Transcript LS 3 Storyboard SMOOTH

SMOOTH
CLINICAL LEAD
SMOOTH TEAM
Sanjoy Nand
Team Lead: Rebecca Lawn
Sonia Varma, Ahmed Marmoush
PROJECT SUPPORT
Doreen Liow, Nazanin Falconer
Karla Rika-Heke, Maika Veikune
Ian Kaihe-Wetting, Truc Nguyen
20,000 Days
Ian Hutchby, Monique Davies
Safer Medicines Outcomes on Transfer to Home
(Discharge Medicines Management)
SMOOTH’s Aim:
2-3% reduction in readmissions associated with medication related problems
by providing 90% of high risk adult medical and surgical patients with a
medication management service at discharge and during the immediate post
discharge period (7 days)
Collaborative 20,000 days campaign
Using a risk predicative tool to determine patients at highest risk of
medication related harm
SMOOTH Driver Diagram
20,000 Days Campaign
1°
Pt
Identification
Reduce
medication
related readmissions
by 2% and
we will do
this by
providing
90% of high
risk adult
and surgical
patients with
a medication
managemen
t service at
discharge
and in the
immediate
post
discharge
period (7
days).
High Risk Pt
discharge
Change Concepts
2°
Discharge
Planning
Process
Identification of patients at
greatest risk of harm and
greatest potential for benefits
Work of “Transitions of
Care” group
Timing of discharge
Specific Change Ideas
Use ART Tool to identify
patients/cf other factors that may
influence patient populations
Modify EDS template to identify
high risk pts
Identification Process – Magnets
on Pt boards (Enrol pts)
Referral mechanism
Medication
Processes
Accuracy of meds
information at discharge
Med Rec on Discharge
Med Review/EDS meds review
Access of meds
Meds Resource Pack
Fax script, access/transport,
check testsafe if picked up
Identify barriers to access
Coordination
Communication
Med card, Patient Info leaflet,
Checklist, Compliance Aid
Medication Passport (mylist)
Training
Resources
VHIU concept familiarisation
Tools
Processes –
SOP/Checkli
st
Follow up significant issues
with GP/community
pharmacy
MR, Concerto, MUR training
Defined Process with
Checklist
Pharmacist
Resource
Follow up patient after
discharge
Use of Checklist as prompt
and to collect information
Recruitment
KEY
MUR: Medicine use review
ART: Assessment of Risk Tool
Last Updated 23 April 2012
Specific Pharmacists
dedicated to service
Pharmacists with right skills
-
Why SMOOTH?
•
Medication management support at the discharge phase has been adhoc –
resulting in inaccurate and incomplete information being provided to
patients and primary care providers resulting in suboptimal medicines use
•
Patients often don’t understand the changes made, some are unaware of
the importance of taking medicines or what the new medicines are for which
results in inappropriate disease management, adverse drug events and
readmissions
•
Evidence suggests that pharmacist interventions at discharge and
pharmacist led follow up of discharges (care integration) results in lower
rates of readmission
•
The intervention improves patient care when transitioning from hospital to
home, optimises medicines use, integrates care and improves overall
patient safety
ART Tool
SMOOTH Change Packages
Discharge Planning
Process
Evidence of
Improvement
 Use ART Tool vs referral process by clinical
pharmacist to identify patients.
 ART tool adopted as captured 70% of
patients identified by clinical pharmacist as
needing SMOOTH services.
Notification process for discharge to be
implemented
 Initially SMOOTH patients reviewed and
assessed on admission and again at discharge.
The average time spent on each patient found
to be 3 hours – too long. Process modified to
provide service when notified of discharge only,
reduced time per patient to average 1 hr
 Implementation of GDD on wards has
improved workflow, more idea of when patients
for discharge
 Magnets introduced – improved profile of
SMOOTH
 SMOOTH sentence in discharge summary to
be entered by clinical pharmacists
 ART access provided to nurses
Average number of errors identified per SMOOTH patient
2.500
2.000
Defects
1.500
1.000
0.500
04/02/2013
28/01/2013
21/01/2013
14/01/2013
07/01/2013
31/12/2012
24/12/2012
17/12/2012
10/12/2012
03/12/2012
26/11/2012
19/11/2012
12/11/2012
05/11/2012
29/10/2012
22/10/2012
0.000
08/10/2012
Identify target population
Change Ideas Tested
Average Number of SMOOTHed Patients per Day
18
16
14
UCL
12
Daily Average
Secondary
Drivers
10
CL
8
6
LCL
4
2
0
12-Nov 19-Nov 26-Nov 03-Dec 10-Dec 17-Dec 24-Dec 31-Dec 07-Jan 14-Jan 21-Jan 28-Jan 04-Feb 11-Feb 18-Feb
Week Commencing
SMOOTH Change Packages
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Week Commencing
% SMOOTH patients receiving Medication card
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Week Commencing
% SMOOTH patients who have prescriptions
faxed
week commencing
04/02/2013
28/01/2013
21/01/2013
14/01/2013
07/01/2013
31/12/2012
24/12/2012
17/12/2012
10/12/2012
03/12/2012
26/11/2012
19/11/2012
12/11/2012
05/11/2012
29/10/2012
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
28/01/13
21/01/13
14/01/13
07/01/13
31/12/12
24/12/12
17/12/12
10/12/12
03/12/12
26/11/12
19/11/12
12/11/12
05/11/12
29/10/12
22/10/12
15/10/12
0%
04/02/2013
28/01/2013
21/01/2013
14/01/2013
07/01/2013
31/12/2012
24/12/2012
17/12/2012
10/12/2012
03/12/2012
26/11/2012
19/11/2012
12/11/2012
05/11/2012
29/10/2012
0%
22/10/2012
Communication of information to other health
professionals
Communication with patient, family or care givers if
medication not collected or reason to follow up. Time
consuming process.
