Reference Number:

The Improvement Model

1. Developing objectives for improvement work

You may find it useful to identify what you want to achieve from your improvement work. The Improvement Model’s three fundamental questions for achieving improvement provide a useful framework for developing your objectives.

Q1.What are we trying to accomplish?

What is the overall aim of what we are doing? What are we hoping to improve?


e.g. increase the range of ways in which patients can access care, improve how we use skills of team members, use our appointment capacity better

Q2.How will we know that a change is an improvement?


What will tell us that our changes make things better than they were before? What can we measure that will demonstrate that our changes are actually an improvement? What data (opinions, observation, process data and results) will be useful?

Q3.What changes can we make that will lead to an improvement?


Include all the ways that you can work towards your objective, so that you can develop plans for PDSA cycles. Think about what has worked for other people, what ideas you have yourself and innovative approaches.

Reference Number: 1

PDSA cycle planning sheet Date:8/11/2010

Overall objective that this cycle links to: 1. Regular review of blood tests results

Specific objective for this cycle

Plan / What are you going to do? / Who is going to do it? / By when / Where
Using recent learning,develop and write the Policy and procedures.
Using the sipc resources and recent experience develop a safety checklist to be used as a monitoring tool. / Marion Foster / March 2011 / Whitefriars Surgery
How are you going to do this(list the tasks/actions involved) / Who is going to do it? / By when / Where
:
  1. Determine Patients who have received a DMARD prescription in the past 6 months.
  2. Determine Patients who have received a DMARD prescription in the past 3 months.
  3. To identify Patients who have received a DMARD prescription in the past 6 months but not in the past 3 months.
  4. To check if these Patients are expected to still be taking a DMARD and present information to Doctor responsible for DMARDS.
  5. To carry out the DMARDS safety check on all Patients who have received a DMARD prescription in the past 3 months and update the medical record through the DMARD’s guideline as appropriate, initiating relevant follow up.
/ Marion Foster / March 2011 / Whitefriars Surgery
What do you think will be the outcome? / How are you going to measure this cycle?
We shall have a robust system in place to monitor patients safety whilst taking DNMARDS / There should be less pts (positive safety checklists) referred to the Lead Clinician for follow-up

PDSA cycle progress sheetDMARDS Tayside

DO / Describe what happened?
Developed the Policy and Procedures and Safety Checklist
Admin provided constructive feedback and checklist amended
Admin tested procedure.
Carried out the process covering all DMARDs so that the practice has improved the whole DMARDs monitoring process.
Set up Macros and letters to ensure correspondence is printed promptly and easily including adding a record into the medical record.
Study / Having gathered your data describe the measured results and compare with predictions
There are still a high quantity of positive Checklists but a number of these are just ensuring that the patient actively has been added to the register. We have yet to decide on the process for this item. The register is not used for recall but those taking therapy within the last 6/3/months. We predicted the same patients would be referred each month. We have highlighted patients prescribed antibiotics.
Act / What will you will take forward from this cycle, or do differently next time. What other tests or cycles will you do?
We have to review the last batch of checklists, determine delegated responsibilities and decide how we can refine the process and ensure it is manageable

1

DMARD MONITORING

THE RED PRACTICE, WHITEFRIARS SURGERY
SHARED CARE MONITORING OF DMARDS
Responsibility to Monitor
Responsibility to carry out Procedure
Review date
Responsibility for Reviewing:
Policy
Procedure
Date and Description of Change
Issue No

X:\Practice Intranet Website\Clinical\NPT\2011\DMARD Monitoring.doc1 of 13

PURPOSE

The treatment of several diseases within the fields of medicine, particularly in rheumatology, is increasingly reliant on drugs that, while clinically effective, need regular blood monitoring. This is due to the potentially serious side-effects that these drugs can occasionally cause. It has been shown that the incidence of side-effects can be reduced significantly if this monitoring is carried out in a well organised way, close to the patient’s home.

This process is to ensure that systematic monitoring of patients on the DMARD register is taking place either in a hospital or general practice setting.

