Ensuring ongoing quality improvement (QI) is an integral part of the role of a pharmacist, and there has never been a more exciting time for pharmacy than now. With the role of the pharmacist constantly evolving, there is a need to develop the future workforce in areas they may have no previous experience in.
In 2018, while both working at Royal Free Hospital (RFH) as band 7 pharmacists, we found ourselves at the junior end of senior roles. Our experiences as band 6 pharmacists were about finding our feet, helping patients and colleagues, and undertaking our duties as ward-based hospital pharmacists. Both extremely passionate about healthcare and the patient experience, we wanted to become more involved in ensuring pharmacists had the tools to provide an efficient, optimised and standardised process on the ward. After discussion with our managers, we discussed the possibility of a project. The opportunity then came from our lead clinical pharmacist, who suggested a QI project, working with the QI coaches in the hospital. Getting involved was exciting, and the ability to influence change and improve healthcare was something we couldn’t say no to. With the support of senior colleagues and the Institute for Health Improvement (IHI), the project was born and implemented.
The initiative aimed to standardise and improve the pharmacy admissions process at Royal Free London NHS Foundation Trust. The change in NICE guidance for when a patient should be seen by a consultant, and the Royal Pharmaceutical Society Hospital Standards stating a full medicines reconciliation for patients must be completed within 24 hours, demonstrates a clear need for a pharmacy admissions process to be embedded into our work. Although one currently exists, it is hard to ensure standardised care, and the current process leaves room for improvement. Documentation is still difficult, and often essential information is missing from a medicines history. Secondly, doctors at clerking complete a history and the pharmacy team second check this and rectify issues. It would be more time efficient and safer for the pharmacy team to be the first to undertake an accurate medicines history from a patient. With support from IHI, and the senior team at RFH, this project will have a significant impact on the way in which medication histories are carried out on admission.
Three junior pharmacists carried out the bulk of the project work, which included a pre project audit, focus groups, presentations and the plan-do-study-act (PDSA) cycles at each step. Also involved were three senior pharmacists, a medical registrar and a member of the workforce transformation team. Working in this team ensured we had a wide skill mix at both clinical and managerial levels to drive outcomes forward. The study is a quality improvement project, and so the PDSA cycles allowed for changes at each stage. The aims of the project are to have 90% of inpatients with a medication history completed by a pharmacy team member documented in the patient notes within 24 hours of admission, and for 90% of inpatients to have a full medicines reconciliation completed and documented on the inpatient prescription chart within 24 hours of being seen by the pharmacy team.
Baseline data around quality and timeliness of current processes were collected. PDSA cycle 1 involved creating a checklist as a guide to remind ward-based pharmacy staff of the necessary requirements for medication histories and reconciliations. This was not successful as pharmacists did not find the checklist helpful, and felt it added to time but brought no benefit. It also did not act as a reminder. This resulted in the QI team holding a focus group to discuss how best to improve both quality and timeliness of the pharmacy admissions process. The creation of a Standard Operating Procedure and/or guideline was suggested, so for PDSA cycle 2 this guideline was drafted and circulated. This guideline has now been implemented, and an audit will be undertaken to ensure staff are working within this guideline. PDSA cycle 3 involved using feedback from the focus group to create a pharmacy admissions care bundle to improve the quality of medication histories and medicines reconciliations. This care bundle is a resource that will be used to document the medicines reconciliation in the notes. It allows the pharmacist to document all relevant information, and gives space to write recommendations for prescribing. It also has a space for documentation of sources used, and information regarding social care (dosette boxes, carers etc), that would facilitate discharge. The first draft of this will be trialled, and further PDSA cycles will help to create an ideal version, fit for purpose.
The project itself is still ongoing and has been challenging and eye-opening. We have had to overcome many challenges and are preparing to face future obstacles, the main problem being the motivation of staff to trial this. Time is a major issue, and encouraging pharmacy staff to understand the importance of this project, and asking them for their support with trialling documents has been difficult, but successful. We are currently on the next PDSA cycle, hoping to implement the care bundle onto selected wards for trial, and hope to role this out in the near future. Not only is this QI project helping to develop the pharmacy admissions process at the Royal Free and improving patient safety and standardising work, it has also helped us develop both professionally and personally. We have further developed our communication skills and enhanced our understanding of the importance of continuing improvement work. It has given us a further passion for our careers and has provided further opportunities to become involved with our profession.
About the authors:
Sarah Cahill is a clinical informatics pharmacist at Royal Free London NHS Foundation Trust.
Sarah Browbank is an urgent care pharmacist at Queen Elizabeth Hospital, Gateshead.