PROMs 2.0

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Bibhas Roy, an orthopaedic consultant at Trafford Hospital slides about his work with Patient Recorded Outcome Measures (PROMs)

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PROMs 2.0

  1. 1. PROMs 2.0 Bibhas Roy, Consultant Orthopaedic Surgeon Trafford General Hospital, CMFTClinical IT Lead for Secondary Care, NHS North West
  2. 2. Experience & OutcomeDefinitionsMeasuring HealthcareValidityPROMs – National approachPREMsExample - PROMs 2.02 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  3. 3. Quality in Healthcare “Even though quality cannot be defined, you know what quality is.”  Robert M. Pirsig 1928 American philosopher “Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
  Institute of Medicine 1990 “Quality is a process of meeting the needs and expectations of patients and health service staff.”
  WHO 2000 We are guests in our patients lives; and we are their hosts when they come to us. Why should they, or we, expect anything less than the graciousness expected by guests and from hosts at their very best. Service is quality – Don Berwick  "The Permanente Journal, Volume 3 No. 1". Kaiser Permanente. Winter 1999. 3 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  4. 4. Donald M. Berwick Chief Executive Officer of the Institute for Healthcare Improvement My right knee will probably need to be replaced soon. This has given me the opportunity to define, in very personal terms, 5 specific dimensions of ―total quality‖ that I will require from the medical institution that does my surgery and that every patient has the right to require of their encounters with the health care system. - Don‘t kill me (no needless deaths). - Do help me, and don‘t hurt me (no needless pain). - Don‘t make me feel helpless. - Don‘t keep me waiting. - And don‘t waste resources, mine or anyone else‘s. Given my requirements, it is not clear that any health care institution in the United States will want to take me on as a patient…‖ 4 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  5. 5. Measuring Healthcare This has become a multi-million pound industry fuelled partly by increasing anxiety by society (especially its political representatives) about the variation in quality and safety of care—an anxiety heightened as the results of more measurements reveal even more problems. Whenever such an industry develops rapidly, it is useful to pause and reflect on the degree to which it is acting optimally and in the interests of society and health. The healthcare quality measurement industry: time to slow the juggernaut? Professor T A Sheldon
 Department of Health Sciences, University of York Qual Saf Health Care 20055 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  6. 6. Prof. Iain Buchan, University of Manchester6 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  7. 7. Measures Institute for Healthcare Improvement (IHI) Balancing Measures - AreOutcome Measures – What is Process Measures - changes designed to improve a the result parts/steps in the system part of the system causing new problems in other areas• For access: Number of days • For access: Average daily • For reducing patients length to appointment clinician hours available For of stay in the hospital: Make• For critical care: ICU mortality critical care: Use of adverse sure readmission rates are not drug event chart review increasing 7 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  8. 8. Hawthorne effectHawthorne Works • 1924 -1932 • commissioned a study to see if its workers would become more productive in higher or lower levels of light.8 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  9. 9. Outcome Measures Blunt figures • Mortality / Number of treatments performed Clinician / Physician reported • Evolution from broad subjective categories to validated sensitive quantified tools • Eg - Constant-Murley Shoulder Score Patient Reported Measures9 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  10. 10. Stratification/Adjusting for risk Conclusions that Variation in outcome outcome differences are Factor not measured or may be due to caused by differences in inadequately differences in quality will always be measured?healthcare quality - BUT tentative. Type of patient - age, gender, co- morbidity, disease severity, socio-economic status etc… Data collection / reporting - numerator / denominator / case mix adjustment definitions Chance 10 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  11. 11. PROMs & PREMsUnidimensional / Condition DesirableMultidimensional Targeted / Generic Attributes • Important • Sound theoretical basis • Validated • Reliable • Sensitive • AcceptableThe Point of Care Measures of patients‘ experience in hospital: purpose, methods anduses - Angela Coulter, Ray Fitzpatrick, Jocelyn Cornwell, July 2009 – The King‘s Fund11 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  12. 12. Experience & satisfaction Experience •what actually occurred, rather than the patient‘s evaluation of what occurred. Satisfaction • the personal preferences of the patient • the patient‘s expectations • response tendencies due to personal characteristics • the quality of the care received12 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  13. 13. PROMs • standardised validated instruments (question sets) • measure patients‘ perceptions of their health status (impairment), • their functional status (disability) • their health-related quality of life (well-being).13 A Practical Guide to Measuring and 08/03/2012 Monitoring Patient Experience
  14. 14. Spreading the projectPeople are not passive recipients of innovations. Rather (and to a greater or lesser extent in different individuals), they seek innovations out, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, ‗work round‘ them, talk to others about them, develop know-how about them, modify them to fit particular tasks, and attempt to improve or redesign them (often through dialogue with other users). How to Spread Good Ideas, A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation Trisha Greenhalgh et.al 2004 14