OBJECTIVES:

To have

  1. a register. Practices should be able to produce and maintain an up-to-date register of all shared care drug monitoring service patients, indicating patient name, date of birth and the indication and duration of treatment and last hospital appointment
  2. call and recall. To ensure that systematic call and recall of patients on this register is taking place either in a hospital or general practice setting
  3. education and newly diagnosed patients. To ensure that all newly diagnosed/treated patients (and/or their carers when appropriate) receive appropriate education and advice on management of and prevention of secondary complications of their condition. This should include written information where appropriate
  4. continuing information for patients. To ensure that all patients (and/or their carers and support staff when appropriate) are informed of how to access appropriate and relevant information
  5. individual management plan. To ensure that the patient has an individual management plan, which gives the reason for treatment, the planned duration if appropriate, and the monitoring timetable
  6. professional links. To work together with other professionals when appropriate. Any health professional involved in the care of patients in the programme should be appropriately trained.
  7. referral policies. Where appropriate to refer patients promptly to other necessary services and to the relevant support agencies using locally agreed guidelines where these exist
  8. record keeping. To maintain adequate records of the service provided, incorporating all known information relating to any significant events e.g. hospital admissions, death of which the practice has been notified
  9. training. Each practice must ensure that all staff involved in providing any aspect of care under this scheme have the necessary training and skills to do so
  10. annual review. All practices involved in the scheme should perform an annual review which could include:

(a) brief details as to arrangements for each of the aspects highlighted in the NES

(b) details as to any computer-assisted decision-making equipment used and arrangements for internal and external quality assurance

(c) details as to any near-patient testing equipment used and arrangements for internal and external quality assurance

(d) details of training and education relevant to the drug monitoring service

(e) details of the standards used for the control of the relevant condition

(f) assurance that any staff member responsible for prescribing must have developed the necessary skills to prescribe safely.

PROTOCOL:

Patients:All Patients who have received a DMARD in the past 6 months.

Staff:Lead Clinician: Admin:

Standard Statement: To run the monitoring and Recall searches monthly:

  1. Determine Patients who have received a DMARD prescription in the past 6 months.
  2. Determine Patients who have received a DMARD prescription in the past 3 months.
  3. To identify Patients who have received a DMARD prescription in the past 6 months but not in the past 3 months.
  4. To check if these Patients are expected to still be taking a DMARD and present information to Doctor responsible for DMARDS.
  5. To carry out the DMARDS safety check on all Patients who have received a DMARD prescription in the past 3 months and update the medical record through the DMARD’s guideline as appropriate, initiating relevant follow up.

X:\Practice Intranet Website\Clinical\NPT\2011\DMARD Monitoring.doc1 of 13

Person Responsible: ADMIN

  • Open Vision Clinical System
  • Select Reporting
  • Select Search and Reporting
  • Open Folder called DMARDS

1. TO DETERMINE PATIENTS WHO HAVE RECEIVED A DMARD PRESCRIPTION IN THE PAST 6 MONTHS.

  • Select and Run search Pts had DMARD prescription in past 6 mths.
  • Save the Search and Close

2. TO DETERMINE PATIENTS WHO HAVE RECEIVED A DMARD PRESCRIPTION IN THE PAST 3 MONTHS.

  • Select and Run search Pts had DMARD prescription in past 3 mths.
  • Save the Search and Close

3. TO IDENTIFY PATIENTS WHO HAVE RECEIVED A DMARD PRESCRIPTION IN THE PAST 6 MONTHS BUT NOT IN THE PAST 3 MONTHS.

  • Go back to Vision Clinical System
  • Select Reporting
  • Select Patient Groups
  • Click on Date Column
  • In name column look for MF:DMARD6M and correct date and click on this group
  • Make the selected group the work group by Clicking on full blue circle
  • In name column look for MF:DMARD3M and correct date and click on this group
  • Remove pts in the selected group from the work group by clicking on the overlapping 2 circles with the bottom area shaded blue.
  • Change Group Description to: Pts had DMARDS prescription in past 6 mths but not in past 3 mths
  • Right click on group of pts appearing in bottom left section and print group for file record.

a. TO CHECK IF THESE PATIENTS ARE EXPECTED TO STILL BE TAKING A DMARD AND PRESENT INFORMATION TO DOCTOR RESPONSIBLE FOR DMARDS.

