PINCERAction Learning Set 2

Todays session

• Review progress so faro share experiences and successes

• Review summary datao identify trends and similarities

• Root Cause Analysiso group activities

• Change Management o identify the need for changeo planning the change (action planning)o reflection and evaluation

Progress so far

View results

Upload baseline

dataRun

searchesData

Processing Agreement

Register with

PRIMIS

Sharing experiences

What went well?What difficulties

did you encounter?

How did you overcome any

issues?What would you do differently?

Role of GP Pharmacists in Quality Improvement

As experts in medicine and their use, pharmacists play a crucial role in quality improvement programmes

The Royal Pharmaceutical Society actively promote the potential benefit that pharmacists can bring to primary care patients particularly in relation to long term condition management

By integrating pharmacist skills with those of therest of the general practice team they can work together to improve patient outcomes and safety

PRIMIS tools provide a solid foundation for aquality improvement programme that can beinstigated and led by pharmacists

• Prescribing safety is a Quality Improvement module

• PINCER is a stated option– NSAIDs and GI bleed risk– Lithium monitoring

QOF – Quality Improvement Domain

Integrating clinical audit with other quality improvement activity

• QOF – Quality Improvement Domain

• Locally Commissioned Services

• RightCare indicators and pathways

• CCG Assurance Framework

• Revalidation

• Raising dissatisfaction

• QIPP agenda

• CQINN scheme

• Pathway and service redesign

• Care Quality Commission

The PINCER intervention

Identify cases of potentially hazardous prescribingPINCER prescribing indicators search on GP clinical systemUpload baseline dataInitial review/triage of identified patients

Explore methods to minimise current and future riskExamine the probable root causes (RCA) of the identified casesUse brief educational materials to discuss the potential risks with practice teamAgree action plan to act on immediate risk and improve the prescribing and medication monitoring systems

Implement and monitor changesPharmacists (and pharmacy technicians) working with, and supporting, general practice staff to implement the agreed action plan Repeating the cycle to monitor improvements in six monthly cycles

Reviewing summary data – understanding results

Which indicators might you focus on in terms of action and why?

How does this compare with other practices in your group?

Which indicators have fewest patients at risk?

Which indicators cause most concern?

Reviewing the data

Pharmacist reviews the data

Action depends on confidence/competence

of pharmacist

Some false positives due to limitations of

searches

Patients who remain at risk after review will

appear at the next run

Look for common themes during the

reviewDocument decisions

clearly

Target should be all patients highlighted are

reviewed (not zero patients at risk)

Managing and facilitating change

Identifying the need

for change

Planning the

change

Reflection and

evaluation

What is Root Cause Analysis (RCA)?

Is the identification of the ‘vital few’ causes that have a material impact on the outputs of a process

Analysis is used to identify areas for change and to develop recommendations which deliver safer care for patients.

Cause and Effect

Person centred System centred

Problem Careless individuals Poor design

Focus Blame System

Solution Remove individual Change system

Neglect and wilful misconduct are a rare source of harm

How can we identify the underlying system failures which contribute to an adverse event or near miss?

1. Need to identify the root cause. This is a factor: which significantly contributes to an adverse event if resolved will eradicate, or significantly contribute to the

resolution of, the identified problem to which it is attached

2. Undertake a root cause analysis (RCA)structured investigation that aims to identify the true

cause(s) of a problem, and the actions necessary to eliminate it (Anderson & Fagerhaug 2000)

Root Cause Analysis (RCA)

Applying the principles of RCA to PINCER

Identify incident

Gather information

Identify and prioritise problems

Explore problems

Identify quality and safety

improvements

Implement action plan and share learning

Determine what happened.

Determine why it happened.

Figure out what to do to reduce the

likelihood that it will happen again.

Root Cause Analysis

Focus on systems not individuals

Cause and effect (fishbone) diagrams

Group activity

Discuss the clinical scenarios for one of the National PINCER Dataset indicators

• What action might you take to reduce risk of harm to current patients?

• What questions might you ask to get to the root cause of the problem?

