improvement toolkit (pdf)

#SPSPMeds2016

Improvement toolkitChair: Arvind Veiraiah

#SPSPMeds2016

OverviewTime Speaker Title

13:35-13:40Aravindan VeiraiahHealthcare Improvement Scotland

Introduction

13:40-13:55Paul Sammons, Nicola True and Margaret Marshall NHS Dumfries & Galloway

Reducing harm at transitions –an atypical collaboration with an effective outcome

13:55-14:10Carolyn SwiftNHS Lothian

Failure Modes and Effects Analysis (FMEA) in medicines management

14:10-14:40 Table top discussion and report back

Facilitator Ian Rudd

#SPSPMeds2016

Objectives

• Delegates will be introduced to other improvement methods and hear from frontline teams that have applied them in improvement projects related to medicines.

#SPSPMeds2016 @dg_improvers

Reducing harm at transitions –an atypical collaboration with an effective outcomeNicola True, Project ManagerMargaret Marshall, Project PharmacistPaul Sammons, Improvement Advisor


The project – Improving reliability and accuracy of medicines reconciliation

• Funded for 18 months – Health Foundation - Safer Clinical Systems methodology with support from local Patient Safety team

• Dedicated Resources

– Project Manager + Pharmacist each 2 days a week

• DGRI Ward 16, all trauma orthopaedic patients

• Project Completion May 2016


Pre 2015 - The challenge

• Medicines Reconciliation aka Reducing Harm at Transitions – SPSP priority since 2008 – not hearing of step change – no new paradigm

• Dependency on ever-changing resources – typically FY1’s

• Variation in quality

• Nurses not seeing how they contribute

• Inadequate pharmacy resources to ‘check up’


Earlier project driven by Pharmacist Laura Graham

• Project in 2012 – prescribing errors in acute medical unit

• Key risk identified as Medicines Reconciliation

• Test of change commenced to develop e-Med Rec solution

• Great idea, but typical development cycle

– IT Development cycle slow to deliver

– FY1’s (user) input to development less than ideal


Mid 2015 - New Approach – might this work?

• Look at quality of transition paperwork in detail

– Admission

– Stay

– Discharge

• Identify Tests of change

• Measure and play back results to practitioners


Sept 2015 - Is it working?

• A number of small tests of change attempted

– Time saving

– Accessibility and availability of information

• Consistent data collection on high quality transition paperwork

• No significant improvement evident


September 2015 - Re-focus on e-Med Rec

• Development work picked up and accelerated

• Involved FY1’s in system spec and testing

• eHealth developer, FY1 and project team together in the ward

• Rapid cycle development – multiple iterations (PDSA’s)

• So what?

– Enhanced engagement between key players

– They all felt engaged and motivated


Reflecting the Data and modifying FY1 perceptions

• FY1 Training - focus on quality of written work at transitions

– Given back their own work (anonymised but handwritten)

– Asked to spot the obvious mistakes

– Interactive session - Highlighted human factors and error rate

– Outcome - Quality can actually be much improved

– Highlighted the criticality of the process and their effect on its quality

– NEXT UP – VIDEO JESS MCGINN

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How have got to this point? How do we keep it going?

• Understand extent of process – where it starts and where it ends

• Work with all stakeholders so they know the part that they play

• Engagement is key – transient FY1’s – eHealth engagement

• E-med rec will spread to remaining wards

• Induction and training for FY1’s must develop to include e-med rec as standard toolset

• Project has an end date. Must assign ownership

Failure Modes and Effects Analysis (FMEA) in medicines management

NHS Lothian

Carolyn Swift

Service Improvement Manager

(Improvement Advisor)

I’ve been asked to discuss…

• What is FMEA

• The benefits

• How we did it

What is FMEA?

