Can we audit for exceptional consumer and carer experience

in Mental Health?

Monash University Seminar 2016

A/Prof Richard Newton, Medical DirectorMs Lindy Bennett, Quality Co-ordinator

Definition of Clinical Governance

“A framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”

Ref G. Scally and L.J Donaldson, Clinical governance and the drive for quality improvement in the NHS in England BMJ (4 July 1998)

Links to Clinical Effectiveness & Clinical Governance

At a local level clinical audit links into both clinical effectiveness and clinical governance:

• Clinical effectiveness aims to identify and appraise existing evidence of best practice. Once identified, audit can ensure that best practice (as defined) is being followed and that patient outcomes are the desired ones.

• Concerns regarding clinical care are often identified through other clinical governance structures which elicit consumer feedback, identify complaints, and review incidents – rich fodder for informing an audit project eg. provision and explanation of rights and responsibilities.

Feedback is Critical

Consumer experience data Jan – June 15

• Discharges 463, Surveys back 190,

• response rate 41%

How would you rate:

Good or excellent

Courtesy, respect and helpfulness of staff

97%

How much you were helped by your stay

93%

Would you recommend this hospital to others with mental health issues?

Yes 98%

No 2%

Review of Critical Incidents (CIRs) 2015

TYPE OF INCIDENT N %

Death cause unknown 4 27%

Death - natural causes 1 7%

Death - suicide 1 7%

Aggression 1 7%

Medication error 1 7%

Overdose 1 7%

Accidental self harm 2 12%

Accidental injury 1 7%

Attempted suicide 1 7%

Aggression 2 12%

Total 15 100YEAR CIRs

2014 61

2015 15CIRs can identify systems issues impacting on the consumer/carer experience which can be addressed, lead to practice changes which can be audited – eg. risk assessment processes, leave processes, impact of care

Benchmarking other ‘Like’ Services

Exceptional Experience?

Mental Health traditionally have struggled to agree on what should be the content of care.

• KPIs primarily process based

• NSMHS focus on processes around consumers and carers

• Funders focus on activities and demand management

Audits undertaken historically by the service had been piecemeal, lacking in consistency in approach, and were time consuming.

It reflected the struggle on determining what was important to audit .

What can a Clinical Audit contribute?

• Tangible evidence as to whether identified universal standards of care are being met - (those which are amenable to the audit process).

• However, a service-wide standard based audit needs to be supplemented by other activities such as:

» Local audits to address idiosyncratic requirements » Trigger tool methodology» Peer review» Criteria based audit

• Missing link is consumer carer driven audit criteria.

Step 1: Identifying what constitutes the “exceptional” experience

In last 12 months, new approach adopted:

Workshops held with staff , consumers and carers to unpack the term ‘exceptional experience’ and general consensus was it could be reflected in 4 domains of care :

1. Person centred 2. Safe3. Effective and appropriate 4. Integrated, continuous and accessible

These domains are also clearly reflected in the National Standards for Mental Health Services and the National Safety & Quality Health Service Standards

Step 2: Developing the audit tool

Audit process revised in14/15 to incorporate focus on those mental health standards which could be readily audited across all the disparate service components (such as provision and explanation of rights and responsibilities to both consumers and carers) .

Audit tool developed in consultation with key staff, consumer and carers. Comprised 37 questions (compared with past audit tool of 74!)

Tool tested across all service components.

LESSON 1

• “Time spent in reconnaissance is seldom wasted” (John Marsden – When the War Began)

• Be explicit about what you are trying to audit : consult with staff, consumers and carers

Translating into Practice: Some examples

Person centred:

Audit questions covered - Evidence of:

• Provision and explanation of rights and responsibilities

• Diversity needs identified - preferred language, indigenous status, religion

• Treatment plan has been developed in conjunction with consumer and where appropriate, carer

• Provision of treatment plan to consumers and where appropriate, carer

Safe Care: Audit Elements

• Risk assessment screen completed on admission and discharge

• Falls/pressure injury risk identified

• Handover

• Patient Identification

• Hand hygiene

Effective & Appropriate Care

• Current comprehensive treatment, care and recovery plan in place and current

• Evidence of collateral information collected from family/carer

• Evidence that carer/family needs have been assessed

Integrated, Continuous & Accessible Care

• GP details provided

• Consumer/carer actively involved in discharge/exit planning

• Provision of discharge summary to consumer and where appropriate carer

• Information in discharge summary on how to re-enter the service

Even then it can be Challenging!

• Do a dry run to see if questions make sense

• Ensure auditors are familiar with what they are auditing and where they can find evidence in the clinical record (eg Rights and responsibilities 0% on audit for compliance but staff maintain 100% compliance - but using checklist not scanned into medical record)

• Ensure auditors given some time/resources to undertake the audit

LESSON 2

• Good preparation is crucial for the success of an audit

Actioning the Results

1. Enter results into simple excel spreadsheet with formula to give visual representation

2. Distribute results back to teams ASAP

3. Celebrate the positives and identify shortcomings.

4. Develop actions plan

5. Apply the PDSA cycle

Summary Report

Improvements made following Audit

Studies show that the relative effectiveness of an audit is likely to be greater when baseline adherence to recommended practice is low and when feedback is carried out with greater intensity (Cochrane database system review 2006).

Focus your audit activities where results are poor , rather than continuing to audit for ‘reasonable ‘ adherence’ to practice standards (except for non-negotiables like patient ID).

Some examples…..

Person centred

25.9

39.8

19.0

37.5

0.0

10.0

20.0

30.0

40.0

50.0

2 (June 2013) 1 (March 2014)

Entry in RecordIndicatingConsumerProvided withWritten Statementof ConsumerRights

June 14 March 15

62.9

78.6

58.1

73.2

52.4

78.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

2 (June 2013) 1 (March 2014)

Documented evidence of carerengagement in the treatmentthat is to be delivered toconsumer (both voluntary andinvoluntary consumers)

Evidence of a carer/familymeeting within 1 month

Evidence that carer/familyneeds have been assessed

June 14 March 15

Safe: Patient ID

• 70 observational audits conducted across 7 areas of the CSU

• 6 inpatient units and one community based residential setting audited

• Medication administration was the selected intervention for auditing

• 40% ID checked with consumer, 19% using ID band, 41% with card/document/photograph.

Results

• All forms of ID methods utilised across the services demonstrated high compliance rates with requirement to identify and match the 3 approved patient identifiers

• 96% compliance with patients stating not confirming their details (should be 100%)

• 100% compliance with checking and matching name, UR and DOB via ID band option and photographic image option

Area for Improvement

• Staff ensuring that consumer states their details, not confirming details offered by staff member

Action Plan:

• Feedback results to all participating service components encouraging staff to maintain high compliance standards.

• Present findings at MHCSU Executive Committee and other relevant Quality Committees

Effective and Appropriate care

40.0

58.949.5

66.1

0.0

20.0

40.0

60.0

80.0

100.0

2 (June 2013) 1 (March 2014)

% with Recovery Plan(ISP) Current(Completed in Last 3Months)

% patients with Goalsin the Recovery Plan(ISP) are Congruentwith Areas Identifiedfor ChangeJune 14 March 15

32.4

42.9

31.4

42.0

32.4

44.6

05

10152025

3035404550

2 (June 2013) 1 (March 2014)

% where Consumer Provided Witha Copy of Treatment/ RecoveryPlan (ISP)

% of Evidence of CarerInvolvement in Development of theRecovery Plan (ISP)

% of Evidence that the Carer hasbeen Provided with the Informationabout the Benefits and Risks ofProposed Treatments/InterventionsJune 14 March 15

Integrated, Continuous and Accessible Care

67.677.7

61.066.1

34.340.2

0102030405060708090

100

Q2 (June 2013) Q1 (March 2014)

% with Name ofLocal DoctorCollected at Point ofEntry

% with ContactPhone Number ofDoctor Collected atPoint of Entry

% with Contact FaxNumber of DoctorCollected at Point ofEntryJune 14 March 15

62.1

68.2

17.2 14.8

62.1

77.3

0

10

20

30

40

50

60

70

80

90

100

2 (June 2013) 1 (March 2014)

Evidence that the carerhas been actively engagedin discharge planning

Evidence that thedischarge summary hasbeen provided to the carer,where applicable

Evidence of involvement ofAllied Health in dischargeplanning

June 14 March 15

Keep Audits on the Quality Agenda

Feedback of Results & Action

LESSON 3

How to get the most from your audit results

• Provide feedback of audit results in timely manner

• Identify areas of poor performance and implement focussed quality improvement activity

• Ensure clinical governance structures in place which will monitor action - agenda on both executive level and local quality committees – and sustain improvements

• Establish an audit calendar to keep staff on track

• Allow enough time between audit rounds for education that will inform practice improvements – 4-6 month cycle

Audit Calendar

Can we audit for exceptional Consumer/Carer experience?

• Consumer and carer involvement crucial to develop audits that might drive exceptional care

• We can use audit tools to track performance against explicit standards which underpin the exceptional consumer experience

• Clinical audit alone cannot determine whether the exceptional consumer and carer experience is being met but will continue to form an integral part of the suite of tools the mental health service utilises

• Clinical audit needs to be augmented by other activities often identified through other clinical governance structures to ensure a rich and comprehensive approach