  • Check Docman and medical records to see if there is any information that will help us understand why the medication is not being requested e.g. any instruction from secondary care, any information from the patient.
  • Provide list and additional information to the responsible Dr who will initiate the appropriate action and update the medical record.

Person Responsible: DOCTOR

Pts who have not had medication in the past 3 months.

  • Doctor responsible for DMARDs decides if the pt should be removed from the register, sent a reminder letter or provide a patient specific communication.
  • To remove pt from Register
  • Click on DMARDS tab to open DMARDS Guideline
  • Click on 2nd line Register
  • Click on Add to DMARD Register button to add an end date.
  • To send The DMARDS Missed medication Letter:
  • Vision – Journal:
  • – Add correspondence – Recall and Review Letters - DMARDS Medication Invite.

OR

  • Use Macro at RH foot of page – “3 green arrows in Circle” ICON -.Recall – DMARDS Missed Medication - Letter 3.

4. TO CARRY OUT THE DMARDS SAFETY CHECK ON ALL PATIENTS WHO HAVE RECEIVED A DMARD PRESCRIPTION IN THE PAST 3 MONTHS. UPDATE THROUGH THE DMARD’S GUIDELINEAS APPROPRIATE.

Person Responsible: ADMIN

Using safetychecklistscrutinise the patient record and Docman files for information. Add detailed notes to the checklist to inform the Doctor.

On completion of the monthly safety checklists deliver any non compliant checklists to the Doctor responsible for DMARDs.

To check Patient is included in the Register and relevant blood monitoring carried out

  • Go to Vision Clinical System
  • Select Reporting
  • Select Patient Groups
  • Click on Date Column
  • In name column look for MF:DMARD3M and correct date and click on this group
  • Make the selected group the work group by Clicking on full blue circle
  • Click on each pt systematically in group at bottom Left of screen to show in bottom Right of screen the DMARD drug they are taking
  • Rt Click on pt down this group to Open Consultation Manager
  • Click on DMARD or Guideline tab to open DMARD Guideline
  • Click on Register to check if Pt is added to Register
  • If not - check Docmanor Journal for date Pt was started on medication
  • Add Pt to register with appropriate start date and episode type.
  • Check record to assess whether blood monitoring has been carried out according to standard recommendation as detailed in the DMARDS Guideline.
  • Inform GP if this is not the case.

To record date of last outpatient appointment with specialist who initiated treatment.

  • Check Docman to determine last outpatient appointment with specialist who initiated treatment.
  • Click on DMARDS tab to open DMARDS Guideline
  • Click on 4th line Patient Review
  • Click on relevant button to which clinic and date of attendance.
  • Inform GP if greater than 12 months since specialist who initiated treatment last reviewed the patient.
  • Go back to Vision Clinical System Reporting
  • Select Patient Groups
  • Click on Date Column
  • In name column look for MF:DMARD3M and correct date and click on this group
  • Make the selected group the work group by Clicking on full blue circle

X:\Practice Intranet Website\Clinical\NPT\2011\DMARD Monitoring.doc1 of 13

DMARDS MONITORING SAFETY CHECKLIST

Name CHI Date

Number Of Consultations
Tel / GP Surgery / GP HV / PN / Other
Triggers / Trigger Present / Did Harm Occur / Severity / Harm Origin / Preventable
Y/N / Y/N / E/F/G/H/I / Prim/Sec / Y/N
3 Consultations in 7 days
New ‘high’ priority Read Code
New allergy Read Code
Repeat medication item stopped
OOH / A+E attendance
Hospital admission
WBC < 4
Hb < 10
AST/ALT > 150
Prescription for Antibiotic
Yes/NO/n/a / NOTES
On Register
Script issued in past 3 mths
Relevant Bloods taken
Blood Tests Reviewed
Patient last seen by Sec Care
Change in monitoring schedule recorded
Action from normal results recorded

X:\Practice Intranet Website\Clinical\NPT\2011\DMARD Monitoring.doc1 of 13