% SMOOTH patients receiving a medication
reconcilliation on discharge
15/10/2012
Communication and
follow up
 Medication reconciliation at discharge to prevent
errors and ensure accuracy of information
communicated to patient and primary care providers.
 Tailored patient education
 Interventions package provided.
 Data collection form created to capture key
measurements and standardised process. Refined
over time to improve efficiency of data collection
 Electronic version created to eliminate process of
data entry proved too time consuming
 Use of laptops to ensure access to computers for
SMOOTH pharmacist at time of discharge allowing
services to be provided in a timely manner.
 Patient questionnaires developed – obstacles in
collection of patient experience data, process currently
being refined
Evidence of
Improvement
08/10/12
Discharge care
package and
medication
processes
Change Ideas Tested
08/10/2012
Secondary
Drivers
SMOOTH Measures Summary
 Total number of patients seen each day is recorded on a work list. This
enables us to measure how close we are to achieving our aim
 A care package was created to formalise the medication management
services the SMOOTH team provides
 A data collection form is utilised to document the number of discrepancies
or errors prevented. Each error is then graded using a standardised
approach
 Additionally, the services each patient receives at discharge and during the
immediate post discharge period is documented on the data collection form,
using a tick box approach
SMOOTH Implementation
Implementation
Areas
Standardisation
Changes to Support
Implementation
1.Standard Criteria to determine which patients seen i.e.
high risk as determined by the ART tool
2. Standard process checklist for seeing pts at discharge
PDSA cycles
1. Asked for referrals by pharmacist, checked ART
score, found 70% of referrals were HR as defined
by ART. Decided ART tool was valid way to select
patients
2.Test process for seeing patients at discharge (see
other pharmacists)
Documentation
1. Job descriptions for pharmacists involved in process
2. Standard data collection form
1.Test description of a care integration pharmacist
2.Devolop and test data collection form against
project measures
Training
1.Training other pharmacists to support implementation of
change eg, SMOOTH sentence, notification of discharge
2.Doctors information at medical handovers
3.Nurses for use of ART tool
1.Test whether the inputting of SMOOTH sentence
increases number of patients seen
2. Medical staff awareness of SMOOTH service
3.Test whether nurse use of ART tool increases
notification to SMOOTH team
Measurement
1. Number of patients seen at discharge
2. Monitoring number of errors and types of errors
3, Patient experience
1. Ensure adequate number of patients seen
2. Test whether EDS contains errors
3. Patient feedback sought at point of admission and
at point of discharge
Resourcing
1. Pharmacist resource
1.Currently adequately resourced for Medicine. Will
PDSA resources when roll out to surgical. Will
assess alternate model for service delivery in
Surgery.
2. Review hours to determine if need for extended
hours within current resource
3.Laptops improved workflow for SMOOTH
pharmacist
2. Modify hours to capture more patients
3. Laptop purchases
Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.
SMOOTH Highlights
 Rapid development and implementation of the SMOOTH change package
 Multiple system refinements: Development of a standardised discharge
process and care package of interventions with clinical pharmacy
 Implementation of a formal process for notification of discharges
organisation wide
 Collaboration with other health professionals: recognition from medical staff
about the need for medication management at discharge interface and
acknowledgment of the quality of clinical and patient centred services
provided by SMOOTH team
 Collaboration with quality improvements personnel and valuable learning
from each other to test change packages and ideas
 Key learning: Small, inexpensive tests of change via PDSA cycles can
provide valuable return in overall learning. Failure can provide successful
learning
.
SMOOTH Lowlights
 Difficulty capturing meaningful patient feedback
 Slow uptake with the notification of the discharges resulting in very low
numbers for SMOOTH
 Reliance on various methods for notification of discharges – not a self
sustained process - workflow not consistent
 Time constraints impacting delivery of services
 Limitations with capturing 90% of high risk patients discharged
.
Variation in processes
 Currently data is collected consistently due to standardisation of the
collection form
 Some variation is noted in provision of service and interventions as these
services are time dependent and reliant on early notification of the
discharge. These variations can be measured by capturing the time of
notification vs the number of interventions provided per patient
 Variation in provision of services provided across different populations due
to language barriers and time restraints. These variations can be measured
by comparing the number of interventions provided per patient vs the
ethnicity of the patient
 Variation in recording information on the EDS by individual SMOOTH
pharmacists. These variations can be measured by retrospectively auditing
20 EDS for information recorded
.
SMOOTH Achievements to date
Change package provided to 385 general medical patients.
Average Number of SMOOTHed Patients per Day
18
16
Daily Average
14
UCL
12
10
CL
8
6
LCL
4
2
0
12-Nov 19-Nov 26-Nov 03-Dec 10-Dec 17-Dec 24-Dec 31-Dec 07-Jan 14-Jan 21-Jan 28-Jan 04-Feb 11-Feb 18-Feb
Week Commencing
SMOOTH Results so far…
From 133 errors - using epifany grading systems
Potential Medication Errors Identified and Resolved by SMOOTH Team
(November 2012-January 2013)
120
100
80
60
40
20
0
Grade ONE
Grade TWO
Grade THREE
Grade FOUR
Grade FIVE
SMOOTH Achievements to date
Out of 365 who received the care package ~35% (133) had at
least one error identified on the discharge summary
Number of errors per patient
140
Number of patients
120
100
80
60
40
20
0
0
1
2
3
4
Number of errors identified per patient
5
6
7