• Identify possible system failures and how these could be addressed

• Consider any wider impact

For example…..

What might be the reason?

Prescription for loop diuretic in ≥ 75 years without U+E in

previous 15 months

Number of patients = 8

Two have a QOF long-term

condition

Six do not have QOF long-term

condition

Possible contributing factors

Furosemide without U+E

Long term condition (e.g. Heart failure)

Recall system did not work and patient not identified

or offered monitoring

Patient offered monitoring but

declined

Patient currently unsuitable for

monitoring e.g. EOL

No long term condition e.g. treating lower leg oedema

Process for recall

Evidence for use• possible

cessation

Missing Read code

Hospital information

Transfer of notes/care

Possible outcomes?

Medication no longer clinically indicated

• Stop loop diuretic and monitor the patient

Clinically indicated and long term condition that should have a robust recall in place

• Improve system and process so that all patients are identified and offered monitoring• If patients are offered monitoring have a process in place if they do not attend (who will contact and when)• If patients do not respond to further contact have a process in place for managing the medication (who to refer

to, reducing the supply quantity until monitoring complete)• Use available prescribing decision support software to identify overdue monitoring

Consider wider impact

• Review other action groups that require routine monitoring in case similar flaws are found with processes• If other action groups have a more robust process for monitoring, transfer the learning to managing loop

diuretics

Group activity

Discuss the clinical scenarios for one of the National PINCER Dataset indicators

• What action might you take to reduce risk of harm to current patients?

• What questions might you ask to get to the root cause of the problem?

• Identify possible system failures and how these could be addressed

• Consider any wider impact

Work in small groups

What would you consider

Prescription of aspirin in combination with another antiplatelet

drug without co-prescription of an ulcer-healing drug

Number of patients = 8

Most have a fixed term for the

second antiplatelet

Second antiplatelet has

always been started in hospital

Process review

Two antiplatelets

Process for addition

Who adds to repeat and do they know to consider gastro-protection

Feedback to hospital

Stop dates for antiplatelets to directions

Review dates for PPI to directions

Education –prescriber and

patient

Use of computer system and

software available

What would you consider?

Prescription of an oral NSAID, without co-prescription of an ulcer-healing drug, to a patient

with a history of peptic ulceration

Number of patients = 8

Five of which have a PPI on repeat but have not collected

regularly enough to be adherent

Process review

NSAID and non-

adherence to PPI

Process for identifying non-adherence in the practice

Medication reviewRepeat issue by reception team

Education of the patient

Clear directions on the medication

What to do if PPI declined

Managing and facilitating change

Identifying the need

for change

Planning the

change

Reflection and

evaluation

Change management is….

…a structured approach to moving

individuals, teams, and organisations from

the current state to a new state

Managing change in general practice

Change necessitated by circumstances is acceptable in general practice Often evidence is not available for required change Change based on fashion is less acceptable than that based on sound evidence Imposed change is more acceptable if it is expressed in terms of outcome rather than detailed behaviour The positive way to deal with imposed change is to create a sense of ownership of the change within the practice

Scott and Marinker (1993), Change and Teamwork in Primary Care (BMJ)

Where to start?

What Who

HowWhy

What Who

HowWhy

What do we want to achieve with this change?

Why do we need to change?

Who is affected by the change and

how will they react?

How much can we achieve

ourselves and what do we need help

with?

Conducting a good practice meeting

Identifying the need

for change

Planning the

change

Reflection and

evaluation

Engagement meeting

• Foster key relationships (PM, lead GP)– initial practice meeting and cascade to rest of practice– discuss data sharing, processing agreements and

relationships• Outlining the PINCER intervention process• Defining your role – what you will and won’t do• Defining practice staff roles in the intervention

• identifying practice member to join PRIMIS hub and sign DPA

• Identifying practice PINCER champion to ensure actions are completed

• Getting commitment• Agreeing time scales and access to meetings to

feedback• Access to records and clinical system

We weren’t strangers to our practices…we have

almost got one foot in the door already so then they

are more receptive to what you are saying…I think if

you sent a stranger in they might be a bit more wary as in who is this person and are they criticising