A structured approach to:

• Identify the ways in which a process can fail

• Estimate risk associated with specific causes

• Prioritise the actions that should be taken to reduce risk

Benefits of FMEA

Adapted from N Dixon (HQQ)

• Shift focus from following up to preventing errors

• Increase reliability of processes

• Learn staff’s point of view and change processes accordingly

• Increase communication, awareness and accountability about patient safety

• Learn how errors are multi-factorial

• Prevent management from allocating resources to safer parts of a process and invest in the most vulnerable parts

• Avoid the culture of automatically blaming or fault finding

• Cumulate evidence about failure modes

• Team members have to have interest, knowledge, skill and time

• FMEA can be seen as tedious to teams when they have to identify all potential failure modes

– FMEA method and leadership are needed

• Team members can expect an immediate fix

• Actions may vary in strength or may not be taken or there may be no follow up on actions

Recognised drawbacks

Adapted from N Dixon (HQQ)

TEAMExecutive Lead

ConsultantST5

PharmacistMedical Nurse PractitionerPatient Services Manager

FYs x 5 as placement allowedClinical Governance

First Steps

What is a Failure Mode?

A Failure Mode is:

• The way in which the component, product, or process could fail to perform its intended function

• Failure modes may be the result of upstream operations or may cause downstream operations to fail

• Things that could go wrongAdapted from R Lloyd (IHI)

Identifying Failure Modes

• Talk through what happens and what goes wrong

• Process Mapping- Deming: Quality Improvement is the Science of Process Management

- All productive work through process management and human input

• Fishbone diagram - identify causes that contribute to an outcome or result (effect) - analyses multiple potential causes (failure modes)

• Asking why five times – identify root cause(s) of a failure mode (particularly involving a sequence of actions, a process flow or a chain reaction)

Basic process mapping for medicines reconciliation

on admission

Basic process mapping for medicines reconciliation on discharge

The Driver Diagram

Timeline of activity and delays in IDLs being written, checked, to pharmacy and back to patients

Cause and Effect

Failure Mode Examples

2Failure Mode: Each patient’s medicines at the point of

discharge are not complete and accurate on the IDL Occ Det Sev RPN

Risks associated with TRAK

1. EDDs and DDs inaccurate 2. Not able to say who prescribed 3.

Drop down meds lists increase risk of errors

2.2 Doctors not fully and accurately transcribing to the IDL from the Kardex 4 5 6 120

2.3Doctors not providing explanations for medicines changes during

admission 5 6 5 150

2.4 Doctors not knowing how to fill in form, or its importance 6 6 6 216

2.5Doctors not knowing what information GPs require and / or don't

provide it 4 5 6 120

2.6Diagnosis is often not written in the notes so unable to put on the

IDL, notes generally vague 7 7 7 343

2.7Unclear on what is necessary on IDL e.g. how much detail re

investigations 4 5 6 120

2.8 Patients do not review the Kardex prior to transcription to the IDL 7 4 5 140

2.9 Discharge drugs late because they have to wait for results 3 3 7 63

Total 1664

7

2.1

7 3928

Med Rec








admission 5 6 5 150










Total 1664

7

2.1

7 3928

Estimate risk associated with specific causes

A Risk Priority Number (RPN) was calculated:

