Slides from the webinar 'A practical approach to delivering seven day services: a focus on pharmacy'. November 2015

1. A practical approach to delivering 7 day services
A focus on pharmacy
4 November 2015
Welcome …………………we will be starting shortly
Seven Day Services Transformational
Improvement Programme
Community of Practice

2. Objectives of the
Session
• To promote NHSE 7 day service case studies in particular those
which relate to pharmacy
• To promote the role of pharmacy as an integral part of delivering a
seven day service
• To share innovative practice and ideas
• For experts to provide practical advice, tips and assistance through
Q & A
• To aid the spread of good practice across England and support
delivery of the 10 seven day services clinical standards
7DayServices@NHSIQ.nhs.uk

3. Agenda
12.00 Participants register
12.05 Introduction to the session – Nick Wade NHSE
7 day services team
12.10 The role of the pharmacist in facilitating earlier
discharge (Clinical Standard 9)- Gareth Price, Chief
Pharmacist, Lancashire Teaching Hospitals
12.25 Implementing a 7 day pharmacy service Andrew
Lowey, Lead Clinician, Pharmacy and Technical
Services, Leeds Teaching Hospitals
12.40 Questions and answers
12.55 Summary and evaluation
1.00 Close of session

4. Role of the NHSE
7 Day Services Team
1. Diagnostics: Spreading evidence-based models
2. Drive for spread: Engaging all healthcare
communities in moving towards services that
meet the clinical standards and identifying the
top interventions – communities of practice
3. Designing new models of seven
day services

5. The role of pharmacists in supporting
delivery of the 10 Clinical Standards
Patient
Experience
Time to first
consultant
review
MDT
Review
Shift
Handovers
Transfer to
community
and Primary
and social care
Mental
Health
Quality
Improvement Diagnostics
On-going
review
Intervention
/Key services

6. Agenda
12.00 Participants register
12.05 Introduction to the session – Nick Wade NHSE 7
day services team
12.10 The role of the pharmacist in facilitating earlier
discharge (Clinical Standard 9)- Gareth Price,
Chief Pharmacist, Lancashire Teaching Hospitals
12.25 Implementing a 7 day pharmacy service Andrew
Lowey, Lead Clinician, Pharmacy and Technical
Services, Leeds Teaching Hospitals
12.40 Questions and answers
12.55 Summary and evaluation
1.00 Close of session

7. Gareth Price
Chief Pharmacist
Lancashire Teaching Hospitals
Gareth.price@lthtr.nhs.uk

8. NHS Services 7 Days a Week
Transformational Improvement Programme
Redesigning the
Medicines Management
process at Discharge.
Lancashire Teaching Hospitals
Gareth Price
Chief Pharmacist

9. Background – Key Challenges
• Prescribing errors
• Accuracy and timeliness of discharge communication
relating to medicines
• Poor patient flow
• Medicines related problems account for up to 38% of
patients readmitted to hospital; most cases are
preventable. Around 6.5% of all hospital admissions
have been attributed to, or associated with, adverse
drug reactions – with up to two-thirds of these being
preventable.
• Traditional roles of staff

10. Discharge Pharmacist Project
• Phase 1 - Baseline data collection to identify current
performance
Establish the role of a prescribing pharmacist on the MAU and
2 Acute Medical Wards. Pharmacist generates the electronic
‘Immediate Hospital Discharge Summary’
• Phase 2 - Post ‘Intervention’ data collection
Establish a ‘Satellite Pharmacy’ located close to MAU
• Phase 3 – Post ‘Intervention’ data collection

11. Outcomes
Prescribing Errors (% prescribed items)

12. Outcomes (continued)
Accurate communication of medicines started, stopped, changed
during in-patient stay (% patients).

13. Outcomes (continued)
• Post-Intervention
• Total time to discharge reduced by 3 hours and 17 minutes
• Medication ready and on the ward after 2 hours and 50
minutes(reduction of 4 hours 12 minutes)

14. Outcomes (continued)
Medication on
the ward before
1.30pm
Baseline (Medic Prescribing)
Post intervention (Pharmacist Prescribing)

15. Outcomes - Satellite Pharmacy Impact

16. Discussion Points
• Prescribing Errors
• Transfer of Information
• Patient Flow
• Other NMPs
• Implications of Prescribing Pharmacist Model
– Pharmacist clinical check?
– Extend the role to admission
– Extend the role to ED
– Career pathway and improved R+R
– Medical staffing

17. Agenda
12.00 Participants register
12.05 Introduction to the session – Nick Wade NHSE 7
day services team
12.10 The role of the pharmacist in facilitating earlier
discharge (Clinical Standard 9)- Gareth Price, Chief
Pharmacist, Lancashire Teaching Hospitals
12.25 Implementing a 7 day pharmacy service Andrew
Lowey, Lead Clinician, Pharmacy and Technical
Services, Leeds Teaching Hospitals
12.40 Questions and answers
12.55 Summary and evaluation
1.00 Close of session

18. Andy Lowey
Lead Clinician
Clinical, Pharmacy and Technical
Services Leeds Teaching Hospitals
Andrew.lowey@nhs.net

19. Medicines Management &
Pharmacy Services
7 day working
Dr Andy Lowey
Lead Clinician – Clinical Pharmacy & Technical Services
Leeds Teaching Hospitals NHS Trust

20. Background – 7 day working
• Pharmacy Services acknowledged as a priority area in
“Keogh Report” December 2013
• MMPS Working Group formed January 2014
• Issues identified for MMPS 7 day service
– Improving ward presence weekends (inc MDT support)
– Improving Medicines Reconciliation Performance at weekends
– Review of shift leadership & handover
– Patient experience – information on medicines
– Information to GP’s via eDAN
– Improving consistency of access to specialist pharmacist advice

21. What changes have we made?
• New integrated 7 day (all day) rotas across all 5 clinical pharmacy
“clusters”
– pharmacists, technicians & support staff
– specific focus on acute medicine as a priority
• Introduction of prioritisation system for patient review
• New “huddle” system across all teams, led by SDM
• New pharmaceutical care section embedded in Medicines Chart
• Use of electronic handover tool to highlight outstanding/high risk
issues to follow-up
• Replacement of on-call “resident pharmacist” service with shift
systems across 24hours, 7 days a week
• Extended aseptics opening hours (8am-8pm Mon-Fri & 8am-6pm
Sat/Sun)
• “Whole department” approach to reconfiguring rotas to support 7
day services, led by the MMPS Senior Leadership Team

22. What does this mean?
• On-site medicines supply & advice available 24/7
• Near-to-patient validation of eDAN’s
– Less errors, better patient contact, less waste, less transport delays
• Access to specialist pharmacists in each major team across 7 days
(e.g. specialist neonatal TPN pharmacist & paediatric pharmacist
present in Leeds Children’s Hospital)
• Access to technical compounding expertise (e.g. urgent cytotoxic
compounding, neonatal parenteral nutrition)
• Better matching of risk/priority with resource
• Improvement in Medicines Reconciliation performance…
(NB. 30-70% patients have an unintentional medication change during a hospital stay –
NICE PSG001 2007)

23. Results (NB. changes began 1st Nov 14)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
AxisTitle
Medicines Reconciliation within 24 hours
2013-14
2014-15

24. Have we sustained this?

25. Medicines Reconciliation by day of admission
(NB Final changes to ward rotas not completed until March 15)
0%
20%
40%
60%
80%
100%
120%
August September October November December January February March
AxisTitle
Significant improvements made for patients admitted on Saturday
Mon
Fri
Sat
Sun

26. What about the Saturday effect?

27. Acute Medicine – Winter 14/15
• Confirmation of drug history <24hrs across 7 days –
↑ from 78 to 88% despite winter pressures
• Average turnaround times for eDAN on the acute floor
decreased to <60 mins despite winter pressures
(via use of remote dispensary support room by routine
staff familiar to working in the area 24/7)
– 96% completed within 2hrs
– 84% completed <1hr

