medicines breakthrough collaborative 1

Medicines Breakthrough

Collaborative 1Wednesday 4

November 2015

A Quality Improvement Approach to Patient Safety in Medicines OptimisationAnna BurhouseDirector of QualityWest of England AHSN

WHAT IS QUALITY IMPROVEMENT SCIENCE?

At present, the evidence is clear that healthcare is not always safe and can lead to poor patient experience and outcomes. At the same time, the economic downturn means an end to year-on-year financial increases. Healthcare services are being challenged to respond to this not through indiscriminate cuts, but by improving efficiency, driving up quality and reducing levels of harm.’

The Health Foundation 2014

The Triple Aim

PopulationHealth

Experienceof Care

Per CapitaCost

Don Berwick 2015

Aims for Improvement

• No Needless Deaths• No Needless Pain or

Suffering• No Unwanted Waits• No Helplessness• No Waste

……For Anyone

• Safety• Effectiveness• Patient-centeredness• Timeliness• Efficiency• Equity

“The First Law of Improvement”

Every system is perfectly designed to achieve exactly the results it gets.

Building Reliable Systems

• Design needs to be woven into working practices, with repeated cycles of adaptation, small steps.

• Find what works, adapt or abandon what does not.• When you know what works on a small scale, look to

implement more widely.• Ask the people who are on the receiving end of care

whether the new methods result in good care.• Open culture, flat hierarchies, challenge is not a threat

but a source of new ideas and improvement

Complexity and Reliability

Aim: “90% compliance with Antibiotic

Received Within One Hour” (4 step process)Probability of on-time successful

completion at each step

Steps 90.00% 99.00% 99.90% 99.99% 99.999%

1 90.00% 99.00% 99.90% 99.99% 99.999%

2 81.00% 98.01% 99.80% 99.98% 99.998%

4 65.61% 96.06% 99.60% 99.96% 99.996%

8 43.05% 92.27% 99.20% 99.92% 99.992%

16 18.53% 85.15% 98.41% 99.84% 99.984%

32 3.43% 72.50% 96.85% 99.68% 99.968%

64 0.12% 52.56% 93.80% 99.36% 99.936%

128 0.00% 27.63% 87.98% 98.73% 99.872%

If the reliability of each step is 90% then the

overall reliability for the 4 steps together is only

65.61% (.90^4=.6561)

How does the complexity of your process

affect reliability?

Diagnosis

Correct antibiotic chosen

Correct prescription

available

Antibiotic given within right time

scale

• ThroughPut Yield (TPY), is defined as the number of units coming out of a process divided by the number of units going into that process over a specified period of time.[1] Only good units with no rework are counted as coming out of an individual process.

• Also related, "first time yield" (FTY) is simply the number of good units produced divided by the number of total units going into the process. First time yield considers only what went into a process step and what went out, while FPY adds the consideration of rework

FIRST PASS YIELD – no rework possible, opportunity missed

• 100 units enter A and 90 leave as good parts. The FTY for process A is 90/100 = .9000

• 90 units go into B and 81 leave as good parts. The FTY for process B is 81/90 = .8889

• 81 units go into C and 73 leave as good parts. The FTY for C is 73/81 = .90

• 73 units got into D and 64 leave as good parts. The FTY for D is 64/73 = .87

• 64 units go into E and 58 leave as good parts 58/64 =.90

• 53 units go into process F 48 leave as good parts 48/53 =0.9

BUT

• The total first time yield is equal to FTYofA * FTYofB * FTYofC * FTYofD or .9000 * .8889 * .90 * .90 = .65

reference - Wikipedia 2/10/14

Reducing Variation

Old Methodology

• Design and them implementation.• Audit, followed by change, followed by audit• Audit time consuming, complex and difficult• Audit of paperwork rather than whether care is better.• Extremely slow process, taking design cycles into years

rather than days

Changing our approach

No action taken here

Reject defectives

Better Quality Worse

Old Way(Quality Assurance)

Requirement,Specification or

Threshold

Action taken on all occurrences

Better Quality Worse

Source: Robert Lloyd, Ph.D

New Way(Quality Improvement

The Three Faces of Performance Measurement

Aspect Improvement Accountability ResearchAim Improvement of care

(efficiency & effectiveness)

Comparison, choice, reassurance, motivation

for change

New knowledge(efficacy)

