Coronary Heart Disease Improvement Management Programme

Transcription

1 Coronary Heart Disease Improvement Management Programme Driving and supporting sustainable continuous improvement in the management of coronary heart disease in Scotland.

2 Foreword The Coronary Heart Disease (CHD) Improvement Management Programme represents the new direction for NHS Quality Improvement Scotland (NHS QIS). By 2010, there will be improvements in both the quality of care provided and outcomes for patients with coronary heart disease and their families. Since 2007, we have listened, consulted widely and reviewed our approach. NHSScotland needs integrated programmes of work that are patient centred and support continuous, sustainable improvement. The programme provides a realistic framework for Managed Clinical Networks (MCNs) through which they can achieve accreditation and demonstrate high quality care. Standards are grounded in evidence from a range of sources including the SIGN CHD guidelines (93-97) published in 2007, which set the tone for high quality care that all patients deserve in Scotland. Measures have been designed to provide assurance from the national perspective but are also flexible enough to reflect locally determined priorities. We have been working with the Institute of Healthcare Improvement to ensure the Scottish Patient Safety Programme CHD measures are embedded within the programme from the outset. A strong emphasis of this programme is placed on supporting MCNs to use a range of improvement methodologies and we will be providing training and resources to make sure that this can happen. Over the next year, we will work even more closely with the CHD clinical community to ensure that this programme delivers demonstrable, patient centred sustainable improvements. Sir Graham Teasdale Chairman, NHS Quality Improvement Scotland This programme of work represents the first nationally coordinated quality improvement programme for heart disease in Scotland. It complements and builds on existing work of CHD Managed Clinical Networks (MCNs). The programme provides linkage between evidencebased practice, patient safety and patientcentred care. It represents a unique opportunity to improve quality of care and to demonstrate to patients and the public that we are delivering this consistently throughout the NHS in Scotland. For the programme to be successful, we need genuine partnership with health professionals and voluntary organisations involved in heart disease. Following the recent publication of the draft clinical standards we are keen to engage further with MCNs to look closely at methods of assessing and measuring the quality of care against the standards. This resource pack provides information on ways of achieving this. While we fully acknowledge the substantial workload involved, we have strived to minimise the number of measurements required and we will provide detailed guidance and advice relating to assessment against each of the NHS QIS standards. During this more intensive period of assessment we will develop sustainable methodologies that will allow continuous measurement of the quality of care for future years. These measures will be based on a limited number of indicators embedded in workflow that represent teamwork and multidisciplinary care, focus on patient safety and blend evidence based care with holistic care centred around the patient and their family. Dr Martin Denvir CHD Clinical Advisor, NHS Quality Improvement Scotland Consultant Cardiologist, NHS Lothian

3 Foreword British Heart Foundation (BHF) Scotland welcomes the development of the NHS QIS CHD Improvement Management Programme that aims to ensure consistently high quality, evidence based care and treatment for patients with CHD throughout Scotland. BHF Scotland has been delighted to play an active part in the process that, from developing the 2007 set of SIGN CHD guidelines through to the consultation events seeking feedback on the draft CHD clinical standards, has actively involved patients, carers and voluntary organisations, as well as a wide range of NHS professionals. BHF Scotland will continue to monitor with interest the process of implementation of the national clinical standards and associated audits. We will be looking to see continued improvements in the quality and safety of NHS services, which will benefit people living with heart disease in terms of better clinical outcomes, improved quality of life and better experiences of NHS care. BHF Scotland will continue to actively campaign for and pioneer further improvements in services for all people with heart disease in Scotland, both independently and working in partnership with the NHS and other organisations. Andy Carver Prevention & Care Adviser British Heart Foundation Scotland

4 Contents Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Section 7 Section 8 Section 9 Section 10 Section 11 Section 12 Section 13 Background SIGN Guidelines Standards Measures and Measurement Heart Failure Acute Coronary Syndrome Cardiac Rehabilitation Atrial Fibrillation Patient Involvement Programme Evaluation Managed Clinical Network Accreditation Improvement Methodologies Contacts

5 Section 1: Background

6 NHS Quality Improvement Scotland The aim of NHS Quality Improvement Scotland (NHS QIS) is to drive improvement in the quality and safety of healthcare through the provision and use of knowledge. Our goal is to have relevant and integrated programmes of work relating to the priorities of NHSScotland that cover the following three components of improvement: guidance and advice, including standards implementation, support for assessment and measurement Guidance NHS QIS Assessment Implementation Nationally Supported Improvement methodologies applied locally The NHS QIS Coronary Heart Disease (CHD) Improvement Management Programme is predicated on the Institute of Medicines, Six Dimensions of Quality 1, which focuses on driving improvements that focus on care being more Safe Effective Patient-centred Timely Efficient Equitable 1 IoM. Medicare: a strategy for quality assurance. Lohr KN ed. Volumes I&II, Washington DC, National Academy Press, 1990

7 NHS QIS Coronary Heart Disease Improvement Management Programme Under the theme of cardiovascular disease, we have established a Coronary Heart Disease (CHD) Improvement Management Programme. Principles of the Programme Approach NHS QIS will work with the service, principally the Managed Clinical Networks (MCNs) for CHD and patient representative groups to: Harness the individual discrete functions of NHS QIS to deliver a proactive, integrated and supportive approach Ensure alignment and integration of work with the Scottish Patient Safety Programme (SPSP) Work with other agencies as required Provide the appropriate resources, tools and mechanisms that will support the service in on-going improvement Build capacity and capability to support service improvement Provide a structured approach and support for a sustained programme of implementation Demonstrate the quality of care throughout NHSScotland. Coronary Heart Disease Improvement Management Programme, NHS QIS has established a programme of work in relation to the management of coronary heart disease that aims to drive and support ongoing improvements in patient outcomes. In order to achieve this, NHS QIS is working with NHSScotland and other stakeholders on a wide range of initiatives which are outlined below: Programme Structure and Governance The NHS QIS Programme Advisory Group has been set up under the chairmanship of Dr Martin Denvir, NHS QIS CHD Clinical Advisor, to coordinate activity and provide governance of the overall programme. The group is drawn from key stakeholders, including NHS professionals and members of the public. The group provides expert opinion, direction and guidance to NHS QIS on the development and delivery of the CHD programme. Regular activity and progress reports across the various work streams are prepared in conjunction with an annual report submitted to the Board of NHS QIS. As the focus on implementation grows, the structure is developing.

8 NHS QIS Board CHD Programme Advisory Group Clinical Audit & Indicators Steering Group Clinical Standards Development Steering Group Atrial Fibrillation Cardiac Rehabilitation Heart Failure Acute Coronary Syndrome Chest Pain/ Angina* Heart Failure Arrhythmia * the Chest pain/angina project incorporates primary prevention of CVD and cardiac rehabilitation Clinical Guidelines and Implementation In 2007, SIGN published five clinical practice CHD guidelines relating to different aspects of the prevention and management of coronary heart disease in addition to the existing guideline on cardiac rehabilitation. A survey has been undertaken to gauge the extent to which the guidelines have been implemented across all 14 NHS Boards. We have looked at three of the guidelines and the findings of this work will be available in May It includes the completeness and value of the information returned, and will be considered by the Advisory Group before further roll out. It is envisaged that the findings will be collated and published as a national report available to NHS Boards and CHD MCNs highlighting progress to date, areas of common concern and opportunities for shared learning. The report will also help to inform the work of the standards and audit streams of the programme. Clinical Standards The standards development stream is using the evidence contained within the SIGN guidelines as a framework. The standards focus on improved outcomes and experience for patients and are linked to the six dimensions of quality (i.e., safe, effective, patient-centred, timely, efficient and equitable, as defined by the Institute of Medicine) 1. This work is being undertaken in collaboration with a wide range of stakeholders including MCNs and patient representatives. The work is overseen by a multidisciplinary standards development steering group. The standards have been developed within the context of the patient journey described by three pathways of care: arrhythmia, chest pain/angina and heart failure. These groups are led by Professor Andrew Rankin, Professor Lewis Ritchie and Professor Allan Struthers respectively. Draft standards were issued to service users and providers for consultation in February It is anticipated that following a wide ranging consultation exercise, final standards will be published at the end of IoM. Medicare: a strategy for quality assurance. Lohr KN ed. Volumes I&II, Washington DC, National Academy Press, 1990

