Review: Improving Medicines Safety Summit

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The Improving Medicine Safety (IMS), a Greater Manchester Academic Health Science Network (GMAHSN) programme hosted by Haelo held it’s summit at The Lowry on Friday 22nd April. The all day session was a celebration of the programme, which began a year ago in April 2015.

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The day began with Haelo’s Associate Director of Science and Capability, Matt Cope, who welcomed and congratulated the teams on completing the programme.

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Matt introduced the debut of Haelo’s latest expert film: Improving Medicines Safety: The Best Bits, a round-up of the three IMS Learning Sessions.

Next, we welcomed Steve Gillibrand, Clinical Pharmacist at Salford Royal NHS Foundation Trust seconded to Haelo and GM AHSN to deliver the IMS collaborative. Steve took a retrospective look at the programme, ‘over the last year we have been on a really rapid journey together’. He finished in inspirational tone believing that it is ‘possible to do anything if you just take the first step and do it!’

We were then delighted to be joined by Caroline Rogers, Senior Programme Manager at Haelo, who presented A Clinician’s Perspective.

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An honest and engaging presentation about Caroline’s personal experience of the impact of medication errors. Caroline then examined the culture surrounding making mistakes which received great feedback from the teams.

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Caroline discusses the need to change the current internal blame culture to a learning culture. She quotes Secretary of State for Health, Jeremy Hunt, ‘Bad mistakes can be made by good people.’ Caroline reiterates this by expressing that ‘all nurses make mistakes, good nurses admit mistakes.’

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The first half of team presentations then began, which were followed by a Q&A sessions where teams discussed joint challenges, solutions and new ideas. The East Lancashire team expressed the value of the input from the patient representative, Bernard Styan, who was ‘driving them forward.’ Other collaborative teams praised the continued inclusion of a patient representative as a great achievement. Despite their setbacks, the East Lancashire team are relaunching the project next month.

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Pennine Acute Hospitals Trust followed with their presentation on the success of PDSA cycles. The team were praised for continuing their work, despite challenges working with limited pharmacy resource. Their learnings included building and maintaining better strategic pharmacy relationships. The team complimented the co-ordination of the project and people, expressing how the project ‘wouldn’t have been able to get anywhere without strong project co-ordination.’

Manchester Mental Health and Social Care Trusts (MMHSCT) discussed their project based at HMP Manchester. The team were measuring time lag in step in the process for medicines reconciliation; working with the prison receptionist and a GP to develop standardised tools. The challenges faced by the team were predominantly pharmacy based, this is also the first quality improvement project in prison so the team had to build new relationships, which they will continue to nurture in the future. The integral use of the process map was praised by colleagues as a great way to engage and start discussions.

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After a short break, Matt Cope led an interactive session on the collaborative’s achievements.

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This session included the significance of data and the importance of the Plan, Do, Study, Act (PDSA) model. All teams cross examined the other teams driver diagrams, analysed the most and least helpful part of the drivers. Matt then led a text poll to collate and show answers live on screen.

After this exercise, Matt premiered a case study film of Wrightington, Wigan and Leigh’s journey through the IMS collaborative, showing how they made use of improvement science methodologies. This film has been produced by Haelo and commissioned by the GM AHSN.

The film was received well with Matt Cope remarking that the team had found the time to think about doing things differently.

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The teams were invited to open their time capsules to reflect upon the pledges they made at Learning Session 1, 9 months ago.
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The teams collectively reviewed data from across the collaborative. Matt extracted interesting highlights from the charts, before breaking into a conversation around measurement where teams discussed if their results had met their expectations.  From cross examination of the whole collaborative, teams were able to see where the other teams strengths lie and share learning and knowledge.

All measurements were collated into the ‘Defect Free Medicines Care’ chart below:

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After the measurement findings, the knowledge exchange breakout sessions began with three sessions; Executive Leaders, Patient and Public Involvement & Health Economy Team Case Studies.

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After lunch, Wrightington, Wigan and Leigh NHS Foundation Trust and Bridgewater NHS Foundation Trust presented their IMS journey, ‘Improvement science really does seem to work,’ The two trusts believe they are moving in a ‘positive direction’ and the collaborative has been ‘good for confidence.’ ‘We’ve laid down foundations for the future’ and ‘thank you to the collaborative.’ The trust had their patient representative Margaret in attendance, as with all other learning sessions and workshops, which was praised universally by the other teams. Jess from the team stated ‘on a personal note, I feel immensely proud to be part of it.’

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Representatives from the Central Manchester team were unable to attend, but keen to remain involved, so recorded a short presentation on film outlining their tests of change, which have led to an improvement in patient confidence to manage medication amongst their pilot cohort of patients.

University Hospital of South Manchester were up next, their learning included approaching the data differently and the trust are very keen to continue closer working relationships with the local Clinical Commissioning Group (CCG), GPs and community pharmacy for the wider benefit of the project.

The summit then moved into the spread and scale up session. First Matt began with implementation, asking the teams for a definition then moved on to the Improvement Guide and the Principles for Implementing Complex Changes effectively and efficiently.

Both final presentations include a patient story and were congratulated for their story telling approach. The team from Bolton health economy took to the stage, sharing a story of a patient who had gone into hospital but was discharged without the right tools and medication to live independently’. This was a story that resonated with other teams and brought home the need to continue to improve processes at transfers of care.

And finally, Salford Royal NHS Foundation Trust, shared their journey again complete with patient story. Over the course of the collaborative they have piloted changes, such as embedding a pharmacy technician within a care home, which has not only significantly increased % medicines reconciliation completed, but decreased the amount of time nursing staff are dedicating to medicines rounds, allowing more time for nursing and care of patients.

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The scale up and spread session continued with a presentation from Prof Maxine Power who described improvement as a ‘life long opportunity’ and that ‘scaling up is the next challenge.’ For this to happen, Maxine stated that the teams needed ‘to understand the system we are working in’ and process mapping is a way of comprehending and analysing systems.

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Maxine then spoke of the text, System of Profound Knowledge by Deming. An integral part of the book is the Lens of Profound Knowledge which Maxine described as ‘the improvement toolkit, perfect for decoding improvement.’ There are 4 component parts; psychology, systems, variation and theory.

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Maxine spoke about Ignaz Semmelweis, who was a Hungarian obstetrician whose work in the 1800’s demonstrated that the simple act of hand washing would drastically reduce the number of women dying after childbirth. Read the full biography here.

NOWAs the summit drew to a close, Jane Macdonald from the GM AHSN reflected on the journey of IMS and provided feedback on the projects to date describing them as ‘ready to spread and implement.’

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Matt Cope then rounded up the summit by presenting four IMS awards; the winners were:

Improvement Scientists: Manchester Mental Health Social Care Trust
Patient Engagement Award: Wrightington, Wigan and Leigh NHS FT / Margaret Hughes
Inspiring Improver: Dave Pitchforth, Pennine Acute Trust
Best in Show Award: Wrightington, Wigan and Leigh NHS FT

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And finally, Mike Burrows, Managing Director, GM AHSN gave the closing remarks to the summit and indeed the project around the importance of the patient.

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What do you think?

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