(CCG Pharmacist focus group Participant 3_Site 11)

Resistance to change

Resistance is a resource

Communication is key

You can change the change

Objections can be valid

Acknowledging history reduces resistance

Resisting Forces

Driving Forces

Dealing with resistance – Force field analysis

Perceived more efficient use of PHCT Time Additional workload

Driving Forces Resisting Forces

STAT

US

QU

O

More accurate clinical data Positive negatives

Safer careTraining time needed on new way of working

Education outreach Fears over sharing data

Change – it’s personal

Competence Security Territory

Relationships Direction

Overcome resistance

Awareness and education

Participation and negotiation

Produce and share an action plan

Identify key personnel and responsibilities

Feedback – top tips

“Everyone is entitled to his own opinion but not to his own facts” Daniel Patrick Moynihan

Focus on systems and tasks not individuals

Feedback works best if it is timely and has elements of praise

along with constructive advice

Aim to close the gap between current and desired performance

(results)

Agree areas to prioritise for

improvement (accept zero patients not always realistic)

Identify your advocates for PINCER

in the practice

Use a feedback process that works

best for you practice and involves the right

people

Present the facts

Time to think…Feedback sessions

How would you undertake a feedback session in your practice?• Who would be at the session?• How much time would you

need/request?• What support would you need?

Factors that facilitated engagement

Knowledge/reputation of team

Evidence base Need Patient safety focus and culture

Peer pressure Role recognition and job satisfaction

Prescribing incentives YES

The change agent

does not have to walk on water but…should be patient, persistent, honest, trustworthy,

reliable, positive, enthusiastic, co-operative, confident (but not arrogant) a good listener, observant (of the

feeling and behaviours of others), flexible, resourceful, difficult to intimidate, willing to take risks and accept

challenge and be able to handle organisational politics.And they should have a sense of humour, a sense of perspective and be able to admit ignorance and ask

for help when appropriate…”

Hutton D.W., The Change Agents’ Handbook. (1994)

Action planning

Identifying the need

for change

Planning the

change

Reflection and

evaluation

Action planning

S

M

A

R

T

Specific

Measurable

Achievable

Relevant

Timely

Be precise about what you want to achieve

Quantify your objectives. How will you know you have achieved what you set out

to achieve

For an objective to motivate people, it should be challenging but not impossible or

too difficult

Is it going to improve your situation? List the benefits that would be achieved by

putting this plan into practice

Give a time frame for achieving the objectives

MoSCoW

Must Do Should Do

Could Do Won’t Do

Responsibility charting

GPs Practice Manager

District Nurses

Practice Nurses

Computer Operator

Reception Patients

Install computerisedappointments system

A R I S R S I

Enter hospitaldischarge summaries onto computer

C S I I R R --

Attend clinical coding training

R R R R R R --

Audit data quality levels

C S -- C R I --

Action planningActions Person

ResponsibleStart Date

Expected Completion Date

Resources Actual Completion Date

Step 1. Triage list of patients

Pharmacist 3rd March 5th March • PINCER indicators• Evidence based summaries• Clinical system access

4th March

Step 2. Arrange medication review with patients

Pharmacist 5th March 6th March • Time to consult admin staff• Clinical system access

6th March

Step 3. Feedback at practice meeting

Pharmacist 13th March 13th March • Clinical system access 13th March

Step 4: One to one session with lead clinician to include academic detailing

Pharmacist 22nd March 22nd March • Clinical system access• Evidence based summaries

22nd March

Avoid failure

Planning too much too soon. Remember that small manageable chunks are best Lack of detail or vague steps without

definition of the tasks involved Not involving people who have been

identified to complete tasks Lack of resources (or poor resource

planning) Poor time planning resulting in

unrealistic deadlines

Lessons learned report

Next steps

Analyse your practice results and carry out RCA

Feedback the findings to your practice

Upload your data to CHART Online

Be prepared to share your experiences

The PINCER programme of work is the result of collaboration with, or funding received from, the organisations acknowledged below: