Assessment 6

Change Management Proposal

Recent evidence and current trends show both nursing and medical professions have a lack of understanding in certain aspects of safe prescribing and safe administration of medicines. The concept of prescribing and the ability to calculate is the basic requirement of all qualified medical and nursing professions

We are proposing over a three year period to run an inter professional collaborative working programme, whereby both student nurses and doctors will come together on a regular basis in a teaching environment to work alongside each other to gain the following skills:

• Patient safety in relation to drug administration • Patient safety in relation to drug prescribing • A clearer understanding of each others role • Practical experience in drug administration and drug prescribing in a non –threatening environment • Insight into pharmacology and pharmokinetics and it’s importance in prescribing and administration of drugs.

This three-year study we propose to write up and evaluate and hope to publish with the intention to produce learning materials and educational packs to be marketed at later date

Rationale for Change Project

Medications Errors within any health care setting can have severe consequences not only for the patient but financially for the organisation if litigation comes about.

Medication errors can be defined as “any incorrect or wrongful administration of a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct drug or formulation for a particular disease or condition, use of outdated drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects of certain drug combinations.” Mosby Medical Dictionary (2009). Causes of medication error may include difficulty in reading handwritten orders, confusion about different drugs with similar names, and lack of information about a patient's drug allergies or sensitivities.

Edwards and Aronson (2000) define an adverse drug reaction (ADR) as "an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen, or withdrawal of the product."

According to the BMA (2006) it was estimated that a growing number of patients are admitted to hospital suffering from harmful effects of prescribed medication and that the number of patients who suffer from adverse side reactions, addiction and withdrawal problems is unrecognised and unreported. Kieve (2007) suggests that “there is a need for more focused education and proactive support from primary care trusts in preventing iatrogenic disease (doctor induced disease). Systemic changes in practice and education can be strengthened to prevent adverse drug reactions, and this will lead to improved patient outcomes.”

The medication administration procedure is a tripartite process involving the prescriber (physician or non medical prescriber) pharmacist and nurse. The prescriber will diagnose the patients presenting condition and then prescribe the appropriate medication, the pharmacist will dispense the medication and then the nurse will administer the medication to the patient. It is during any stage of this process that mistakes can occur.

From the audited figures of medication errors reportable within the trust it is noted that a significant proportion comes from newly qualified staff. A training issue has been identified that newly qualified nurse do not have the necessary numeracy skills to pass the requirement medication maths assessment and newly qualified doctors feel unprepared for effective prescribing.

As an organisation, we require newly qualified nurses to under take a maths test to ascertain their level of competency prior to dispensing medications to patients. Students at the end of their training are tested as part of the interview process. Within LTH nursing students have routinely been tested for over five years (two intakes per year) and it is evident from these results that there is a poor rate of numeracy within student’s nurses. Whilst these results are as yet unpublished, it mirrors reports that newly qualified nurses are unprepared for practice as reported in the Nursing Research Unit (2009) scoping document and Whitehead & Holmes (2011). LTHTR medication errors are monitored and are in line with the findings of the GMC 2009 & 2008 reports which concluded that newly qualified doctors (FY1 and FY2) are responsible for the majority of prescribing errors. It should be noted that prescribing errors by a medics will often be corrected by the administrating nurse or dispensing pharmacist before any “harm” occurs to the patient. Serious harm to the patients tends to happen after a combination of the safety checks fail to happen.

It is proposed to encompass these failing that as an organisation we develop a comprehensive training package which will be delivered over three years to pre-registration nurses and years 3-5 undergraduate medical students. It will target prescribing and administration of medications, with elements of numeracy and pharmacology. This will be a 3 year funded research project in conjunction with LTH, University of Central Lancashire (School of Health) and University of Manchester (School of Medicine). The numbers of students involved would be estimated at 80-100 nursing student and 30-40 medical students in the first co-hort.

