Our Experience

09/10/2012

Tracy Walker Clinical Lead Stroke Lancashire care foundation trust

Measuring Performance in a Community Stroke Service

Why do we need to evidence our stroke service performance?

Ensuring Quality, Effectiveness and Satisfaction: “Quality Assurance”

For supporting evidence of meeting commissioning performance indicators and re commissioning

To ensure we are providing the a quality service to our patients

To build evidence to inform the national picture (SIP) around models and outcomes

To highlight current pathway for stroke pts or inequity in service provision

To inform research questions of the future To use data as a living source to influence our practice 

Areas of Performance Measurement in BWD Stroke Service

Improvements in patient pathway or journey: Length of stay, how many people return home, how many pts go into rehabilitation beds, re admission rates.  Monthly

Monthly contract monitoring: contacts, referrals, DNA and discharges.

Quarterly CQUIN and Schedule 3 quality targets: QOL, NICE 72 hr, access to psychological therapies, re admissions for stroke.

Patient Outcomes and cost savings:  Yearly reports on detailed profile of pts accessing service, pathways used, length of stay, place at discharge, average change in Barthel, NEADL, MAS, work out care hours saved using Barthel dependency hours change, workforce and interventions provided per professional group.

Yearly benchmarking of standards of practice against our model

Evidencing we are improving the patient pathway More people returning home Length of stay split acute/rehab

Percentage of patients discharged to normal place of residence post stroke

5664

5971

01020304050607080

2006-2007 2007-2008 2008-2009 2009-2010

year

% o

f pat

ient

s 2006-20072007-20082008-20092009-2010

Acute and rehab average length of stay for stroke

29.09 27.38

17.49 18.51 16.7912.55 13.25 11.5

37.47 37.62 36.05

05

10152025303540

2005-2006

2006-2007

2007-2008

2008-2009

2009-2010

year

days

Total ave LOS

Acute LOS

Rehab LOSPendle/BGH

Monthly length of stay informationLenght of stay for BWD Stroke Patients Jan 2011- Jan 2012

8.4

39.6

6.6 5.9

1819.8

32.5

24.5

18.6

12.9

22.9

28

19.75

6.1

13.1

6.43.4

5.77.5

11.8

5.37.5

3.9

8.86.6 7.41

15.5

50.2

9

14.3

41 41.8

35 36.3

29.7

34

42.3

36.7

32.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

ja nuary

march

may ju ly

september

december

Total

Month of year

Bed

day

s

Total

Acute

Rehab

monthly hospital reporting

Patients admitted with stroke 01/04/2011 to 31/03/2012

Ensuring we are meeting contractual requirements

Evidencing our impact on patient outcomes/Cost savings

Important to measure change in function and ability in activities of daily living.

This ensures quality and impact of team.

Figures illustrate the positive impact of rehabilitation post stroke.

11

8 89

0

2

4

6

8

10

12

MBI Nott ADL MAS Berg Balance

Changes in Patient Related Outcome MeasureAverage change post team intervention

Evidence of improvement in more severe patients

Stroke dependency level change

9 4 1 6 2 3 5 2

18 121 1

97

1

3724

0

20

40

60

80

100

120

num

ber o

f pts

Impact of reducing dependency levels

Reduction in dependency post team intervention reduces help needed.

Saving yearly of 12,480 of care hours needed to support stroke survivors in activities of daily living

Saving could be financial or time  provided by family or local authority.

£7.50 hr for carer = £93,600 per year saving.

0

69

0

7

100

52.5

0

7 4.5

0

0

10

20

30

40

50

60

70

80

90

100

1

dependency level change

Reduction in care needed in hours per week post team input

Mild - mild

Mild - minimal

Minimal - minimal

Moderate - mild

Moderate - minimal

Severe - mild

Severe - severe

Total - moderate

Total - severe

Total - total

Hours savedPer weekTotal: 240 (143 cases)

Start End Variance

Care package: average weekly cost £423 £152 (£271)

Depression score 39 41 2

Carer score 40 39 (1)

Outcome Measures - Results

Streamlining our data collection and influencing commissioning data requirements

Problem Team are collecting data on changes in outcome measure: not linked to CQUIN/Schedule 3

Performance indicators on service specs

National ASI/NICE/SSNAP Not always streamlined and masses of data to collect

Clinicians have specialist knowledge to feed into development of local targets and are often not involved.

