Focussing on Outcomes: Improving the Quality of Patient Care

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Focussing on OutcomesImproving the Quality of
Patient Care

• Dr Jane Moore
• Associate Regional Director of Public Health
• NHS London
• 15 July 2009

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Types of Indicator

• Process Indicators
• A change in the effectiveness/efficiency of the
  processes used to deliver healthcare
• eg. Reduction in emergency re-admissions to
  hospital with 28 days of discharge from hospital
• Output Indicators
• A change in the outputs delivered by healthcare
  processes
• eg. Increase in smoking cessation rates
• Outcome Indicators
• A change in the level of ill-health morbidity or
  death (mortality)
• eg. Reduction in preventive mortality for CVD
• Behavioural Cultural Indicators
• A change in the individual /population perception
  of health status or the care receive
• eg. Staff experience, surveys

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Quality Assessment has traditionally focussed on
process measures (reliable delivery of
evidence-based interventions)
Number of incidents reported, by quarter, October
2003 to December 2007
4
And process measures are important where
measuring outcomes is difficult
Time from Stroke to Scan
5
but we are increasingly looking at outputs
Managing acute myocardial infarctions, England
and Wales 2002-5
6
Results of heart bypass surgery in England
.. and beginning to look at true outcomes
UK average
All results fall well within the expected range
adjusted for the level of risk for the patients
operated upon
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even at the level of individual clinicians

• Comparison of the outcomes of cardiac surgeons

Risk adjusted mortality for Coronary Bypass
Graft (CABG)- Individual Surgeons -(01.04.2002
- 31.03.2005)
 
 
  .
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Need to focus more on outcomes that matter to
patients
Patient-reported outcome measures Recommended
PROMs for elective surgery
Source LSHTM/RCS report to DH, December 2007
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Patient-reported outcome measures
Possible PROMs for chronic conditions
Source National Centre for Health Outcomes
Development, November 2006
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The challenge

• The challenge is to devise measures of patient
  outcomes and patient experience which
• reflect peoples real experience of healthcare
• focus on the outcomes that matter to them, not
  just the ones that are easily measurable
• can be measured at reasonable cost without
  interfering with the normal process of healthcare
• differentiate sensitively between good and less
  good quality of care
• can interpreted and used by patients and carers,
  providers, commissioners and regulators
• . and for all significant conditions!

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Some approaches

• Clinician-observed outcomes
• Survival rates
• Complication rates (unintended outcomes)
• Proxy outcomes (eg tumour response)
• Global assessments
• Patient-reported outcome measures (PROMs)
• Condition-specific
• Generic measures of health status
• Patient-reported complication rates

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Using Health Outcome measures

• How is the indicator to be used?

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Practical applications advising patients on
choice of treatment
Source BUPA 2008 (data collected using SF-36)
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Practical applications choice of facility
(Treatment hip replacement)
Source NHS Choices website
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Practical applications commissioning and demand
management

• Standard NHS contract for acute hospital
• services requires
• Commissioners to review clinical quality monthly
  with providers
• Providers to collect PROMs for 4 procedures using
  standard instruments
• Commissioners and providers to agree other
  quality requirements and relevant indicators
  including outcome measures

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Practical applications commissioning and demand
management

• Potential applications of PROMs include
• Quality of commissioned services (risk adjusted
  changes in health status)
• Appropriateness of referrals (PROMs scores for
  patients referred for treatment compared with
  national benchmarks)

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Possible application detecting outliers
Centre T has particularly good, centre K poor
outcomes (high good)
Source LSTHM/RCS report to DH, December 2007
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Practical applicationsclinical service
frameworks

• Traditional National Service Frameworks have set
  standards in terms of the evidence-based
  interventions which patients should be offered
• Service frameworks in future will increasingly
  describe the outcomes which care should achieve
• eg the COPD NSF (in development is likely to
  recommend
• regular review of patients lung function
• treatment for individual patients to be adjusted
  in the light of outcome measurement
• quality of services in different health
  communities to be compared using the same measures

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What are the changes interested in from a quality
perspective

• Safe
• Levels of Patient Safety Incidents
• Effective
• Increase in health status (SF12) functionality as
  a result of CABG
• Patient experience
• Improved percentage patients say, treated with
  dignity and respect
• VfM/Productivity
• QUALYs vs DALYs

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How to use quality indicators

• How do you want to use indicators?
• Clinical understanding
• Organisational development
• Performance management
• System management

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How to use quality indicators
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How to use quality indicators

• How do you want to use indicators?
• Clinical understanding
• Organisational development
• Performance management
• System management
• What are the important changes you want to
  understand you may not need to look at outcomes
• Measure what is important do not make important
  what is measurable
• Consider the ability of the indicators to
  leverage real improvement in the system

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Choosing an outcome measure - Diabetes

• Model of Care for Diabetes
• Patient focussed
• Promotes and enables self-management
• Offers multi-disciplining integrated care with
  joined up services
• Informed on an ongoing basis by rigorous
  evaluation and governance
• Key change benefits expected
• Better outcomes for people with diabetes
• Reduction in the complications of diabetes
• Better management of people with diabetes across
  the care pathway

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Examples of the potential indicators that could
be selected for assessing improvements in the
care of people with diabetes
Indicators in bold are those that the HfL
project has identified as potential indicators
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Examples of the potential indicators that could
be selected for assessing improvements in the
care of people with diabetes
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Use SMAART Outcome measures

• Specific clear what outcome the indicator is
  focussed on
• Measurable part of standard data collection and
  if not can easily be collected
• Appropriate a reasonable measure to use
• Acceptable will both clinicians and the public
  understand and buy in to this indicator
• Reliable will the indicator give consistent
  measures across sites, organisations and time
• Targeted this is not the same as is a target
  but is it clear what population, conditions,
  interventions it is focussed on.

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How to use Quality Indicators

• What makes indicators effective?
• Ownership (clinical and managerial)
• Relevance
• Understanding the impact
• Contributes to people engaging with the need for
  change
• Supports change

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Design a quality indicator

• In small group consider an issue where a PCT
  would want to develop a quality indicator
• What is the quality issue?
• What is the change that is required?
• What will give the most useful information of
  change?
• What will engage clinicians and managers in the
  need for change?
• What might I measure?
• What can I measure?
• Make the case for the indicator