Quality Indicators for Primary Care Out-of-Hours Services. July Evidence

Quality Indicators for Primary Care Out-of-Hours Services July 2012 Evidence

Healthcare Improvement Scotland is committed to equality. We have assessed these quality indicators for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Officer on 0141 225 6999 or email contactpublicinvolvement.his@nhs.net Healthcare Improvement Scotland 2012 ISBN 1-84404-612-5 First published July 2012 The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document s date and title specified. www.healthcareimprovementscotland.org

Contents Foreword 3 1 Introduction 4 2 Development of the quality indicators for primary care out-of-hours services 5 3 Primary care out-of-hours services patient journey 8 4 Format of the quality indicators for primary care out-of-hours services 9 5 Quality indicators for primary care out-of-hours services 10 Indicator 1: Response times 10 Indicator 2: Accuracy of triage for home visits 12 Indicator 3: Effective information exchange 13 Indicator 4: Implementing national clinical standards and guidelines 15 Indicator 5: Antimicrobial prescribing 17 Indicator 6: Patient experience 18 6 Driver diagram and suggested change concepts and change ideas for primary care out-of-hours service improvement 20 Appendix 1: Appendix 2: Membership of the primary care out-of-hours services expert group 30 Membership of the primary care out-of-hours services expert group patient experience subgroup 31 Appendix 3: About Healthcare Improvement Scotland 32 Appendix 4: References 34 2

Foreword The Healthcare Quality Strategy sets out ambitious commitments for making quality the organising principle of the NHS in Scotland. In line with these quality ambitions, the Scottish Government commissioned Healthcare Improvement Scotland to develop a set of national indicators that support the delivery of safe, effective, responsive and personcentred primary care out-of-hours services. Out-of-hours medical services are a fundamental part of the healthcare service in Scotland. The service provides support to those who require medical assistance outwith normal GP surgery hours. It involves a number of agencies and healthcare professionals working together to provide an integrated service for patients. The quality and safety of out-ofhours care is extremely important and patients should have access to consistent, high quality standards of care across the country. By using these indicators to measure performance and implementing the suggested change concepts and change ideas, out-of-hours providers will: identify areas of good practice highlight potential quality concerns identify areas that need further study and investigation, and track measurable improvements over time. The next phase of the project will be to develop support packages to help NHS boards use these indicators to improve patient care. We would like to thank all those who have given their time to support the development of these indicators, particularly the Expert Group, the National Out-of-Hours Operations Group, Information Services Division and staff at the two test sites of NHS Greater Glasgow and Clyde, and NHS Highland. Finally, we would like to thank all those working in the delivery of out-of-hours services across Scotland who were willing to share their knowledge and experience so freely with the Healthcare Improvement Scotland team. Brian Robson Executive Clinical Director Healthcare Improvement Scotland Laura Ryan Chair National Out-of-Hours Operations Group 3

1 Introduction Primary care out-of-hours services From 1 April 2004, the Primary Medical Services (Scotland) Act 2004 1 placed a duty on NHS boards to provide primary medical services for everyone living in the NHS board area. These are the services GP practices provide to patients registered with them. NHS boards have a legal responsibility to ensure these services are provided at all times, including out-of-hours. The out-of-hours periods are: Monday to Thursday from 6.30pm until 8.00am a the following day Friday from 6.30pm until 8.00am the following Monday, and Christmas Day, New Year s Day and other public or local holidays. Since 2004, GPs have had the option of continuing to provide a service during the out-ofhours period or to opt out of providing this service on condition that there is an acceptable alternative. Over recent years, alternative arrangements for providing out-of-hours care have been established. In many cases, this involves a number of agencies and healthcare professionals working together to provide an integrated service for patients. Figure 1: Providers of healthcare services out-of-hours b a The out-of-hours period is subject to local variation. b In some areas, it should be noted that many of these services are co-located or can be provided by one service. 4

2 Development of the quality indicators for primary care out-of-hours services Background In response to the requirements of the Primary Medical Services (Scotland) Act 2004, NHS Quality Improvement Scotland (now Healthcare Improvement Scotland) published the Standards for The Provision of Safe and Effective Primary Medical Services Out-of-Hours 2 in August 2004. At a time when new arrangements for providing medical care out-of-hours were being established, the standards focused on the infrastructure considered necessary to support the development of safe and effective services. Since then, primary care out-of-hours services have continued to develop, changes in policy have taken place and an emphasis on improvement in the quality of healthcare services has increased. Following an inquiry in 2010 by the Health and Sport Committee into out-of-hours healthcare provision in rural areas 3, the Scottish Government asked Healthcare Improvement Scotland to: review the standards, and develop a set of national quality indicators for primary care out-of-hours services. The purpose of the quality indicators is to support the delivery of consistent care and enable continuous improvement within local primary care out-of-hours services. The indicators accompany and augment the existing standards. Developing the quality indicators The quality indicators for primary care out-of-hours services have been developed by an expert group established by Healthcare Improvement Scotland. Membership of the expert group and patient experience subgroup is provided in Appendices 1 and 2, respectively. The quality indicators cover the following areas; response times accuracy of triage for home visits effective information exchange implementing national clinical standards and guidelines antimicrobial prescribing, and patient experience. These areas of focus are based on patient needs and expectations. They were identified by consideration of the journey undertaken by individuals contacting primary care out-ofhours services. The quality indicators are measurable elements of practice within these key stages of the patient journey that can be used to assess and continuously improve the quality of primary care out-of-hours services. The approach used to develop the quality indicators is based on the principles of The Improvement Guide 4 and that the indicators will influence changes in local services to improve care, and that these improvements will be measurable using the indicators. This reflects the Scottish Government s requirement that the quality indicators enable continuous improvement within local services, in line with the philosophy of The Healthcare Quality Strategy for NHSScotland 5 to improve the quality of healthcare across Scotland. 5