The higher the RPN the higher the risk

Likelihood of event

occurring

Likelihood of Detection

Severity of harmX X

1 = not likely

10 = very likely

1 = likely to detect

10 = not likely to detect

1 = not severe

10 = very severe








admission 5 6 5 150










Total 1664

7

2.1

7 3928

Prioritise the actions that should be

taken to reduce risk

Excel TabWARD: 25 SJH

Occ Det Sev RPN Occ Det Sev RPN Occ Det Sev RPN Occ Det Sev RPN

1.1 Fewer than 2 sources of information are used 8 7 8 448 8 7 8 448 8 7 8 448 8 7 8 448

1.2 Doctors not taking responsibility for completion of form 6 6 5 180 6 6 5 180 6 6 5 180 6 6 5 180

1.3 Doctors not knowing how to fill in form, or its importance 6 6 6 216 6 6 6 216 6 6 6 216 6 6 6 216

1.4 Changes to original list are not documented 7 5 7 245 7 5 7 245 7 5 7 245 6 4 7 168

1.5 Some meds may be a guess e.g. EC v Dispersible, some a judgment 5 5 5 125 5 5 5 125 5 5 5 125 5 5 5 125

1.6Patients are not aware of the importance of providing accurate

information 5 6 5 150 5 6 5 150 5 6 5 150 5 6 5 150

1364 1364 1364 1287


2.11. EDDs and DDs inaccurate 2. Not able to say who prescribed 3.


2.2 Doctors not fully and accurately transcribing to the IDL from the Kardex 4 5 6 120 4 5 6 120 4 5 6 120 4 5 6 120


admission 5 6 5 150 5 6 5 150 5 6 5 150 4 5 5 100

2.4 Doctors not knowing how to fill in form, or its importance 6 6 6 216 6 6 6 216 6 6 6 216 6 6 6 216

2.5 Doctors not knowing what information GPs require and / or don't

provide it4 5 6 120 4 5 6 120 4 5 6 120 4 5 6 120

2.6 Diagnosis is often not written in the notes so unable to put on the

IDL, notes generally vague7 7 7 343 7 7 7 343 7 7 7 343 7 7 7 343


investigations 4 5 6 120 4 5 6 120 4 5 6 120 4 5 6 120

2.8 Patients do not review the Kardex prior to transcription to the IDL 7 4 5 140 7 4 5 140 7 4 5 140 7 4 5 140

2.9 Discharge drugs late because they have to wait for results 3 3 7 63 3 3 7 63 3 3 7 63 3 3 7 63

1664 1664 1664 1614

3

3.1 Doctors not having time to complete the IDL in a timely manner 6 6 5 180 6 6 5 180 6 6 5 180 6 6 5 180

3.2Doctors not knowing the importance of completing the IDL in a

timely manner 6 6 6 216 6 6 6 216 6 6 6 216 6 6 6 216

3.3 IDL is printed but given to different people 7 4 4 112 7 4 4 112 7 4 4 112 7 4 4 112

3.4 Nurses may not know the procedure for printing and sending the

IDL6 6 7 252 6 6 7 252 6 6 7 252 6 6 7 252

760 760 760 760

Failure Mode: Each patient’s medicines 16 hours after admission are not complete and accurate

Failure Mode: A complete and accurate list of each patient’s medicines and desired information re admission is not provided to GP

Failure Mode: Each patient’s medicines at the point of discharge are not complete and accurate on the IDL

877 7 392873927 8 39287392 7

Nov-10 Dec-10

7

Jan-11 Feb-11

Total Risk Priority Number (RPN)

as per Failure Modes and Effects Analysis (FMEA)

shows a 77% reduction in the risk that medicines will not be reconciled safely

THE

STORY

Links to NHS Lothian's

Medication Matters

campaign to ensure

sustainablity

Feedback to various groups

and meetings

IDL common conditions

templates devised, and

used

Gold standard defined /

process map

Comments re changes

written on Kardex

Structured Ward Round

with sticker template

Changes documented on

printed ECS - held with

kardex

TRAK team / clinicians

SLWG incorporating TRAK

changes by other ward

based teams (RIE

improvements)

Role of FY's defined

Minimum datasets and

requirements determined

with West Lothian Interface

Group

Meetings with patients from

Patients' Forum

2 sources and prompt on

Med Rec Form and posters

in doctors' room

0

500

1000

1500

2000

2500

3000

3500

4000

Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Mar-12 Oct-12

Date

Ris

k P

rio

rity

Nu

mb

er (R

PN

)Cumulative FMEA

Compliance with accurate reconciliation of medicines

on admission to one medical ward (Aug 2010 - Oct 2012)

Definition

1) Accuarte list (incl'

dose, frequency,

allergy)

2) 2 sources

documented

3) Comments re

changes

documented

4) Kardex matches

lists and what

patient is taking

New median

= 93%

Baseline median

(extended)

= 10%

0

10

20

30

40

50

60

70

80

90

100

Aug

10

Sept

10

Oct

10

Nov

10

Dec

10

Jan

11

Feb

11

Mar

11

Apr

11

May

11

June

11

July

11

Aug

11

Sept

11

Oct

11

Mar

12

Oct

12

Date

Per

cen

t re

con

cile

d

Results on Admission

Compliance with accurate reconciliation of medicines

on discharge from one medical ward (Oct 2010 - Oct 2012)

