Welcome & Introductions The Core Programme Overview Dr Paul Ryan Clinical Director, North East Sector, Glasgow City CHP
House Keeping No Fire Alarm scheduled Toilets are located round to the right, past the café and right again. Breakout rooms are located round to the left and through the swing doors name of breakout room is on your welcome pack.
8:30:9:00 Registration & Coffee Learning Session 1 Programme 9:00-9:15 Welcome & Introductions The Core Programme Overview Dr Paul Ryan, Clinical Director, North East Sector, Glasgow City CHP 9:15-9:30 Introduction to Harm in Primary Care Dr Jennifer Armstrong, Medical Director, NHSGG&C 9:30-10:30 Science for Improvement : Measuring and Improving Care Andy Crawford, Head of Clinical Governance 10:30-11:00 Coffee & Networking 11:00: 12:00 Parallel Workshops Work Streams DMARDS Kathy Kenmuir,Primary Care Support Nurse Medication Reconciliation Rachel Bruce, Lead Clinical Pharmacist Results Handling Dr Neil Houston, National Clinical Lead SPSP, Lynnette Cameron, Clinical Risk Co-ordinator, CGSU Outpatient Communication Dr Paul Ryan, Clinical Director, North East Sector, Glasgow City CHP Prevention of Pressure Ulcers Linda Davidson, Head of Department, CGSU (Partnerships) 12:00-12:15 Questions & Reflections Dr Paul Ryan, Clinical Director, North East Sector, Glasgow City CHP 12:15 Close
Aims & objectives of SPSP-PC National Programme To reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting. All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.
SPSP-PC National Programme Workstreams Work streams 1.Safer Medicines 2.Safe and reliable patient care across the interface and at home. 3.Leadership and Safety Culture Interventions relating to Safe and reliable prescribing, monitoring and administration of high alert medications (e.g. DMARDs, warfarin, insulin, lithium Reducing high risk prescribing data / alerts Medication reconciliation Management of test results Communication at point of referral Handling written communication Promoting a culture of safety and learning using Trigger Tool, Safety Climate Survey, safety walk rounds Promoting organisational learning from Significant Event Analysis (SEA) Building capacity and capability to support the programme Ensuring patients become partners in making care safer.
NHSGG&C Programme Themes 2011-2013 NHS GG&C have been testing various aspects of the SIPC 1 and 2 programmes locally since Nov 2011, with a selected number of practices and district nursing teams testing care bundles on the following:- Medicines Reconciliation DMARDs ( disease modifying anti rheumatic drugs) LVSD ( heart failure) Prevention of Pressure Ulcers in the Community (District Nurses) Insulin Administration in the Community (District Nursing) 11 practices and 11 District Nursing Teams were involved in the programme
DMARD Care Bundle Compliance collated practices DMARDS care bundle compliance % Median Linear (Subgroup) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% TARGET 80% 11/1/11 11/15/11 11/29/11 12/13/11 12/27/11 1/10/12 1/24/12 2/7/12 2/21/12 3/6/12 3/20/12 4/3/12 4/17/12 5/1/12 5/15/12 5/29/12 6/12/12 6/26/12 7/10/12 7/24/12 8/7/12 8/21/12 9/4/12 9/18/12 10/2/12 10/16/12 10/30/12 DATE
Methotrexate 2.5mg tab scripts as a % of all MTX tab: scripts by HB Sep 06 to Jul 2012 GG&C GG&C now 98.1%
Annotated run chart for the Prevention of Pressure Ulcers for one of the District Nursing Teams Overall % compliance - Prevention of Pressure Ulcers 100% All information documented SSKIN 90% 80% 70% 60% Patient one Grade3 pressure sore End of life.no waterlow for patient 2,Highlighted need to trigger careplan for skin assessment. Care plan not completed for 1 patient and leaflet not given..compliance continues.compliance continues 50% 40% compliance on patient information poor 30% 20% 10% 0% start collecting data 2012 may 15 2012 may 31 2012 jun 30 2012 jul 31 2012 aug 31 2012 sep 30 2012 oct 31 Overall % compliance - Prevention of Pressure Ulcers
Implementation of SPSP-PC in 2013/16 within NHS GG&C GP Practices QOF Local Enhanced Services Safety Climate Survey within clinical teams Using the trigger tool to identify previously undetected evidence of patient safety incidents and identify learning from them Medicines Reconciliation as part of Polypharmacy LES Core Programme Pilot Programme with 20 GP Practices, in preparation for 2014/15, 2015/16 Workstreams. GP Practices to choose from:- Meds Rec DMARDS / Near Patient Testing Management of test results Communication at point of referral in addition District Nursing Choose one project that is locally identified as high risk/patient harm Prevention of Pressure Ulcers Care Bundle Further key areas for improvement have been identified to include catheter associated infections and falls Preparatory work will need to commence for implementation of SPSP into the other primary care contractor groups - Pharmacy, Dentistry and Optometry.
GP Core Programme Outline for 2013/14 Small Scale Testing DMARD Outpatient Communication Results Handling Medication Reconciliation In addition:- one local safety concern of choice must involve patients This further testing phase will support the development of the care bundles for inclusion in the wider programme going forward in 2014-16.
Community Nursing Core Programme Outline for 2013/14 Small Scale Testing Pressure ulcer prevention increase size of teams Develop and test: Catheter Associated Urinary Tract Infection (CAUTI) Falls MUST Working with small teams to develop the prototype for spread in 2014/15.
National Collaborative NHS Board Staff Train the trainers Share resources/ experience Learning across NHS Scotland Identify successes and challenges Build network
Local Collaborative Practice staff attend (3 members) Learn about tools Share resources Share successes and challenges Support practices
Collaborative within a Collaborative Approach NHS GG&C s Commitment Dedicated programme management Clinical leadership and Quality Improvement support to: Attend national events Run local collaborative Build knowledge and skills Support GP practices Support District Nurses
Infrastructure to Support Programme Board Medical Director Clinical Director (Clinical Lead) Clinical Lead (currently recruiting to post) Project Manager SPSP Fellow Clinical Governance staff with quality improvement expertise Currently recruiting PDN post for 12 months Patient Safety Steering Group - includes public representatives
Patient Safety It s no Trouble at All Reminder as to why we are all here today and why the Patient Safety Programme is so important Patient Safety Margaret Murphy