To support the implementation of the Healthcare Quality Strategy, the quality indicators are aligned with the three quality ambitions specified within the strategy and the Institute of Medicine s six dimensions of healthcare quality 6, on which the quality ambitions are based, as detailed below. The quality ambitions: 1. Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. 2. There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times. 3. The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. The dimensions of healthcare quality: person-centred safe effective efficient equitable, and timely. Testing phase Healthcare Improvement Scotland launched a testing phase for the draft quality indicators in September 2011, working with colleagues from out-of-hours services in NHS Greater Glasgow and Clyde, and NHS Highland. The testing phase included events held in September 2011, October 2011 and February 2012 with NHS board representatives and other stakeholders, leading to: the collection of quality indicator data the identification of areas for improvement within their local services the identification of potential change concepts and change ideas that could be tested within their services, and a move away from auditing the out-of-hours service to using data to improve local services, ensuring patients have the best possible experience. In recognition of those patients with specific palliative and /or end-of-life care needs, Healthcare Improvement Scotland will work in collaboration with the Scottish Government, the Living and Dying Well team and primary care out-of-hours services to develop indicators in this area, for completion by October 2012. 6

Data collection Data to evidence the indicators were explored during indicator development and testing. It is recognised that there remains significant variation in how data are collected and used, and more work is required locally and nationally to address this. Information Services Division (ISD) has undertaken work to assess: what data are collected the commonalities in data recording between primary care out-of-hours services, and data linkages with other unscheduled healthcare information. This work is ongoing, and it is acknowledged that out-of-hours data remains a gap in unscheduled healthcare information. All 14 territorial NHS boards in Scotland use the Adastra out-of-hours patient management system, following its adoption by NHS Tayside, NHS Borders and NHS Forth Valley in April 2012. Whilst Adastra has the potential to help local and national data collection against the quality indicators for primary care out-of-hours services, there is wide variation in its use for data collection. It should be noted that NHS boards initially agreed separate contracts for Adastra, and many of these are extant. As these individual contracts end, NHS boards will move towards one NHSScotland-wide contract for Adastra. This offers opportunity to source some supporting data as a by-product of care from this system. This will be further explored with Adastra. Who do these quality indicators apply to? The quality indicators apply to: all patients using primary care out-of-hours services in Scotland all territorial NHS boards in Scotland with responsibility for delivering primary care out-of-hours services NHS 24 where its service interfaces with primary care out-of-hours services, and all primary care out-of-hours services whether directly provided by an NHS board or secured on behalf of the NHS board. The quality indicators do not apply to: emergency services provided by the Scottish Ambulance Service and NHS board accident and emergency services emergency and/or out-of-hours dental services minor injuries units, and NHS organisations that do not deliver primary care out-of-hours services, including Healthcare Improvement Scotland, NHS Education for Scotland and NHS Health Scotland. 7

3 Primary care out-of-hours services patient journey As noted in Section 2, the areas of focus of the quality indicators are based on patient needs and expectations, as identified by consideration of the usual journey undertaken by individuals contacting primary care out-of-hours services. Figure 2 below, sets out this patient journey, showing the key stages in terms of patient needs and expectations, and the indicators primary care out-of-hours services will use to assess how well they meet these patient needs and expectations, ultimately leading to optimal clinical outcomes and the best possible patient experience. Figure 2: Primary care out-of-hours services patient journey A patient accesses the primary care out-of-hours service via telephone call to NHS 24 Indicator 1 Response times 1.1 Proportion of calls to NHS 24 answered within 30 seconds by an NHS 24 call handler. 1.2 Proportion of home visit cases where a clinician arrives at the destination of care within the timescale recommended by triage. 1.3 Volume and proportion of 1, 2 and 4-hour home visit referrals. Indicator 3 Effective information exchange 3.1 Proportion of primary care out-of-hours consultations during which the patient s electronic care summary (ECS) is accessed. 3.2 Proportion of primary care out-of-hours consultations with patients registered with a GP within the same NHS board for which consultation information is provided to their GP by 8.30am the following working day. 3.3 Proportion of primary care out-of-hours consultations resulting in admission to acute care for whom referral information is provided at the time of referral. The patient s telephone call is answered promptly. The patient is triaged according to clinical need. The patient is seen by an out-of-hours clinician without undue delay. The out-of-hours clinician has access to the patient s relevant medical history. National clinical guidelines are reliably implemented. The record of the patient s out-of-hours consultation is transferred to other NHS services as appropriate. Optimal clinical outcomes Best possible patient experience Indicator 2 Accuracy of triage for home visits 2.1 Proportion of clinically accurate 1, 2 and 4-hour home visit referrals. Indicator 4 Implementating national clinical standards and guidelines 4.1 Proportion of patients with a suspected or confirmed diagnosis of asthma assessed in line with current national standards and guidelines. 4.2 Proportion of patients with a suspected diagnosis of stroke assessed in line with current national standards and guidelines. Indicator 5 Antimicrobial prescribing 5.1 Proportion of prescriptions of antimicrobial medications that are for high risk antimicrobial medications (cephalosporins, quinolones and co-amoxiclav). Indicator 6 Patient experience 6.1 Proportion of primary care out-of-hours service patients who provide feedback on their experience. 6.2 Proportion of primary care out-of-hours service patients who provide feedback and report a positive experience. 6.3 Proportion of palliative care patients who provide feedback and report a positive experience. 6.4 Proportion of complaints received from primary care out-of-hours service patients. 6.5 Proportion of complaints received from primary care out-of-hours service patients that are upheld. 8

