Toni HowellACHS Surveyor

Med Safety Pharmacist, St Vs Melbourne

Primary Health Care: Remote (Botswana)Private: Regional (Bendigo) & Metropolitan (Melbourne)Public: Metropolitan (Melbourne Health & St Vs)

Pharmacist (Med Safety & Strategy) at St Vincents Public in MelbourneSurveyor and Education Consultant for ACHS

Do surveyors know everything?

Are they trying to catch you making a mistake?

Guilty confessions

2

Why do I love accreditation?

What does good look like?

What are surveyors looking for?

How can you do it all without more?

3

Why do I love accreditation?

What does good look like?

What are surveyors looking for?

How can you do it all without more?

4

5

It is about doing a better job

It is about being smarter with our time

It is about making all patients safer

It raises the priority of medication safety

It is about dropping things which add no value

6

Think about where weve come from:

Labelling medicines the tablets

Typewriters

Checking sheets for clinical pharmacists

What comes next?

7

8

Why do I love accreditation?

What does good look like?

What are surveyors looking for?

How can you do it all without more?

9

10

Australian Commission on Safety and Quality in Healthcare website

Safety and Quality Improvement Guides

One for each of the 10 Standards

Very comprehensive

(you dont have to do everything!)

Accreditation Workbooks

Reflective questions (simple English)

Tick boxes

11

lots o

f link

s !

lots o

f ide

as !

12

1. Governance for Safety and Quality in Health Service Organisations2. Partnering with Consumers3. Preventing and Controlling Healthcare Associated Infections4. Medication Safety 5. Patient Identification and Procedure Matching6. Clinical Handover7. Blood and Blood Products8. Preventing and Managing Pressure Injuries9. Recognising and Responding to Clinical Deterioration in Acute

Health Care10. Preventing Falls and Harm from Falls11. Service Delivery12. Provision of Care13. Workforce Planning and Management14. Information Management15. Corporate Systems and Safety

13

14

Criteria:1) Governance and systems for medication safety2) Documentation of patient information3) Medication management processes4) Continuity of medication management5) Communicating with patients and carers

Actions (example): a) A system is in placeb) Use of the system is monitoredc) Action is taken to improve the system

15

Introspection look at what you do, then take action to improve it.

Innovationyou might get it wrong sometimes but full points

for trying.

Integrationif you are only looking after your own patch, then it

does not look good.

16

Why do I love accreditation?

What does good look like?

What are surveyors looking for?

How can you do it all without more?

17

the basics!evidence-based initiativesmeasuring thingsusing the results of the measurementinforming staff so they can do betterinforming staff so they make fewer mistakesinforming patients so they are reassuredinforming patients so they make fewer mistakes

Collaboration. Its not just about Pharmacy

18

How have YOU been involved in the National Standards??Exec said: Pharmacy, fix this!?Did you decide: Standard 4 is ours to solve?Quality did the Gap Analysis without consulting with Pharmacy

This is NOT the Pharmacy Standard, but it IS Medication Safety

so we are integral but it needs collaboration

Driving change in what we know needs to be changed.

19

Identified risk of administration errors during the medication round.

A patient info leaflet

asking patients not to speak to nurses during the round.

20

An organisation created and successfully implemented a medication history and reconciliation form with clear documentation of changes during the admission.

Plus BONUS efficiency measures

a legend detailing the abbreviations in medication names which can be used.

21

An organisation with a single pharmacy department and a distance of several hours between health services.

Claimed100% of patients get a med history prepared

and 100% received medication reconciliation.

22

It depends

You dont have to do it like I would choose toIf it works for you, then thats fine, e.g. medication trolleys

Often, I cant find something so I just ask

If it isnt available, then up to 120 days to fix it

23

Ensuring there is a structure around a task or tasks

Leadership, policy, frameworks

Committee definitions and responsibility: Medication Safety Committee OR Drug & Therapeutics Committee

Are they given the power to drive good practice?

Exec to Coal face to Exec the information has to flow both ways

24

Leadership

Vision

Policy

Strategy

Motivation

Plans

Executive

25

Risks

Requests

Advice

Staff

26

27

How do you know this will be done?

28

(I hate this question!)

29

30

Howdoyouknow systemsareembeddedintopractice?

31

Why do I love accreditation?

What does good look like?

What are surveyors looking for?

How can you do it all without more?

32

Useful measures of quality improvement:

-Key Performance Indicators (KPI)- reported monthly or quarterly to Exec on Score Card

-Clinical Indicators (CI)- reported annually (or more or less, depending)

-Area Performance Indicators (PI)- reported to manager quarterly (more or less)

-Annual Performance Appraisal- including annual review of PI

Hopefully, the trend is ongoing improvement

33

Key Performance Indicators (KPI) Review

-Did our KPIs change how we did things?

-Could different KPIs make things better?

-What could we measure instead?

-Review of KPIs at monthly meetings and sent to Exec

-Poor performance stimulated projects!

34

Altered activity of Committee, one example

- Pharmacy Quality Council

- Reviewed KPIs, acted on poor results

- Shared projects around lots of staff

- Fostering a quality improvement / research culture

35

Area Performance Indicators (PI)

- reported to manager quarterly

Annual Performance Appraisal

- including annual review of PI

36

Summary sheets for accreditation:

1.What was the risk?

2.What did we do?

3.How do we know it makes it better?

(safer, cheaper, more efficient)

37

Causing some stress.

Start with the basics:

Credentialing of medical staff (same as EQuIP)

Registration of nursing, pharmacy

How do you know?

38

Then ask the next questions:

How about staff with increased responsibilities? ICU or Coronary Care nurses

How about the unusual ones managing meds? Physios?

How do you know?

39

Competency?

Performance measures?

Systems like:Formulary restrictions (reviewed at a committee)Specific Imprest on each ward controlling accessAntimicrobial stewardshipHaematology consultant to prescribe certain medsAnnual audits of prescribing habits, perhaps?

How do you know?

40

May be challenging: recruitment retention distances

Dont waste time: on misinterpreted actions inventing what is already available collecting too much of the wrong kind of evidence

On the good side, often very supportive communities!

41

How do you know ?How do you know ?

42

ItIts not about the s not about the processprocess,,

it is about it is about outcomesoutcomes for the patientfor the patient

43

44

45

46

First impression looks ok

Intelligent articulates his story well

Principled has policies and lives by them encourages others to do same

Perhaps has some flaws we all do

Is this Mr Clooneyor your organisation & staff?

47

the Standards are about improving patient care

this should remain the focus

48