FEATURE


GMAHSN partnered with Haelo, an improvement science centre, to deliver the Breakthrough Series Collaborative across a 12 month period from April 2015, with a three month lead in period.


Setting the Wheels in Motion


All 12 provider trusts and CCGs in the AHSN were invited to be involved in the project, with eight teams undertaking the programme from start to finish. GMAHSN established an expert panel, comprising patients, clinicians, and leaders, both national and international, to design and deliver the programme.


The programme focused on National Patient Safety Agency data which illustrated that medication errors are more likely to occur during transitions of care. Any time patients move to different service providers or are discharged and sent home there is a larger risk of a medication error. This could be due to a lack of timely information being relayed to the clinical staff in charge, poor communication within teams, or a lack of understanding by the patient.


With this in mind the panel focused the teams involved on the importance of good communication to make sure that nothing was missed within our ‘complex healthcare system’.


During the project teams were asked to explore the way they assessed patient allergy status, medicine reconciliations and medicine reviews to see if they could amend their processes to move closer to medicine safety improvement.


Speaking to Tomorrow’s Care GMAHSN’s Dai Roberts, Programme Development Lead, was keen to stress that the Improving Medicine Safety initiative wasn’t about imposing preconfigured processes onto teams and telling them how to implement them, it was about creating a learning system and a space where teams could come up with new approaches themselves.


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A Fast Learning Curve The concept of a Breakthrough Series Collaborative model is designed to gather people, and organisations, together to give them the tools to create a new approach.


Dai Roberts spoke about the initiatives overall aim of providing defect free care to 95% of people experiencing a transfer of care by April 2016. He commented: “There was a shared aspiration to reduce medicine error and improve patient safety across all the teams. After our launch and learning event the teams then went away to their own setting and worked out how to make that improvement themselves.”


Jane added: “The multiple learning days we held meant that the learning was being done in real time. It helped some teams fail, and fail quickly, but it was helpful because what they learned could then be shared with other teams.”


One of the teams involved in the project weren’t carrying out any medication reviews before the initiative began. By carrying out reviews and establishing new processes, with more man power, they saw a dramatic reduction in readmissions to their hospital.


The same hospital also overcame patient medication issues when transferring patients from hospital to intermediate care. The usual process involved a GP visiting the patient in their new environment to review their meds and prescribe them more. Often GP’s were late doing this review and as a result patients were going without vital medication.


The hospital therefore ensured that all patients transferring from one service to another were equipped with more medication to avoid these situations in the future.


Overcoming


Structural Barriers The prisons project team struggled with the implementation of new processes because of the structure of their organisation. They wanted


to ensure mental health patients received their medications effectively.


Speaking about this project Dai said: “When someone goes to prison the system is geared towards getting them processed and locked up - a medication review isn’t really addressed. The team found that the prison system didn’t really accommodate that side of a patients’ needs. As a result they had difficulty persuading the prison team to include this aspect of a prisoners needs in the process and encountered some resistance.”


The team did however overcome this challenge and managed to implement new processes in the prisoner’s day to day operations to ensure prisoner’s medication was not forgotten.


So, did the teams achieve what they set out to?


Well it’s a complicated yes from Jane and Dai!


Have the teams achieved their aspirational goal to provide 95% harm- free care across the area and to make Greater Manchester the safest place to take medicine? The short answer is no. But are they much closer to achieving these objectives and are CCGs and trust providers in the area now better equipped with a greater breadth of knowledge and successful processes to ensure medicine safety? Yes.


As Dai said: “This is the beginning of a journey – this project has been a really good start for teams across Greater Manchester to implement change. We can’t expect a team to achieve the aspirational goal straight away – once people see they can deliver improvement slowly that level is sure to creep up.”


After acknowledging the project hadn’t completely solved the issue of medicine safety, Jane said GMAHSN are currently scoping out similar projects to undertake next year. She continued: “We might not have made Manchester the safest place to take medicines but we have definitely made it a safer place.”


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