4 Format of the quality indicators for primary care out-of-hours services Title What we are trying to achieve. Indicator 2: Accuracy of triage for home visi Indicator 2 consists of a measure of the clinical accuracy of patients who receive a home visit from a primary care out- Proportion of clinically accurate* 1, 2 and 4 Indicator The information required to demonstrate progress. *Clinically accurate is defined as agreement hours services that the NHS 24 nurse advis based on the information available to the n (provided by the patient or third party on th Rationale The initial access point to primary care out-of-hours servic by telephoning NHS 24. People are assessed by telephone subsequent referral to a primary care out-of-hours service, the individual s problem. Rationale The reason why this indicator is considered important. Referrals can include a request for a home visit and are prio 4-hour requests. Accurate prioritisation of home visit reque this creates specific demands on the primary care out-of-ho The purpose of this indicator is to determine that : NHS 24 accurately prioritises the home vist requests for Measuring this element of NHS 24 and primary care out-o that: the most unwell people are seen urgently, and people using the service have the best possible experien This indicator may also provide data relating to the standar Patients are assessed and responded to, b professional judgement. Measurement How information is collected to demonstrate performance against the indicator. Numerator The top number of a fraction or proportion. Denominator The bottom number of a fraction or proportion. Data source Where to obtain information for measurement. How to measure this indicator Number of clinically accurate 1, 2 and 4-h Total number of home visit requests mad Data source Manual data collection sampling, as described under on pages 23-24 of this document. 9

5 Quality indicators for primary care out-of-hours services Indicator 1: Response times Indicator 1 consists of three measures of response times for patients contacting primary care out-of-hours services. Indicator 1.1 Proportion of calls to NHS 24 answered within 30 seconds by an NHS 24 call handler. Indicator 1.2 Proportion of home visit cases where a clinician arrives at the destination of care within the timescale recommended by triage*. *Start time is defined as the time the request for a home visit is received by the primary care out-hours service from NHS 24. Indicator 1.3 Volume and proportion** of 1, 2 and 4-hour home visit referrals. **Both volume and proportion of 1, 2 and 4-hour home visit referrals will offer context when considering the results for indicator 1.2, as a change in either has the potential to affect the resource required to meet the timescale recommended by triage. Rationale The initial access point to primary care out-of-hours services for the majority of users is by telephoning NHS 24. People are assessed by telephone and NHS 24 prioritises any subsequent referral to a primary care out-of-hours service, according to the seriousness of the individual s problem. Referrals can include a request for a home visit, which are prioritised by NHS 24 as 1, 2 or 4-hour requests. Home visits place particular demands on the primary care out-of-hours service. The purpose of this indicator is to determine: if people accessing primary care out-of-hours services through NHS 24 have their call answered promptly if people, for whom a home visit has been requested by NHS 24, are seen within the recommended timescale, and the volume of home visit requests and the proportion of 1, 2 and 4-hour home visit requests from NHS 24. This is important in interpreting whether variation to measures 1.1 and 1.2 is caused by issues with process or by peaks/troughs in demand. Measuring these elements of NHS 24 and primary care out-of-hours services should ensure that: potentially life-threatening and/or emergency cases are identified as soon as possible the most unwell people are seen urgently resources are allocated appropriately to ensure people are seen within the timescale requested by NHS 24, and people using the service have the best possible experience. This indicator may also provide data relating to the standards. Specifically: criterion 1(a)3: Arrangements are in place for patients or their representatives to access care by telephone (in the first instance). criterion 2(b)2: Patients are assessed and responded to, based on clinical need and professional judgement. 10

How to measure this indicator Indicator 1.1 Numerator Number of calls to NHS 24 answered within 30 seconds by an NHS 24 call handler. Denominator Total number of calls to NHS 24. Indicator 1.2 Numerator Number of home visit cases where a clinician arrives at the destination of care within the timescale recommended by triage. Denominator Total number of home visit requests made by NHS 24. Indicator 1.3 1.3.1 Numerator Number of 1-hour home visit requests. Denominator Total number of home visit requests made by NHS 24. 1.3.2 Numerator Number of 2-hour home visit requests. Denominator Total number of home visit requests made by NHS 24. 1.3.3 Numerator Number of 4-hour home visit requests. Denominator Total number of home visit requests made by NHS 24. Equates to volume. Data sources 1.1 NHS 24 data collection systems. 1.2 Adastra and/or manual data collection (numerator) and NHS 24 data collection systems (denominator). 1.3 NHS 24 data collection systems or Adastra. 11

Indicator 2: Accuracy of triage for home visits Quality indicators for primary care out-of-hours services Indicator 2 consists of a measure of the clinical accuracy of NHS 24 telephone triage for patients who receive a home visit from a primary care out-of-hours services clinician. Indicator 2.1 Proportion of clinically accurate* 1, 2 and 4-hour home visit referrals. *Clinically accurate is defined as agreement between NHS 24 and out-ofhours services that the NHS 24 nurse adviser made the correct assessment, based on the information available to the nurse adviser at that time (provided by the patient or third party on the telephone call). Rationale The initial access point to primary care out-of-hours services for the majority of people is by telephoning NHS 24. People are assessed by telephone and NHS 24 prioritise any subsequent referral to a primary care out-of-hours service, according to the seriousness of the individual s problem. Referrals can include a request for a home visit and are prioritised by NHS 24 as 1, 2 or 4-hour requests. Accurate prioritisation of home visit requests by NHS 24 is important as this creates specific demands on the primary care out-of-hours service. The purpose of this indicator is to determine that : NHS 24 accurately prioritises the home vist requests for the given clinical presentation. Measuring this element of NHS 24 and primary care out-of-hours services should ensure that: the most unwell people are seen urgently, and people using the service have the best possible experience. This indicator may also provide data relating to the standards. Specifically: criterion 2(b)2: Patients are assessed and responded to, based on clinical need and professional judgement. How to measure this indicator Indicator 2.1 Numerator Number of clinically accurate 1, 2 and 4-hour home visit referrals. Denominator Total number of home visit requests made by NHS 24. Data source 2.1 Manual data collection sampling, as described under Suggested change concepts and change ideas on pages 23-24 of this document. 12