Using Lewin’s Model of change (1951) the change management process can be simplified as:-

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The PESTLE framework will give an overview of the different macro environmental factors that will affect the project. Pestle analysis delineates the broad environmental factors and external drivers that affect the business.

| |Descriptor |Example |Reference |
|Political |Meeting the Interprofessional education|Changing the way we educate |DoH 2011, |
| |agenda, by ensuring effective joint |health care staff. |DoH 2011 (Sept) |
| |working between professionals during | |DOH 2003 |
| |the training programmes | |Kieve 2007 (1) |
| |Serious medication errors make headline| |CAIPE 2002 |
| |news and damage the reputation of the | | |
| |NHS | | |
|Economical |Reduction in financial recompense due |Reduction of patient harm due |Ross et al 2000 |
| |to litigation claims. |to medication errors. | |
| |Reduction in associated cost from | | |
| |medication errors. | | |
|Social |Reduction of admissions due to hospital|Number of patients admitted to |Pirmohamed et al BMA 2004 |
| |for adverse drug reactions. |Hospital with a ADR | |
| |Increase in patient Expectation- |Patients have a expectation | |
| |patients have a greater awareness of |that doctors should “do no | |
| |their health needs |harm” | |
|Technological | National development of medication and|SN@P project, |Medical Schools Council 2008 |
| |numeracy assessment tools |NWNMP numeracy test. | |
| | |Prescribing skills assessment | |
| | |project (University of | |
| | |Edinburgh) | |
|Legal |Reduced ligation from medication errors|Achieve level 2 within NHSLA |NHSLA - Risk Management |
| |and ADRs | |Standards 2011/12 |
|Environmental |Maintain public confidence within the |Safe care- improving patient |NHS III 2011 |
| |hospital |safety | |

Aims, Objective and Success criteria

The most well known method for setting objectives is by doing it the S.M.A.R.T. way, the SMART approach is well understood amongst managers, but is often poorly executed. Frey & Osterloh (2002) argue that for any project or change management situation to be successful the objectives must be jointly written in such a way that it is meaningful for all members to agree and understand.

Aims

The aims of this project are to decrease medication errors within the Trust by newly qualified nurses and medics.

To give the opportunity for nurses and medics to engage in interprofessional education activities

Objectives

|Specific |To develop a three year training packages which will run concurrently with the students placements within|
| |the trust for pre-registration student nurses (years 2-3) and medical student (years 4-5) |
|Measurable |Evaluation is a vital component of any project (Mohanna et al 2000) and this will be measured in a variety|
| |of ways. During the initial phase it will be measured by the number of students who successfully complete|
| |the programme and their initial feedback via an electronic survey. Long term the trust will also be |
| |looking to monitor the success rate of the programme by a noticeable reduction in medication errors by |
| |newly qualified staff |
|Achievable |The proposal has been approved by all parties as achievable within the given time framework |
|Realistic |LTH, with the combination of UoM has the resources, availability of effective teaching staff and clinical|
| |skill labs to facilitate an effective interprofessional learning environment. The undergraduate department|
| |has applied and being granted additional funding for the project. |
|Time |Starting with the (Oct 11 – year 2) cohort of degree nurses and Year 3 (Oct 10) medical students to |
| |commencing during their first clinical placement Jan 2013. |

Success criteria.

This study has the potential to provide both qualative and quantative data. For example, the medical students within the sample group their prescribing stations in their OSCE’s being compared with the controlled groups from other three base hospitals. For the nursing student’s comparative studies from previous interview selection maths test compared with the sample group. However, there is potential to link with a satellite hospital to perform a direct comparison with this group of students.

Ultimately and long term we will be looking to reduce the number of medication errors occurring in the organisation.

Proposed Strategy – with justification.

Methodology.

When looking at implementing a change within an organisation it first is useful to identify the current culture of the organisation (Balogun 2001). LTH has three core services – secondary care provider to the local health economy, specialist care provider to the NW region and health care education provider. The medication teaching project will sit within the health care education function. A cultural web is a useful tool to assess the extent of the change required (Paton & McCalman 2008). In appendix 3 is a cultural web analysis of the current climate. Medical and nursing training traditionally not taught together so this will be a new way of working for the nursing educators and the clinical medical tutors. There is a great divide within the funding for medical and nursing education. Currently there are differences between the two departments in the sizes of funding and numbers of students. Undergraduate (medical) has a large team of staff and budget for a relative small numbers of medical students, the training and development team responsible for the pre-registration (nursing) has a very small number of staff and even smaller training budget for a large number of students. The language of the two departments are different as medical training is referred to as the under graduate department but nursing (even though from 2012 it will be a graduate profession) is referred to as pre-registration.