Methods:• Test Observability Test observable

No test, evaluate current performance Test blinded or controlled

• Bias Accept consistent bias Measure and adjust to reduce bias

Design to eliminate bias

• Sample Size “Just enough” data, small sequential samples

Obtain 100% of available, relevant data

“Just in case” data

• Flexibility of Hypothesis

Flexible hypotheses, changes as learning

takes placeNo hypothesis

Fixed hypothesis(null hypothesis)

• Testing Strategy Sequential tests No tests One large test• Determining if a change is an improvement

Analytic Statistics(statistical process

control) Run & Control charts

No change focus(maybe compute a

percent change or rank order the results)

Enumerative Statistics(t-test, F-test, chi square, p-values)

• Confidentiality of the data

Data used only by those involved with improvement

Data available for public consumption and

review

Research subjects’ identities protected

Knowledge Base for Continual Improvement

Knowledge for Improvement ▪ Systems▪ Variation▪ Psychology▪ Improvement techniques

Continual Improvement

Subject andDiscipline Knowledge

+

Adapted from Don Berwick 2015

• Appreciation of a system• Understanding of Variation• Theory of knowledge• Psychology

(adapted from Langley et al)

The Science of Improvement

THE MODEL FOR IMPROVEMENT: PLAN, DO, STUDY, ACT

When you combine the 3 questions with

the…

PDSA cycle, you get…

Source: The Improvement Guide p. 10

…the Model for

Improvement.

A Modelfor Learning and

Change

Bayes’ Simple Rule

Thanks to Bob Lloyd for this slide

“By updating our initial belief about something with objective new information, we get a new and

improved belief.”

Rev. Thomas Bayes(1701-1761)

Changes that Result in

Improvement

HunchesTheories

Ideas

A P

DS

A P

DS

AP

DS

A P

DS DATA

Learning over Time

Repeated Uses of the Cycle

Develop approaches to improve glycemic

control

Proactive glycemic control an integral part

of system

A PS D

APS

D

A PS D

D SP A

DATA

D SP A

Cycle 1: Develop system to track Hbalc levels for diabetic population

Cycle 2: Establish protocol for HbAlc routine measurements

Cycle 3: Collaborative planning or control levels

Cycle 4: Set target levels for HbAlc levels

Cycle 5: Implement protocol with all staff

Learning over Time

Improving Management of Population – Diabetic Blood Sugar Levels

Detail D

esign

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P A

Self CareSupport

Delivery SystemDesign

Decision Support

Clinical Information

Systems

Using Multiple “Ramps” over time:

Chronic Disease Care

A Collaborative Approach

• Do you know how good you are?

• Do you know where you stand relative to the best?

• Do you know where the variation exists?

• Do you know the rate of improvement over time?

The Breakthrough Series

National AHSN MO patient

safety collaborative

People support what they help to create: microsystems

“The most important single change in the NHS… would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end…”

Don Berwick

Diabetes Digital Coach

Elizabeth Dymond Deputy Director of Enterprise West of England AHSN

AHSN’s Mission

• Building a culture of collaboration and partnerships

• Speeding up adoption of innovation into practice

• Creating wealth through co-development testing and early evaluation and spread of new products and services

Driving Innovation by making the NHS a Lead Customer

Challenge led approach

AHSN Challenges R4H

National scene

“We want to see patients and carers involved in decisions about their care, receiving appropriate structured education to support self-management, having more control and managing their own health, care and treatment.” Act for Diabetes 2014 NHS England

Provide staff and patients with access to high-quality tools for structuring and recording care-planning and shared decision-making. Kings Fund 2014

The NHS Five Year Forward View committed to developing a National Diabetes Prevention Programme. A delivery group from NHS England, Public Health England and Diabetes UK is currently leading the design of the programme.

Challenge Process

• Members work together

• Define an unmet need

Challenge Definition

• Challenge is published

• Companies respond

Challenge Launch • Best solutions

picked• Lead

Customers• Projects up to

£50KReview

• Evaluation• Learning shared• Next steps

Go - live

Soft Start Innovation

Content slide heading

Clinical Commissioning Groups

Bath and North East Somerset

Bristol

Gloucestershire

North Somerset

South Gloucestershire

Swindon

Wiltshire

• “By working with the AHSNH we would be able to access technologies and providers that otherwise we would not be aware of but neither would we have the internal resource to procure.” (South Gloucestershire CCG)

• “Together we are leading on redesigning the clinical pathway for our patients with Diabetes and are consequently very interested in this project.” (BANES CCG)

• “I was interested to read about the diabetes mobile and web based work in the West of England AHSN newsletter. We would be keen to be involved in testing and evaluation of products if you are looking for this.” (North Somerset CCG)

Opportunities for company applicants

Your innovative product will be used & evaluated in a real world setting.

You will submit a quotation rather than a tender as we are looking to evaluate a number of innovative solutions with the costs of each one less than £50,000

You will receive a report on the evaluation which will also be shared with West of England

AHSN members who commission and provide healthcare services across our region with a population of 2.4 million people.

You have the opportunity to develop your products in line with commissioner and provider

requirements.

Increased potential for sales in West of England healthcare providers.

Increased potential for national sales as the 15 AHSNs across England share case studies.

Registration on national portals to receive alerts on further relevant public sector procurement opportunities.

What if ……healthcare records were shared

between the person with diabetes and other people

and services that the person wishes to share

that record with? Viewing, inputting and editing rights

are controlled by the person with diabetes and records are available in

real time.

What if….. services were set up so that

healthcare professionals and patients can email,

text and phone each other?

What if ……services were truly joined up to be person-centric and personalized to account for many

people with diabetes having

another long term condition?

What if ….we can enable every citizen to self-care in their

own way to the benefit of their health,

both physical & mental?

Diabetes

139 per cent more likely to be admitted to hospital with angina 94 per cent more likely to be admitted to hospital with myocardial

infarction 126 per cent more likely to be admitted to hospital with heart failure 63 per cent more likely to be admitted to hospital with a stroke 400 per cent more likely to be admitted to hospital for a major

amputation and 817 per cent more likely to be admitted with a minor amputation

272 per cent more likely to be admitted to hospital for renal replacement therapy (ESKD)

http://www.hscic.gov.uk/nda

http://www.hscic.gov.uk/nda

mHealth

• ….also known as mobile health, covers medical and public health practice supported by mobile devices

• Mobile phones• Patient monitoring devices• Apps• Wearables• Health information• Medication reminders

Self-Management

99% of diabetes care falls to self-management.

Shared decision making: clinicians and patients working together to

– clarify treatment, management or self-management support goals,

– share information about options and preferred outcomes

to reach mutual agreement on the best course of action

Key Dates 2015

• 23rd June – Launch• 22nd July – Deadline for submissions - 27• 27th July – Prepare shortlist - 19• 31st July – Review panel - 8• 15th Sept – Interviews - 5• 4th Nov – Test Bed submission

http://www.mapmyhealth.co.uk/

Thank you

Next steps• Discussions starting on how this programme

links with MO work• Test Bed decision end Dec 2015• Start Diabetes Digital Coach tools projects

• Thank you

Transfer of Care – Supporting PatientsMartin Littleton, Implementation Manager

Avon Local Pharmaceutical Committee

Supporting Community Pharmacy across Avon


Why is it needed?


Hospital Discharge Project• At point of discharge from hospital patients are signed

up to the service• Patient information securely transferred to the chosen

pharmacy• Pharmacy accesses data on PharmOutcomes

– Includes an attached TTA letter• Pharmacy contacts the patients

– Medication review– Review of new medicines where appropriate– Ensure the patient is clear about their condition and how to

administer their medicines


Proof of concept

• The technology of PharmOutcomes would work for this service

• Pharmacies would contact patients• Patients would be receptive to the service• Demonstrated outcomes (small scale)


Patients are benefiting


Outcomes Are Better

• Mid July patient discharged and not seen in pharmacy• Patient re-admitted. Discharge in September and pharmacy

followed up• Patient not been discharged through service since

Patient not intervened

with

• Patient went in with one medication and came out with nine• Pharmacist spent time explaining and introduced a

compliance aid• Patient now happy

Multiple medication

• GP didn’t want to get involved • Pharmacy contacted hospital and investigated• Diagnosis correct, pharmacist intervened and patient now

happy to take medication

Pharmacist interventio

n with hospital


What next?

• Pharmacy contractor engagement and training• Is the payment via an MUR or NMS

sustainable?– Good outcomes achieved without these

• Is there the possibility of a commissioned service…what would this look like?