Lack of robust databases

Solutions Try  to combine national and local measures

Lead clinicians push to influence selection of local targets.

Development of stroke database Look to the horizon for national measure needed and implement: MRS 6 months.

Commissioning is not as specialist as you! Offer them advice/feedback

Using Our Models/Pathways to benchmark our Performance

Stroke Care Pathway Community ServiceGold Standard Protocol

Referral Source: Step down from Stroke unit In reach (virtual or attendance) daily 7 days week by the community stroke team via telephone/Daily board round by ward team – Discuss patients

Does patient meet Early Supported Discharge Criteria?Live safely at home, based on practicality and disability (Barthel score

10/20 to 17/20) Mild – Moderate (40% pts): i.e. cantransfer safely with one with an able carer, or independently if living alone.

No

Yes

Ward email referral/functional summary same day to CST

CST contact ward same day to discuss discharge plans/coordination and intervention needed.

Intervention by the CST to begin within 24- 48 hours post discharge.Same intensity as hospital range: daily 5/7 7/7 -4-5 day’s week depending on need. Provided for 6 weeks then reduced as pt improves.

Outcome measure completed within one week of arrival and one week post discharge including dependency scale, ADL, pt satisfaction, PROM QOL, Mood evaluation.

Short and long term goals wet with patient/carer within 2 weeks of admission to CST

Discharged when goals met with discharge summary to GPAverage service provided between 6 weeks – 3/12 months nationally.Arrange 6 week/6 month review date (use modified Rankin scale 6 months)

Re referral back into service if needed

Non – ESD Pathway for patients outside of ESD criteria (residential/nursing home, intermediate care beds, lower functioning pts). All patients to be referred.

YesNo

CST Contact patient within 72 hours via telephone: Screen for no problems/mood, check driving advice and arrange 6 week/6 month review then discharge.

Ward email referral/functional summary same day to CST CST checks referrals daily/liaise with ward team.

Rehabilitation need identified

CST contact ward within 24 hours to discuss discharge plans/coordination and intervention needed.

Contact patient within 72 hours via telephone: Initial assessment within a week and all professions to have completed assessments within two weeks for all patients including residential care. Input provided to intermediate care units/enabling services to assist in management of stroke patients as needed. Intensity to be offered up to 45 min day 7/7

Outcome measure completed within one week of arrival and one week post discharge including dependency scale, ADL, pt satisfaction, PROM QOL, Mood evaluation.

Short and long term goals wet with patient/carer within 2 weeks of admission to CST

Discharged when goals met with discharge summary to GPAverage service provided between 6 weeks – 6/12 months nationally.Arrange 6 week/6 month review date (use modified Rankin scale 6 months)

Making our Data Accessible

• Often data in lots of places• Time spent searching for    data when requested for reports• Data is not visible to team  members or managers • Reduced engagement from staff • Therefore our performance data is often not used as a live source to inform actions and analyse practice 

Stroke Dashboard

Summary Data collection and evidencing performance of our team is a high priority to ensure quality, safety, effectiveness and excellent patient experience.

Meeting contractual targets and quality schedule Data gives us in depth details about our stroke pathway and how we are affecting that as a team.

It helps us to prove we are improving patients functional outcomes and making cost savings

Having a live data resource can help to organise all data performance and requirements in one place

All staff need to be aware of performance and clinical leads try to influence and streamline the data set required so its meaningful and the tools used to measure are relevant.

All this information we can use to show effectiveness in new world of GP commissioning/CCG: already looking at outcomes framework

Thank you for listening