“All models are wrong, some models are good” George Box (In: Burnes 2009)

The problem with working to one model of change is that it will not guarantee a success or is meant to be used as a blue print for success. Whilst there are many models change management and project development, this project is based upon the works of Kotter (1995), Belogun &Hope Hailey (1999) and Parkin (2009). Kotter places emphasis on choosing the right team for the job at the start, the “team” was chosen after consideration to include individuals who had a proven track in planning, delivery and implementation of teaching programmes. Parkin’s “Approach to managing” model places importance on the planning stages and sees it as one of the most importance skills when dealing with a range of multi professional staff and scarce resources. He suggests that SWOT and PESTLE tools are important components when considering new projects, as they identify not only the drivers both internal and external, but also can focus the resources and indentify potential blockers. Both Balogun & Hope Hailey and Kotter highlight the importance of evaluation, and within this project the implementation plan uses a RAG system (red, amber, green) as a visual representation so that each stage is eventually completed in green. If at any stage there is a red or amber alert then the implementation team will re-evaluate and reform to amend the plans. As part of the end stage of the evaluation of the project will be presented to the academic community.

Project model of change at LTH

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SWOT analysis is a tool for auditing an organization and its environment. It is used within the first stage of planning and helps to focus on key issues

|Strengths |Weaknesses |Opportunities |Threats |
|Large number of trained |Financial costs incurred in |Opportunity to participate in |Large numbers of students in |
|clinical educators and |funding the project. |interprofessional education. |cohorts and unable to |
|specialists within the trust. |Co-ordination of large numbers |Grow your own staff- ability to|facilitate them all. |
|Comprehensive training |of students and facilitators |train staff to requirement of |Students already under take |
|facilities including skills |Additional facilities such as |own organisation. Fit for |some pharmacology theory within|
|labs, education centres, |library services, sufficient |purpose |course and therefore may be |
|simulation centres and |BNF’s (British National |Provide consistent tripartite |reluctant to undertake any |
|libraries. |Formulary) or access to eBNF, |teaching between two |further within the practice |
|Established links with the |mock medications |universities and acute sector. |hours |
|HEI’s and network of tutors |End results may be flawed as |Ability to publish findings to |Reduction of practice hours for|
| |once qualified both medical |academic communities. |students. |
| |students and nurse do not all |Enhance patients experience by |Current traditional teaching |
| |gain employment within LTHTR, |reduction in medication errors |practice does not support the |
| |therefore inability to |/ adverse drug reactions |interprofessional agenda. |
| |accurately establish whether |Level 2 NHSLA – reduction in | |
| |training package has a direct |insurance premiums. | |
| |effect on the medication errors|Reduction in litigation | |
| |caused by newly qualified |requiring financial recompense.| |
| |staff. | | |
| |Low numbers of pharmacy | | |
| |students to complete the | | |
| |tripartite training | | |

Following from the SWOT analysis, Levitt’s Diamond (1964) tool was used to establish and focus the direction of the project. This is a simplistic tool to establish the right skilled people for the project, identify specialist equipment needed, numbers of rooms/ skills labs and equipment. etc

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As students learn in a variety of ways (Burgoyne 1999, Honey and Mumford 1986) and there is no one method of teaching which suits all, there will be a variety of learning activities. Active engagement with the student encourages lifelong learning, critical thinking, group process skills, problem solving, information literacy and success (Young & Patterson 2007) The proposal is based on combination of taught and practical sessions. The basis upon which is that learning is assumed to be best facilitated by providing students the opportunities to construct knowledge in the context of social environments and not by simply allowing them to obtain it ( Brooks and Brooks 1994). The taught elements will be pharmacological based, using both taught, self directed study and e-learning. Then they will have the opportunity to practice in an stimulated way using the skills lab, where a “mock” ward will be set up and the students will each take turn to complete a ward round in which the “doctor “ will prescribe for the “patients” and then the “nurse “ will administer the medication. The students will have both formative and summative assessments to consolidate the learning and have opportunity to reflect upon the experience.

Stake holder analysis.

A stakeholder analysis is an approach or set of tools used to generate knowledge about individuals or organizations to understand their behaviour, intentions, interrelations and interest which can be used to assess the influence and resources on the decision making or implementation process. (Varvasosvsky & Brugha 2000). The development of ideas (Lupton 1971) includes the suggestion that change should not just be driven from the top of the organisation but should engage those at the bottom and therefore a stakeholder analysis will identify the individuals or groups that are likely to affect or be affected by a proposed action. It will identify individuals according to their impact on the action and the impact the action will have on them. The strength and effectiveness of the internal relationships enable the project team to function effectively and allows the team (or the project) to interact and influence its surrounding stakeholder community

Mapping of Stakeholders

| |

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The research proposal is to be an agenda item within each key stakeholders’ regular meetings and a member of the project team would presents a brief overview of the proposal and ask for comments or feedback to be given to the project lead chair. The patient involvement representative engaged with the project will identify key patient representation groups to discuss the proposal. APRIL (Adverse Psychiatric Reactions Information Link) was identified as a patient involvement group which may have an interest within the programme.

