Clinical Audit for Improvement: HQIP update

Transcription

1 Clinical Audit for Improvement: HQIP update Mirek Associate Director for Quality and Development National Clinical Audit and Patient Outcomes Programme Healthcare Quality Improvement HQIP aims to improve health outcomes by enabling those who commission, deliver and receive healthcare to measure and improve our healthcare services.

2 Content An update from Healthcare Quality Improvement Partnership (HQIP) National Clinical Audit Patient Outcomes Programme (NCAPOP) Quality Assurance or Quality Improvement National Clinical Audit and Quality Improvement (QI) Data and Measurement Quick example National Clinical Audit supporting and stimulating QI Top Tips

3 Slides from Matt Tite NHS Elect

4 Audit and feedback although effective. is undertaken without providing any formal upskilling in quality improvement techniques. does not train clinicians in how to address any gaps. The need to provide patient-centred care, and provide value for money, means that health professionals require more than clinical skills alone. Healthcare professionals also need to know how to assess, enhance and disseminate good practice.

5 Communication and relationship management To engage with the funders and stakeholders below to plan and deliver the scope of the NCAPOP programme Very few clinicians actually accept outcome NCA data - long way to go to have clinicians actually see variations and understand why and how they differ minimising this variation in hip replacements and cataract surgery alone can reduced the NHS deficit to 0.

6 Opportunity Count pubmed - clinical audit publications The new NHS - clinical governance Trust boards responsible for quality of care Public inquiry Bristol Royal NICE Best Practice in Clinical Audit White paper Working for patients All doctors should become involved in audit 1990 NHS Health Circular Nurses to be involved in audit as well formally introduced into NHS (DOH) s quality management Publication Year

7 Healthcare Quality Improvement Partnership

8 Our structure and funding

9 The National Clinical Audit & Patient Outcomes Programme (NCAPOP) National Clinical Audit Programme 34 national audits covering: Acute Cancer Children and Women's Health Heart Long-term Conditions Mental Health Older People Clinical Outcome Review Programmes 4 national programmes: Maternal, Newborn and Infant Medical & Surgical Mental Health Child Health Programme Audits collect and analyse data supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, NCAPOP audits aim to provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help services identify necessary improvements for patients in pathways of care. Clinical outcome review programmes help assess the quality of healthcare and stimulate improvement by enabling clinicians, managers and policy makers to learn from adverse events and other relevant data Other National Programmes National Learning Disability Mortality Review Programme National Mortality Case Record Review Programme National Perinatal Mortality Review Programme Child Death Review Database Project National Joint Registry Collects joint replacement information, monitoring implant, hospital and surgeon performance.

10 Commissioning principles Patient and public involvement and focus Alignment with health priorities Tailored outputs Effective clinical leadership National Clinical Audit Minimal data burden/maximise linkage Complete, high quality benchmarked data Clear quality improvement intent Robust methodology Value for money

11 What is clinical audit? Clinical audit: a quality improvement cycle measuring effectiveness of healthcare against standards, & taking action to bring practice in line with these standards. New Principles of Best Practice in Clinical Audit (HQIP, January 2011)

12 Developing Evidence Based Indicators to Drive Quality in Healthcare Guidelines Quality Standards Develop Metrics Clinical Audit (National / Local) Improvement Plan Re-Audit

13 What is national clinical audit? Beautiful data unique internationally commissioning mechanism to drive improvement against standards support quality dissemination, transparency

14 What is unique about an NCAPOP project/audit? Clinical leadership and engagement to support data use to improving change in patient outcomes in pathways of care Patient focussed and patient involved whether through audit governance or inclusion of patient views or key measures from a patient perspective High (95%) plus participation of all those that provide care to NHS patients Robust trustworthy data System alignment: NICE standards or other evidence based standards used to underpin, supports other system improvement initiatives (eg BPT, GRIFT, CQC, etc) Delivers national QA, support for local QI and enables quality planning Information flows from the NCAPOP need to speak to clinical teams, those who QA the service, commissioners and patients

15 Key audiences People who: receive care deliver care commission care Assure/ regulate care

16 Specification Development Patient representatives SDM Service commissioners CSG Proposal lead Clinical lead National Quality Improvement and Clinical Audit Network (NQICAN) Policy leads Experts in the clinical area Experts in the relevant methodology Self-nominated experts

