring outcomes, recommended changes in practice are discussed at the CPG Quality and Safety Group to ensure learning is shared and that action are enacted and monitored. Concerns relevant to nursing staff and medicine management are also discussed at the Medicine Management Nursing Strategy Group

• The CPG has also formulated key performance indicators relating to formal and

‘on the spot’ concerns as part of its quality and safety monitoring process across primary & secondary care. This process is to identify trends to inform the quality and safety agenda.

4.6 Policy and Written Control Procedure Management - please provide an

assurance statement on how the CPG ensures that its processes for policy and written controlled procedure management are effective? Appendix 1 included as an aide memoire.Please provide the CPG weblink address:

• Following the MHRA inspection in 2010, BCUHB made a successful bid for

monies to purchase Q-Pulse for a Quality Management System. Aseptics have loaded their documentation onto the system. Next steps will be to utilise Q-Pulse to manage BCUHB PGDs, and CPG policies and written control procedures

5. Please report any other issues deemed appropriate to highlight to the Q&S

Committee including but not restricted to: • Risk management • Health & Safety • Healthcare associated infections/Infection control • Activity measures • Improving service user experience


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Appendix 1: Policy and Written Control Procedure Management

1. Does the CPG have a comprehensive list of all policies and written control documents with clear details of the title, organisation i.e. BCUHB or legacy organisation, review date and owner?

2. Does the CPG have a clear plan/timetable to review each policy, ensure it has been Equality Impact Assessed, gained approval (as the process stipulated in GC01 a and b) and been included on the intranet?

3. Has the CPG ensured all policies that have not been formally reviewed and updated to be BCU HB documents reflect current practice, policy, legislation or guidance?

4. Does the CPG have mechanisms in place to ensure all policy and written control documents within the CPG will be BCUHB documents only (not legacy documents) within a reasonable timeline as part of a planned approach?

5. Does the CPG ensure that all legacy documents will be withdrawn from the Intranet and any other areas in the organisation, including old hard copies held in files on wards once reviewed and updated?

6. Does the CPG have a nominated officer co-ordinating and gate-keeping the policy / written control documents process as per GC01 a and b?

7. Are the CPG nominated officer’s contact details and purpose of role advertised within the CPG?

A pharmacist has been recently recruited into a governance role and policy and written control is a part of his remit. P & MM CPG chair and run the Policies and Procedures sub-group of the Drug and Therapeutic Group. Q-Pulse was purchased with a grant from WG in the last financial year and all aseptic controlled documents are being loaded onto the system. Once this has been complete all remaining CPG controlled documents will be added.


clinical programme groups name of cpg: programme group (p&mm cpg) · 2012. 10. 29. · plan....

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