Improving prescribing quality

Richard Seal

Programme Director

National collaborative medicines management services programme

Every system is perfectly designed to get the results it achieves ! Don Berwick, Institute for Healthcare Improvement

Unwanted medicines ?

Unwanted effects !

Brain-shakers

The majority of your problems derive from your systems, processes and methods, not from the workers

Changing the system will change what people do, changing what people do will not change the system

The majority of changes in organisations have nothing to do with improvement

Quality in prescribing ?

Prescribing with EASE

Effectiveness

Appropriateness

Safety Economy

Parish PADrug prescribing – the concern of allJ Roy Soc Health 1973;4:213-217

Looking at it another way

Respecting Patient Choices

Minimising Cost

Minimisingrisk

Maximisingbenefit

Barber NWhat constitutes good prescribing ?BMJ 1995;310:923-925 (8 April)

Problems with prescribing

• Inefficient management systems

• Inappropriate variation• Irregular review• Knowledge of the evidence

• Risks vs benefits• Lack of patient involvement

in decision-making• Medication errors

What’s a collaborative ?

“A proven improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common goal.”

…hence it is not a research project a passive exercise

The collaborative programme

Key elements of a collaborative

Challenging aims Identifying and sharing ideas which lead to

successful changes Testing and refining small changes Measuring progress Implementing and sustaining change

found to work

Goal and aims

“…optimise prescribing and improve health outcomes and patient experiences, where medicines are involved”– Identify and address unmet pharmaceutical need

– Help patients get more help with their medicines, thereby achieving real improvements in health

– Improve efficiency and reduce waste

– Better access to a range of medicines management services which make better use of skills of pharmacists

Collaborative StructureEach organisation will work towards the collaborative objectives

by developing and implementing their own locally acceptable models of work

‘EXPERT’Panel

0 41 to 3

Report & Rollout

Five Learning Sessions

LocalActions

LocalActions

LocalPrep

Support from core team

3 waves of activity

Wave 1 site

Wave 2 site

Wave 3 site

London Region

Improvement measures

Improvement not performance management

Reflect improvement activities in a number of areas

Teams develop additional local measures

4 practice level– Polypharmacy (med reviews from wave 2), equivalence and

compliance, safety, satisfaction

3 PCT level– Med review in NH, VFM & health improvement, discharge,

Practice level

Collected monthly from the 5 practices initially involved in the programme

Wave 1 -Average number of repeat items in over 65s on 4 or more

4

4.5

5

5.5

6

6.5

7

7.5

Baseli

ne B+1 B+2 B+3 B+4 B+5 B+6 B+7 B+8 B+9B+1

0B+1

1B+1

2

Wave 2 - % over 65s with documented medication review in past 12 months

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5

10

15

20

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30

35

40

45

% scripts each month where not all regular items are requested

0

10

20

30

40

50

60

Wave 1Wave 2

% scripts leaving surgery without specific dose instructions

0

5

10

15

20

25

Wave 1Wave 2

% patients experiencing problems with repeat medicines

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Wave 1Wave 2

PCT level

Collected monthly from practices across the PCT

% nursing home residents with documented med review in past 12 months

0

5

10

15

20

25

30

35

J an-02

Feb-02

Mar-02

Apr-02

May-02

J un-02

J ul-02

Aug-02

Sep-02

Oct-02

Nov-02

Dec-02

Receipt of discharge info for 90% of patients before next request for medicines

0

10

20

30

40

50

60

J an-02

Feb-02

Mar-02

Apr-02

May-02

J un-02

J ul-02 Aug-02

Sep-02

Oct-02

Nov-02

Dec-02

Areas of improvement activity

General Practice

CommunityPharmacy

PCT

• Repeat prescribing processes• Medication review• Drug monitoring• Practice staff empowerment• Telephone consultations

• Medicines managers• Incentivised medicines management• Formulary development• Practice-based pharmacists• HIMP & NSF priorities• Care home services• Interface issues• Multidisciplinary teams

• Patient involvement• Workshops

• Prescription interventions• Medication review• Minor ailments• Services to practices• Enhanced DUMP campaigns• Patient education• Case-finding

What next

Range of spread activities

– Regional events and networks

– Partnership working

Wave 4 planning

Evaluation Identification of key

improvements for roll-out – Medication review

– Prescription intervention schemes

– Minor ailment schemes

– Repeat prescribing systems

– Medicines management in NSFs

Things to think about

All improvements require change but not all changes lead to improvement

Changes travel through conversation and interaction between trusted peers

Ideas that spread more rapidly– Relative advantage – “better than it is now”

– Compatible with existing beliefs and values

– Simple to understand and implement

– Easily tested before committing fully

– Observable difference

Final thought

“Great discoveries and improvements invariably involve the co-operation of many minds”

Alexander Graham Bell