9 Measurement for Improvement National Audits A national audit programme is underway which is directly linked to the standards. The work is overseen by the Clinical Audit and Indicators Steering Group, which is chaired by Dr Iain Findlay, and supported by subgroups covering heart failure, acute coronary syndromes, atrial fibrillation and cardiac rehabilitation. The groups are led by Professor Henry Dargie, Dr Allan Bridges, Dr David Murdoch and Ms Catherine Mondoa respectively. Audits will begin in Formal reporting mechanisms are also being put in place to ensure that local and national results are communicated widely, to drive improvement. Clinical Indicators Clinical indicators will be developed, within the programme for CHD, informed by the results of audit activity. Work on developing measures of quality and safety in primary care will also be included within this work stream. It is envisaged that a small, focused suite of indicators will provide the ongoing mechanism by which NHS boards can monitor local activity and highlight where improvement may be required. Responsibility for this element of the CHD work programme falls within the remit of the Clinical Audit and Indicators Steering Group. Additional Advice and Guidance NHS QIS will ensure that emerging results and issues associated with this programme of work are shared between parallel work programmes e.g. long-term conditions and primary care to capitalise on the knowledge brokering role and to ensure that the maximum benefits for people with or at risk of heart disease are realised. The evolving CHD Improvement Management Programme will be informed by, and aligned with, the Scottish Government Health Directorates updated Coronary Heart Disease and Stroke Strategy. We will be developing and piloting Patient Reported Outcome Measures as part of the programme. This work will commence in late summer, The Managed Clinical Networks (MCNs) are pivotal in taking the programme forward. We will work closely with a range of key stakeholders but particularly the MCNs to ensure the success of this work. Accreditation of local CHD MCNs will also form part of this work. The emerging programme framework will support the MCNs in achieving accreditation.

10 NHS QIS Coronary Heart Disease Improvement Management Programme New & Other Evidence SIGN Guidelines & Resource Impact Reports Self reported compliance with SIGN Guidelines Draft Standards Audit Data Sets & Questions Developed Consultation Final Standards Pilot Visits Publication & Support for Implementation Assessment Audit 2 cycles Qualitative Questions On-going Monitoring Core Quality Indicators (NHS QIS) national picture Locally identified required actions (MCNs) local improvements MCN ACCREDITATION Q U A L I T Y I M P R O V E M E N T M E T H O D S

11 The Scottish Patient Safety Programme In March 2007, the Scottish Patient Safety Alliance was launched to drive forward improvements in patient safety and, as a result, established the Scottish Patient Safety Programme (SPSP). The SPSP, part of NHS QIS, is being developed in partnership with Scotland s NHS professionals. It supports frontline staff to make changes in practice. The Institute of Healthcare Improvement (IHI) is providing expertise to the SPSP to help NHS boards improve the reliability and safety of their systems and processes, based on their extensive and evidence based approach developed in the USA. The programme is unique in that Scotland is the first country worldwide to apply this approach to systematic improvement in the safety of all its hospital care. The SPSP have identified 12 key aspects to focus initial attention on during the first phase. Two of these are concerned with myocardial infarction (MI) and heart failure (HF). The CHD Improvement Management Programme has been working closely with the SPSP and the IHI to ensure that the CHD measures are aligned across the programme. Audit activity and indicator development has taken cognisance of this. Although the SPSP will not start to focus on CHD until later in 2009 and into 2010, it is important that the SPSP measures for MI and HF are embedded within the overall datasets from the outset to avoid duplication of effort. What are the IHI CHD Measures? In 2005, the IHI launched its Saving 100,000 lives campaign in the USA to great success. Key measures for MI and HF were included within this campaign. NHS QIS and the CHD community have been working with the IHI to establish the appropriateness of these measures in the Scottish context. The MI and HF measures that will be used within the SPSP are identified within the individual datasets in the condition specific sections that follow (SPSP). We will use the experience of the developing CHD Improvement Management Programme to test and confirm these measures. What this means however, for MCNs and NHS boards is: No additional activity will be required to collect the measures for the SPSP in 2010 Clinical staff should be able to adopt and implement improvement methodologies to the benefit of patient care Support for clinical staff is available locally through the network of SPSP facilitators and Improvement Support personnel throughout Scotland. Further contact details are provided in the contacts section of this pack. In addition, training delivered by IHI and SPSP colleagues in improvement methodologies has been provided to approximately 100 clinically focused CHD staff. The purpose being to provide frontline staff with a range of improvement methods that they could start to use to help them drive improvement from the outset.

12 Achieving a Sustainable Mechanism that Supports Continuous Improvement NHS QIS is well aware that to ensure long term sustainability of the standards and their associated measures, the approach adopted has to reflect the burden on health care providers of collecting and providing data. The ultimate aim for this programme is to provide a legacy at national level, of a number of core measures that will give an indication of quality that local services can respond to flexibly alongside locally identified priorities. To this end, we envisage a dramatically collapsing suite of measures SIGN Recommendations 18 standards 105 essential criteria 45 audit criteria core indicators

13 What does this mean for NHS Boards/ MCNs? Key Milestones February 2009 May IHI Improvement Methodologies Training: 26th February CHD clinicians representing all MCNs provided with training in improvement methodologies by Institute of Healthcare Improvement (IHI) and NHS QIS Patient Safety Programme. The purpose of this workshop was to equip clinical staff with the knowledge and skills to be able to utilise these approaches during phase 6 (below). 2 NHS Board Visits: Raising Awareness: February-May 2009 All NHS boards will be visited by members of the CHD Improvement Management Programme to raise awareness of the overall approach and provide details about key milestones for MCNs and boards. 3 Consultation on Draft Standards: March-May 2009 A series of regional professional and patient focused meetings will have taken place to explore the acceptability and completeness of the standards. 4 NHS Board Visits: Assessing Overall Appropriateness: June-August 2009 Two NHS boards will take part in the pilot of the relevance of the standards and overall approach adopted. This will involve being invited to share the outcome of test audit data alongside qualitative data results and the experience of undertaking the assessment with a NHS QIS / clinical expert team. 5 Baseline Audit of Clinical Practice: July-September 2009 Audit of practice in relation to: Cardiac Rehabilitation, Atrial Fibrillation, Acute Coronary Syndrome using datasets and data collection methods informed by the standards and provided by NHS QIS. Datasets will contain embedded items that will allow for measurement of required SPSP CHD measures. It is anticipated that the audits, supplemented by a small number of qualitative answers will be the primary measure of assessment against the standards. Results by each NHS board will be provided. 6 Implementation of Required Changes: September 2009-Ongoing All NHS boards will be expected to develop and implement a timescaled action plan based on their audit findings using appropriate improvement methodologies. Support will be provided by NHS QIS and local Scottish Patient Safety Programme co-ordinators. 7 Publication of Final Standards: December 2009 NHS QIS will publish the final CHD standards. 8 Re-audit of clinical practice: February-March 2010 As outlined in (5). Will measure any improvement in practice. 9 Clinical Indicator Development: March-May 2010 NHS QIS will develop core clinical indicators that all NHS boards will be expected to monitor on a regular basis. MCNs will be encouraged to continue to work on improvements in required areas as identified locally. MCN Accreditation Local MCNs will be accredited through NHS boards. NHS QIS will provide an enhanced range of tools in support of this. It is viewed that the overall CHD programme actively supports MCNs achieving accreditation.

14 Section 2: SIGN Guidelines

15 SIGN CHD Guidelines (2007) In 2007, five clinical guidelines were published by the Scottish Intercollegiate Guidelines Network (SIGN). These support the guideline previously published in 2002 relating to Cardiac Rehabilitation. Those published in 2007 include guidelines for the management of Acute Coronary Syndrome, Cardiac Arrhythmia, Chronic Heart Failure, Stable Angina and Risk Estimation and Prevention of Cardiovascular Disease.

