CLINICAL LEAD Sanjoy NandSMOOTH TEAM Team Lead: Rebecca Lawn

Sonia Varma, Ahmed Marmoush

PROJECT SUPPORT Doreen Liow,Nazanin Falconer Karla Rika-Heke, Maika VeikuneIan Kaihe-Wetting, Truc Nguyen

20,000 Days Ian Hutchby, Monique Davies

SMOOTH

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-

Last Updated 23 April 2012

20,000 Days Campaign

Reduce medication related re-admissions by 2% and we will do

this by providing

90% of high risk adult

and surgical patients with a medication management service at discharge and in the immediate

post discharge period (7

days).

High Risk Pt discharge

Discharge Planning Process

Medication Processes

Training Resources

Processes –SOP/Checkli

st

Pt Identification

1° 2°

Identification of patients at greatest risk of harm and greatest potential for benefits

Change Concepts

Timing of discharge

Defined Process with Checklist

VHIU concept familiarisation

Specific Pharmacists dedicated to service

Use ART Tool to identify patients/cf other factors that may influence patient populations

Work of “Transitions of Care” group

Modify EDS template to identify high risk pts

Identification Process – Magnets on Pt boards (Enrol pts)

MR, Concerto, MUR training

Use of Checklist as prompt and to collect information

Specific Change Ideas

Pharmacist Resource

Recruitment

Coordination

Referral mechanism

Accuracy of meds information at discharge

Access of meds

Meds Resource Pack

Med Rec on DischargeMed Review/EDS meds review

Fax script, access/transport, check testsafe if picked upIdentify barriers to access

Med card, Patient Info leaflet, Checklist, Compliance Aid

Medication Passport (mylist)

Communication

Follow up patient after discharge

Follow up significant issues with GP/community pharmacy

Tools

Pharmacists with right skills KEY

MUR: Medicine use review

ART: Assessment of Risk Tool

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

Secondary Drivers

Change Ideas Tested Evidence of Improvement

Identify target population 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.

Discharge Planning Process

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

0.000

0.500

1.000

1.500

2.000

2.500

08

/10

/20

12

22

/10

/20

12

29

/10

/20

12

05

/11

/20

12

12

/11

/20

12

19

/11

/20

12

26

/11

/20

12

03

/12

/20

12

10

/12

/20

12

17

/12

/20

12

24

/12

/20

12

31

/12

/20

12

07

/01

/20

13

14

/01

/20

13

21

/01

/20

13

28

/01

/20

13

04

/02

/20

13

De

fec

ts

Average Number of SMOOTHed Patients per Day

UCL

CL

LCL

0

2

4

6

8

10

12

14

16

18

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

Da

ily

Av

era

ge

SMOOTH Change Packages

Secondary Drivers

Change Ideas Tested Evidence of Improvement

Discharge care package and medication processes

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

Communication and follow up

Communication of information to other health professionalsCommunication 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

29/1

0/20

12

05/1

1/20

12

12/1

1/20

12

19/1

1/20

12

26/1

1/20

12

03/1

2/20

12

10/1

2/20

12

17/1

2/20

12

24/1

2/20

12

31/1

2/20

12

07/0

1/20

13

14/0

1/20

13

21/0

1/20

13

28/0

1/20

13

04/0

2/20

13

Week Commencing

% SMOOTH patients receiving Medication card

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

08/1

0/12

15/1

0/12

22/1

0/12

29/1

0/12

05/1

1/12

12/1

1/12

19/1

1/12

26/1

1/12

03/1

2/12

10/1

2/12

17/1

2/12

24/1

2/12

31/1

2/12

07/0

1/13

14/0

1/13

21/0

1/13

28/0

1/13

Week Commencing

% SMOOTH patients who have prescriptions faxed

0%10%20%30%40%50%60%70%80%90%

100%

08/1

0/20

12

15/1

0/20

12

22/1

0/20

12

29/1

0/20

12

05/1

1/20

12

12/1

1/20

12

19/1

1/20

12

26/1

1/20

12

03/1

2/20

12

10/1

2/20

12

17/1

2/20

12

24/1

2/20

12

31/1

2/20

12

07/0

1/20

13

14/0

1/20

13

21/0

1/20

13

28/0

1/20

13

04/0

2/20

13

week commencing

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

AreasChanges to Support

ImplementationPDSA cycles

Standardisation 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

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

2. Modify hours to capture more patients

3. Laptop purchases

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

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

Average Number of SMOOTHed Patients per Day

UCL

CL

LCL

0

2

4

6

8

10

12

14

16

18

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

Dai

ly A

vera

ge

Change package provided to 385 general medical patients.

Potential Medication Errors Identified and Resolved by SMOOTH Team (November 2012-January 2013)

0

20

40

60

80

100

120

Grade ONE Grade TWO Grade THREE Grade FOUR Grade FIVE

From 133 errors - using epifany grading systems

SMOOTH Results so far…

SMOOTH Achievements to dateOut of 365 who received the care package ~35% (133) had at

least one error identified on the discharge summary

Number of errors per patient

0

20

40

60

80

100

120

140

0 1 2 3 4 5 6 7

Number of errors identified per patient

Nu

mb

er o

f p

atie

nts