Indicator 3: Effective information exchange Quality indicators for primary care out-of-hours services Indicator 3 consists of three measures of the use of patient information transferred from other NHS services, and the transfer of out-of-hours consultation information to other NHS services. Indicator 3.1 Proportion of primary care out-of-hours consultations during which the patient s electronic care summary (ECS) is accessed. Indicator 3.2 Proportion of primary care out-of-hours consultations with patients registered with a GP within the same NHS board for which consultation information is provided to their GP by 8.30am the following working day. Indicator 3.3 Proportion of primary care out-of-hours consultations resulting in admission to acute care for which referral information is provided at the time of referral. Rationale Effective information exchange allows the treating clinician to assess the patient using upto-date patient information. This is particularly important for out-of-hours services where the treating clinician will rarely have the benefit of having previously treated the patient. The purpose of this indicator is to determine that: information provided by other NHS services is used in the diagnosis and treatment of patients attending primary care out-of-hours services, and information from out-of-hours consultations is provided to the NHS service(s) the patient attends following their out-of-hours consultation. Measuring these elements of NHS 24 and primary care out-of-hours services should ensure that: patients attending primary care out-of-hours services receive the correct treatment according to their medical history and/or requests expressed in a care plan. there is continuity of care between primary care out-of-hours services and other NHS services. This indicator may also provide data relating to the standards. Specifically: criterion 2(c)2: Systems are in place for receiving and communicating information to inform patients ongoing care, by the next working day. 13

How to measure this indicator Indicator 3.1 Numerator Denominator Number of primary care out-of-hours consultations during which ECS is accessed. Total number of primary care out-of-hours consultations. Indicator 3.2 Numerator Denominator Number of primary care out-of-hours consultations with patients registered with a GP within the same NHS board for which consultation information is provided to their GP by 8.30am the following working day. Total number of primary care out-of-hours consultation completed by 8.00am. Indicator 3.3 Numerator Denominator Number of primary care out-of-hours consultations resulting in admission to acute care for which referral information is provided at the time of referral. Total number of primary care out-of-hours consultations resulting in admission to acute care. Data sources 3.1 Adastra and/or manual data collection. 3.2 Adastra. 3.3 Adastra and/or manual data collection. 14

Indicator 4: Implementing national clinical standards and guidelines Indicator 4 consists of two measures of the use of national standards and guidance in the treatment of primary care out-of-hours patients. Indicator 4.1 Proportion of patients with a suspected or confirmed diagnosis of asthma assessed in line with current national standards and guidelines. Indicator 4.2 Proportion of patients with a suspected diagnosis of stroke assessed in line with current national standards and guidelines. Rationale Ensuring high quality care is provided consistently by primary care out-of-hours services is challenging. The care provided by these services is often one part of a complex patient pathway, interfacing with a range of other healthcare professionals and services. In addition, the service has to meet the demands of a diverse community with a wide range of healthcare needs and expectations. Accurate assessment of patients, in line with current national standards and guidelines, should ultimately contribute to achieving the best clinical outcomes for patients. The purpose of this indicator is to determine if: national clinical standards and guidelines are reliably implemented within primary care outof-hours services for specific priority conditions. Measuring this element of primary care out-of-hours services should ensure that: patients reliably receive evidence-based care. Caveats: Asthma and stroke are suggested as tracer conditions to be measured, in the first instance, to test service quality and to create comparable national data for service improvement. The indicator is not designed to assess compliance with the full management pathway, but rather to measure and improve key elements of care (see Section 6, pages 24-25) which would be reasonably expected to be reliably applied to patients presenting with these tracer conditions. This indicator may also provide data relating to the standards. Specifically: criterion 2(b)2: Patients are assessed and responded to, based on clinical need and professional judgement. 15

How to measure this indicator Indicator 4.1 Numerator Denominator Number of patients with a suspected or confirmed diagnosis of asthma assessed in line with current national standards and guidelines. Number of patients with a suspected or confirmed diagnosis of asthma. Indicator 4.2 Numerator Denominator Number of patients with a suspected diagnosis of stroke assessed in line with current national standards and guidelines. Number of patients with a suspected diagnosis of stroke. Data sources 4.1 Manual data collection via sampling, as described under Suggested change concepts and change ideas on pages 24-25 of this document. 4.2 Manual data collection via sampling, as described under Suggested change concepts and change ideas on pages 24-25 of this document. 16

