measuring improvement: using metrics and data to evaluate seven day services

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

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

Measuring the impact NW London – Seven Day Services

Inpatient Model of Care Pilots

The challenge Metrics Our solution Learnings Context

AGENDA

Rachel Tustin – Assistant Director, Seven Day Services

Xiao Cai – Implementation lead, Inpatient Model of Care

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

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

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.

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:

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

“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


HDU/ICU admissions

Falls

Pressure ulcers

VTE


Reverse engineering

10

Mortality

Outcome Input Process

Length of stay

Patient experience

Staff experience


HDU/ICU admissions

Falls

Pressure ulcers

VTE


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

Patient experience matters

11

Mortality

Outcome

Length of stay

Patient experience

Staff experience


HDU/ICU admissions

Falls

Pressure ulcers

VTE


Mortality


HDU/ICU admissions

Falls

Pressure ulcers

VTE


Length of stay

PLUS • Friends and family test • Exit questionnaire

Staff experience

Experience based design

What have we learned so far?

12

Go back to first principles

- Focus on the clinical outcomes

1

Ensure the whole process is clinically driven

- With input from patients and academic partners 2

Rapid PDSA

- Tweak and refine… very rapidly 3

Invest in the data collection

- If you want good data 4

Contacts

13

Rachel Tustin – Assistant Director, Seven Day Services

Email: [email protected]

Phone: 020 3350 4895

Xiao Cai – Implementation lead, Inpatient Model of Care, Seven Day Services


Phone: 020 3350 4685

mailto:[email protected]


Developing 7 Day Services

14

Lessons learned through use of quality improvement methodology

George Thomson

Consultant Endocrinologist

Executive Medical Director

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

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%

How have we done this?

Reducing HSMR was a key step HSMR NEL admissions – 69/136 acute trusts

How have we done this?

Reducing HSMR was a key step

HSMR Elective admissions – 130/136 acute trusts

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




I472 Ventricular tachycardia













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.

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)

Improving H&SC community offer

21 30% bed reduction but maintained acute performance

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

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

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

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

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)

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

% 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

% 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

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.

Seven-day Services

Experimental statistics

Chris Dew,

NHS Digital, December 2016

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

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

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

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





Gloucestershire Hospitals NHS Foundation Trust

1.31 1.19 1.45 2.70







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

https://www.surveymonkey.co.uk/r/seven_day_services_2016

Discussion

40

www.digital.nhs.uk

@nhsdigital

[email protected]

0300 303 5678

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Discussion & Summary

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• or if there are other topics you are interested in







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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:

[email protected]




