This document discusses quality improvement approaches to patient safety in medicines optimization. It provides an overview of quality improvement science and outlines several key principles, including using small tests of change and repeated PDSA cycles to drive continuous learning and improvement over time. The document also discusses using a collaborative approach to improvement that engages both staff and patients in the process.

1. Medicines Breakthrough
Collaborative 1
Wednesday 4 November 2015

2. A Quality Improvement
Approach to Patient Safety in
Medicines Optimisation
Anna Burhouse
Director of Quality
West of England AHSN

3. WHAT IS QUALITY IMPROVEMENT
SCIENCE?

4. 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

5. The Triple Aim
Population
Health
Experience
of Care
Per Capita
Cost
Don Berwick 2015

6. 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

7. “The First Law of Improvement”
Every system is perfectly designed to
achieve exactly the results it gets.

9. 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

10. 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
How does the
complexity of
Diagnosis
Correct
antibiotic
chosen
Correct
prescription
available
Antibiotic
given within
right time
scale

11. • 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

12. Reducing Variation

13. 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

14. 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

15. The Three Faces of Performance Measurement
Aspect Improvement Accountability Research
Aim 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 place
No 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

16. Knowledge Base for Continual Improvement
Knowledge for
Improvement
▪ Systems
▪ Variation
▪ Psychology
▪ Improvement techniques
Continual
Improvement
Subject and
Discipline
Knowledge
+
Adapted from Don Berwick
2015

17. • Appreciation of a system
• Understanding of Variation
• Theory of knowledge
• Psychology
(adapted from Langley et al)
The Science of Improvement

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

19. When you
combine the 3
questions with
the…
PDSA cycle,
you get…
Source: The Improvement Guide p. 10
…the Model for
Improvement.
A Model
for Learning and
Change

20. 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)

21. Changes that
Result in
Improvement
Hunches
Theories
Ideas
A P
DS
A P
DSDATA
Learning over Time
Repeated Uses of the Cycle

22. Develop approaches to
improve glycemic
control
Proactive glycemic
control an integral part
of system
A P
S D
A P
S D
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

23. Self Care
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Using Multiple “Ramps” over time:
Chronic Disease Care

24. 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?

25. The Breakthrough Series
National AHSN
MO patient
safety
collaborative

26. People support what they help to create:
microsystems

29. “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

30. Diabetes Digital Coach
Elizabeth Dymond
Deputy Director of Enterprise
West of England AHSN

31. 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

32. Challenge led approach
AHSN Challenges R4H

33. 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.

34. 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
£50K
Review
•Evaluation
•Learning shared
•Next steps
Go - live
Soft Start Innovation

35. Content slide heading

38. Clinical Commissioning Groups
Bath and North East Somerset
Bristol
Gloucestershire
North Somerset
South Gloucestershire
Swindon
Wiltshire

39. • “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)

40. 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.

41. 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?

42. What if ….we can
enable every citizen
to self-care in their
own way to the
benefit of their health,
both physical &
mental?

44. 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

45. 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

46. 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

47. 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

49. Thank you

50. 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

51. Transfer of Care – Supporting Patients
Martin Littleton, Implementation Manager
Avon Local Pharmaceutical Committee
Supporting Community Pharmacy across Avon

52. Supporting Community Pharmacy across Avon
Why is it needed?

53. Supporting Community Pharmacy across Avon
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

54. Supporting Community Pharmacy across Avon
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)

55. Supporting Community Pharmacy across Avon
Patients are benefiting

56. Supporting Community Pharmacy across Avon
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
intervention
with
hospital

57. Supporting Community Pharmacy across Avon
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?