28. Winter is definitely coming…
… and it is
EVERYONEs
business

29. Children's’ emergency admissions (0 to 14 years) for Leeds-registered patients at
Leeds Teaching Hospitals NHS Trust with a respiratory primary diagnosis (exc.
Lengths of Stay of 29 days or longer)
AdmissionsChangeinbed
occupancy
FALSE
Period Daily
Ave.
95%
variation
FALSE
FALSE
TRUE
TRUE
TRUE
FALSE
4.39 ± 5.7
3.53 ± 4.3
3.99 ± 6.2
0
5
10
15
20
25
30
Apr-09
Aug-09
Dec-09
Apr-10
Aug-10
Dec-10
Apr-11
Aug-11
Dec-11
Apr-12
Aug-12
Dec-12
Apr-13
Aug-13
Dec-13
Apr-14
Aug-14
Dec-14
Apr-15
Aug-15
Dec-15
Dailyactivity(withsevendaycentredmovingaverage)
0.0
5.0
10.0
15.0
20.0
25.0
30.0
1-Apr
1-May
1-Jun
1-Jul
1-Aug
1-Sep
1-Oct
1-Nov
1-Dec
1-Jan
1-Feb
1-Mar
1-Apr
FALSE
Period Daily
Ave.
95%
variation
FALSE
FALSE
TRUE
TRUE
TRUE
FALSE
5.19 ± 13.5
3.22 ± 8.8
4.25 ± 13.7
-10
-5
0
5
10
15
20
25
30
35
40
Apr-09
Aug-09
Dec-09
Apr-10
Aug-10
Dec-10
Apr-11
Aug-11
Dec-11
Apr-12
Aug-12
Dec-12
Apr-13
Aug-13
Dec-13
Apr-14
Aug-14
Dec-14
Apr-15
Aug-15
Dec-15
Dailyactivity(withsevendaycentredmovingaverage)
-10.0
-5.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
1-Apr
1-May
1-Jun
1-Jul
1-Aug
1-Sep
1-Oct
1-Nov
1-Dec
1-Jan
1-Feb
1-Mar
1-Apr
29

30. User Feedback
• Medical/nursing staff very positive on access to more
“normal” MMPS on weekends – esp. acute medicine
• “It made such an enormous difference - patients
received their non-stock medication promptly, and
discharge medications were delivered without delay,
helping patient flow, and reducing patients’ waiting. The
service ran smoothly and efficiently and we had no
complaints. The difference was massive”
• Romy Smith, Senior Sister – Acute Medicine

31. MMPS Staff Feedback
“I’m working in my normal area instead of fire-
fighting in the dispensary or on a random ward”
“The better service on the acute floor at the
weekends means Monday is less chaotic – less
‘catch up’ and fewer delayed/missed doses”
Lisa McCreadie, Pharmacy Technician, Higher Level

32. Case study – Ward Service
• May 4th 2015, Acute Medicine
• Patient AB admitted to J29 on bank holiday Monday
• Specialist pharmacist reviews Drug History
• Reconciles Drug History with medicines chart
• “New” nitrazepam & pregabalin challenged by
pharmacist
• Investigated – appears patient had forged prescription
• Outcome - medics informed, prescriptions discontinued

33. Case study - Aseptics
• Kai, 26 week premature neonate
• Reviewed by neonatal TPN pharmacist in am – TPN
prescribed & validated
• Blood gases reviewed ~4pm – drop in K+
• Amendments made to TPN formulation in conjunction
with registrar
• Prevented need for any (high risk) ward-based IV
manipulations
• Outcome – K+ level normalised overnight

34. Case study – Dispensary
• LTH at SILVER command due to bed pressures, notably
SJUH
• MMPS responds by prioritising eDAN’s
• New staffing & skill mix until 10pm in SJ inpatient
pharmacy to process high workload
– 27% of workload was received 5pm-10pm during winter 14/15
– 85% completed within 2hr target
• Co-ordinator moves staff from LGI to SJUH
• Overnight shift pharmacist reviews Bluespier eDAN
system
– processes appropriate eDAN’s for early next day and/or
highlights priorities to follow up specialist pharmacist

35. 35

36. Future plans
• Review of service specification & models in each area
• Use technology to improve efficiency and follow-up
– Specify date of next pharmacist review according to risk on
MedChart system
– Medicines Reconciliation added to e-Whiteboard – better
prioritisation & data for performance management
• Skills escalator +++ - non-registrants in ward areas,
maximise use of highly skilled technicians to release
p’cist resource
• Expand use of NMP’s to help patient flow
• Assess other areas of our CSU for 7 day working –
medicines warehouse, IT support, production unit etc

37. Limitations & barriers
• Tension between generalist and specialist roles
• What is a high priority/risk patient?
• Workforce issues:
– pipeline for technicians & scientific non-registrants to fulfil
“supervisor” roles
e.g. AfC band 4 clean room supervisor
– “brain drain” to other sectors with M-F working
• Resilience of outsourced services e.g. home PN
• Discharge pathways complex
• Transfer & handover to primary care
• Pressure on patient flow – pts going home without eDAN

38. Outliers

39. Summary
• Significant changes in MMPS service delivery over 7
days in last 12-18months
• Significant improvement in responsiveness in all key
areas of MMPS across 7 days including evenings &
overnight
• Skill mix & IT changes releasing registrant resource to
improve patient care
• Multiple discussions with CSU’s over “enhanced roles”
for MMPS staff
• ……all being delivered within our current budget
• Nominated for “LTH Time to Shine” Award for Quality &
Patient Safety – Highly Commended (October 2015)

40. “Breakthrough 7 days” Vision
“We are committed to being recognised as
the leading Pharmacy department in
England for 7 day services”
MMPS Project Team

41. Agenda
12.00 Participants register
12.05 Introduction to the session – Nick Wade NHSE 7
day services team
12.10 The role of the pharmacist in facilitating earlier
discharge (Clinical Standard 9)- Gareth Price, Chief
Pharmacist, Lancashire Teaching Hospitals
12.25 Implementing a 7 day pharmacy service Andrew
Lowey, Lead Clinician, Pharmacy and Technical
Services, Leeds Teaching Hospitals
12.40 Questions and answers
12.55 Summary and evaluation
1.00 Close of session

42. Question
And
Answer
Session

43. Agenda
12.00 Participants register
12.05 Introduction to the session – Nick Wade NHSE 7
day services team
12.10 The role of the pharmacist in facilitating earlier
discharge (Clinical Standard 9)- Gareth Price, Chief
Pharmacist, Lancashire Teaching Hospitals
12.25 Implementing a 7 day pharmacy service Andrew
Lowey, Lead Clinician, Pharmacy and Technical
Services, Leeds Teaching Hospitals
12.40 Questions and answers
12.55 Summary and evaluation
1.00 Close of session

44. Summary
And
Evaluation

45. Communities of Practice Evaluation Process-
Webinar: Pharmacy Supporting 7DS.
• Aim of the evaluation: To determine what we did well and what
we could improve upon in terms of content and style.
• To agree future direction of travel
• Method of evaluation: on screen evaluation using the “raise hand”
function and comments/chat box to respond

46. Evaluation:
Question 2:
Did webinar work as a
mechanism for
delivering this
session?
Yes – Raise hand
No – do nothing
Question 1:
Will today’s session
help you in your
journey towards
delivering 7 day
services?
Yes – Raise hand
No - do nothing

47. Evaluation:
Question 3:
What would you like to see offered in
subsequent sessions
Please type a short sentence in free text box.
Thank you

48. Agenda
12.00 Participants register
12.05 Introduction to the session – Nick Wade NHSE 7
day services team
12.10 The role of the pharmacist in facilitating earlier
discharge (Clinical Standard 9)- Gareth Price, Chief
Pharmacist, Lancashire Teaching Hospitals
12.25 Implementing a 7 day pharmacy service Andrew
Lowey, Lead Clinician, Pharmacy and Technical
Services, Leeds Teaching Hospitals
12.40 Questions and answers
12.55 Summary and evaluation
1.00 Close of session