A Quality Improvement Program

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A Quality Improvement Program

• Ensuring explanations for changes to medication
  therapy in the discharge summary

Insert your hospital logo here
Presenter
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Overview

• Background
• Aims and methods
• Feedback on current practices
• Education- Support 4 Success
• Questions

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Background

• NSW Therapeutic Advisory Group (NSW TAG) survey
  to identify top 3 issues in medication safety.
  
• -SAFER Medicines Group
• -TAG and TAG Net members
• Top issue to address Medication changes and
  explanations for changes in the discharge summary
  

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About NSW TAG

• Independent, not-for-profit organisation
• Membership consisting of clinical
  pharmacologists, pharmacists and other clinicians
  from teaching hospitals
• Representatives from every Drug and Therapeutics
  Committee across NSW.
• Core goal to promote the Quality Use of Medicines
• www.nswtag.org.au

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What is the purpose of the discharge summary?

• Frequently, the discharge summary is the only
  communication provided to the General
  Practitioner (GP) about their patients and the
  events that occurred whilst their patients were
  in hospital.

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Medication Error and ADEs

• Transferring patients are those most vulnerable.1
• Poor quality communication1

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Identified gaps in practice

• Inaccurate, incomplete and illegible
  information are common deficiencies within the
  discharge summary2
• In the medicines list
• -Omitted medications 3,4
• -Medication not previously prescribed (or
  justified) 3,4

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Aims

• To use drug use evaluation (DUE) methodology to
  describe the extent to which explanations for
  medicine therapy changes are being documented in
  discharge summaries from participating NSW and
  ACT hospitals.
• 2. To increase awareness of the APAC Guiding
  Principles within the hospital setting, in
  particular communicating medicines information
  (Guiding Principle 9).5
• 3. To optimise the discharge summary as a
  communication tool to General Practitioners (GPs)
  on explanations for alterations to patients
  medicine therapy.

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QUM Indicator 5.3

• What are the Quality Use of Medicine (QUM)
  Indicators?
• QUM Indicator 5.3 aims to measure6
• Percentage of discharge summaries
• that include medication therapy
• changes and explanations for
• changes
• Quality improvement initiative
• involving 16 hospitals across NSW/ACT

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Defining changes to and explanations for
medication therapy?

• Refers to changes to the patients pre-admission
  regimen which are intended to continue after
  discharge2
• New medication
• Change in the dose, form, route or frequency of a
  medicine taken prior to admission
• Cessation of a medicine taken prior to admission
• Explanations for changes Should include
  sufficient detail to inform future management
  decisions in the discharge summary or discharge
  letter.

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Completing high quality discharge summaries

• National E-Health Transition Authority (NEHTA)
  Continuity of Care
• program March 20107
• Barriers include
• devaluing of discharge summaries
• over emphasis on coding requirements
• uncertainty over what information a GP desires

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Support for quality improvement in the discharge
summary

• Work toward improving the processes and forms
  required to produce a quality discharge summary
  is underway.
• Nationally
• Australian Pharmaceutical Advisory Council
  (APAC)
• National E-Health Transition Authority (NEHTA)
• Australian Commission for Safety and Quality in
  Health Care
• Statewide
• NSW Health Systems Support
• Forms committee
• NSW Therapeutic Advisory Group NSW/ACT program
  (QUM Indicator 5.3)

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DUE Methodology
Feedback
SHPA Drug Use Evaluation Cycle8
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Program Methods
August 2010

• Ethics approval
• Support from senior clinicians
• Data collection
• Education and Feedback
• Data collection
• Evaluation, Feedback and Sustainability

June 2011
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Pre-intervention results continued
Hospital NSW/ACT
Baseline Baseline
Patients discharged where a discharge summary is documented in the notes
Patients who had medication reconciliation undertaken on admission
Discharge summaries which comply with NSW Policy (PD2007_092) for a documented list of medications on admission and on discharge
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Pre-intervention results
Hospital NSW/ACT
Baseline Baseline
Discharge summaries which should have explanations for medicine therapy changes
Discharge summaries which document all changes to medicine therapy
Number of medicine therapy changes which require an explanation
Of those, proportion which had a documented explanation for the change
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Pre-intervention results continued
Hospital NSW/ACT
Baseline Baseline
Of the discharge summaries reviewed, those which were computer generated
Discharge summary templates prompting documentation for changes to medications
Number of discharge summary templates reviewed
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Discussion

• Encouraging aspects of our results

• Aspects to improve

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EDUCATION
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Educational Tools Expert Advisory Committee

• Clinical Education and Training Institute (CETI)
  Representatives
• JMO Forum
• Prevocational Training Council / Director Medical
  Services
• Head of Department , General Paediatrics
• General Practitioner
• Education and Training Pharmacist
• Quality Manager
• Head of Department, Clinical Pharmacology

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Educational Intervention Tools

• Discharge Summary Workshop
• Top Tips lanyard cards
• Checklist for JMO Term Supervisors
• Feedback presentation today!

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Discharge Summary Workshop

• Target audience Junior Medical Officers
• Consists of
• -PowerPoint presentation
• (Good, great and ugly discharge summary
  examples)
• -Practical case examples and activities

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Lanyard Cards
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Checklist for JMO Term Supervisors
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Support 4 Success!

• Many staff members can provide support and
  contribute to make this program an successful
• JMOs
• Term supervisors and their senior team members
• Pharmacists
• Nursing

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Hospital Program Contacts

• Clinical Champion
• xxxxx
• Local Project Team
• xxxxx

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References

• Easton K, Morgan T, Williamson M. Medication
  safety in the community A review of the
  literature. National Prescribing service. Sydney,
  June 2009.
• 2. Wong JD, Bajcar JM, Wong GG et al. Medication
  reconciliation at hospital discharge Evaluating
  Discrepancies. Ann Pharmacother
  2008421373-1379.
• 3. Lisby M, Nielsen LP, Mainz J. Errors in the
  medication process frequency, type, and
  potential. Int J for Qual in Health Care 2005
  17(1)15-22.
• 4. Perren A, Previsdomini M, Cerutti B, et al.
  Omitted and unjustified medications in the
  discharge summary. Qual Saf Health Care
  200918205-208.
• 5.Guiding principles to achieve medication
  management Australian Pharmaceutical Advisory
  Council 20051-55.
• 6. Indicators for Quality Use of Medicines in
  Australian Hospitals NSW Therapeutic Advisory
  Group, 2007.
• 7.Continuity of Care Program- National E-Health
  Transition Authority, March 2010 Issues and
  barriers faced by Junior Hospital Doctors for the
  Implementation of the Discharge Summary
  (unpublished)
• 8. SHPA Committee of Specialty Practice in Drug
  Use Evaluation. SHPA Standards of Practice for
  Drug Use Evaluation in Australian Hospitals. JPPR
  2004 34(3) 220-222.
• .

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Acknowledgements

• NSW TAG
• SAFER Medicines Group
• Drug Use Evaluation Support Group
• Indicator 5.3 Expert Advisory Committee

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Questions/Discussion