  15. 15. Product & Process Know your products Map processes  Break it into components and timeframes  Discover what works well  Discover what does not work well
  16. 16. Clinical Engagement? Clinician  a doctor having direct contact with patients rather than being involved with theoretical or laboratory studies. - oxforddictionaries.com HICAT version (for informatics)  Figurehead Clinicians (Doctors, Nurses, AHPs etc.)  These Clinicians no longer have clinical responsibility and are not on the front-line  Clinicians who work part-time in the Programme.  These Clinicians work for 40-60% of the time in the Programme and 40-60% of the time in clinical care  Fulltime clinicians  Clinicians who are fully committed to improving patient care through the use of IT
  17. 17. Establishing the Culture and Beliefs toDeliver Clinical Engagement1. engagement follows debate at a local level2. place the patient at the centre of development3. evidence - ―observability & trialability‖ is required Rogers & Plsek4. local clinical leaders are essential – real full time clinicians5. concept applied successfully in a local context, this ―strength of evidence‖ is very compelling6. align objectives between clinician and manager7. a request to change their working process will produce dissonance – change management
  18. 18. New Double HelixApproach Value Belief Engagement Patients Programme Pathway implementation Driver Driver
  19. 19. Clinical Engagement Escalator Aligned with Managerial Colleagues Project Plan Framing as described in Large Scale Change Business as Usual Clinical Champions to bring about Clinical Engagement and Service New Improvement becoming business Acceptance and as usual implementation Vision Dissemination Evidence on quality & benefit realisation Early implementers Clinical volunteers Evidence on quality & benefit realisation Awareness-raising
  20. 20. Upscaling the change Sixty Three NHS Organisations Cancer network Trauma Network Clinical Leaders GP Consortia Network Network An Ethos of Medical Clinical Expertise BMA Implementation Quality, Design Directors At LHC Governance ―Realise the cultural change‖ Pathology Mental PEC CHIL Health Chairs Enabling Health Informatics Respiratory LMC network Children’s Stroke Royal AHP Nursing network network Colleges network Directors
  21. 21. PROMs 2.0 National PROMs  PROMs are measures of a patients health status or health-related quality of life. They are typically short, self- completed questionnaires, which measure the patients health status or health related quality of life at a single point in time. – NHS Information Centre  Must be Validated tools Shared decision making with patients QIPP principles  Quality   Innovation   Productivity 
  22. 22. 22 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  23. 23. E-mail to patient
  24. 24. Validate the patients into the system 24 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  25. 25. No passwords 25 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  26. 26. Patient Generated data – their responsibilities 26 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  27. 27. List of scores that require completion 27 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  28. 28. Confirmation of Completion 28 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  29. 29. Logic based feedback to guide patients about their care 29 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  30. 30. Birth of PROMs 2.0 Business case Software for £250,000 £15,000 • rejected Innovations Dragon‘s Lair funding (2010) £20,000 award30
  31. 31. Phase IIAdoption bursaries for 10 more organisations(2011) - £150,000• 9 Acute Trusts• 2 CCG Clinical Leaders Network funding (2012) • Further 2/3 organisations Many different PROMs now in system • Minimal Data set • EQ5D 31
  32. 32. Experience & satisfaction Experience (PREMs) •what actually occurred, rather than the patient‘s evaluation of what occurred. Satisfaction • the personal preferences of the patient • the patient‘s expectations • response tendencies due to personal characteristics • the quality of the care received32
  33. 33. Trust SpecialitySalford Royal NHS Foundation Trust OrthopaedicsNorfolk & Norwich University Hospital OrthopaedicsUniversity Hospital of South Manchester OrthopaedicsEast Lancashire Hospitals NHS Trust OrthopaedicsEast Cheshire Clinical Commissioning Group Pulmonary rehabilitationStockport NHS Foundation Trust OrthopaedicsCentral Manchester University Hospitals NHS Foundation Trust Anaesthetic, UrologyWrightington, Wigan and Leigh NHS Foundation Trust OrthopaedicsUnited League Clinical Commissioning Group ENTCountess of Chester Hospital Trauma NetworkRoyal Liverpool and Broadgeen University Hospitals Orthopaedics
  34. 34. PROMs 2.0 Team All organisations represented PROMs & PREMs Mapping Governance Consent 34 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  35. 35. PROMs 2.0 a success? Funding process  The software development and pilot  cheap due to the direct relationship between the stakeholders and the designer  No elaborate reports necessary to justify funding  Implementation of product required Business requirements analysis to convince early adoptors  adoptors were actively chosen Future?  PROMs Summit (6th December Manchester) 35 PROMS 2.0 - Patient Generated Data and 26/07/2012 enhancing decisions
  36. 36. Why do we fail? Lack of user involvement  clinical engagement Poor requirements Long or unrealistic timeframes Scope creep- the scope increases insidiously as the project progresses No change control system - especially in consideration of changing requirements Poor testing- testing is not done by those on the front-line, but by contract workers

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