improving medicines safety at transfers of care … · improving medicines safety at transfers ......

Improving medicines safety at transfers

of care across Greater Manchester

Improving Medicines Safety and Transfer of Care: A Quality Improvement Programme in Greater Manchester

Jane Macdonald

Director of Nursing and Improvement

Greater Manchester Academic Health Science Network (GM ASHN)

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This programme has been commissioned by the Greater Manchester Academic Health Science Network (GM AHSN) and is delivered in partnership by Haelo, an innovation and improvement science centre based in Salford, Manchester

Declaration of interest

Transfers of Care: A Quality Improvement programme

How to approach improve medicines safety at transfers of care for vulnerable patients

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GM AHSN Membership

AHSN footprint

4 Universitie

s

1 Ambulance Service

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Achieving safe medicines management during transfer of care was identified as a healthcare priority that affects many patients

Our solution: To create a collaborative quality improvement programme across multiple healthcare systems, teams and individuals in Greater Manchester

Introduction and objectives

Today’s presentation will:

• Share our I.H.I. Break Through Series Collaborative model and show how a using a ‘plan-do-study-act’ approach helped build effective cross-organisational teams and projects

• Report the outcomes of the programme against our ambition to achieve 95% ‘defect-free’ medicines care

• Provide individual exemplars of success from project teams and share what we learned

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Receiving safe medicines on transfer of care should be every patient’s expectation…

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Objective: 95%

defect-free care

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Baseline: 26.6%

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Baseline: 26.6%

Objective: 95%

defect-free care

Proportion of patients with allergy status documented

Proportion of patients with meds rec started within appropriate time frame

Proportion of patients with meds rec finished within appropriate time frame

Proportion of patients with a meds review completed

Proportion of patients that feel confident to self-manage

Appropriate adoption of technology

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Using the Breakthrough Series (BTS) collaborative model

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9/14 Health economies participated

Teams from Manchester Mental

Health and Social Care and HMP Manchester

reviewed medicines reconciliation for newly

transferred patients

Wrightington, Wigan and Leigh pharmacy team improved documentation and effectively used patient / public involvement to improve patient discharge

Salford Royal collaborated with Heartly Green Care

Home to improve transfer from

acute hospital to intermediate care homes

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Page 30 of 32

Posters produced by More than Minutes at Learning Session 2 of each of the

participating teams

East Lancashire (refertopharmacy) and began to share learning with one another through

knowledge exchange sessions.

Resources from the second Learning Session, including a film summary of the event are

available online.

Following the event teams were encouraged to undertake rapid PDSA cycles linked to the

driver diagram, building on change ideas developed in Learning Session 2. Teams were

requested to submit data and progress reports on a monthly basis.

At this stage in the project, the majority of teams utilised site visits as an opportunity to

receive coaching support to tackle issues affecting progress. Common issues were around

difficulties in collecting sufficient data and addressing the need to be fully documenting all

PDSA cycles. Some teams raised issues around losing key staff involved in the project

through various staff changes.

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Case Study 1: Salford team embedding medicines reconciliation in Intermediate Care

• The Salford team looked at how they could improve medicines processes for patients discharged to intermediate care

• An in-house pharmacy technician was introduced at a pilot intermediate care home

• It immediately impacted the number of patients who had medicine reconciliations within 72 hours: from 0% to 93.8%

• The introduction of an onsite medicines stock cupboard reduced omitted or delayed doses

• A business case has now been approved to introduce pharmacy technicians to all intermediate care units in Salford

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Case Study 1: Salford team embedding medicines reconciliation in Intermediate Care

Proportion of patients with meds recs started Proportion of patients with meds recs finished

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Case Study 2: Manchester Mental Health and HMP process mapping in the prison system

• A process mapping session was held with the prison pharmacist, GP and senior reception nurse to understand the current system of care from intake to final medicines reconciliation. The Mental Health Trust facilitated staff relations.

