Consultant Neurologist Jane Alty talks about the 'Improving care of patients with Parkinson’s quality improvement project' at Leeds Teaching Hospitals NHS Trust, and how it has highlighted the value of involving staff from across the organisation and carers to make services better.
How did this project come about?
We had a case where a patient with Parkinson's was cared for in our trust for a period of time, during which there were frequent occasions on which his Parkinson's medications were delayed or not given. This sadly contributed to a deterioration in his swallowing and overall condition, and lengthened his time in hospital.
His wife wrote a letter outlining a number of solutions that could have made things better for her husband. We also knew this was not a unique set of events, as audits and complaints had previously shown missed opportunities to deliver timely administration of medication. This was taken on board by the Chief Medical Officer, with a clear commitment to improve the service.
This was taken on by myself, as a consultant neurologist sub-specialising in the care of people with Parkinson's, and Ali Cracknell, a care of the elderly physician who also has a quality improvement (QI) remit within the trust. Ali met with the family and used a quality improvement methodology to help us identify our specific objectives and what outcome measures we were going to use to measure our progress. Whilst our overall objective was to ensure people with Parkinson's got their medication on time, more specifically we planned to monitor delays to first medications after admission, percentage of medications omitted and average delays to receiving medication.
We also measured these in relation to medications for other conditions such as diabetes because it was important from a quality improvement perspective that improving outcomes for one patient group did not happen to the detriment of the management of others.
We felt that to get solutions that would truly work in practice, we needed to utilise the expertise of different people across the trust and not just the ward staff and clinicians specialising in Parkinson's. Therefore, along with the carer, we organised weekly multidisciplinary team meetings that could be attended by anyone. These were held 3 times a month at St James's University Hospital and once a month at Leeds General Infirmary to help ensure different people could get involved and to keep the momentum going.
It was amazing was to see a breadth of people coming along - IT managers, porters, consultants, junior doctors, nurses, therapists, pharmacists, carers – all with ideas as to how they could help, which we would not have easily worked out for ourselves. For instance, the IT managers spoke about how an online system could be set up to alert us when someone with Parkinson's was admitted to the trust and the porters said that they could ask anyone with Parkinson’s if they had taken their medication before taking them off the ward for a test, and alert staff if they hadn't.
Soon we had more than 60 people in the trust signed up to get notifications of the meetings so we had tremendous buy-in. We also presented the QI project at the local Parkinson's UK branch meeting and the Yorkshire and Humber Excellence Network meetings, and used these opportunities to gain feedback from people with Parkinson’s and their carers to further shape the project.
Were there any challenges with this approach?
At the beginning, it did feel like different staff groups were speaking a different language to each other. However once we overcame this, we could play to everyone’s strengths which has proved to be incredibly beneficial.
So what changes were implemented?
We decided to focus on 6 key wards in each site – these included A&E, care of the elderly, general medical and orthopaedics – with a view of wider roll-out later on. We created an intervention bundle which consisted of resources such as an alarm clock and the Get It On Time laminated clock as well as a 6 monthly educational masterclass day that all staff are invited to.
We identified some dedicated people who would collect data on each of these wards. This was then sent to the IT department who helped to create some lovely improvement charts. We also had medical students review medical notes to gather retrospective data prior to the intervention.
What has changed?
So far, we have seen some dramatic results across the trust, with the delay of the first medication on admission going down from over 7 hours to below 1 hour. The average percentage of Parkinson’s medication doses omitted over a 24 hour period has also fallen from 15% to 5%. We still want to make improvements, but this shows that the incredible effort of everyone has made a difference.
What's happening now?
We’ve been approached by clinicians from a couple of other hospitals who are looking to trial the intervention bundle in their areas. We have clearly seen that it can work in our trust, so it would be useful to see how it could help improve medicines management elsewhere. We are also working on spreading the bundle of interventions across the whole of our trust. In addition, we are using the education as part of the junior doctors’ training, so that no matter where they work, they will understand how critical timely medication is for people with Parkinson’s.
And how does the carer who wrote the original letter feel?
She has been an integral part in this project. The fact that she was able to take a bad experience and use it for something so positive is amazing. As a family they feared the time he may need to come back into hospital, and although this did occur, they really noticed a huge improvement. She said that the culture in the hospital had completely changed from the previous time. She particularly noticed that the staff are a lot more knowledgeable about Parkinson’s and they had much more confidence in the quality of care. You can’t really ask for much more than that.
Connecting to share good practice
If you would like to find out more about the Leeds quality improvement project, you can follow the team on Twitter at @LTHTParksQI. You can also follow Jane at @janealty1 and Ali at @ali_cracknell.
If you would like your service to feature in a future spotlight, contact us at [email protected].