SMOOTH

1. SMOOTH Safer Medicines Outcomes on Transfer Home CLINICAL LEAD Sanjoy Nand SMOOTH TEAM Team Lead: Rebecca Lawn Sonia Varma, Ahmed Marmoush PROJECT SUPPORT Doreen Liow, Nazanin Falconer Karla Rika-Heke, Maika Veikune Ian Kaihe-Wetting, Truc Nguyen 20,000 Days Ian Hutchby, Monique Davies

2. Safer Medicines Outcomes on Transfer to Home (Discharge Medicines Management) SMOOTH’s Aim: 2-3% reduction in readmissions associated with medication related problems by providing 90% of high risk adult medical and surgical patients with a medication management service at discharge and during the immediate post discharge period (7 days) • Collaborative 20,000 days campaign • Using a risk predicative tool to determine patients at highest risk of medication related harm

3. SMOOTH Driver Diagram -

4. Why SMOOTH? • Medication management support at the discharge phase has been adhoc – resulting in inaccurate and incomplete information being provided to patients and primary care providers resulting in suboptimal medicines use • Patients often don’t understand the changes made, some are unaware of the importance of taking medicines or what the new medicines are for which results in inappropriate disease management, adverse drug events and readmissions • Evidence suggests that pharmacist interventions at discharge and pharmacist led follow up of discharges (care integration) results in lower rates of readmission • The intervention improves patient care when transitioning from hospital to home, optimises medicines use, integrates care and improves overall patient safety

5. ART Tool

6. SMOOTH Change Packages

7. SMOOTH Change Packages

8. SMOOTH Measures Summary • Total number of patients seen each day is recorded on a work list. This enables us to measure how close we are to achieving our aim • A care package was created to formalise the medication management services the SMOOTH team provides • A data collection form is utilised to document the number of discrepancies or errors prevented. Each error is then graded using a standardised approach • Additionally, the services each patient receives at discharge and during the immediate post discharge period is documented on the data collection form, using a tick box approach

9. SMOOTH Implementation Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

10. SMOOTH Highlights • Rapid development and implementation of the SMOOTH change package • Multiple system refinements: Development of a standardised discharge process and care package of interventions with clinical pharmacy • Implementation of a formal process for notification of discharges organisation wide • Collaboration with other health professionals: recognition from medical staff about the need for medication management at discharge interface and acknowledgment of the quality of clinical and patient centred services provided by SMOOTH team • Collaboration with quality improvements personnel and valuable learning from each other to test change packages and ideas • Key learning: Small, inexpensive tests of change via PDSA cycles can provide valuable return in overall learning. Failure can provide successful learning .

11. SMOOTH Lowlights • Difficulty capturing meaningful patient feedback • Slow uptake with the notification of the discharges resulting in very low numbers for SMOOTH • Reliance on various methods for notification of discharges – not a self sustained process - workflow not consistent • Time constraints impacting delivery of services • Limitations with capturing 90% of high risk patients discharged .

12. Variation in processes • Currently data is collected consistently due to standardisation of the collection form • Some variation is noted in provision of service and interventions as these services are time dependent and reliant on early notification of the discharge. These variations can be measured by capturing the time of notification vs the number of interventions provided per patient • Variation in provision of services provided across different populations due to language barriers and time restraints. These variations can be measured by comparing the number of interventions provided per patient vs the ethnicity of the patient • Variation in recording information on the EDS by individual SMOOTH pharmacists. These variations can be measured by retrospectively auditing 20 EDS for information recorded .

13. SMOOTH Achievements to date Change package provided to 385 general medical patients.

14. SMOOTH Results so far… From 133 errors - using epifany grading systems

15. SMOOTH Achievements to date Out of 365 who received the care package ~35% (133) had at least one error identified on the discharge summary