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Implementing the Scottish Patient Safety Programme in Primary Care

Implementing the Scottish Patient Safety Programme in Primary Care. Dr Stuart Cumming GP and Associate Medical Director Primary Care NHS Forth Valley March 2014. The wider context. Phased Approach. Our aim.

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Implementing the Scottish Patient Safety Programme in Primary Care

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  1. Implementing the Scottish Patient Safety Programme in Primary Care Dr Stuart Cumming GP and Associate Medical Director Primary Care NHS Forth Valley March 2014

  2. The wider context

  3. Phased Approach

  4. Our aim All 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 2013 82% 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

  5. 3 workstream aims

  6. Focus in the first year • 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

  7. 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)

  8. Methodology – Collaborative within a CollaborativeProtected Learning Time

  9. 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 …….

  10. Impact on DMARD prescribing Methotrexate 2.5MG TABS AS % OF ALL ORAL RX : Forth Valley OTHER HBS

  11. Impact on Warfarin INR control in Forth Valley INR< 1.5 and > 5.0 All INR Requested By Practice: May to Oct 2013

  12. INRs out of range FV 2012-2013

  13. DAWN practices. INRs within range 2012-2013

  14. Reducing High Risk Prescribing NSAIDs

  15. Reducing High Risk Prescribing • 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 1999 • Howard et al Br J pharmacology 2006 • Zhang et al BMJ 2009 • Howard et al qshc 2003

  16. 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

  17. Proportion of Patients aged 65 years or over currently prescribed an NSAID who do not have co-prescribed PPI Gastroprotection

  18. 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%

  19. Medicine Reconciliation Over 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

  20. Medicines Reconciliation Bundle Whole System Working Project Practices will carry bundle data collection on medicine reconciliation on a random 10 patients a month that have • been discharged form an acute medical admission, or • 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

  21. FALKIRK EARLY YEARS COLLABORATIVE

  22. 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

  23. SMALL SCALE TESTS http://youtu.be/_ZcUM-_7kEE

  24. 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?

  25. FALKIRK TESTS 80-85% of woman being booked for ante-natal services by 12 weeks gestation

  26. FALKIRK TESTS 130 requests received for Psychology of Parenting Programme

  27. FALKIRK TESTS 4 Leadership Walkrounds Undertaken

  28. ** planned

  29. FALKIRK TESTS Health Visitor increased attendance at 27-30 month reviews from 43% to 100%

  30. Prescribing Management in Primary Care:From strategy to operational delivery Fiona Allan Primary Care Pharmacist April 2014

  31. 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

  32. 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

  33. Challenges & Opportunities:Variation in Prescribing Costs across Scottish HBs

  34. Challenges & Opportunities:Variation in Prescribing Costs across FV Practices HB Average Cost/Patient = £168 Range from £126 to £196

  35. 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

  36. 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

  37. PRISMS shows FV HB is an outlier for an particular topic

  38. Best practice is agreed and outlined in a local prescribing protocol

  39. Strategic messages embedded with electronic formulary/local prescribing bulletins

  40. 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

  41. PRISMS supports HB level evaluation of success

  42. Summary: What has worked for us in achieving prescribing change?

  43. Prescription for Excellence Gail Caldwell Pharmacy Director April 2014

  44. 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

  45. 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

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