17 Specification development meeting: what is discussed? Included patient groups Excluded patient groups Risks Audit elements Methodology Relevant policies and quality drivers Cost / benefit SDM Data collection burden Data linkage and sharing Quality improvement Current landscape Stakeholder needs

18 Specification development meeting: what is discussed? Included patient groups Excluded patient groups Risks Audit elements Methodology Relevant policies and quality drivers Cost / benefit SDM Data collection burden Data linkage and sharing Quality improvement Current landscape Stakeholder needs

19 Commissioners meeting Review of discussions at SDM Benefits, risks, local burden CSG Additional information required? Agreement of commissioning brief

20 Current Focus Moving clinical audit away from an emphasis on data collection to a tool for quality improvement. Clear improvement intent - focused, targeted and bespoke application with good vision for end point outcome and intent. Timely reporting for national reports (at least within 6 months of data close) Frequent information/data visualisations that support local clinical services use of data for improvement, assurance and planning of quality care Efficient and sustainable Avoid data burden from a collection and outputs point of view

21 Evolving NCAPOP Patient and Public Involvement (PPI) Routine data Live data Parity of esteem Resources and guides including hosting/running QI events Collaborations: at neighbouring hospital to national level Pathway wide ie prevention to end of life Impact local, system, public, academic Direct relationships with improvement, regulation and performance enhancing bodies eg CQUIN, Best Practice Tariffs, Quality Standards and Commissioning Specifications for care service provision

22 Current and potential PPI engagement in HQIP commissioning cycle service user representatives to be supported to be involved in all parts of procurement Project Closure Extension Topic Prioritisation Specification Development Current PPI through topic specific representation at Specification Development Meeting Contract Management Tender launched Pilots underway in: Emergency Laparotomy Stroke Falls and fragility fracture Contract award Procurement underway Potential PPI through evaluation panel membership (non-topic specific representation ie SUN): PQQ (pre qualification questionnaire and only if two stage tender process) ITT (invitation to tender) Tender evaluation meeting

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24 Bristol public inquiry report Clinical Outcomes Publication programme Individual cardiac surgeon data publication Publication of consultant outcomes data from 10 specialties, linked from NHS Choices to specialty association NHS Choices websites launch MyNHS launch Consultant directory launched on NHS Choices /15 Named hospital cardiac surgery mortality publication Everyone Counts Publication of consultant outcomes data from 12 specialties on NHS Choices and MyNHS

25 Clinical Outcomes Publication Published in April 2016 Guidance for: audit providers trusts professional societies

26 NHS Choices ( MyNHS ( Comprehensive general health and social care information and data about conditions, treatments and services Aimed at those with direct or indirect health or care needs in England Vision to transform NHS Choices A single place where health and care organisations and the public can compare the performance of services Aimed at informed patients and service users, providers, commissioners Led by Department of Health and partners Improvements to design and functionality this year

27 An example from the National Emergency Laparotomy Audit

28 Audits working in partnership with patients & families What will be done to relieve my pain? What will be done to help me if I have memory problems or become confused? When will I meet a geriatrician to plan my care and rehabilitation? Will I have surgery on my first or second day in hospital? Will a senior surgeon and anaesthetist be in charge of my operation? What will be done to help me if I have difficulty with eating or drinking? How soon after surgery will I get out of bed and start physiotherapy? Will I be able to go home and if so how soon? How will I be kept informed of my progress, so that my family and carers can make arrangements for me when I leave hospital? What will be done to try and reduce my risk of falling in the future? What will be done to see if I need bone strengthening treatment? Will you check up on me after I leave hospital?

29 Audits working with NHS improvement drivers: Best Practice Tariff Quarter by quarter BPT criteria compliance and BPT achievement:

30 Communicating key messages: National Neonatal Audit NNAP audit measure: Do all babies <1501g or a gestational age of <32 weeks at birth undergo the first Retinopathy of Prematurity (ROP) screening in accordance with the current guideline recommendations?