16 Section 3: Standards

17 Standards Development of CHD standards The standards workstream is directed and overseen by the CHD Clinical Standards Development Steering Group. Development of the standards, where appropriate, has followed the patient journey of care. In addition to core standards that address generic issues such as information and communication, draft clinical standards have been developed for: Primary prevention of cardiovascular disease Management of the patient with chest pain in the scheduled care setting Management of the patient with chest pain (suspected heart attack and acute coronary syndrome) in the unscheduled care setting Cardiac rehabilitation Management of the patient with arrhythmia, and Management of the patient with heart failure. HeartDisease_CHDDraftStandards_FEB09. pdf These draft standards have been developed by multidisciplinary groups, chaired by a senior clinician with experience of that pathway. The groups comprise patients, representatives from voluntary and charitable organisations linked to CHD and a broad range of NHS staff nominated by the CHD MCNs around Scotland. month consultation exercise. A number of consultation events have taken place in locations throughout Scotland to try and ensure that everyone with an interest in CHD has an opportunity to participate and comment on the draft standards. Information about these events was disseminated through MCNs. An important part of the consultation process is to test the measurability of the standards and to identify which data collection and information sources exist to provide evidence of compliance. Two NHS boards will pilot the process and this will help to establish the appropriateness of the standards in both rural and urban settings. Comments will be compiled on an ongoing basis and at the end of the consultation period all comments will be shared with the CHD Clinical Standards Development Steering Group and the individual project groups. The groups will reconvene to consider and amend the standards as appropriate. As a result of this exercise, a consultation document will be produced that explains what action, if any, was taken in response to the comments received. A copy of consultation document will be available on request and also via the website. The final version of the standards will be disseminated throughout NHSScotland and the wider healthcare community by the end of Consultation is a key component of standards development and allows a wide range of service providers, users and carers to participate in the process. The draft standards were issued in February 2009 for a three

18 Section 4: Measures and Measurement

19 Measures and Measurement for Improvement Approach to Measurement During 2009/10, the level of compliance against the standards will be measured in a number of ways. MCNs will be asked to provide information and data in the form of: Audit of Quantifiable Elements, (things that can be counted) - NHS QIS will provide audit datasets that will cover approximately 60% of the standards - MCNs will also be asked to undertake a limited number of small scale audits, which will cover approximately an additional 10% of the standards Qualitative Responses (descriptions of how services are organised, and provided) - Where qualitative elements of the service are explored via the standards e.g. description of the service, existing documentation, such as guidelines, pathways or template letters may be provided to demonstrate compliance. Information about this element of the process will be issued separately. Funding Funding has been provided to MCNs for 2009/10 to support the collection of data associated with these audits. Allocations have been based on numbers of Coronary Artery Bypass Grafts (CABGs), angioplasties and angiographies (by Health Board (HB) of treatment), and emergency MIs (by HB of residence) recorded on SMR01 for year ending September This has been overseen by the CHD Data and IT Sub Group of the National Advisory Committee on CHD. Confirmation of these arrangements were issued to MCNs in October Long Term Measurement and Monitoring As previously stated, it is envisaged that longer term monitoring of the standard of care and extent of continuous improvement will be an integral part of MCN accreditation. By spring 2010, a core of measures, will be identified and include those measures required to support the CHD elements of the Scottish Patient Safety Programme. There will be between measures which will be sensitive enough to monitor change, provide on-going assurance and identify where improvement needs to happen. Other Sources - Information to evidence local service provision will also be sourced from central sources e.g., Information Services Division (ISD) of NHS National Services Scotland and the Quality and Outcomes Framework of the General Medical Services Contract. Measures for standards not included in the national audits outlined in these sections i.e. the local audits and supporting qualitative questions will be tested by two pilot sites during 2009 before being considered for national implementation in 2010.

20 Measures and Measurement for Improvement Development of Measures As part of the integrated approach, NHS QIS is working closely with colleagues from across the organisation and a range of other stakeholders including ISD. The CHD national audit programme is overseen by a Clinical Audit and Indicators Steering Group consisting of key individuals from across NHSScotland. The steering group is being supported by four subgroups that are focussing on: Heart Failure (HF) Acute Coronary Syndrome (ACS) Atrial Fibrillation (AF) Cardiac Rehabilitation (CR) Based on the evidence contained within the standards and after consideration of the Patient Safety Measures advocated by the Institute of Healthcare Improvement, each audit development group has identified a number of measures (average 10 per topic) that will be used to assess compliance against specific draft standards. These measures will be used during both cycles of audit during 2009/10. Data Protection All data that is collected as part of this programme will be collated in line with the Data Protection Act It will also be patient non-identifiable and be provided with the endorsement of each NHS boards Caldicott Guardian. Ethical approval for data collection and use is not required as the associated activities are classified as service improvement. Data Collection Periods MCNs/ NHS boards will be asked to provide audit data for specified periods (see individual sections that follow) that fall between: July-September 2009 February 2010-March 2010 The second cycle of audit will be followed by a further period of analysis and feedback during the spring of Data Population Sample With the exception of cardiac rehabilitation, the 2009/10 audits will NOT require services to collect data on ALL patients during the data collection periods. Details of the required sample sizes are provided in the audit topic specific pages that follow. To re-emphasise, it is anticipated that after both cycles of audit and from early 2010, a core of measures will be identified (15-20). MCNs will thereafter be required to collect data relating to these measures for ALL patients to provide an on-going national picture of the quality of service provision. These measures will be supplemented by additional activity determined locally and based on MCN priorities.

21 Section 5: Heart Failure

22 National Audit of Heart Failure Management NHS QIS is supporting a National Audit of Heart Failure Management led by Professor Henry Dargie, NHS Glasgow & Clyde. Work commenced in February 2008 with the first cycle of data collection. The second cycle of audit will be aligned to mirror the wider CHD programme and include the required measures as identified by the Standards and Scottish Patient Safety Programme. Data Measurement in Primary Care: MCNs will need to recruit general practices May-June 2009: General Practice Recruitment It will be the responsibility of MCNs to recruit general practices. We strongly advise that recruitment starts as soon as possible. Information about the demographic and deprivation profile of general practices taking part will be required from MCNs. For MCN populations in excess of 250,000 and served by more than 50 general practices, data will be required from: a minimum of 20% of general practices from the area the general practices should represent the range of practices found in the area in terms of socio-economic deprivation, geographical setting i.e. urban and rural and overall size of practice For MCN populations of less than 250,000 and / or served by 50 or fewer general practices: MCNs are asked to contact NHS QIS to determine the exact size of sample required. mel.miller@nhs.net or

23 National Audit of Heart Failure Management MCNs will be asked to provide the following information about the proportions (%) within primary care with: Suspected heart failure having an ECG or BNP Suspected heart failure, having an echocardiogram carried out within 14 `working days of referral Chronic heart failure with any record of echocardiography being performed (SPSP) CHD & LVSD confirmed by echocardiogram (QOF LVD2) Chronic heart failure on: (SPSP) - Diuretics - ACEi and / or ARB - Beta blockers - Warfarin - Spironolactone therapy - Digoxin Chronic heart failure having had immunization for: (SPSP) - Influenza (within the last year) - Pneumoccocal (within the last five years) On the primary care palliative care register On the palliative care register with an individualised care plan placed in the patient s emergency care summary With atrial fibrillation With history of previous MI

24 How will Primary Care Data about Heart Failure Management be Collected? A search tool/s will be issued to MCNs to run in General Practices that will extract the required primary care data. Electronic search and full instructions issued via to MCNs by 1st June 2009 Identified Practices run search as outlined (5 mins) Patients will be identified via the search tool if they: Are on the register of CHD patients with LVSD Populated spreadsheets DUE BACK date by: First Cycle: 28th July 2009 Second Cycle: 28th February 2010 Q. How do we encourage practices to take part? A. As well as appealing to General Practices, you could consider using some of the provided funding to reimburse practices for their time. Q. When should the search be run? A. General Practices will be asked to run the search tool at a convenient time during July 2009 for the first cycle and during the first two weeks of February 2010 for the second cycle. Q. How will practices do this? A. When we send out the electronic search tool, we will provide detailed information for practices as to how to execute the search and what to do with the results. Q. Will this be time consuming for practice staff? A. Not at all, the search will take less than one minute to run. Results will automatically populate a spreadsheet/ database. Q. How secure is the data? A. The spreadsheet does not contain any patient identifiable information, just the location of its source. It can then be very safely ed to NHS QIS via the secure nhs.net. We have made significant efforts to ensure that this method does not compromise patient confidentiality in any way.

25 Heart Failure Secondary Care Measures & Data Collection: For the purposes of assessing service provision in secondary care against the standards, the identified measures will be extracted from the full dataset. These include the proposed heart failure measures that will be used within the Scottish Patient Safety Programme, identified by SPSP. The following secondary care data measures will be extracted from the National Heart Failure Audit dataset, providing information about the proportions (%): Admitted to hospital with suspected heart failure having an ECG Having an echocardiogram performed prior to discharge (SPSP) With documented review of medication prior to starting CHF medications On diuretics and dose of diuretics used (SPSP) On ACE inhibitors and dose of ACE inhibitor used (SPSP) On ARB in patients intolerant of ACE inhibitors and dose of ARB used (SPSP) On heart failure specific beta blockers and dose of beta blocker used (SPSP) With NYHA III-IV symptoms receiving spironolactone (SPSP) With chronic heart failure due to left ventricular dysfunction with access to a MDT Service including specialists in heart failure/cardiologists With chronic heart failure due to left ventricular dysfunction managed within a Multidisciplinary CHF service which includes specialist heart failure nurses With chronic heart failure in class NYHA II-IV that are offered exercise training Receiving exercise training Receiving cardiac resynchronisation therapy (CRT). Plus CRT rates per million population Receiving implantable cardiac defibrillation (ICD). Plus ICD rates per million population Receiving CRT-D. Plus CRT-D rate per million population Receiving smoking cessation advice, if appropriate (SPSP) With documentation in the hospital record of having received written discharge instructions or educational material, given to patient or caregiver addressing all of the following: (SPSP) - Activity level - Diet - Discharge medications - Follow-up appointment - Weight monitoring - What to do if symptoms worsen. Referred to the Scottish Advanced Heart Failure Service

26 Section 6: Acute Coronary Syndrome

27 NHS QIS National Audit Acute Coronary Syndrome The Acute Coronary Syndrome (ACS) Audit Development Group has identified data measures that will need to be collected to show compliance against the standards. For the purpose of this audit the definition of STEMI, NSTEMI and other forms of ACS are outlined in Appendix 1 of this section. These conform with recent guidelines from the European Society of Cardiology and have previously been agreed with the Scottish Cardiac Society. First Cycle Data Collection Method In terms of data collection, we envisage that there will be two methods available: Paper Proforma: A paper based, anonymised tick box proforma has been designed to collect the required data (see Appendix 2). It should be placed at the front of the patient record and remain there until the patient is discharged. Local arrangements should be made to ensure proforma are completed and collected. On discharge completed proforma should be returned to NHS QIS in the envelope provided. We suggest that batches of completed original proforma are returned at the end of weeks four and eight. Sites should retain a photocopy of all proforma with the local CHD audit team. We recommend that these copies contain a local patient identifier to allow you to track back to the patient record if required. No patient identifiable data should be sent to NHS QIS. The original and not the photocopy should be returned to NHS QIS. This is very important as each sheet contains a bar code that identifies the provider site which is not readable once photocopied. SCI CHD-ACS, web based data collection application SCI CHD-ACS will be used in the longer term as the national ACS register and for SPSP data reporting. We are aware that not all service providers currently have access to or utilise SCI CHD-ACS. We clearly see the opportunity the SCI CHD- ACS system offers for longer term data collection and feedback, both locally and nationally. All data fields required for the NHS QIS national audit will be available in the SCI CHD-ACS system for the first round of audit. We envisage that sites will have the option of either capturing the data on the proforma (Appendix 2) and then transferring this data into SCI CHD-ACS or capturing the data directly into SCI CHD- ACS from the clinical record. A specific NHS QIS audit number will be available in SCI CHD-ACS to allow you to identify and extract these patient data locally before reviewing and returning the data to NHS QIS. The advantage of this approach will be that hospitals and MCNs will be able to review their collected data locally before submitting to NHS QIS. We will confirm with MCNs by mid-june further details of the recommended approach for using SCI CHD-ACS for data collection. Second Cycle Data Collection Option It is envisaged that for the second round, all NHS boards will utilise SCI CHD-ACS. Centres not currently using SCI CHD-ACS should contact Mel Miller on mel.miller@nhs. net or as soon as possible to discuss arrangements to make the system available within your board area.

28 NHS QIS National Audit Acute Coronary Syndrome Data Measures MCNs will be asked to provide the following information about the proportions (%) within a sample of patients. Specific Scottish Patient Safety Programme measures are identified by SPSP: With STEMI receiving reperfusion within 60 minutes (call to needle time) for thrombolysis and within120 minutes (call to balloon time) for primary angioplasty (SPSP) With suspected ACS having troponin assayed: - on admission - 12 hours after onset of symptoms With confirmed ACS assessed by their local cardiac rehabilitation team during their hospital admission With confirmed ACS having a GRACE and / or TIMI score calculated and documented in records With medium to high risk assessed for invasive strategy within 72 hours of admission With high risk non ST elevation MI identified for invasive treatment receiving intravenous glycoprotein IIb/IIIa receptor antagonist With confirmed MI having an assessment of left ventricular function prior to discharge from hospital With confirmed ACS treated with heparin/low molecular weight heparin or fondaparinux With confirmed ACS with blood glucose >11 mmol/l receiving immediate intensive blood glucose control for at least 24 hours At time of admission, administered with: (SPSP) - Aspirin - Clopidogrel At time of discharge: (SPSP) - Aspirin - Clopidogrel - Beta blockade - ACE inhibitor or angiotensin receptor /ARB - Statin therapy - GTN spray With confirmed MI complicated by left ventricular dysfunction (ejection fraction <0.40), in the presence of either clinical signs of heart failure or diabetes commenced on long term eplerenone therapy Smoking cessation advice prior to discharge With confirmed ACS who had discharge planning that included: - An immediate printed discharge letter - Detailed instructions of what to do if their symptoms worsen - Written information explaining and providing education about their condition, activity levels, diet, - drugs and /or device therapy - A date for a follow up appointment

29 How will Data about Acute Coronary Syndrome be Collected? Prior to the first cycle of data collection, MCNs will be provided with the required number of pre-printed paper proforma which should be used to collect the data. A copy, for information only, is provided in this section at Appendix 2. You are advised to take the first few weeks to trial the paper proforma and/or the SCI CHD-ACS audit screens to ensure staff are familiar in their use How Many Patients will this involve? This will be different depending on whether your MCN /NHS board is an Intervention Centre or not. Data will be collected on: All STEMIs First NSTEMI each day confirmed by troponin elevation First chest pain/suspected ACS each day with negative troponin. Daily for 8 weeks. Attach proforma to patient record - it should remain at the front of the patient record until discharge. If the patient is transferred to another hospital, please ensure the proforma accompanies the patient for completion at destination. All tertiary centres also need to continue to fill in audit proforma started in referring hospital if patient is transferred in. The final discharge hospital is responsible for final completion and submission of data relating to all patients irrespective of their pathway of care. SCI CHD-ACS It should be noted that where SCI CHD-ACS is being used, the final discharge hospital is responsible for final completion and submission of data relating to all patients irrespective of their pathway of care. To complete the SCI ACS audit page, you may wish to collect data on the paper proforma first. Continued on next page... Q. When should data collection start? A. Start to complete the proforma/sci CHD- ACS audit screens once you are sure staff are confident in their use. Start your data collection by mid July 09 and for the second cycle by 1st Feb Q. How long should data be collected for? A. Collect data for eligible patients over the next 8 weeks. For those admitted towards the end of the period, continue to complete as many proforma/sci CHD- ACS audit screens as possible. There are two weeks between the end of the 8th week and the Due Back date to allow you to finalise this information. Q. Who should complete the proforma? A. Responsibility for ensuring the completeness of the proforma should be determined locally and made clear to relevant staff. Final completion and submission of the data is the responsibility of the final discharge hospital. Q. What happens if the patient moves to a different hospital? A. The proforma should accompany the patient at all times to ensure the required data are completed. Q. What happens if the patient dies? A. Complete all information up to time of death and indicate on the proforma under discharged to using the code 00. Return proforma or input the information into SCI CHD-ACS as appropriate.