New median

= 87%

Definition

1) Accurate list on

IDL (incl' dose,

frequency)

2) Changes

documented on IDL

3) IDL matches

admission meds

and Kardex Baseline median

(extended)

= 20%

0

10

20

30

40

50

60

70

80

90

100

Oct

10

Nov

10

Dec

10

Jan

11

Feb

11

Mar

11

Apr

11

May

11

June

11

July

11

Aug

11

Sept

11

Oct

11

Mar

12

Oct

12

Date

Per

cent

rec

onci

led

Results on Discharge

Failure Mode Cause / Effect Occ Det Sev RPN Actions Notes and Outcomes

1

1.1Forgetting to sign that meds have been

administered (and distractions)

double-dosing /

omitted meds5 5 5 125

PDSA(1.1)A: Tabards (variable success so far).

PDSA(1.1)B: Supervised med rounds for all

new starts and if an error has been made -

SC/N or DC/N sign-off

PDSA(1.1)B - in place; Team to

look at Datix info at next meeting

(CS to bring)

1.2

Errors can be made when there have been

increases in patient activity, acuity and time

constraints

Errors in reading

kardex2 7 2 28

PDSA(1.2)A: Time wasted topping up POD

Lockers during round - responsibilities defined

as for last person to do round - highlighted at

Safety Briefing (SBrf), ward meeting, induction

(back up by technician)

By Feb 2012 PDSA(1.1)A not

100% success - next test

PDSA(1.1)B: Night shift to

undertake top-up, and continue

with SBrf

1.3

Oxygen may not be prescribed (note: Nurse

Guidelines in Emergency patients) and may

not be administered properly (devices and

concentration)

Over / under

dosing9 7 8 504

PDSA (1.3)A: Local training by physios to

medics and nurses to introduce new policy (Mar

12); PDSA(1.3)B: Example kardex to be

displayed in Drs room and induction folder

Physios (Nicola) to audit use

before and after (DM checking).

FY/Reg to come to next meeting.

Dates available for ward-based

training

FMEA Ward 54 WGH November 17th 2011 (updated 12th Dec 2011, 16th Jan, 13th Feb, 5th Mar 2012)

General

FMEAs for 10 ward areas

Linked to PDSAs

Ward work led to a whole programme of improvements, including mind mapping and pocket cards

Large Mind Map

Small Z-cards

Questions

#SPSPMeds2016

Table top discussion

#SPSPMeds2016

#SPSPMeds2016

Time Title Room

14:40-14:50 Coffee and transition to NHS board huddles

14:50-15:20 NHS board team huddles See next slide

15:20 Transfer to plenary

15:25-15:45 NHS board team huddles report back

Lord Provost & Imperial Suites15:45-16:05SPSP Medicines –a multi-disciplinary approach

16:05-16:15 Wrap up

16:15 Close

For the rest of the afternoon

NHS board Room

NHS Ayrshire & Arran Lord Provost & Imperial Suite

NHS Borders Alloway Suite

NHS Dumfries & Galloway Alloway Suite

NHS Fife Ellisland Suite

NHS Forth Valley Ellisland Suite

NHS Grampian Ellisland Suite

NHS Greater Glasgow and Clyde Cambridge Suite

NHS Highland Cambridge Suite

NHS Lanarkshire Lord Provost & Imperial Suite

NHS Lothian Lord Provost & Imperial Suite

NHS Shetland Cambridge Suite

NHS Tayside Ellisland Suite

NHS Western Isles Cambridge Suite

Golden Jubilee National Hospital Cambridge Suite

#SPSPMeds2016

NHS board team huddle questions (30 mins)

1. Do you know everyone and their role?

2. What are the key areas for improvement related to medication reconciliation in your system?

3. What are your local high risk medicines priorities? How do you know?

4. Who are the key people you need to work with to address the above areas?

5. What are you going to by next Tuesday?

#SPSPMeds2016

improvement toolkit (pdf)

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