31 Use of run charts

32 30 day mortality over time % of patients who died within 30 days Sentinel Stroke Audit RCP London. Year of audit

33 The case for changing stroke care London Stroke Units Sentinel Audit Comparison 2004 and 2006 London Stroke Providers against Sentinel Audit 12 key indicators 2006 Change in London Stroke Providers against Sentinel Audit 12 key indicators 2006 vs 2004 scores Above Target Below Target Target Indicators included: % of patients admitted directly to a stroke unit Screening for swallowing within 24 hours Brain scan within 24 hours Aspirin within 48 hours if appropriate

34 Eight designated HASUs London SUs

35 Findings Morris et al 2014

36 Maximising the use of audit data to support quality improvement measures at Trust level and support the CQC regulatory process

37 Improving quality in IBD services

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39 Audit reports that meet stakeholder needs 1. Audiences People who deliver care People who receive care People who commission care People who assure/regulate care 2. Scheduling 3. Language and tone 4. Report structure 5. Communications planning 6. Dissemination

40 How should an audit support quality improvement?

41 Using national clinical audit data for improvement

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43 What is quality improvement and does it differ from clinical audit? Knowing why or what you need to improve (audit will have provided this information). Having a feedback mechanism to identify if improvement has happened (closing the audit loop). Developing a change that will lead to improvement. Testing a change before implementation, this may lead to multiple cycles of further change. Knowing when you have an effective change that will lead to an improvement.

44 Simplicity X Patient sees doctor Y Healthy and productive member of the community

45 Complexity

46 The NHS 133 People to take care of the patient The Patient

47 Complex systems

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49 Scientific method provides the foundation for all quality improvement models and approaches

50 Audit cycle

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52 Why are we measuring?

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55 Setting the foundations for quality improvement through audit Measuring Clinical Quality You can t fatten a cow by weighing it - Palestinian Proverb Improvement is NOT just about measurement but you can t improve something without measuring it!

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58 Maturity

59 Quality accounts

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61 Extrapolating Falls as an example of measuring for QI

62 In-patient falls audit Most commonly reported patient safety event in hospital Over 600 reported per day in England and Wales (>200,000 a year) Not all result in injury but affects confidence and increases anxiety >2500 hip fractures occur in hospital (4.2%) 15 million per year

63 How do we prevent falls in hospital? No easy answer Multiple interventions performed by MDT reduces falls by 20-30% Patients with dementia and delirium at particular risk NICE CG161 and NPSA guidance Audited all hospitals in England and Wales (and Northern Ireland)

64 National Audit of Inpatient Falls

65 Potential learning and QI work/projects

66 Key indicator recommendations 6 Dementia and delirium review their dementia and delirium policies to embed the use of standardised tools and documented relevant care plans. Falls teams should work closely with dementia and delirium teams (if present) to ensure team working for these high-risk patients.

67 Key indicator recommendations 12 Call bells We recommend that all trusts and health boards regularly audit whether the call bell is within reach of the patient and embed change in practice if needed.

68 Cyclical framework for helping to increase the impact of audit on the quality and outcomes of care This framework can address Accountability Population level outcomes Value Research Cross cutting assumptions Patient Involvement Networking Collaboration Clinical Leadership Whole pathway Celebrating success Service Evaluation Quality Improvement Audit

69 National clinical audit and QI be&list=plmide-j6izk5n7u2gmd0itfyzyxgdawa2

70 Trust Discharge Year & Month Pressure ulcers % (annual) Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Median 7.50

71 Year Average Average 6 Average

72 Trust Discharge Year & Month Pressure ulcers % (annual) Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Using graph paper, ruler and a pencil: 1. Draw and label the axis 2. Plot the dots 3. Work out the median and draw a line across the graph 4. Add a title with dates 5. Add a legend 6. Analyse.. Median 7.50

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74 Testing and scaling Holding the gains Baseline data

75 Synchronising audit and QI to sustain improvement in clinical care processes

76 Testing and scaling Holding the gains Baseline data

77 Slide from Matt Tite NHS Elect

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79 Slides from Matt Tite NHS Elect

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83 The bundle approach raises the bar Brain imaging Swallow Aspirin Weight Audit score Patient 1 x x Patient 2 x x Patient 3 Patient 4 x x Total 75% 50% 50% 75% 63 All or none x x x 25% Source: NHS NW Stroke 90/10 initiative (with thanks to Maxine Power) Only 1 patient (25%) got perfect care

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86 "Creativity is seeing what everyone else has seen, and thinking what no one else has thought" ~ Einstein

87 Design versus user experience and what could happen when you respond to user

88 Top Tips QI projects stable and normal cause variation are rotations ie juniors rotating into stable projects Clinical audit should inform QI projects Look at existing data (national, regional and local) to: Establish baseline (clinical audit is a great start) Use as measurement system for QA and QI Drive and stimulate QI and monitor QA, plan for quality Involve patients QI and audit teams collaborate and join forces! Get in touch with HQIP how can we help?

89 THANK YOU Let s share and learn, please connect: