Achieving quality with limited data - growing an organisational culture for improvement
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1 Achieving quality with limited data - growing an organisational culture for improvement Professor Michael Dooley Director of Pharmacy, Alfred Health Professor of Clinical Pharmacy Faculty of Pharmacy and Pharmaceutical Science, Monash University
2 Changing clinical practice Achieving quality Limited data growing an organisational culture for improvement
3 Changing clinical practice.. Thinking about what to do High Do first Impact Don t do Low Low Difficulty in implementation High
4 Changing clinical practice Disease Management Clinic Pre-admission clinic Anticoagulation management Weekend clinical pharmacy services Unit based clinical pharmacy services
5 Changing clinical practice Unit based Team based Agreed clinical need Multi-disciplinary support Defined scope of practice Multi-disciplinary education Formal competency assessment Formal evaluation
6 Anticoagulation Unit based Team based Agreed clinical need Multi-disciplinary support Defined scope of practice Multi-disciplinary education Formal competency assessment Significant problems with anticoagulation management Long time to get patients to therapeutic dose in HITH program Why couldn t we reduce this by several days Formal evaluation
7 Anticoagulation Pharmacist led anticoagulation program was developed Pharmacists independently responsible for managing and dosing warfarin 7 day a week service Formal credentialing program developed Implemented in HITH and expanded to general medical inpatients
8 Anticoagulation Dooley MJ, McGuiness JV, Choo S, Ngo-Tai L, Tong E, Neave K, Poole SG. Successful implementation of a pharmacist-led anticoagulant dosing service. J Pharm Pract Res 2011; 41:
9 Changing clinical practice Disease Management Clinic Pre-admission clinic Anticoagulation management Smoking cessation Weekend clinical pharmacy services TDM charting Unit based clinical pharmacy services
10 Therapeutic drug monitoring Unit based Team based Agreed clinical need Multi-disciplinary support Defined scope of practice Multi-disciplinary education Formal competency assessment Formal evaluation Significant problems with the dosing of aminoglycosides and vancomycin Clinical pharmacists would make recommendations regarding levels and dosing Why couldn t pharmacists order the levels and dose directly on the medication chart?
11 Therapeutic drug monitoring
12
13
14 Changing clinical practice Disease Management Clinic Pre-admission clinic Anticoagulation management Smoking cessation Weekend clinical pharmacy services TDM charting Partnered charting Unit based clinical pharmacy services
15 Partnered charting Unit based Team based Agreed clinical need Multi-disciplinary support Defined scope of practice Multi-disciplinary education Formal competency assessment Formal evaluation Significant problems with medications at admission ie wrong, delayed, unknown Pharmacist involvement traditionally retrospective Why couldn t medications get sorted as soon as the patient presents
16 Partnered charting Pharmacist charting credentialing program was developed with input from medical and nursing Formal guideline developed for charting model Implemented in two weeks
17 Partnered charting 17
18 Partnered charting 18
19 Partnered charting 19
20 Partnered charting 20
21 Partnered charting
22 Partnered charting Demographics and clinical characteristics of patients * Statistically significant Variable Doctor Charting (n=473) Partnered Pharmacist charting (n=408) Age (years)* 71.5 (18.4) 75.0 (16.3) Male sex 218 (46.1%) 175 (42.9%) Managed in general medical unit 268 (56.7%) 220 (53.9%) Number of regular medications 7 (4-11) 8 (5-11) Number of PRN Medications 1 (0-3) 1 (0-2) Triage category - ATS 1 1 (0.2%) 1 (0.2%) - ATS 2 67 (14.7%) 52 (13.4%) - ATS (51.9%) 204 (52.7%) - ATS (32.6%) 126 (32.6%) - ATS 5 3 (0.7%) 4 (1.0%) Past history - Myocardial infarction 47 (9.9%) 45 (11.0%) - Congestive cardiac failure 61 (12.9%) 66 (16.2%) - Cerebrovascular disease 77 (16.3%) 66 (16.2%) - Dementia 48 (10.1%) 41 (10.0%) - COPD 100 (21.1%) 86 (21.1%) - Connective tissue disorder 28 (5.9%) 32 (7.8%) - Liver disease- mild 37 (7.8%) 11 (2.7%) - Mod-Severe 9 (1.9%) 3 (0.7%) - Diabetes- uncomplicated 77 (16.3%) 84 (20.6%) - Diabetes- complicated 33 (7.0%) 25 (6.1%) - Peptic ulcer disease 12 (2.5%) 10 (2.4%) - Peripheral vascular disease 41 (8.7%) 32 (7.8%) - Leukaemia 7 (1.5%) 7 (1.7%) - Malignant Lymphoma 11 (2.3%) 4 (1.0%) - Solid tumour- localised 28 (5.9%) 25 (6.1%) - Metastatic 13 (2.7%) 11 (2.7%) - AIDS 0 0 Charlson Comorbidity Index 5 (2-7) 5 (3-7)
23 Partnered charting Clinical significance of errors Pharmacist charting Medical Charting No. of errors No. of errors P-value Total < Insignificant 11 (0.3%) 904 (20%) < Low risk 1 (0.02%) 58 (1%) < Moderate risk 6 (0.15%) 292 (7%) < High risk 1 (0.02%) 285 (6%) < Extreme risk - 34 (0.8%) <0.0001
24 Changing clinical practice Gen med clinic IBD clinic Haematology clinic Lung Transplant Cardiac clinic Discharge summary Disease Management Clinic Pre-admission clinic Anticoagulation management Smoking cessation Unit based clinical pharmacy services Weekend clinical pharmacy services TDM charting Partnered charting Opioid descalation Smoking cessation clinic Stroke call-out Partnered Pharmacist Medication Charting Expansion project
25 Changing clinical practice Career Progression Model Disease Management Clinic Pre-admission clinic Clinical Fellowship Program Anticoagulation management Smoking cessation IBD clinic Haematology clinic Part-time PhD Program Lung Transplant Cardiac clinic Gen med clinic Discharge summary Clinical Residency Program Unit based clinical pharmacy services Weekend clinical pharmacy services TDM charting Partnered charting Opioid descalation Smoking cessation clinic Stroke call-out
26 Changing clinical practice Achieving quality Limited data growing an organisational culture for improvement
27 Changing clinical practice.. Thinking about the team as well High Happy but not much getting achieved Happy and getting a lot done Positivity Unhappy and not much getting done Getting a lot done but not happy Low Low Productivity High
28 Changing clinical practice.. Thinking about the team as well
29 Changing clinical practice.. Thinking about the team as well
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