Advancing Quality The early Learning

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Advancing Quality The early Learning

• Jan Ledward
• Programme Director

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The NW original hypothesis

• The Reform Incentives unlikely to deliver
  immediate quality improvement other than in the
  medium to longer term
• Issues include
• Variable use and attitude to effectiveness
  evidence
• Clinical quality measurement poor or piecemeal
• Skills gaps in data collection, management and
  quality improvement
• Clinical quality isolated from perception and
  experience
• Disconnected hierarchy national regulation
  local deliver
• Roll over commissioning activity to outcomes
• Designing stand alone quality campaigns and
  incentives would be confusing and sub optimal
• We wanted a NW Quality Programme, consistent with
  reform, but based on addressing shorter term
  skills and information gaps

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Challenge of Context
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What is Advancing Quality?

• A voluntary programme to improve the quality of
  care for patients in the NHS North West
• An incentive scheme that will reward healthcare
  providers for providing high quality of care to
  patients
• A programme that promotes world class
  commissioning for quality and outcome
• The programme will incentivise improvement in
  clinical outcomes, patient reported outcomes and
  patient experience

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AQ - Objectives

• Move to benchmarked quality indicators
• Clinical outcome (mortality LOS readmission)
• Patient Reported Outcome Measures (PROMS)
• Patient experience (Perception)
• Cost health economics
• At least consistent with best in class
• Systematic, evidence-based, disciplined approach
  based on skills development and knowledge
  management/transfer
• Develop a positive incentive based system across
  NHSNW
• Commissioner and provider alignment on quality
• Create a transparent mechanism for sharing
  quality data
• Voluntary but seeking high rate of adoption
• World class leadership and Governance (inc Info.
  Gov.)

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Strategic Partnership - Premier Inc
Financial incentives / transparency improve
hospital quality performance
Hypothesis

• Findings
• Financial incentives did focus hospital executive
  attention on measuring and improving quality
• Hospitals performance has improved continuously
  over time

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Improvement across all HQID participants
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Quality Pays
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Advancing Quality measures

• Acute myocardial infarction (AMI)
• Aspirin at arrival
• Aspirin prescribed at discharge
• ACE or ARB for LVSD
• Smoking cessation advice/counseling
• Beta blocker at arrival
• Beta blocker prescribed at discharge
• Thrombolytic received within 30 minutes of
  hospital arrival
• PCI received within 90 minutes of hospital
  arrival
• Inpatient mortality rate
• Coronary artery bypass graft (CABG)
• Aspirin prescribed at discharge
• Prophylactic antibiotic received within one hour
  prior to surgical incision
• Prophylactic antibiotic selection for surgical
  patients
• Prophylactic antibiotics discontinued within 48
  hours after surgery end time
• Inpatient mortality rate
• Heart failure (HF)

• Community-acquired pneumonia (CAP)
• Percentage of patients who received an
  oxygenation assessment within 24 hours prior to
  or after hospital arrival
• Initial antibiotic selection
• Blood culture collected prior to first antibiotic
  administration
• Antibiotic timing, percentage of pneumonia
  patients who received first dose of antibiotics
  within six hours after hospital arrival
• Smoking cessation advice/counseling
• Hip and knee replacement
• Prophylactic antibiotic received within one hour
  prior to surgical incision
• Prophylactic antibiotic selection for surgical
  patients
• Prophylactic antibiotics discontinued within 24
  hours after surgery end time
• Recommended Venous Thromboembolism prophylaxis
  ordered
• Appropriate Venous Thromboembolism prophylaxis
  within 24 hours prior to surgery to 24 hours
  after surgery

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Is any of this relevant to the NHS?

• AMI Measures Tested
• For Compliance
• 1. Early Aspirin
• 2. Early Beta blocker
• 3. Aspirin at discharge
• 4. Beta blocker at discharge
• 5. ACE inhibitor at discharge
• 6. Timely reperfusion
• 7. Smoking cessation

• In the audit sample of the 97 patients who were
  admitted to CCU 36 received perfect care (37)
• Of the 27 patients not admitted to a CCU only 3
  received perfect care (11).