Indicator 5: Antimicrobial prescribing Quality indicators for primary care out-of-hours services Indicator 5 consists of a measure of the use of high-risk antimicrobial medications (cephalosporins, quinolones and co-amoxiclav) by primary care out-of-hours services. Indicator 5.1 Proportion of prescriptions of antimicrobial medications that are for highrisk antimicrobial medications (cephalosporins, quinolones and co-amoxiclav). Rationale While there are limited indications for the use of cephalosporins, quinolones and coamoxiclav within primary care settings, a reduction in the inappropriate use (outwith local formulary and antimicrobial prescribing guidance) of these medications will reduce instances of Clostridium difficile infection. The purpose of this indicator is to determine if: primary care out-of-hours services over prescribe high-risk antimicrobial medications. Measuring this element of primary care out-of-hours services should ensure that: patients are not exposed to unnecessary infection risk through the prescription of a highrisk antimicrobial medication where there is a suitable lower risk alternative. This indicator may also provide data relating to the standards. Specifically: criterion 2(a)4: Service providers operate a system of risk management to ensure that risks are identified, assessed, controlled and minimised. How to measure this indicator Indicator 5.1 Numerator Denominator Number of prescriptions of cephalosporins, quinolones and co-amoxiclav. Total number of prescriptions of antimicrobial medications. Data sources 5.1 PRISMs and GP10 data systems in collaboration with the Scottish Antimicrobial Prescribing Group (SAPG) and hospital pharmacy computer systems and/or manual data collection for to-take-out (TTO) prescriptions. 17

Indicator 6: Patient experience Quality indicators for primary care out-of-hours services Indicator 6 consists of five measures of patient experience for primary care out-of-hours services patients. Indicator 6.1 Proportion of primary care out-of-hours service patients who provide feedback on their experience. Indicator 6.2 Proportion of primary care out-of-hours service patients who provide feedback and report a positive experience. Indicator 6.3 Proportion of palliative care patients who provide feedback to primary care out-of-hours service and report a positive experience c [draft]. Indicator 6.4 Proportion of complaints received from primary care out-of-hours service patients. Indicator 6.5 Proportion of complaints received from primary care out-of-hours service patients that are upheld. Rationale NHS services exist for the patient and should be designed to meet the needs and expectations of the individual receiving care and treatment. Use of patient feedback supports the Healthcare Quality Strategy quality ambition of mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision making. There is a particular focus on palliative care patients in this indicator as this patient group constitutes a small, but significant, group of out-of-hours consultations, who often use out-of-hours services on multiple occasions. The purpose of this indicator is to determine if: primary care out-of-hours services actively engage with service users to ensure a positive experience when accessing services, and primary care out-of-hours services actively engage with service users with palliative care needs. Measuring this element of primary care out-of-hours services should ensure that: patient views are sought in the planning, design, development and review of primary care out-of-hours services. This indicator may also provide data relating to the standards. Specifically: criterion 2(a)1: Throughout the service, work is undertaken in partnership with individuals, communities and community planning partners in the design, development and review of services. The results of this work are acted upon and feedback is provided to all those involved. c In recognition of those patients with specific palliative and/or end-of-life care needs, further work to develop indicators in this area will be undertaken for completion by October 2012. 18

How to measure this indicator Indicator 6.1 Numerator Denominator Number of primary care out-of-hours service patients who provide feedback on their experience. Total number of primary care out-of-hours service patients. Indicator 6.2 Numerator Denominator Number of primary care out-of-hours service patients who provide feedback and report a positive experience. Number of primary care out-of-hours service patients that provide feedback. Indicator 6.3 Numerator Denominator Number of palliative care patients who provide feedback to the primary care out-of-hours service and report a positive experience. Number of palliative care patients who provide feedback to the primary care out-of-hours service. Indicator 6.4 Numerator Denominator Number of complaints received from primary care out-of-hours service patients. Total number of primary care out-of-hours consultations. Indicator 6.5 Numerator Denominator Number of complaints received from primary care out-of-hours service patients that are upheld. Number of complaints received from primary care out-of-hours service patients. Data sources Manual data collection in collaboration with the Scottish Health Council sampling, as described under Suggested change concepts and change ideas on pages 27-28 of this document. 19

6 Driver diagram and suggested change concepts and change ideas for primary care out-of-hours service improvement A driver diagram is a framework used to conceptualise an issue and to determine its system components, which will then create a pathway to achieve a desired outcome. Primary drivers are system components which will contribute to the aim. Secondary drivers are elements of the associated primary driver that contain change concepts, which can be used to create projects that will affect the primary driver. The driver diagram on page 21 places the key components of out-of-hours care, as identified in the patient journey diagram in Section 3, within this framework. The care provided out-of-hours is often one part of a complex patient pathway, interfacing with a range of other healthcare services. The majority of the indicators are measures of process rather than outcome. When reliably applied, these process measures will drive the overall outcome of improved patient experience and high quality, reliable, evidence-based clinical care. Improvement in the areas of out-of-hours care, identified within the driver diagram, will contribute to existing national measures, accompanying and augmenting the existing Standards for The Provision of Safe and Effective Primary Medical Services Out-of-Hours. Suggested change concepts and change ideas are detailed following the driver diagram. Local primary care out-of-hours services can use these suggested change concepts and change ideas to focus their improvement effort, on areas identified as priorities, through measurement of the quality indicators. Each of the secondary drivers has a hyperlink, which link to further details relating to suggested change concepts and change ideas (pages 22-29). 20

AIM PRIMARY DRIVERS System components which will contribute to the aim Quality indicators for primary care out-of-hours services SECONDARY DRIVERS Elements of the associated primary driver. These contain suggested change concepts and change ideas used to create projects that will affect the primary driver. Patients can access primary care out-of-hours services without undue delay. 1. Calls to primary care out-of-hours services are answered within 30seconds. 2. Patients are seen by an out-of-hours clinician within the timescale determined by the triage process. Optimal triage of patients who contact primary care out-of-hours services. 3. Patients accessing primary care out-of-hours services receive clinically accurate triage outcomes. Improve outcomes for primary care out-of-hours service users Patients who attend primary care out-of-hours services receive evidence-based care Effective information transfer between primary care out-of-hours and other NHS services. Primary care out-of-hours services provide the best possible patient experience. Develop an infrastructure and culture that promotes the delivery of high quality care. 4. Patients accessing primary care out-of-hours services receive clinical assessment in line with current national standards and guidelines. 5. Patients accessing primary care out-of-hours services receive treatment in line with current national standards and guidelines. 6. Primary care out-of-hours services clinicians have, and access, each patient s relevant medical history. 7. Primary care out-of-hours services provide relevant onward referral material to other NHS services. 8. Primary care out-of-hours services engage with and work collaboratively with other NHS services. 9. Primary care out-of-hours services foster mutually beneficial partnerships between patients, their families and those delivering healthcare services. 10. Executive leadership of primary care out-of-hours services improvement. 11. Clinical leadership within primary care out-of-hours services. 12. Multidisciplinary team working within primary care out-of-hours services and with other NHS services. 13. Primary care out-of-hours services are underpinned by high quality, effective clinical governance mechanisms. 21

SECONDARY DRIVERS 1 Calls to primary care out-ofhours services are answered within 30seconds. Click to return to driver diagram 2 Patients are seen by an outof-hours clinician within the timescale determined by the triage process. Click to return to driver diagram SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS Measurement of Indicator 1.1: Proportion of calls to NHS 24 answered within 30 seconds by an NHS 24 call handler. Data collected may include: All calls to NHS 24 between 6:30pm 8:00am weekdays, weekends and public holidays. Time from first ring to call being answered. Date and time of call. Call handler ID. Change concepts and change ideas: Flexible call-handler workforce to meet spikes in demand at busy periods. Patient education to reduce information only calls at busy periods this may include a front-end message to all callers to NHS 24, signposting alternative sources of information at busy periods. Use of Lean methodology to review and redesign call flows. Measurement of Indicator 1.2: Proportion of home visit cases where a clinician arrives at the destination of care within the timescale recommended by triage, and Indicator 1.3: Volume and proportion of 1, 2 and 4-hour home visit referrals. Data collected may include: Time call is answered for all calls to NHS 24 triaged as a home visit. Time of referral as home visit to appropriate primary care out-of-hours service. Time out-of-hours clinician arrives at destination of care. Change concepts and change ideas: Resource (staff/estates/transport/emergency equipment) should be geographically located so it provides a responsive service. This should be captured in local business continuity plans and NHS board bad weather/winter/contingency planning. Establish a comfort call system. Where a timescale is identifiably not attainable by an out-of-hours service (for example due to diverting resource to a co-existing need in another patient or other area of the service), telephone contact with the patient will ensure patient safety, and allow management of patient expectation and service demands. 22

SECONDARY DRIVERS SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS 2 Production of a daily report, as a regular monitor of the service s ability to respond, to include: - number of 1, 2 and 4-hour calls - number of calls in each category which are out of time - the actual time taken to reach the outliers. NHS board Clinical Directors for primary care out-of-hours services regularly analyse the clinical details of the outliers to ensure no clinical risk. Production of quarterly service reports to NHS board Quality Assurance Group (or equivalent) on percentage of 1, 2 and 4-hour calls and percentage reached within time. 3 Patients accessing primary care out-of-hours services receive clinically accurate triage outcomes. Click to return to driver diagram Measurement of Indicator 2.1: Proportion of clinically accurate* 1, 2 and 4-hour home visit referrals. * Clinically accurate is defined as agreement between NHS 24 and out-of-hours service that the call handler made the correct assessment, based on the information available to them at that time (provided by the patient on the telephone call). Data collected may include: Triage stratification determined by NHS 24 for home visit referrals to primary care out-of-hours services for example, Adastra field priority on referral. Stratification determined by primary care out-of-hours service upon face-to-face contact with patient for example, Adastra field priority on completion. Change concepts and change ideas (NHS 24): Increase in scrutiny of requests for home visits by senior clinicians within NHS 24 real time. Introduction of a clearly worded standard statement for NHS 24 staff, which defines when a home visit should be requested and when such a visit should be urgent. Development of regular feedback, as part of safety briefing, provided to clinicians undertaking triage in NHS 24 on outcomes in face-to-face setting. Novel techniques in triage training which may include training in face-to-face triage in the classroom setting. Change concepts and change ideas (NHS 24 with primary care out-of-hours service): Sampling of blinded reviews of calls with NHS 24 and primary care out-of-hours service involvement (as part of monthly account meetings). 23

3 SECONDARY DRIVERS SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS Need to agree: 1) total number of calls per week to be analysed 2) to develop a tool to aid analysis 3) to discuss at monthly partner meetings 4) to present at quarterly quality assurance group 5) acceptable percentages (initial work will inform this), and 6) actions if percentages not reached. Review of cases where blinded review suggests the nurse adviser made the correct triage assessment given the information available to them. However, review of further details of the case identifies this decision was not correct for the patient. Use of the Adastra data fields priority on referral and priority on completion to identify patients whose triage stratification changes when seen by a clinician. 4 Patients accessing primary care out-of-hours services receive clinical assessment in line with current national standards and guidelines. Click to return to driver diagram Measurement of Indicator 4.1: Proportion of patients with a suspected or confirmed diagnosis of asthma assessed in line with current national standards and guidelines, and Indicator 4.2: Proportion of patients with a suspected diagnosis of stroke assessed in line with current national standards and guidelines. Asthma management Data collected may include: Number of patients attending primary care out-of- hours services with a suspected or confirmed diagnosis of asthma. Proportion of notes in which the key elements of care for asthma are documented: 1. Assessment of severity: - Peak expiratory flow rate (PEFR) / Spirometry - clinical symptoms / signs 2. Recorded management plan for episode 3. Recorded grade of severity mild, moderate or severe. Change concepts and change ideas: Analysis of 10 asthma cases per week, which are discussed at professional update meetings, and cascaded throughout the organisation. 24

4 SECONDARY DRIVERS SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS Stroke management Data collected may include: Number of patients attending primary care out-of-hours services with a suspected diagnosis of stroke. Number of FAST c compliant patients referred to the primary care out-of-hours service by NHS 24. Proportion of notes in which the key elements of care for stroke are documented: - Is the patient FAST compliant? (NHS 24) - Perform ABCD d scale check - Perform glucose check - Can the patient swallow? - Listen to carotid artery. Change concepts and change ideas: Monitor critical incident reviews (CIRs). Work with NHS 24 on cases of stroke not dealt with exclusively by NHS 24. The primary care out-ofhours service should: - Feedback to NHS 24 cases of stroke sent to primary care out-of-hours service for action. - Identify jointly with NHS 24 such cases and agree appropriate learning, and - Highlight to clinicians in primary care the need to feedback in such cases. c A test to detect and enhance responsiveness to stroke; Facial weakness? Arm weakness? Speech problems? Time to call 999. d A tool to determine risk of stroke following a transient ischemic attack; Age, Blood pressure, Clinical features and Duration of symptoms. 25

SECONDARY DRIVERS 5 Patients accessing primary care out-of-hours services receive treatment in line with current national standards and guidelines. Click to return to driver diagram 6 Primary care out-of-hours services clinicians have and access each patients relevant medical history. Click to return to driver diagram 7 Primary care out-of-hours services provide relevant onward referral material to other NHS services. Click to return to driver diagram SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS Measurement of Indicator 5.1: Proportion of prescriptions of antimicrobial medications that are for highrisk antimicrobial medications (cephalosporins, quinolones and co-amoxiclav). Data collected may include: cephalosporins, quinolones and co-amoxiclav prescriptions - PRISMs data - GP10 data - TTO (to-take-out) prescriptions. Change concepts and change ideas: Work with Scottish Antimicrobial Prescribing Group (SAPG) to develop form for data collection. Education programme via Scottish Antimicrobial Prescribing Group (SAPG). Amendments to NHS board prescribing formulary to reduce use of high risk medications. Measurement of Indicator 3.1: Proportion of primary care out-of-hours consultations during which the patient s electronic care summary (ECS) is accessed. Data collected may include: Accessing of ECS within primary care out-of-hours service consultations. Change concepts and change ideas: Education programme on the value of ECS and the expectation that it will be accessed during consultations. Automatic opening of ECS at start of out-of-hours consultation. Future expansion of Indicator 3.1 to include the electronic palliative care summary (epcs). Measurement of Indicator 3.2: Proportion of primary care out-of-hours consultations with patients registered with a GP within the same NHS board for which consultation information is provided to their GP by 8.30am the following working day, and Indicator 3.3: Proportion of primary care out-of-hours consultations resulting in admission to acute care for whom referral information is provided at the time of referral. 26

SECONDARY DRIVERS 8 Primary care out-of-hours services engage with and work collaboratively with other NHS services. Click to return to driver diagram 9 Primary care out-of-hours services foster mutually beneficial partnerships between patients, their families and those delivering healthcare services. Click to return to driver diagram SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS Data collected may include: Proportion of patients for whom consultation information is provided to their GP by 8.30am the following working day collected via Adastra. Failure rate of Adastra system/email system that produces returns to GP. Proportion of primary care out-of-hours consultations resulting in admission to acute care for whom referral information is provided at the time of referral. Change concepts and change ideas: Follow-up to automatic email, eg send GP practices a morning fax flagging cases that require GP action/follow-up. Test the contingency plan to ensure that patient information is sent to GP practices timeously in the event of automatic email failure. Quarterly feedback to the NHS board s Quality Assurance Group (or equivalent) reporting any episodes of email failure and robustness of contingency. Work with acute admissions ward and clinical governance team to track receipt and use of referral information. Sampling of referrals to acute care to assess quality and completeness of referral information. Measurement of Indicator 6.1: Proportion of primary care out-of-hours service patients who provide feedback on their experience, Indicator 6.2: Proportion of primary care out-of-hours service patients who provide feedback on their experience and report a positive experience, Indicator 6.3: Proportion of palliative care patients who provide feedback to the primary care out-of-hours service and report a positive experience, Indicator 6.4 Proportion of complaints received from primary care out-of-hours service patients and Indicator 6.5: Proportion of complaints received from primary care out-of-hours service patients that are upheld. Change concepts and change ideas: In collaboration with local offices of the Scottish Health Council, develop process(es) to capture patient experience to be identified by NHS boards. Local arrangements may vary. Work with the Scottish Health Council to create a bank of appropriate questions for use by primary care out-of-hours services as part of patient/carer questionnaires. 27

SECONDARY DRIVERS SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS 9 Make telephone contact with the household within 48 hours of the visit for a sample of palliative care patients to ascertain: - What went well? - What was not so good, and how could it have been improved? Review of palliative care patients treatment needs/desires (via review of their electronic palliative care summary (epcs) Use a range of methods of service user engagement: - press releases - meetings with clinicians - focus groups, and - meeting with local organisations. Patient involvement in the planning, design, development and review of primary care out-of-hours services. Lay representation on the NHS board Quality Assurance Group (or equivalent). Use of Equality Impact Assessment (EQIA) tool for frontline clinical services, leading to the development of an action plan. 10 Executive leadership of primary care out-of-hours services improvement. 11 Clinical leadership within primary care out-of-hours services. Click to return to driver diagram Change concepts and change ideas: Develop the infrastructure to support quality and safety improvement - Ensure executive level engagement to improvement process. - Assign an NHS board programme manager with responsibility for improvement programmes boardwide. - Assign a senior leader to each improvement area or areas (response times, accuracy of triage). - Establish an improvement committee (or equivalent). - Ensure a feedback mechanism for issues raised (during walkrounds). - Ensure the development of a measurement system used to understand and drive patient care quality and safety indicators. Provide oversight to improvement programme - Meet with programme manager to remove barriers. - Meet regularly with improvement committee (or equivalent) to track progress and remove barriers. - Display the Gantt chart (or equivalent) that depicts progress towards improvement goals. 28

SECONDARY DRIVERS SUGGESTED CHANGE CONCEPTS AND CHANGE IDEAS 11 Promote the position of safety and quality in the organisation - Ensure the senior team participates in walk-rounds. - Place safety and quality issues at the top of the senior leader meeting agendas. - Add improvement progress and outcomes to the NHS board agenda. 12 Multidisciplinary team working within primary care out-of-hours services and with other NHS services Click to return to driver diagram 13 Primary care out-of-hours services are underpinned by high quality, effective clinical governance mechanisms Change concepts and change ideas: Collaborative working with NHS 24 in relation to: - Secondary driver 3 / indicator 2.1 accuracy of triage - Secondary driver 4 / indicator 4.2 stroke management Collaborative working with the Scottish Antimicrobial Prescribing Group in relation to: - Secondary driver 5 / indicator 5.1 high risk antimicrobial medications Collaborative working with GPs in relation to: - Secondary drivers 7 and 8 / indicator 3.2 information transfer to GP Collaborative working with Acute Admissions and Clinical Governance in relation to - Secondary drivers 7 and 8 / indicator 3.3 information transfer to acute care Collaborative working with the Scottish Health Council in relation to: - Secondary driver 12 / indicator 6 patient feedback. Develop links with Healthcare Improvement Scotland s Safety in Primary Care Programme. Clinical governance aspects of primary care out-of-hours services are covered within the existing Standards for The Provision of Safe and Effective Primary Medical Services Out-of-Hours. Click to return to driver diagram 29

Appendix 1: Membership of the primary care out-of-hours services expert group Name Title NHS board area/ Organisation Dr Andrew Buist Dr George Crooks Dr Denys Greenhow Mrs Meena Johnstone Mrs Alyson MacDonald Deputy Chair of the Scottish GP Committee Medical Director GP Programme Manager Senior Information Analyst British Medical Association NHS 24 and Scottish Ambulance Service Royal College of General Practitioners NHS National Services Scotland, Information and Services Division National Services Scotland, Information and Services Division Dr Sheena MacDonald Senior Medical Adviser Scottish Government Mrs Stella Macpherson Patient representative Dumfries & Galloway Mr George McLean General Manager NHS Grampian Dr Ken Proctor Dr Brian Robson (Chair) Associate Medical Director (Primary Care) Executive Clinical Director NHS Highland Healthcare Improvement Scotland Mrs Anne Simpson Patient representative Tayside Ms Carol Sinclair Dr Marion Storrie Mr Frank Strang Programme Director Better Together Programme Clinical Director for Out-of-Hours Chair of National Out-of-Hours Operations Group (Chair until October 2011) Deputy Director, Primary Care Division Scottish Government NHS Lothian Scottish Government Dr David Taylor GP NHS Grampian Dr Susan Taylor GP NHS Highland Mr Ian Williamson Performance Manager Scottish Government 30

Appendix 2: Membership of the primary care out-of-hours services expert group patient experience subgroup Name Title NHS board area/ Organisation Mr Gregor Boyd Statistician Scottish Government Mrs Linda Harper Lead Nurse for Unscheduled Care NHS Grampian Ms Catriona Hayes Statistician Scottish Government Mrs Stella Macpherson Patient representative Dumfries & Galloway Mrs Anne Simpson Patient representative Tayside Ms Carol Sinclair Programme Director Better Together Programme Scottish Government 31

Appendix 3: About Healthcare Improvement Scotland Healthcare Improvement Scotland was launched on 1 April 2011. This health body was created by the Public Services Reform (Scotland) Act 2010 7 and marks a change in the way the quality of healthcare across Scotland will be supported nationally. Our vision Our vision is to deliver excellence in improving the quality of the care and experience of every person in Scotland every time they access healthcare. Our purpose Our organisation has key responsibility to help NHSScotland and independent healthcare providers to: deliver high quality, evidence-based, safe, effective and person-centred care, and scrutinise services to provide public assurance about the quality and safety of that care. What we do We are building on work previously done by NHS Quality Improvement Scotland and the Care Commission, and our organisation includes: Healthcare Environment Inspectorate Scottish Health Council Scottish Health Technologies Group, and Scottish Intercollegiate Guidelines Network (SIGN). Our work programme supports Scottish Government priorities, in particular those arising from The Healthcare Quality Strategy for NHSScotland. Our work encompasses all three areas of the integrated cycle of improvement (see Figure 3) with patient focus and public involvement at the heart of all that we do. The integrated cycle of improvement involves: developing evidence-based advice, guidance and standards for effective clinical practice driving and supporting improvement of healthcare practice, and providing assurance about the quality and safety of healthcare through scrutiny and reporting on performance. 32

Figure 3: Integrated cycle of improvement Visit our website: www.healthcareimprovementscotland.org for more information. 33