Currently there is very little pharmokecnics taught within the medical curriculum, so the enthusiasm from both students and universities has been positive. Also newly qualified nurses are seen as “not fit for purpose” once when they commence their new roles and have to undertake an extensive 14 month preceptorship programme to enable them to practice safety and efficiently and to meet the 1st gateway of the Knowledge Skills Framework. As 50% percent of the training lies within practice it is not acceptable to apportion blame to the HEI, therefore the trust feels justified in initiating this project.

Implementation

For the purposes of this assessment the development (initial) stage of project will be incorporated into the implementation plan.

Implementation plan (Development stage)

|Time Frame |Tasks |Persons Responsible |Status |
| | | |RAG |
|Oct – Dec 11 |Project leads identified, roles determined |See project team structure |Completed |
| |Business plan with research proposal completed |Clinical Skills Development |Completed |
| | |Manager/ Quality Education | |
| | |Manager/ PEF | |
| |Stakeholders identified and analysis process |Quality Education Manager, |Completed |
| |commenced |Equality & Involvement lead/ PEF | |
|Jan – Feb 12 |Secure funding |Clinical Skills Development |Completed |
| | |Manager | |
| |Analysis Stakeholder’s view |Quality Education Manager/ |Ongoing |
| | |Equality & Involvement Lead/ PEF | |
|March 12 | Revise proposal to incorporate stakeholders views|Quality Education Manager, | |
| |and re-consult |Equality & Involvement lead/ PEF | |
|April/May 12 |Appointment of pharmacist and apprentice |Director of Pharmacy, Admin | |
| | |manager | |
| |Design content of teaching package, e- learning |Project Lead Pharmacist, | |
| |material |E-Learning Co-ordinator, clinical | |
| | |education teams, undergraduate | |
| | |teams, medical and nursing | |
| | |lecturers | |
|Jun/July 12 |Plan logistic of education sessions – room |PEF’s, Education Administration | |
| |bookings, facilitators, equipment |staff | |
|Sept 12 |Consolidate and finalise teaching material |Project Lead Pharmacist | |
|Oct 12 |Validate course material with HEI’s, Review |Project Lead Pharmacist | |
| |teaching material | | |
| |Confirm room bookings and facilitators |PEF’s, CLT’s | |
| |availability | | |
|Nov 12 |Finalise no. of students from both cohorts and |PEF’s, CLT’s | |
| |allocate to “home groups” | | |
| |Students informed of process as part of course |HEI Course Leads | |
|Dec 12 |Upload teaching material upon HEI’s learning |E-Learning Co-ordinator | |
| |environments | | |
| |Students given pre- course reading and information|HEI Course leads | |
|Jan 12 |First co-hort of combined medical and nursing |Teaching Team | |
| |students to commence training package during first| | |
| |clinical placement. | | |
|Feb 12 |Continuum phase to commence |ALL | |

References

Balogun (2001) Strategic Change. Management Quarterly Part 10 Faculty of Finance and Management.

Balogun & Hope Hailey (1999) Exploring Strategic Change. Prentice Hall

BMA (2006) Reporting Adverse Drug Reactions: a guide for healthcare professionals. London, British Medical Association.

Brooks & Brooks (1994) In search of understanding the case for Constructivist Classrooms. ASCD. USA.

Burgoyne (1999) Developing yourself, your career and your organisation. Lemos and Crane

Burnes (2009) Managing Change 5th Ed. Prentice Hall.

CAIPE 2002 Defining IPE http://www.caipe.org.uk/about-us/defining-ipe/ (accessed 29/12/11 – 11.50)

DoH (Sept 2011) Proposed NHS Educational Outcomes Framework, London, Department of Health

DoH (2011) Changing the way we plan training for health care staff, London, Department of Health

DoH (2003) The Victoria Climbe Inquiry, London, Department of Health

Edwards & Aronson (2000) Adverse Drug reactions: definition, diagnosis and management. Lancet . 2000 Oct 7;356(9237):1255-9.

Freeth et al 2005 Effective Interprofessional Education: Development, delivery and Implementation. CAIPE. Blackwell publishing, Oxford.

Frey & Osterloh (2002) Successful management by motivation: Balancing intrinsic and extrinsic incentives. Swiss Association for Organisation & Management. Springer- Verlag. Berlin.