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Patient Reported Outcome Measures

• Ultimate arbiter of success of treatment to be
  measured and rewarded
• Will increasingly become the future outcome
  measure of choice
• Every patient has a measure
• More evidence to build a richer picture of
  quality improvement
• Now contracted with RCOS to implement

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PROMs EQ-5D descriptive system
Self Care

• No problems with self care
• Some problems washing or dressing
• Unable to wash or dress

Health State
Usual activities

• No problems with usual activity
• Some problems with usual activity
• Unable to perform usual activity

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Is quality of life restored to normal after CABG?
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Patient Experience

• Regional programme on customer service
• Various approaches already in existence
• Healthcare Commission
• Trust surveys
• Hand held electronic systems
• Distinct from satisfaction
• Empathy measures
• Respect, Self Confidence, Re-assurance,
  Effectiveness, Safety, Understanding Honesty
• Simple, rapid, reproducible, real-time
• Will be in place by April 2009

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Three year AQ incentive rewards

• Each AQ year is October September
• Incentive reward scheme will include
• Top performance (from year one onwards) at 4
  2 - top up on national tariff 3.2m
• Patient Reported Outcome Measures (from Jan 09
  onwards) - 1m HK and CABG
• Patient experience (from April 09 onwards) - 1m
• Greatest improvement (from year two onwards)
• Attainment (from years two/three onwards)
• Ambulance reward scheme -performance rewarded by
  a 25 top slice of hospital top performers for
  AMI.

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Potential annual benefits
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Development Areas

• Mental Health
• Stroke
• Extension of existing clinical areas into
  community primary care
• Patient experience

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Governance framework
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Reflections Impact so far

• Creating a culture of quality and a genuine
  improvement movement!
• A focus on data evidence driven improvement
  providing the ability to compare performance at
  clinician, team, hospital and trust level
• A system wide approach
• Broad acceptance and sign up to the need for
  transparency and openness re the outcome -
  enabling clear sensible public comparison of
  quality
• Incredible engagement and involvement of
  clinicians
• Comparable, early results/learning and data
  sharing taking place
• Best practice/solutions being shared voluntarily
• Learning network emerging particularly amongst
  project leads
• Recognition that this is about organisational
  development not just a data collection exercise
• Strong communications plan is vital
• Effective procurement process expertise in
  place to support identification and selection of
  strategic partners

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AQ Cquin for the NW system

• Common principles
• Incentive scheme will develop over time
• Learning will be built into the programme
• Independent evaluation will support this learning
• AQ formally commended 1.10.08
• Will form part of quality accounts in 2010

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How will Advancing Quality help?

• Establishes across NW uniform data set and set of
  measures that are clinically relevant
• Develops the approach to commissioning patient
  journeys/pathways
• Starts to develop commissioning for quality not
  just volume
• Develops the mechanism to assess the impact of
  the money they use to commission
• Ability to assess and improve efficiency whilst
  reducing cost
• Changes behaviours from competitive to
  collaborative
• Engages clinicians
• Increase capacity and flow
• Directly relates to the 7 core competencies for
  world class commissioner
• Creates a win win situation between Commissioner
  provider

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The 5 Rs
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www.advancingqualitynw.nhs.uk
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Learning Points

• The focus on quality as a key principle of reform
  was supported by clinicians and managers
  instantly aligning them on a path of cultural
  and organisational change.
• AQ is a relatively large and complex piece of
  work which has been implemented quickly,
• adherence to a philosophy of lift and implement
• Chief Executives agreeing the need to focus on
  quality
• clinicians engaged fully leading the
  co-production of measures
• The governance structure changes to reflect what
  works and what doesnt work
• At local health system level the need for project
  management was identified
• The health system was committed to independent
  evaluation to provide assurance and verify
  whether anticipated benefits have been achieved

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Learning Points

• The NW health system concluded that clinical
  support would only exist and alignment achieved
  when a rigorous process had been followed and the
  criteria for co-production of CFAs was
  stringently observed and agreed by clinicians
  themselves. Removed arbitrary veto
• The health system took a belt and braces
  approach to information governance which took
  time and creativity to identify a solution.
• Overtime directing financial incentives at the
  right AQ measures will ensure alignment,
  relevance and effectiveness. A blended approach
  is required that rewards top performance in the
  first year and attainment and most improved in
  subsequent years.
• The recognition that the capacity and skills
  needed to deliver a Pay for Performance type
  programme and to communicate effectively required
  external expertise.