Table 3

Analysis of GP-based pharmacist work system

A health board employed pharmacist had been working at a GP practice for 2 months. She worked in the practice in the mornings and at a neighbouring practice in the afternoons. One task she completed was reconciling medication changes after hospital discharge which was previously undertaken by GPs. Their introduction had not had the desired impact and a meeting was held between relevant parties who used the STEW principles to reach a shared understanding of the system and design system improvements.
PrincipleApplication of principle to the issue
Foundation conceptPurpose of system
  • They agreed that the purpose was to reduce GP workload and increase the quality of prescribing by improving safety and effectiveness of prescribed medication and reducing costs and waste.


Agree boundaries
  • They agreed to consider the practice and their patients and the effects on linked systems such as community pharmacy and secondary care.

Seek multiple perspectivesPractice-based pharmacist
  • Trained to follow the protocol and felt their role was predominantly to ensure there was no harm from prescribed medication.

  • Often contacted secondary care to determine if medication that was not included on the list of discharge medications was meant to be stopped or if it had been missed unintentionally.

  • Felt a pressure from GP practice to complete work quickly and from local pharmacy leads to make cost saving switches.


GPs
  • Felt that unnecessary work was created. For example, adding new medications to prescribing list for a limited time period. This results in a review being needed at the end of this time.


GP administrative staff (including the practice manage)
  • Were able to ask the pharmacist to address community pharmacy or secondary care queries pharmacist more easily than a GP as they were not with patients. This reduced stress experienced by the admin team. However, processing was delayed resulting in complaints from patients to the administrative staff.


Patient representative
  • Liked having access to the pharmacist to discuss medication problems after discharge but also had heard of delays for fellow patients.


Community pharmacists
  • Felt it was beneficial to be able to contact pharmacist and discuss queries about medication—access was much easier than if they had to speak to a GP.


Local pharmacy clinical lead
  • Noted a reduction in ‘cost savings work’ and formulary compliance—fewer medications had been changed to those recommended locally based on efficacy and cost.


Secondary care representative (a pharmacist who was usually based on an acute medical ward)
  • Noted a large volume of telephone calls from GP practice-based pharmacists regarding queries about discharge letters.

Consider work conditionsDemand/capacity
  • Local protocols stated that medication reconciliation should be completed within 7 days. On Mondays there were always more discharge letters than on other days but there were also a larger number of other prescribing tasks that required to be processed within a shorter time frame.


Resources
  • Practice-based pharmacists spent a lot of time telephoning hospital colleagues to clarify medication changes. The secondary care pharmacist explained that the hospital electronic prescribing system could provide this information.


Constraints
  • Information was often missing from immediate discharge letters from hospital, such as medications that patients usually took were not included on the discharge list and no reason for stopping them was included.

  • Protocols for completion of medication reconciliation were very prescriptive, stating when pharmacists should seek extra information about prescribing tasks (such as ‘missing’ medication). They also stated that once changes are made these should always be discussed with the patient or carer.


Leading indicators
  • The pharmacist recognised that certain situations were a higher risk and would take longer and had the potential to increase GP work if these were not processed accurately. These included:

    • Medication supplied by the community pharmacy in a compliance aid (a blister pack)—had to make sure the community pharmacy was aware of changes and old compliance aids were removed.

    • High-risk medications such as anticoagulants—pharmacists often recalculated to ensure correct doses suggested by hospital.

    • Medication reconciliation for patients in nursing homes—pharmacists had to ensure that they had correct medication as the nursing homes often phoned late on Fridays to ask for prescription items.

Analyse interactions and flowInteractions and flow
  • Telephoning secondary care increased workload in secondary care and slowed the process of completing tasks which meant there was a delay in some patients receiving their medication.

  • Contacting some patients seemed to increase confusion about medication regimes.

  • Interactions with community pharmacies were very useful to ensure changes were communicated and that the correct medications were supplied. Patients appreciated the GP practice and the community pharmacy communicating after discharge to ensure medications were correct.

  • The pharmacist found it difficult to find a GP with which to discuss prescribing problems. At the end of GP surgeries they often went out on visits just as the pharmacist had to leave for another practice.

Understand why decisions make sense at the time
  • Pharmacists added limits to the number of times medications could be issued as they wanted to make sure monitoring of medication took place.

  • Similarly, they contacted hospitals to check medication as they felt their goal was to reduce the chance of medication-related harm.

  • Pharmacists were worried that if they did not follow the protocol and a patient came to harm that they would be blamed. They had, however, begun to deviate from the protocol at times (see below).

Explore performance variabilityGPs and the pharmacist discussed the different ways they completed medication reconciliation and identified workarounds and trade-offs that would help achieve the goals of the system (reduced workload and increased quality).
  • For short admissions and those to certain specialties (eg, orthopaedics), medication changes were less likely and so if medication was missing from a discharge letter they presumed this was a mistake and did not check with secondary care.

  • Pharmacists realised that sometimes it was quicker to check with the patient if medication had been intentionally stopped while in hospital. The patient representative felt most patients would find this approach reasonable.

  • The pharmacist recognised the trade-off between reduction in workload and increasing quality. This meant they did not make changes to local recommendations in order to process more prescription tasks.

  • GP, general practitioner; STEW, Systems Thinking for Everyday Work.