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 www.pharm.monash.edu.au
Changing clinical practice Achieving quality Limited data growing an organisational culture for improvement
Changing clinical practice.. Thinking about what to do High Do first Impact Don t do Low Low Difficulty in implementation High
Changing clinical practice Disease Management Clinic Pre-admission clinic Anticoagulation management Weekend clinical pharmacy services Unit based clinical pharmacy services 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
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
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
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
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: 208-11
Changing clinical practice Disease Management Clinic Pre-admission clinic Anticoagulation management Smoking cessation Weekend clinical pharmacy services TDM charting Unit based clinical pharmacy services 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
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?
Therapeutic drug monitoring
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 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
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
Partnered charting Pharmacist charting credentialing program was developed with input from medical and nursing Formal guideline developed for charting model Implemented in two weeks
Partnered charting 17
Partnered charting 18
Partnered charting 19
Partnered charting 20
Partnered charting
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 3 237 (51.9%) 204 (52.7%) - ATS 4 149 (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)
Partnered charting Clinical significance of errors Pharmacist charting Medical Charting No. of errors No. of errors P-value Total 19 1573 <0.0001 Insignificant 11 (0.3%) 904 (20%) <0.0001 Low risk 1 (0.02%) 58 (1%) <0.0001 Moderate risk 6 (0.15%) 292 (7%) <0.0001 High risk 1 (0.02%) 285 (6%) <0.0001 Extreme risk - 34 (0.8%) <0.0001
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 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Partnered Pharmacist Medication Charting Expansion project
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 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Changing clinical practice Achieving quality Limited data growing an organisational culture for improvement 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
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
Changing clinical practice.. Thinking about the team as well
Changing clinical practice.. Thinking about the team as well