30 How will Data about Acute Coronary Syndrome be Collected? Return all completed proforma to NHS QIS in provided envelopes including those where SCI ACS has been used. Completed forms should be returned in batches at the end of week 4 and week 8. Collated and anonymised SCI ACS data should be returned electronically via NHSnet to NHS QIS. DUE BACK date/s for last proforma or collated SCI ACS data are: First cycle: 16th Sept 2009 Second cycle: 14th March 2010

31 Acute Coronary Syndrome: Appendix 1 Clarity of Definition of Myocardial Infarction and Other Acute Coronary Syndromes Within the programme, we are endorsing the information circulated in 2008 throughout Scotland by the CHD National Advisory Committee Data & IT Sub Group. National Consensus for Diagnosis and Coding of Acute Myocardial Infarction 1. All hospitals in Scotland should use the term NSTEMI (non ST elevation myocardial infarction) for any troponin rise associated with clinical presentation consistent with myocardial infarction (in the absence of ECG ST elevation). 2. Acute myocardial infarction should ONLY be diagnosed where there is troponin release in conjunction with at least one of the following: a. Typical symptoms of myocardial ischaemia b. ECG changes indicative of NEW ischaemia c. Development of pathological Q waves d. on ECG Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. 3. These events will be coded as subendocardial myocardial infarction - I21.4 for the purposes of SMR01 reporting. 4. Each hospital should use the level equivalent to the 99th centile of the upper reference range in their centre for the threshold or detectable level to make this diagnosis. 5. STEMI (ST elevation myocardial infarction) should be coded as transmural MI (see table 1). 6. The term unstable angina (I200) should be reserved for ACS without detectable troponin release. 7. Troponin release associated with events other than acute coronary insufficiency should be reviewed by a cardiologist and a judgement made as to the specific cause and diagnosis. These may be coded as myocardial infarction (NSTEMI) if judged to meet the criteria in section 2 above. 8. Late presentation of myocardial infarction where the cardiac enzymes are negative (or unhelpful) should be coded as either NSTEMI or STEMI using the criteria in section 2 above. Late presentation with inferior or anterior pathological Q waves (without ST elevation) at the time of presentation should be coded as STEMI.

32 Table 1: Recommended Terms and Coding for Myocardial Infarction and other Acute Coronary Syndromes ICD10 READ code ICD10 description Discharge letter description I200 G3111 Unstable angina Unstable angina (only use with negative troponin) I210 G301z Acute transmural MI of anterior wall Anterior STEMI I211 G308 Acute transmural MI of inferior wall Inferior STEMI I212 G304 posterior, G305 lateral Acute transmural myocardial infarction of other sites Posterior or lateral wall STEMI I213 G30X Acute transmural myocardial infarction of unspecified site I214 G307 Acute subendocardial myocardial infarction I240 G3110 Coronary thrombosis not resulting in myocardial infarction STEMI (site unspecified) NSTEMI (any elevation of troponin with features of cardiac ischaemia) Aborted MI R074 R065z Chest pain unspecified Chest pain unspecified Implications A diagnosis of myocardial infarction has significant implications for patients and their families with respect to psychological effects, life insurance, careers, and lifestyle (including driving). Against that, a more precise diagnosis and recognition that even minor elevation in troponin is associated with a poorer prognosis means that more appropriate initial and long term treatment is offered to the patient. The following issues need to be addressed locally within each MCN 1. Patient groups and charity organisations need to be informed of this national consensus particularly in areas where this represents a significant change in the diagnosis rates of acute MI. These include local patient support groups charitable organisations (e.g. BHF, CHSS, Arrhythmia Alliance) and the Scottish Patient Safety Alliance. 2. All clinical staff involved in caring for CHD patients need to understand the rationale for this change and promote it within their own hospital, participating in education of colleagues and nursing staff outside the specialist cardiology environment. 3. Cardiac rehabilitation (CR) departments need to be aware of this policy change and the likely increase in patients diagnosed with NSTEMI. Some form of risk assessment may be applied as to which patients are most likely to benefit from CR in MCNs where service provision is limited. 4. Hospital coding departments need to be informed of this change in policy. 5. General practitioners need to be made aware that this may result in an apparent rise in the number of patients coded as having myocardial infarction and that this could have an impact on their CHD registers. 6. Hospital biochemistry/pathology departments need to review their troponin assay and ensure that they are aware of 99th percentile of upper reference range and that their troponin assay achieves optimal precision, defined as coefficient of variation at the 99th percentile of <10%. viewarticle/564652

33 Acute Coronary Syndrome: Appendix 2 Data Collection Form

34 Acute Coronary Syndrome: Appendix 2 Data Collection Form

35 Acute Coronary Syndrome: Appendix 3 Completion Notes Health Board Code Enter the letter for the patients health board of residence i.e. A = Ayrshire & Arran B = Borders Y = Dumfries & Galloway Admission Hospital Code 5 digit code assigned to hospital provider e.g S123H All brief A&E attendances should be recorded even if the patient is transferred to another hospital. Patient Code (Heading & in bold) 3 digit sequential number to be assigned in the range 001 to a maximum of 999 for each patient participating in the audit. For the second round, patient code should follow on from the last number assigned in the first audit. Call for help For patients who call an ambulance the date and time which the Scottish Ambulance Service received the call should be recorded For patients who self present at hospital the date and time of admission should be recorded. For patients seen by a GP the date and time of the consultation with the GP should be recorded. Date and Time recording All dates should be in the format of DDMMYY e.g 16 March 2009 equates to All times should in the format of 24 hour clock i.e HHMM Discharge Hospital Code Record the hospital code from which the patient is finally discharged using the 5 digit code as outlined under hospital code above. Discharged to Information on final discharge location to be recorded as noted below: Discharged home (including care home or residential care) 10 Transferred to another NHS unit 40 Patient died 00 Other not specified 99

36 Section 7: Cardiac Rehabilitation

37 NHS QIS National Audit Cardiac Rehabilitation Data Measures Since 2007, a group of healthcare professionals representing cardiac rehabilitation teams throughout Scotland have been meeting to develop a national minimum dataset based around a patient record. When discussed with the wider cardiac rehabilitation community in April 2008, there was consensus that this was a useful undertaking and providers were keen to be involved. Many cardiac rehabilitation providers in Scotland have previously contributed to the National Audit of Cardiac Rehabilitation (NACR) hosted in York and supported by the British Heart Foundation. In order to be able to support sites to continue or begin to contribute to the NACR audit, an interim data collection system has been devised. Service providers without an electronic system will be offered a paper based proforma for each patient containing: The minimum dataset The embedded data items that are required to support the NHS QIS national audit. Once completed, the proforma or results collated from existing electronic systems will be returned to NHS QIS who, together with ISD, will oversee the processing of the full dataset. Results will be made available to sites to allow them to use the information locally and to make a contribution to the NACR. A computerised system to support this patient record is being endorsed and procured for national use. It is anticipated that this new electronic system will be available later in The dataset and definitions are provided within this section. In addition, a number of primary care measures will also need to be assessed. These will be achieved by interrogating the data available through the QOF based on the 8 CHD QOF measures.

38 NHS QIS National Audit Cardiac Rehabilitation Data Measures MCNs will be asked to provide the following information about ALL patients seen by cardiac rehabilitation teams. This will be achieved by interrogation of the proforma / database information in order to determine the proportion (%) of ACS, CABG, PCI, patients with new onset or worsening angina: Assessed for cardiac rehabilitation Receiving a menu based out-patient cardiac rehabilitation programme including: - An exercise programme including risk stratification and functional assessment with access to a long term exercise programme - Formal assessment of anxiety and depression - Psychological and educational interventions targeted at individual needs - Access to staff with specialist training in cognitive behaviour therapy and motivational interviewing At completion of out-patient cardiac rehabilitation programme: - Eating 5 or more portions of fruit and vegetables per day - Participating in at least 30 minutes of physical activity 5 times per week - Not smoking (in previous smokers) - With a systolic BP below 140mmgHg (SIGN 97 secondary prevention goal) - Prescribed aspirin, clopidogrel (where indicated), ACEi/ARB, beta-blocker and statin In addition, information will be extracted from local QOF data for each MCN to review in relation to the standard. These data will provide an overview of the long term management of CHD patients in primary care. Measures will include the proportion (%) of... Local population on primary care CHD registers corrected for background CHD mortality figures Patients on CHD register currently on: - Asprin or similar drug, or contraindicated - ACEi - Beta-blocker CHD patients with cholesterol <5mmol/l recorded within the last 15 months CHD patients with BP recorded 150/90 or less within the last 15 months CHD patients receiving flu immunisation between Sept March 08 (or declined)

39 How will Data about Cardiac Rehabilitation be Collected? MCNs will be provided with a supply of pre-printed proforma on which to record data in May You are advised to take the first few weeks to trial the proforma ensuring that staff are familiar in its use You are asked to collect data relating to ALL PATIENTS as from the 1st June 2009 Data will be collected on: This data will be collated and made available for local use It will also be used to contribute to the UK audit Attach proforma to patient record - it should remain at the front of the patient record until discharge Photocopy completed proforma, retain photocopy in patient record Return original proforma to NHS QIS in provided envelopes after deleting (blocking out all patient identifiers, including CHI). Completed forms should be returned in batches at the end of each month NHS QIS will analyse all data returned up to 20th September 2009 for the first cycle, and, all data returned by 1st March 2010, for the second cycle. Q. When should data collection start? A. Start to complete the proforma once you are sure staff are confident in its use and by 1st June 2009 at the latest. Q. How long should data be collected for? A. This is a continuous audit so data should be collected until further notice. Q. Who should complete the proforma? A. Responsibility for ensuring the completeness of the proforma lies with the healthcare professional with responsibility for the patient at time of discharge. Q. What will happen to the data? A. The data from the completed forms will populate a database. This will be analysed by ISD and made available to MCNs. It will also be used to contribute to the NACR audit. MCNs will be able to review their own aggregated data before it is shared with NACR.

40 Cardiac Rehabilitation: Appendix 1 Data Collection Form

41 Cardiac Rehabilitation: Appendix 1 Data Collection Form

42 Cardiac Rehabilitation: Appendix 1 Data Collection Form

43 Cardiac Rehabilitation: Appendix 2 Data Definitions Hospital Code 5 digit code assigned to hospital provider e.g. 5123H. Current Gender Definition: A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned). Other specific Not specified The person has a clear idea of what their gender is, but it is neither discretely male nor female, e.g. intersex, transgender, third gender. The person is unable to specify their current gender or does not have a clear idea of what their current gender is. Reason for no referral Definition: Explanation for why an intervention was not performed where it might be expected to be, e.g. when clinical guidelines recommend it should be performed. Contraindicated Not indicated Clinical decision Not available Generally acknowledged clinical contraindication exists e.g. severe co-morbidity No clinical indication for intervention Clinical judgement of inappropriateness of intervention in an individual patient due to their specific set of circumstances. Intervention is not available Not applicable Not disclosed Patient chose not to have intervention Not known Referred for specialist intervention Definition: A record of any non-routine specialist intervention(s) to which the patient has been referred for reasons unrelated to the original referral for cardiac rehabilitation and over and above the routine input from the cardiac rehabilitation team. Physiotherapist Occupational Therapist Dietician Clinical Psychologist Social Work Cardiologist Community Nursing Specialist Vocational Advice Self Help Group Secondary Prevention Clinic Sexual Dysfunction Advice Other Not known Referred to a physiotherapist for a non-cardiac reason Referred to a occupational therapist for a non-cardiac reason Referred for specialist dietetic input Referred for specialist psychological treatment This includes home help Referred back to a cardiologist for ongoing cardiac problems Referred to community nursing for a non cardiac reason Advice about returning to work Referred to a community secondary prevention clinic in primary care Referred to GP, specific sexual dysfunction clinic or specialist organisations such as Relate

44 Cardiac Rehabilitation: Appendix 2 Data Definitions Exercise Risk Stratification (Cardiac Rehabilitation) Definition: A record of the patient s risk stratification for exercise. Low - No significant LV dysfunction (EF > 50%) - No resting or exercise-induced complex dysrhythmias - Uncomplicated MI; CABG; PCI - absence of CHF or signs/symptoms indicating post-event ischaemia - Normal haemodynamics during exercise and recovery - Asymptomatic including absence of angina with exertion or recovery - Functional capacity > 7.0 METs* - Absence of clinical depression - Lowest risk classification is assumed when each of the risk factors in the category is present Moderate - Moderately impaired left ventricular function (EF = 40-49%) - Signs/symptoms including angina at moderate levels of exercise (5-6.9 METs) or in recovery - Moderate risk is assumed for patients who do not meet the classification of either highest risk or lowest risk High - Decreased LV function (EF <40%) - Survivor of cardiac arrest or sudden death - Complex ventricular dysrhythmias at rest or with exercise - MI or cardiac surgery complicated by cardiogenic shock. - CHF, and/or signs/symptoms of post-procedure ischaemia - Abnormal haemodynamics with exercise (especially flat or decreasing systolic blood pressure or choronotropic incompetence with increasing workload) - Signs/symptoms including angina pectoris at low levels of exercise (< 5.0 METS) or in recovery - Functional capacity < 5.0 METS* - Clinically significant depression - Highest risk classification is assumed with the presence of any one of the risk factors included in this category

45 Section 8: Atrial Fibrillation

46 NHS QIS National Audit Atrial Fibrillation Data Measures The majority of data measures within the Atrial Fibrillation (AF) dataset can be sourced through primary care, general practice computerised systems as they are routinely collected as part of the Quality and Outcomes Framework of the General Medical Services Contract. A search tool has been developed that will identify appropriate patients with AF and extract the required data directly into a spreadsheet/database format. The search tool is available for a variety of systems, and will be sent to MCNs to distribute to general practices in their locality. The data tool will extract the following information about the proportion (%) of patients with AF: Having had an ECG With a referral to cardiology With a documented record of Stroke risk in their case record (e.g. NICE 36 stroke risk stratification algorithm or CHADS2) Currently receiving aspirin Currently receiving warfarin Not on antithrombotic therapy with a reason / contraindication documented in their case record With a documented measurement of blood pressure With a documented measurement of TFTs May-June 2009: General Practice Recruitment It will be the responsibility of MCNs to recruit general practices. We strongly advise that recruitment starts as soon as possible. Information about the demographic and deprivation profile of general practices taking part will be required from MCNs. For MCN populations in excess of 250,000 and served by more than 50 general practices, data will be required from: a minimum of 20% of general practices from the area the general practices should represent the range of practices found in the area in terms of socio-economic deprivation, geographical setting i.e. urban and rural and overall size of practice For MCN populations of less than 250,000 and /or served by 50 or fewer general practices: MCNs are asked to contact NHS QIS to determine the exact size of sample required. mel.miller@nhs.net or

47 How will Data about Atrial Fibrillation be Collected? Electronic search and full instructions issued via to MCNs by 1st June 2009 Identified Practices run search as outlined (5 mins) We suggest that this search is run at the same time as the heart failure search The search will identify all patients with a diagnosis of Atrial Fibrillation seen within the time parameters set Populated Spreadsheets/Databases DUE BACK date by: First Cycle: 28th July 2009 Second Cycle: 28th February 2010 Q. When should the search be run? A. We suggest that you run the search towards the end of June 2009 for the first cycle and during the first two weeks of February 2010 for the second cycle. Q. How will practices do this? A. When we send out the electronic search, we will provide detailed information for practices as to how to execute the search and what to do with the results. Q. Will this be time consuming for practice staff? A. Not at all, the search will take less than one minute to run. Results will automatically populate a spreadsheet/ database. Q. How secure is the data? A. The spreadsheet does not contain any patient identifiable information, just the location of its source. It can then be very safely ed to NHS QIS via the secure nhs.net. We have made significant efforts to ensure that this method does not compromise patient confidentiality in any way.

48 Section 9: Patient Involvement

49 Patient Involvement In common with NHS services throughout the rest of the United Kingdom, Scottish health policy aims to embed patient experience information in improving and assessing the performance of NHSScotland. We will be working with patients, voluntary organisations, clinicians and the Better Together Programme to progress this element of our work. Traditionally, the productivity of services has been measured by indicators that might be better thought of as inputs, numbers of procedures carried out, numbers of consultations and admissions etc. In 2005, The Office of National Statistics commissioned a review of public service performance that highlighted the scope for patients and users to report judgements of outcome in relation to health services. The enormous array of patient-reported outcome measures that have been developed over the last thirty years offer a clear opportunity to involve patients and users directly in judgements of the outcomes of services. As part of the NHS QIS CHD Improvement Management Programme, we will be developing and piloting Patient Reported Outcome Measures (PROMs) during 2009 and into

50 Section 10: Programme Evaluation

51 Programme Evaluation As previously stated, this programme represents a new direction for NHS QIS. It will be important to ensure that aims are achieved, that it is fit for purpose and acceptable. Evaluation will therefore be continuous and multi-faceted and include: Aspect of Evaluation Determining the relevance of standards Testing the appropriateness of the measures Ascertaining the validity of the approach to and method of data collection Establishing a mechanism through which the Scottish Patient Safety Programme measures are achieved Achieved through/by - Consultation with healthcare professionals, patients and the wider public - Piloting in two NHS boards - Cross referencing against both the draft and final standards - Establishing the extent to which primary care measures are supported by the QOF, and, as required, use these results to influence the current QOF review process - Establishing the extent to which the methods chosen actually procure the measures i.e. the completeness of returned datasets - Establishing the extent to which the means of data collection actually supports the process i.e. fitness for purpose of electronic searches, SCI CHD-ACS and cardiac rehabilitation system - Feedback from pilot sites to determine the feasibility, acceptability and relevance of the approach i.e. can criteria not currently included in the national audits be assessed qualitatively or are additional measures required - Feedback will be sought from all MCNs after the first cycle - Feedback will be sought from steering group members and NHS QIS internal support team - Ascertaining the extent to which the SPSP measures can be reliably provided as a by-product of the overall measures Determining the quality of care being delivered to patients with CHD in Scotland - The quality of care being delivered in relation to the standards alongside the national and local audit results Establishing evidence in relation to continuous improvement Confirming the sensitivity of the final indicators Providing an overall evaluation of the programme approach - Comparing the results achieved between the first and second cycles of audit - Evidence that MCNs have action plans in place to address issues identified as local priorities - Evidence that MCNs have action plans that embrace a range of improvement methodologies - Mapping the final indicators to the supporting measures and underpinning standards - Evidence that MCNs are using the indicators to identify local priorities - Ensuring that systems are in place that support data collection, local analyses and national monitoring - All of the above will be considered prior to producing an overall evaluation report with key lessons for future activity

52 Section 11: Managed Clinical Network Accreditation

53 Managed Clinical Network Accreditation Accreditation is the process whereby the MCN quality assurance programme is formally assessed and approved. It specifically has three components to support improvement in the quality of care; Implement the core principles set out in HDL (2007) 21 Establish agreed standards based on existing national standards Performance assessment and monitoring arrangements. As stated in HDL (2007) 21, arrangements for the accreditation of local MCNs sits with their parent NHS board and the adoption of the NHS QIS standards is central to accreditation. Although NHS QIS will not be directly involved in this local NHS board accreditation process, external scrutiny of local arrangements will be undertaken by NHS QIS as part of future clinical governance and risk management reviews. It is envisaged that longer term implementation will be monitored by NHS QIS through the on-going reporting of compliance against the limited set of core indicators. If required, further exploration will be initiated in association to the MCN and its parent board. These arrangements will be confirmed after consideration of the appropriateness and relevance of the overall approach. Further guidance for the accreditation of MCNs is available on request. MCN Accreditation Diagram MCN Quality Assurance Programme Core Principles 1. Clear management arrangements and leadership of the MCN 2. A defined MCN structure 3. MCN annual work plan 4. Documented evidence base 5. MCN constitution is multi-disciplinary and multi-professional 6. Patient focused 7. MCN quality assurance programme 8. CPD for MCN professionals 9. Better value for money Standards 1. Existing NHS QIS national standards 2. NHS QIS clinical governance and risk management standards 3. Other applicable existing standards Quality Assurance 1. MCN Annual reports 2. Self Assessment tool 3. MCN Accreditation

54 Section 12: Improvement Methodologies

55 Improvement Methodologies Embedding Continuous Improvement As part of the overarching CHD programme, NHS QIS is looking to promote continuous improvement of CHD services across Scotland. NHS QIS advocates and supports the use of a number of improvement methodologies both available to and / or in use throughout Scotland. A recently published systematic narrative review of the literature of quality improvement models within healthcare 2 identified the evidence associated with these models. Foremost among these are Total Quality Management (TQM), Continuous Quality Improvement (CQI), Business Process Reengineering (BPR); rapid cycle change; lean thinking and Six Sigma. The review concluded that all had their place and could provide evidence of good effect. The success of the intervention depends crucially on the interaction between the local context and the approach as it is adopted. Whilst acknowledging these different approaches, NHS QIS is working closely with the IHI and the Improvement Support Team (IST) at the Scottish Government Health Directorate (SGHD). We will be encouraging MCNs and NHS boards to further develop their approach to improvement using methodologies most appropriate to their local context and utilize the range of support mechanisms available. With regard to CHD, we would like to see the introduction / development of improvement approaches beginning after the first round of audit has been completed in September. We recognise that you may wish to make use of the data submitted for the audits rather than wait for formal feedback to identify any areas of practice within your MCN that may benefit from further attention. Networks may also wish to determine the mechanisms for deciding which areas to concentrate on, in the first instance, rather than trying to tackle a number of projects simultaneously. With the expansion of the SPSP programme to include elements of CHD we would strongly recommend that MCNs make use of improvement methodologies such as those outlined above. Work in this area could be initiated by deploying small cycles of change at local, possibly even at ward level, and testing them out in terms of sustainability and compliance before trying to implement them more widely. We have included, in the following pages, material relating to the Institute of Healthcare Improvement PDSA approach. You may wish to contact the SPSP coordinator in your NHS board or a member of the IST to help you get started and their contact details have also been included for information in the 'Contacts section. In addition, you might like to draw on the experience of colleagues in other areas of the organisation who have already been involved in improvement activities as part of the wider SPSP programme. In February, NHS QIS ran an introductory workshop to IHI methodologies. As part of the ongoing support for the Programme a further event will be hosted in the autumn which will again be facilitated by IHI/SPSP colleagues. The event will provide you with the opportunity to share with CHD colleagues the work you have been undertaking over the summer and at the same time act as a forum for looking at issues and concerns and how these have been addressed. Details of the event have yet to be determined but we will notify Networks in advance in order that as many people as possible can attend. 2 NHS Quality Improvement Scotland. A systematic narrative review of quality improvement models in health care. Powell AE, Rushmer RK, Davies HTO: University of Dundee and St Andrews, 2009

56 Using the Model for Improvement The Model for Improvement* is a simple yet powerful tool for accelerating improvement. It has two parts: 3 fundamental questions that can be answered in any order The PDSA cycle to test and implement changes What changes can you make that will result in improvement? All improvement requires change, but not all changes result in improvement. Testing Change The PDSA cycle is shorthand for testing a change in the real work setting by planning it, trying it, observing the results and acting on what is learned. Plan List the tasks needed to set up the test of change. Predict what will happen when the test is carried out. Determine who will run the test. Do Run the test. Document what happened when you ran the test. Describe problems and observations. Study Describe the measured results and how they compared to predictions. Act Determine what your next PDSA cycle will be, based on your learning. When using the model you should consider the following: * The Model for Improvement was developed by Associates in Process Improvement and is used by IHI. Langley GL, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A practical Approach to Enhancing Organizational Performance. What are you trying to accomplish? Your aim should be time-specific and measurable; it should also define the specific population of patients that will be affected. How will you know your change is an improvement? Use quantitative measures and qualitative learning to determine if a change actually leads to an improvement. Communications toolkit: Patient safety tool: version 1 (April 2009)

