Measuring Improvement: Using metrics and data to evaluate seven day services
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The document discusses the implementation and evaluation of seven-day services in NHS North West London, focusing on improving patient care through metrics and data. Aims include ensuring timely consultant reviews, daily evaluations of inpatients, and overall compliance with care standards, with ongoing pilots to test new models of care. Additionally, NHS Digital's report highlights issues related to patient outcomes based on admission timing, emphasizing the need for continuous improvement in service delivery.
Measuring Improvement: Using metrics and data to evaluate seven day services
- 1. www.england.nhs.uk Discussion slides only Measuring Improvement: Using metrics and data to evaluate seven day services Welcome we will begin at 13.00 06 December 2016
- 2. www.england.nhs.uk Agenda • Welcome Rhuari Pike, Programme Lead - Seven Day Services, London NHS England Sustainable Improvement Team • North West London Collaboration of CCG’s In-patient Model of Care Rachel Tustin Assistant Director – 7 Day Services, Strategy and Transformation Team Xiao Cai – Implementation lead, Inpatient Model of Care NHS North West London Collaboration of Clinical Commissioning Groups • Northern Devonshire NHS Trust on mortality and near miss reviews and how this led to developing their plan for improvement Dr. George Thomson Medical Director & Consultant Endocrinologist, Northern Devon Healthcare NHS Trust • NHS Digital will discuss their report into seven-day service provision across the NHS Chris Dew Information Analysis Lead Manager NHS Digital Sally Harrison Analytical Section Head Clinical Indicators • Questions and Discussion • Summary
- 3. Measuring the impact NW London – Seven Day Services Inpatient Model of Care Pilots The challenge MetricsOur solution LearningsContext AGENDA Rachel Tustin – Assistant Director, Seven Day Services Xiao Cai – Implementation lead, Inpatient Model of Care
- 4. Over 2 million people Over £4bn annual health and care spend 4 acute trusts 10 acute and specialist hospitals 4 8 local boroughs 8 CCGs and Local Authorities Over 400 GP practices 2 mental health trusts 2 community health trusts NW London is a National Seven Day Services First Wave Delivery Site Standard 2: Time to Consultant Review – ensure all admitted patients are seen by a consultant within 14 hours of admission. Standard 8: On-going Review – ensure all inpatients are reviewed daily by a consultant, and are seen twice a day if acutely unwell. 78% compliant 69% compliant in AMU, ASU, ITU & ICU 45% compliant in downstream wards NW London in context
- 5. The Challenge 5 Our ambition is to be 90%+ compliant in 2017. Modelling has shown that if we extended status quo from five to seven days, we will need an additional 171 consultants in NW London. Timeline Financial climate Workforce Evidence- base
- 6. Solution designed by our clinicians 6 New model of care – using a formal patient categorisation system to target our workforce at the right cohorts of patients.
- 7. Building an evidence-base through pilots 7 • 6x pilots in medical and surgical specialties • What does an ideal 7 day model look like and how does it impact on outcomes? Example: pilot on an acute care of the elderly ward:
- 8. Designing metrics with core principles in mind 8 1. Focus clinical outcomes: Designed by our senior clinicians, with input from our academic partners and patients 2. Use existing datasets wherever possible 3. This is not research, it’s practical quality improvement 4. Some things can’t be measured using metrics, don’t forget the narrative • 1. Define the desired clinical, patient and staff outcomes Outcomes • 2. Identify changes in process during the pilots that contributed to the outcome Process • 3. Measure the changes in workforce or financial inputs during the pilots Input
- 9. “Why are we collecting this?” 9 Mortality Outcome Length of stay Patient experience Staff experience Emergency readmissions HDU/ICU admissions Falls Pressure ulcers VTE Catheter associated UTI Length Of Stay Hypothesis With improved consultant cover and MDT input 7 days a week, quicker and better decisions will be made, more effective treatment will be provided, deterioration will be better managed and the patient will recover quicker, and be discharged sooner. In addition, increased consultant availability will result in better leadership of care team, and more focussed care, in turn leading to quicker treatment and recovery and reduced LoS Details of measure Date and time patient admitted to ward Date and time patient leaves ward (discharged or transferred) Date and time patient admitted to hospital Date and time patient leaves hospital (discharged or transferred) Los = Leave time - Arrive time Measure of success Reduction in lengths of stay (specialty specific targets) Comment LoS is also affected by other factors, such as suitable post-discharge care being available which is outside the scope of these pilots. Other measures such as time declared ready for discharge will be used to unpick these constraints in the system. Mortality Patient experience Staff experience Emergency readmissions HDU/ICU admissions Falls Pressure ulcers VTE Catheter associated UTI
- 10. Reverse engineering 10 Mortality Outcome InputProcess Length of stay Patient experience Staff experience Emergency readmissions HDU/ICU admissions Falls Pressure ulcers VTE Catheter associated UTI Patient categorisation Time and date of review NEWS calls Diagnostics measures Discharge measures Therapy hrs on ward Consultant hrs on ward Designation of reviewer Cost Initial EDD & changes Date medically fit Date functionally fit Radiology Pharmacy
- 11. Patient experience matters 11 Mortality Outcome Length of stay Patient experience Staff experience Emergency readmissions HDU/ICU admissions Falls Pressure ulcers VTE Catheter associated UTI Mortality Emergency readmissions HDU/ICU admissions Falls Pressure ulcers VTE Catheter associated UTI Length of stay PLUS • Friends and family test • Exit questionnaire Staff experience Experience based design
- 12. What have we learned so far? 12 Go back to first principles - Focus on the clinical outcomes1 Ensure the whole process is clinically driven - With input from patients and academic partners2 Rapid PDSA - Tweak and refine… very rapidly3 Invest in the data collection - If you want good data4
- 13. Contacts 13 Rachel Tustin – Assistant Director, Seven Day Services Email: Rachel.Tustin@nw.london.nhs.uk Phone: 020 3350 4895 Xiao Cai – Implementation lead, Inpatient Model of Care, Seven Day Services Email: Xiao.Cai@nw.london.nhs.uk Phone: 020 3350 4685
- 14. Developing 7 Day Services 14 Lessons learned through use of quality improvement methodology George Thomson Consultant Endocrinologist Executive Medical Director
- 15. Institute for Health Improvement Quality Improvement method • NDHT uses the IHI Model for Improvement as the framework to guide improvement work • Improvement requires setting aims. An organization will not improve without a clear and firm intention to do so • Measurement is critical to testing and implementing changes; measures tell a team whether the changes they are making actually lead to improvement. • All changes do not lead to improvement, but all improvement requires change. The ability to develop, test, and implement changes is essential for any individual, group, or organization that wants to continuously improve. • The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change — by planning it, trying it, observing the results, and acting on what is learned. • Spread is the process of taking a successful implementation process from a pilot unit or pilot population and replicating that change or package of changes in other parts of the organization or other organizations. 15
- 16. What are we trying to accomplish 16 Improvement from initial 7 day service audit: • Daily consultant review – Weekday -27% – Saturday - 6.7% – Sunday - 10% • Twice daily consultant review – Weekday - 2% – Saturday – 0% – Sunday – 10%
- 17. How have we done this? Reducing HSMR was a key step HSMR NEL admissions – 69/136 acute trusts
- 18. How have we done this? Reducing HSMR was a key step HSMR Elective admissions – 130/136 acute trusts
- 19. Analysis of cardiac dysrhythmia deaths suggests medical record keeping is the issue where arrythmia is secondary to primary cause….. Age 92 83 87 92 58 75 94 74 84 89 78 90 93 89 89 89 74 88 Diagnosis ICD10 I48X Atrial fibrillation and flutter I48X Atrial fibrillation and flutter I48X Atrial fibrillation and flutter I48X Atrial fibrillation and flutter I472 Ventricular tachycardia I48X Atrial fibrillation and flutter I48X Atrial fibrillation and flutter I472 Ventricular tachycardia I48X Atrial fibrillation and flutter I48X Atrial fibrillation and flutter I472 Ventricular tachycardia I48X Atrial fibrillation and flutter I48X Atrial fibrillation and flutter I472 Ventricular tachycardia I472 Ventricular tachycardia I472 Ventricular tachycardia I48X Atrial fibrillation and flutter I495 Sick sinus syndrome DW Coding CODING CORRECT AS REPATRIATION FOLLOWING PPM FOR AF CLINICAL IMPRESSION - CONTINUED DETERIORATION FOLLOWING PPM - 10 DAYS IN RD&E - TRANSFERRED FOR REHAB RE-CODED AS PNEUMONIA / UTI 16/06/2016 RE-CODED AS HEART FAILURE 16/06/2016 RE-CODED AS CONGESTIVE HEART FAILURE 16/06/2016 CODED CORRECTLY AS PER DOCUMENTATION - CANNOT USE ? SECONDARY TO INFECTION AS DIAGNOSIS HAS TO BE PRESUMED / TREATED INFECTION CODED CORRECTLY AS PER DOCUMENTATION - CANNOT USE ? SECONDARY / LIKELY CVE/TIA AS DIAGNOSIS CVE NEVER DOCUMENTED AS PROBABLE / PRESUMED / TREATED CODED AS REPATRIATION FOLLOWING PPM FOR PAF CLINICAL IMPRESSION - ORIGINAL ADMISSION #NOF DUE TO PAF (PAUSES OF 6 SEC) - SENT FOR PPM - ON RETURN PROBABLE INTERCRANIAL BLEED DUE TO ANTI COAGULATION CODED CORRECTLY AS PER DOCUMENTATION ? AORTIC STENOSIS WITH SYNCOPE - af CLINICAL IMPRESSION - LONSTANDING AF, WORSENING AORTIC STENOSIS - CONFIRMED ON ECHO IN SECOND EPISODE - NOT INCLUDED IN DR FOSTER DATA CODED CORRECTLY AS PER DOCUMENTATION - VT SECONDARY TO ? NSTEMI CLINICAL IMPRESSION - RUN OF VT ON ADMISSION FURTHER VT - UNRESPONSIVE TO DRUGS & DCC -DIED NFR / TEP IN PLACE CODED CORRECTLY AS PER DOCUMENTATION - AF WITH HEART FAILURE, & RECENT URTI CLINICAL IMPRESSION - TREATED FOR CAP ABX GIVEN BUT NOT DOCUMENTED AS PRIMARY DX CODED CORRECTLY AS PER DOCUMENTATION - AF WITH CONSTIPATION CLINICAL IMPRESSION - LONG STANDING AF NORMALLY RATE CONTROLLED WARFARIN STOPPED PREVIOS DAY DUE TO HIGH INR.
- 20. Improving H&SC community offer 20 Close partnership working across health and social care has improved admission avoidance, 7/7 discharge (RIC and pathfinder discharge to assess)
- 21. Improving H&SC community offer 2130% bed reduction but maintained acute performance
- 22. LOS Monitoring & Progress In 2016-17 thus far there have been; 23 weeks where +10 & +14 Day LOS is below the previous year 8 weeks where +10 & +14 Day LOS has been above the previous year Further analysis is required to understand LOS bed occupancy and configuration trajectory options/targets for the remainder of 2016-17 and 17-18. 22 This KPI continues to show general improvement
- 23. Key Work-streams FLOW DISCHARGE 23 Improve Time of Day discharge Change Time of Day ward rounds and frequency Clinical Site Manager Role to be Revised Ward Board Reviews Planned Date of Discharge & Estimated Date of Discharge improvements Ward based ‘Pull’ from A&E Medical Outliers Standard Operating Procedure 7 Day services preparedness Speciality Interface post Transforming Emergency Care Plan (TEC) Pre-Emptive ward transfers at height of escalation Medical Staff Handover Escalation policy revised Medical Expected pathway as per TEC Plan Surgical Capacity Plan as part of TEC Optimise Physician Of the Day process FLOW DISCHARGE These actions are already established as a key component of the Patient Flow Plan and will be re-visited as part of the 16-17 Delivery Plan
- 24. Patient Flow - current ED D I S C H A R G E Walk-in Ambulance 999 GP Expected Own transport/ Ambulance MAU clinic/bed Pathfinder ASU Surgery Med Ward The current patient flow model results in bottlenecks within the ED department and impacts on patient experience and A&E performance. 24
- 25. Patient Flow – proposed v1.1 ED D I S C H A R G E Walk-in Ambulance 999 GP Expected Own transport Surgery MAU/Admission GP Expected Ambulance Assess & Treat Area CDU • Pathfinder inc. Social Care • MAU Clinic • TIA Clinic • Acute Oncology Service • Frailty Service • Day Treatment Unit • Fluids • Bloods • Procedures : Drains/Aspirations/Urodynamics • ?TWOC ASU Treatment • ODs • Head Injury • Tropanins The new patient flow proposal will utilise all of the H&SC capability that the Trust has Ambulatory surgical /medical & Frailty assessment will be established 25
- 26. 26 Transforming Emergency Care – patient flow (proposed) v1.2 The Integrated Unscheduled Care Division has established a Task and Finish Group and Project Group to ensure the programme plan is delivered. Monitoring of this will be via the Clinical Services Executive Committee (CSEC)
- 27. Executive Oversight Medicine • MD sign off is required for revised admitted and non admitted pathways • MD oversight of plans to ensure they compliment variable pay objectives • MD to agree QA process and EQIA if required • MD to support AMD with 8 week plan • MD to provide external interface with partners where required Nursing • ND to lead process and sign off for revised roles/responsibilities for Nursing • ND to lead development of the CH residual bed model • ND to agree patient experience and quality indicators required • ND to ensure QA process is in place and EQIA if required • ND to ensure variable pay objectives aren’t negatively impacted • ND to provide professional interface with partners external Ops • DoO to ensure robust monitoring of programme compliance • DoO to take corrective action where required • DoO to act as responsible Director for overall programme of work • DoO to provide weekly update to CEO via CSEC • DoO to provide external /internal assurance re performance impact 27
- 28. % patients receiving one review per day by a Consultant 27% 94% 6.70% 78% 10% 62% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Mar-16 Sep-16 Mar-16 Sep-16 Mar-16 Sep-16 Weekday Saturday Sunday
- 29. % of patients receiving twice daily review 2 62 0 22 13 18 0 10 20 30 40 50 60 70 Mar-16 Sep-16 Mar-16 Sep-16 Mar-16 Sep-16 Weekday Saturday Sunday
- 30. Some of our next steps Prospective audit of all medical GP referrals • What could we have done differently to improve the patients journey? • How can we reduce the number of patients with exacerbations of chronic conditions being referred into the medical assessment unit? Increasing capacity in the medical assessment clinic / ambulatory care • Can we proactively take patients out of ED into ambulatory care? • Can we safely widen our cohort of patients attending ambulatory care rather than ED? • Can we provide better advice and guidance to our primary care colleagues to help support patients at home? Prospective audit of medical patients attending emergency department • What has made the patient attend ED rather than seek advice elsewhere? • Can we stream these patients from ED to an alternative HCP/service more suitable to their needs? Planned “breaking the cycle” week to review if recommended changes will make a difference to patient outcomes. Planned “perfect week” with primary care / rapid intervention teams.
- 31. Seven-day Services Experimental statistics Chris Dew, NHS Digital, December 2016
- 32. NHS Digital’s role in Seven-day Services NHS Digital commissioned by DH to develop a suite of indicators to measure activity in hospitals covering: • mortality • emergency readmissions • length of stay 32
- 33. October 26 Publication 33 Experimental statistics published including: Mortality within 30 days of admission by week-part of admission to hospital Emergency readmissions within seven days of discharge from hospital by day of discharge Length of stay following an emergency admission to hospital by day of admission
- 34. National findings 2015-16 34 Mortality • Patients admitted at the weekend had an increased likelihood of mortality within 30 days of admission compared to those admitted midweek Readmissions • Patients discharged on Friday, Saturday and Sunday had an increased likelihood of an emergency readmission within seven days of discharge compared to those discharged on a Wednesday Length of Stay • Patients admitted in an emergency stayed slightly longer in hospital if they were admitted between Friday and Sunday
- 35. Trust level findings 2015-16 Odds ratio Lower CI limit Upper CI limit Over- dispersed z- score Gateshead Health NHS Foundation Trust 1.15 1.01 1.32 0.06 George Eliot Hospital NHS Trust 1.22 1.03 1.45 0.72 Gloucestershire Hospitals NHS Foundation Trust 1.31 1.19 1.45 2.70 Great Western Hospitals NHS Foundation Trust 1.24 1.09 1.40 1.21 Guy’s and St Thomas’ NHS Foundation Trust 1.04 0.93 1.16 -1.72 Hampshire Hospitals NHS Foundation Trust 1.11 0.98 1.26 -0.49 Harrogate and District NHS Foundation Trust 1.25 1.05 1.49 0.94 Heart of England NHS Foundation Trust 1.16 1.08 1.24 0.21 Hinchingbrooke Health Care NHS Trust 1.23 1.02 1.47 0.72 35
- 36. Trust level findings 2015-16 Odds ratio Lower CI limit Upper CI limit Over- dispersed z- score Gateshead Health NHS Foundation Trust 1.15 1.01 1.32 0.06 George Eliot Hospital NHS Trust 1.22 1.03 1.45 0.72 Gloucestershire Hospitals NHS Foundation Trust 1.31 1.19 1.45 2.70 Great Western Hospitals NHS Foundation Trust 1.24 1.09 1.40 1.21 Guy’s and St Thomas’ NHS Foundation Trust 1.04 0.93 1.16 -1.72 Hampshire Hospitals NHS Foundation Trust 1.11 0.98 1.26 -0.49 Harrogate and District NHS Foundation Trust 1.25 1.05 1.49 0.94 Heart of England NHS Foundation Trust 1.16 1.08 1.24 0.21 Hinchingbrooke Health Care NHS Trust 1.23 1.02 1.47 0.72 36
- 37. Trust level findings 2015-16 Odds ratio Lower CI limit Upper CI limit Over- dispersed z- score Gateshead Health NHS Foundation Trust 1.15 1.01 1.32 0.06 George Eliot Hospital NHS Trust 1.22 1.03 1.45 0.72 Gloucestershire Hospitals NHS Foundation Trust 1.31 1.19 1.45 2.70 Great Western Hospitals NHS Foundation Trust 1.24 1.09 1.40 1.21 Guy’s and St Thomas’ NHS Foundation Trust 1.04 0.93 1.16 -1.72 Hampshire Hospitals NHS Foundation Trust 1.11 0.98 1.26 -0.49 Harrogate and District NHS Foundation Trust 1.25 1.05 1.49 0.94 Heart of England NHS Foundation Trust 1.16 1.08 1.24 0.21 Hinchingbrooke Health Care NHS Trust 1.23 1.02 1.47 0.72 37
- 38. Trust level findings 2015-16 Odds ratio Lower CI limit Upper CI limit Over- dispersed z- score Gateshead Health NHS Foundation Trust 1.15 1.01 1.32 0.06 George Eliot Hospital NHS Trust 1.22 1.03 1.45 0.72 Gloucestershire Hospitals NHS Foundation Trust 1.31 1.19 1.45 2.70 Great Western Hospitals NHS Foundation Trust 1.24 1.09 1.40 1.21 Guy’s and St Thomas’ NHS Foundation Trust 1.04 0.93 1.16 -1.72 Hampshire Hospitals NHS Foundation Trust 1.11 0.98 1.26 -0.49 Harrogate and District NHS Foundation Trust 1.25 1.05 1.49 0.94 Heart of England NHS Foundation Trust 1.16 1.08 1.24 0.21 Hinchingbrooke Health Care NHS Trust 1.23 1.02 1.47 0.72 38
- 39. Feedback There are many possible explanations for the variation shown in the data including: • differences in the case-mix of patients (over and above that accounted for in the analysis) • patient behaviour • provision of services both in and outside of the hospital (including social care) NHS Digital welcome feedback on using these statistics 39
- 40. Discussion 40
- 42. www.england.nhs.uk Discussion & Summary • Let us know if you have any work you would like to share • or if there are other topics you are interested in Email: england.si-7ds-support@nhs.net
- 43. www.england.nhs.uk The next seven day services webinar: ‘Workforce and Delivering Seven Day Services’ • Tuesday 17th January 2017 • This webinar will explore how the use of enhanced roles can help trusts in the delivery of seven day services, and aims to help understand the practical issues associated with developing enhanced roles and implementing these into their organisations. To register interest email: england.si-7ds-support@nhs.net