GMC (2008) The prevalence and incidence of prescribing errors: Systematic Review
Report to The General Medical Council http://www.pharmacy.manchester.ac.uk/cip/CIPPublications/commissionedreports/prescribing_errors_prevalence_incidence.pdf (accessed 15/11/2011 15.15)

GMC (2009) An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education - EQUIP study

http://www.gmc-uk.org/about/research/research_commissioned_4.asp (accessed 14/11/11 14.10)

Honey and Mumford (1986) Using Your Learning styles. Peter Honey. Maidenhead. In:- Mohanna et al (2000)

Kieve (2007) (1) Falling on deaf ears. New Scientist.24. 15 Sept 2007

Kieve (2007) (2) Adverse Drug reactions (ADRs): a patient perspective on assessment and prevention in primary care. Quality in Primary Care; 15:221-7

Leavitt, H. J. (1964). Applied organizational change in industry: structural, technical and human approaches. In W.W. Cooper, H.J. Leavitt and M.W. Shelly II (eds), New Perspectives in Organization Research. Wiley, New York.

Lewin (1951) Field Theory in Social Science, Harper

Lupton (1971) Organizational Change: ‘top-down’ or ‘bottom-up’ management? Personnel Review, Autumn, pp.22-28.

Mohanna et al (2000) Teaching Made Easy – A manual for Health professionals. Radcliffe

Mosby Medical Dictionary 8th Edition 2009 Elsevier

Medical School Council 2008 Outcomes of the Medical Schools Council Safe Prescribing Working Group http://www.medschools.ac.uk/AboutUs/Projects/Documents/Outcomes%20of%20the%20Medical%20Schools%20Council%20Safe%20Prescribing%20Working%20Group.pdf (accessed 29/12/11 12.50)

NHSIII (2011) LIP’s Shaping the Future. http://www.institute.nhs.uk/images/documents/SaferCare/NHSI_LIPS_Shaping_the_future_indd.pdf accessed 05/01/2012 15.30)

National Nursing Research Unit (2009) Preceptorship for newly qualified nurses: impacts, facilitators and constraints, Kings College London http://www.kcl.ac.uk/content/1/c6/05/06/70/PreceptorshipReview.pdf (accessed 15/11/11 15.00

Parkin 2009 Managing Change in Health Care –using action research. SAGE London

Paton & McCalman 2008 Change Management – A guide to effective implementation. 3rd ed. SAGE.

Pirmohamed et al 2004 Adverse Drug reaction as a cause of admission to hospital: a prospective analysis of 18820 patients. British Medical Journal 2004 329:15-19 http://www.bmj.com/content/329/7456/15.full (accessed 29/12/11 12.45)

Ross et al (2000) Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 2000;83:492–497. http://adc.bmj.com/content/83/6/492.full.pdf (accessed 05/02/2012 14.52)

Varvasovszy & Brugha (2000) How to do (and not to do)… Stakeholder analysis. Health Policy planning: 15(3):338-345 http://arkangelo.org/Leprosy%20training%20manual/Session%206/health%20policy%20and%20planning%20stakeholder%20analysis.pdf (accessed 12/01/12 09.05)

Whitehead & Holmes (2011) Are newly qualified nurses prepared for Practice – Nursing times May 17-30;107(19-20):20-

Young and Patterson (2007) Teaching Nursing – Developing a student centred learning environment. Lippincott Williams and Wilkins. Philadelphia

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UNFREEZE

The majority of medication errors are caused by newly qualified health professionals, which has identified a training issues and the opportunity for inter-professional learning

CHANGE

Develop a three year training programme for student nurses and doctors designed specifically around medications

RE-FREEZE

A reduction in medication errors within the trust.

Pre-Plan

Build the Team

Tools for Analysis

PESTLE

SWOT

Strategy

SMART objectives

Budget

Goals

Time frame work

Skill mix

Roles

Communicate – vision, rational,

Consult – stakeholder analysis

Collaborate – team building, participation

Co-ordinate – lead, inspire,, motivate

Re-plan

Trouble shoot

Achieve Solutions

Evaluate

Lessons learned

Develop Team

Technology – Audio Visual equipment, eBNF. E-learning material. Teaching facilities – lecturer hall, clinical skill labs

Structure – pre- course information, reading lists , taught elements, practical assessment , evaluation

People - students /facilitator ratio, identify HEI and clinical staff / key stakeholders

Task – Interprofessional learning between nursing and medical students