Storyboard Entry Form 2015
Main author: Melanie Thomas
Email: [email protected]
Telephone: 07939 115 974
1. Storyboard title:
Reducing Waste, Harm and Variation in Lymphoedema Services in Wales
through collaboration with Community Pharmacy Wales and Medicine
Management Teams
2. Brief outline of context:
Improvement work was identified at the All Wales Lymphoedema Services
Clinical Leads Meetings held in the Programme Management Unit.
Followed by discussions with the All Wales Medicine Management group
addressing lymphoedema compression garments issues and complaints
and then subsequent further collaboration was developed with Community
Pharmacy Wales (CPW). The audit was held in two Health Board
lymphoedema Services ABMU and CT. Staff including nurses,
physiotherapists and pharmacists and lymphoedema patients were
involved in the audit.
3. Brief outline of problem:
Lymphoedema is a chronic condition which causes gross swelling to a limb
or limbs. Compression garments are the mainstay of treatment as they
reduce the amount of swelling thereby improving pain and discomfort.
Since the development of lymphoedema services in Wales, specialists
have recommended specific garments be prescribed from primary care
and issued to patients based on their clinical need.
However in 2012, it became apparent through numerous patient and
professional complaints that incorrect garments were being prescribed and
supplied causing significant harm to patients and waste for NHS Wales.
Patients were disappointed in not accessing the right garments at the
right time and felt disheartened. Professionals too felt that the process
was taking them away from clinical interaction as they had to duplicate
prescription requests and administrative duties. Ultimately, the current
process of patients accessing garments was a problem.
4. Assessment of problem and analysis of its causes:
Although patient’s complaints were taken seriously assessment of the
problem had to be undertaken to quantify the concerns. Following the
PDSA format, emails were sent to the Medicine Management teams in
ABM to discuss the problem encountered. To quantify the problem an
audit was undertaken with a prescribing adviser. Fifty, randomly selected
ABM Lymphoedema patients were selected and the garments requested
were cross checked with garments issued from the prescription catalogue
and CASPA database.
The results showed that of the 50 patients 25 (50%) had been dispensed
wrongly. This included wrong size, shape, colour and quantity. Harm was
identified in the garments being dispensed were causing more swelling
e.g. an arm garment dispensed which ended at the wrist instead of the
fingers caused massive hand swelling. A leg garment was issued 3x
smaller than should have been causing a superficial would on the ankle.
It was also highlighted that the average time taken for a patient to receive
a garment was 42 days. The audit was repeated at another HB and
showed similar findings. It was agreed that this current process was not
fit for purpose and changes needed to occur.
It was believed that as a result of a lack of familiarity and the vast range
of available compression garments, sometimes incomplete information on
prescriptions were causing incorrect garments inadvertently being
supplied to patients causing waste, harm and variation.
A possible
solution maybe improved communication/education for pharmacists and
utilising non-medical independent prescribers.
5. Strategy for change:
Based on the audit results, collaborative meetings were held with LNW,
Medicines Management Teams and CPW to agree a way forward. Staff and
patient representation were present to ensure all groups were given a
voice. It was agreed that changes to the process be developed which
would include:

Education for all community pharmacies on compression garments
Creation of a generic all Wales Lymphoedema Prescription
Recommendation form which would be faxed to the community
pharmacist of the patient’s choice. This form is designed to capture the
key information necessary to facilitate the correct prescribing and
supply of lymphoedema garments.
Two HB’s were keen to implement this new process based on current
patient complaints.
1. ABMUHB where two non-medical independent prescribers would
directly issue prescriptions to patients and as well as faxing the
nominated pharmacy the AWLS Prescription Recommendation
Form.
2. CTUHB where the Lymphoedema Specialist will be issuing the AWLS
Prescription Recommendation Form to the patients GP for them to
issue a prescription.
The main objectives of this change would be
 Ensuring patients are supplied with the correct garments
 Improving patient outcomes
 Reducing delays in patients receiving garments
 Reducing harm, waste and inconsistency
 Improving flow of information to pharmacies
 Improving
communication,
knowledge
and
awareness
of
compression garments to community pharmacies
Time was given for further discussions and dissemination amongst teams
and the change was agreed to commence 6 weeks later in December 2013
the new process would be initiated and audited for 6 months. An audit
was vitally important to ensure measurements were taken to quantify an
improvement.