• This immediately identified the absence of pharmacy from the clerking process and that critical medicines were not available in the reception drugs cupboard

• The need for a guiding pathway for prison reception staff was also identified

• Several tests of change are now ongoing based on this evidential analysis

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Case Study 2: Manchester Mental Health and HMP process mapping in the prison system

Proportion of patients with meds recs started

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Case Study 3: Wrightington, Wigan and Leigh pharmacy team improving discharge communications

• The pharmacy team identified variations in the quality of patient communications in different healthcare settings

• The objective was to make patient medication information of equal quality at discharge as it is at admission

• A group of patient representatives, district nurses and CCG pharmacists collaborated to develop seven key tests of change

• The most effective solution was a discharge summary sheet that is sent to the community pharmacy to support all discharge prescriptions

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Case Study 3: Wrightington, Wigan and Leigh pharmacy team improving discharge communications

Proportion of patients confident to self-manage

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Outcomes, achievements and key learnings…

Objective: 95%

defect-free care

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Baseline: 26.6%

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One-year outcome:

42.4%

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58% improvement

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The project established critical relationships across

health economies

We gained a better, evidential understanding of systems and

opportunities for improvement

Participants reported personal benefits for their training and

development

Patient / public involvement kept us asking the question

“Is this good enough?”

More teams would have liked to engage executive level

sponsors / chief pharmacists

Data collection and outcomes measurement was a key

challenge

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Did we make Manchester the safest place to take medicines..?

..no, but we did make it safer

Outcomes from its first 18 months

Why refer to Community pharmacy?

• New Medicine Service: ↑10% in medicines adherence

• Discharge Medication Review: every £1 spent saves £3

• Patient Safety: sharing the right information when it matters

↓Waste

↓ED attendance

↓(re)admissions

↑Safety

World’s first fully integrated pharmacy

referral system:

• Fast

• E-discharge letter attachment

• Secure

• Auditable

• Two-way communication

• Adaptable

How it works on hospital wards

Every Eligible Patient: Referred

• Consultation-referral – NMS & MURs

• Information-referral – MDS, Care Home, Information

• Hospital Admission Notification – when appropriate

• Home Visit referral – Domiciliary Medicines Support Teams

Patient engagement film

www.elht.nhs.uk/refer

How it works in Community Pharmacy

Every Referred Patient: Accepted • Intuitive to use

• Discharge letter reviewed

• Outcomes captured

Demonstration

Referral statistics 29.10.15 to 30.4.17

Total referrals = 9220

Number of

referrals Percentage

MDS (Blister Pack) 3035 33%

Medicines Use Review 2142 23%

Information 1612 17%

New Medicine Service 1142 12%

Care Home 1068 12%

Home Visit (since 26.6.16) 221 2%

Referrals Number

Saved Dispensing Time 64 3954 minutes 65 hours (net)

Reduced Medicines Waste average item value £9.18 49 200 items (net)

= £1,836

Unintentional prescribing errors rectified 46

GP intentionally did not affect changes 9

Outcome statistics MARCH - APRIL 2017

•

An early SIGNAL: % readmissions for the same diagnosis from medical wards at 28 days

139 fewer people readmitted

in this 10 month period Lord Carter’s report: £3,500/patient episode

Period N

January – October 2015 590

January – October 2016 451

Making it work, aiding spread • Community Pharmacy support – CPPE

• Royal Pharmaceutical Society support

• R2P monthly newsletter

• Service evaluation: Manchester University

Multi-award winning

• Ward pharmacist works on same ward throughout working day

• Participates in Consultant-led ward round

• Greater patient contact: ↑ medicines adherence

• Every eligible patent referred to community pharmacist

Dedicated Ward Pharmacy

• Pharmacy technician time on ward increased

• Completes medicines reconciliation on ALL patients

• Prepares medicines sections of electronic discharge letter

• Ensures all medicines available before discharge


• 5% increase in discharges by midday

• 18% increase in discharges by 5pm

• 16% decrease in discharges after 5pm

• Late finishes from pharmacy team virtually eliminated

• Dispensed items getting back to wards sooner

Dedicated Ward Pharmacy: Improved discharge times

• Reduced by 1.7 days in original 4-ward pilot (Jan ‘16)

• Reduced by 2.2 days in November ‘16 analysis of 6 wards

Influenced by pharmacy clinical interventions

(average 341/week)

Dedicated Ward Pharmacy: Reduction in Length of Stay

• At least £259,668 from 8 wards

• Extrapolates to at least £1,388,707 for Trust annually

Dedicated Ward Pharmacy: Annualized reduction in drug costs


Spreading good practice

Get in touch:

[email protected]

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