57 Model for Improvement The Improvement Guide, Associates in Process Improvement (API) Communications toolkit: Patient safety tool: version 1 (April 2009)

58 PDSA Worksheet for Testing Change Aim Describe your first (or next) test of change: Person Responsible When to be done Where to be done Every goal will require multiple smaller tests of change Plan List the tasks needed to set up this test of change: Person Responsible When to be done Where to be done Predict what will happen when the test is carried out: Measures to determine if prediction succeeds Do Describe what actually happened when you ran the test: Study Describe the measured results and how they compared to the predictions: Act Describe what modifications to the plan will be made for the next cycle from what you learned: Communications toolkit: Patient safety tool: version 1 (April 2009)

59 Tips for Measurement for Quality Improvement How will we know that a change is an improvement? Answering this question usually requires more than one measure. A balanced set of five to eight measures will ensure that the system is improved. Three types of measures: - Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result? Outcome measures will most likely lag behind process measures. - Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned? Process measures will start to move first. - Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)? Monitoring balancing measures; you are not looking for movement (pay attention if there is movement). Measurement Guidelines: A few key measures that clarify a team s aim and make it tangible should be reported, and studied by the team, each month. Be careful about over-doing process measures for monthly reports. Make use of available databases to develop the measures. Integrate data collection for measures into the daily routine. Plot key measures on an annotated run chart monthly during the life of the project. Integrate Data Collection for Measures into Daily Work: Include the collection of data with another current work activity. Develop an easy-to-use data collection form or make Information Systems input and output easy for clinicians. Clearly define roles and responsibilities for on going data collection. Set aside time to review data with all those that collect it Measurement Data Collection during PDSA Cycles: Collect useful data, not perfect data - the purpose of the data is learning, not evaluation. Use a pencil and paper until the information system is ready. Use sampling as part of the plan to collect the data to reduce workload. Use qualitative data (feedback) rather than wait for quantitative data. Record what went wrong during the data collection process. Minutes Huddles tried Cycle Time in Office Nurses start early Lab changes Patient moved into rooms ASAP 6/12 7/12 8/11 9/10 10/10 11/9 Communications toolkit: Patient safety tool: version 1 (April 2009)

60 Leadership Driver Diagram Outcome Primary Drivers Secondary Drivers Provide the Leadership system to support the implementation of safety and quality outcomes in your Board. Develop the infrastructure to support quality and safety improvement Provide oversight to programme Establish an SPSP Implementation Committee Ensure a feedback mechanism for issues raised in walk-rounds Ensure the development of a measurement system used to understand and drive patient care quality and safety indicators Assign a senior leader to each improvement area (critical care, general ward, medicines management and peri-operative care) Meet with Programme Manager remove barriers Meet regularly with SPSP Implementation Committee to track progress and remove barriers Display the Gantt chart that depicts the progress towards SPSP goals Promote the position of safety and quality in the organisation Ensure that the senior team participates in walkrounds Place safety and quality issues at the top of senior leader meeting agendas Add SPSP progress and outcomes to the Board agenda The Institute for Healthcare Improvement Communications toolkit: Patient safety tool: version 1 (April 2009)

61 Critical Care Driver Diagram Outcome Primary Drivers Secondary Drivers Provide appropriate, reliable and timely care to critically ill patients using evidencebased therapies Reduce complications from ventilators Reduce complications from central venous catheters Optimal glucose control Prevent healthcare associated infections and cross contamination Proper sepsis recognition and treatment Improve Critical Care outcomes (reduce mortality, infections and other adverse events) Integrate patient and family into care so they receive the care they want Involve patient/family in daily goal setting process Promote open communications among team and family Ensure clarification of care wishes and end of life care planning Develop an infrastructure that promotes quality care Ensure appropriate infrastructure and leadership to provide consistent, reliable, evidence based care Improve ICU throughput Ensure competent staff with knowledge in improvement work Create a highly effective and collaborative multidisciplinary team and safety culture Reliable care planning, communication and collaboration of a multidisciplinary team The Institute for Healthcare Improvement Communications toolkit: Patient safety tool: version 1 (April 2009)

62 General Ward Driver Diagram Outcome Primary Drivers Secondary Drivers Provide appropriate, reliable and timely care to patients using evidence-based therapies Early warning system (EWS) to identify patient deterioration Early response system Outreach of Rapid Response Team (RRT) to respond to deterioration Prevent healthcare associated infections Prevent pressure ulcers Deliver reliable evidencedbased care to CCHF and MI patients Improved General Ward outcomes (reduced infections, crash calls, pressure ulcers, AE in CHF and AMI patients) Create a highly effective and collaborative multidisciplinary team and safety culture Ensure patient and family centred care Reliable care planning, communication and collaboration of a multidisciplinary team Involve patient/family in goal setting process Promote open communication among team and family Ensure clarification of care wishes and end of life care planning Ensure patient s physical comfort Develop an infrastructure that promotes quality care Optimise transitions to home or other facility (CHF, MI) Optimise flow and efficiency in admission process, handoffs, discharge process, routine care for high volume clinical conditions (CHF, MI) The Institute for Healthcare Improvement Communications toolkit: Patient safety tool: version 1 (April 2009)

63 Medicines Management Driver Diagram Outcome Primary Drivers Secondary Drivers Provide safe and effective Medicines Management (reduce adverse drug events: r/t high risk processes and medicines e.g. medicines at the interface, anticoagulation) Reliable Medicines Management Processes Coordination of care Use standardised protocols and algorithms for high risk meds Routine and reliable patient and laboratory monitoring Identify high-risk areas using FMEA Pharmacy consultation service Identify patients at risk with high-alert medications Standardise recovery protocols (e.g. opiate oversedation) Accuracy of medicines at the interface One stop delivery system Reliable in-hospital handoffs Communication with primary care High risk medicines management services Patient and family involvement Patient and family education Self management protocols The Institute for Healthcare Improvement Communications toolkit: Patient safety tool: version 1 (April 2009)

64 Peri-operative Driver Diagram Outcome Primary Drivers Secondary Drivers Improved Peri-operative outcomes (reduced peri-operative adverse events: infections, cardiovascular events) Provide appropriate, reliable and timely care to patients using evidence-based therapies to prevent surgical site infections Create a team culture attuned to detecting and rectifying intra-operative errors Prevent Surgical Site Infection Ensure proper prescribing and administration of prophylactic antibiotics If at all possible avoid hair removal; if hair removal is necessary, avoid the use of razors Maintain normal blood glucose level (for known diabetic patients) Ensure normal body temperature (excludes cardiac patients) Use Briefings Use standard intraoperative procedures to prevent AEs Undergo team training Maintain team focus during surgery Have responses to intraoperative adverse events ready Provide appropriate, reliable and timely care to patients using evidence-based therapies to prevent peri-operative cardiovascular events Identify patients at risk DVT prophylaxis Continuation of beta blockers The Institute for Healthcare Improvement Communications toolkit: Patient safety tool: version 1 (April 2009)

65 Your SPSP extranet The extranet is an online area hosted by The Institute for Healthcare Improvement (IHI), and used by staff working on SPSP. The extranet lets you: measure improvement report your fi ndings track changes using the advanced graphing features share the learning you gained by testing. Collaboration between NHS board teams is encouraged through communication services such as: discussion groups news postings listserve for SPSP the communications centre. How to access the extranet The SPSP extranet is located within the IHI. org website at To access it you need an assigned team role and IHI.org membership. To get your SPSP role: contact your NHS board s Programme Manager and ask to be assigned a role. To register with IHI.org: visit follow the Register with IHI.org button join the IHI.org community free of charge Features of the extranet Centralised resource to keep up to date with current SPSP activities and communications Resources section holds a vast amount of information from call schedules, past learning session materials and handouts, workstream specifi c examples from teams, and access to team pages Separate workgroup access, such as the VAP workgroup or WalkRounds Workgroup Search feature that lets you fi nd your colleagues contact information Monthly reports data Discussion group feature It is free to join IHI.org and as a member you can access many special features available only to registered users. For security reasons, only the Programme Manager from your NHS board can give you your extranet role. Communications toolkit: Patient safety tool: version 1 (April 2009)