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

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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

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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

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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