6. Measurement of improvement:
To facilitate the audit, community pharmacies were asked to complete a
time frame on the following data:



The
The
The
The
date
date
date
date
the
the
the
the
prescription was received.
garment was ordered.
garment was received from the manufacturer.
garment was supplied to the patient
Additionally similarly to baseline data analysis 50 new patients would be
randomly selected and data would be analysed on the prescription
catalogue & CASPA database utilising and comparing information to the
Prescription Recommendation sheets. This data was collated by the
National Clinical Lead for Lymphoedema and her deputy with a medicine
management prescription adviser from ABUHB
To improve knowledge two education sessions were created for all
community pharmacists and technicians in the ABMUHB and CTUHB areas.
This education was part of the collaboration with the Wales Centre for
Pharmacy Professional Education (WCPPE).
7. Effects of changes:
Following analysis of data returned from 160 ABMUHB and 58 CTUHB
community pharmacies the following results have been identified
1. Some delays are due to patient’s untimely pick up of
prescriptions not the NHS process
The longest a patient took to take a prescription to a community
pharmacist was 65 days. The average was 5.4days. This has a bearing on
the overall time a patient is waiting for a garment at no fault to the NHS.
In certain cases the community pharmacists actually ordered the
garments based on the faxed recommendation sheet without a
prescription thus resulting in negative days waiting.
Health board
Average days wait
% ordered same day by
prescription to pharmacy
pharmacists
ABMUHB
4.2
81%
CTUHB
6.6
62%
2. The collaboration has significantly improved pharmacists
knowledge
34 pharmacists and pharmacy technicians attended the two hour training
sessions. All evaluated the events very highly and all stated they had
learned something new. Based on this, WCPPE asked for pre-graduate
pharmacists and pharmacy technicians to have dedicated training on an
annual basis. So far over 220 pharmacists have been educated on
lymphoedema and compression garments in Wales.
3. The time waiting for an off shelf patient garment has
decreased from 42 days to an average of 10 days
Average off the
shelf garments
days wait
ABMUHB
CT
Average
7.75
12.1
10 days
Average Made to
measure
garments days
wait
13.8
22.3
18 days
There are significant improvements made in both HB’s in reducing wait
times for garments. However there are differences in the process from
utilising Non-medical independent prescribers and asking the GP to
prescribe. Utilising NMIP nearly halves the time. This is also supported by
auditing against the targets set by the manufacturers.
4. Wrong garments issued has decreased from 50% to 5%
This is highly significant in decreasing waste and harm as well as
increasing patient benefit. Patient data was analysed on the prescription
catalogue and CASPA database utilising and comparing information to the
AWLS Prescription Recommendation sheets. Patients complaints and
concerns have significantly reduced since the introduction of the
recommendation form and pharmacy education however further work is
still needed once the National Lymphoedema Compression Garments
Formulary is introduced in spring 2015.
8. Lessons learnt:
We assumed that community pharmacists had prior knowledge of
compression garments which was misleading as nearly all expressed
learning needs about the differences in compression classes. This led to a
larger piece of work with the WCPPE.
Additionally compression garment manufacturers expected community
pharmacists to pay pre delivery with a credit card leading to unnecessary
delays. Through collaboration all manufacturers now deliver to all
community pharmacists and invoice within 31 days as per secondary care
procurement process.
Based on the results this new process of prescribing, education and
dispensing has now been agreed to be rolled out across Wales from the All
Wales Medicine Management Group and Community Pharmacy Wales and
by November 2014 every Lymphoedema HB Service is following this
process- all for the improvement of care for our patients.
9. Message for others:
Sometimes the simplest of things can have the biggest effect- like faxing
a form to the community pharmacist so they have correct pertinent
information and contact details. Who would have anticipated that
something so simple can have huge impact in patient care. Additionally,
we should never underestimate how important communication is and
collaborating with professionals for the benefit of care to our patients.
10. Please summarise how your entry reflects the principles of
prudent healthcare:
People often ask why Lymphoedema services in Wales are often tagged as
an example of a prudent service. Limited funding was available, therefore
our focus centred on ensuring that we maximised the impact of the
investment by identifying opportunities to improve the service for the
population of Wales. We follow the 6 principles in every programme of
work ensuring equitable care, greatest need are prioritised, not doing
harm, evidence based care, coproduce with our patients and openly work
with the third sector.