Improving clinical care. The English experience Sr. Chris Spry, CBE
Firstly – a fundamental assumptionIt is usually the case that good quality treatment and care,guided by evidence, consistently delivered with an eye tosafety, will be more efficient and effective in its use ofresources than treatment and care which are out of touchwith evidence, second rate and cheap in concept,inconsistently delivered, and prone to error.Dealing with errors & complications and having to do thingstwice are expensive!So, the approach in England tries to focus on quality andsafety rather than ‘efficiency’ (but the approach itself is anerratic mixture of not very well connected initiatives).
A decade of the Pin Ball Machine approach From Donaldson’s simplicity of concept – ‘focus on getting clinical practice right and promote a culture of openness and learning’ To ‘NHS crisis in patient care’ (excessive avoidable mortality plus poor quality care plus a culture of denial) Via a bewildering multitude of different service improvement techniques and fashions Beset by relentless focus on targets (waiting times; financial; hospital-acquired infection), time-intensive but variable regulatory regime, and a toxic top-down culture
WHY? Most individual top-down initiatives have started as well-intentioned efforts to improve patient care But most initiatives are accompanied by bureaucratic procedures to record and check compliance Regulators (Care Quality Commission; Monitor; and others) have been added to an only slightly weakened hierarchy from local to national level. The quality of regulatory approaches has been erratic, often poor, and much criticised politically and by the media. The UK has an unpleasant blame culture Too little recognition is given to time being needed to become experienced in new approaches Each time there is public controversy about some aspect of care, a new initiative is launched Politician knee-jerks + political dogmas + civil service love of bureaucratic processes + Regulator panics + the appearance of a macho tone of NHS central leadership = too many changes in direction and too daunting an environment for many local NHS leaders More about this later……
What’s in the toolbox for Clinical Service Improvement? Sources of guidance + Regulatory disciplines Commissioning Intra-hospital clinical governance processes Change management tools Networks (clinical, quality-comparison & research) Leadership
Sources of guidance – a strong positive NICE – the authoritative UK source. Very careful validation processes. Pathways – based on best practice (evidenced wherever possible) Evidence on effectiveness of diagnostics; clinical interventions; medicines; devices; medical technologies – well regarded. Expectation that they will be followed. Clinical and quality standards – expressed as what patients can expect (disease-specific) Recommendations not only evidence-based but take account of cost-effectiveness considerations (QALYs) ‘Do not do’ recommendations database available to be searched
Care Quality Commission standards Care Quality Commission: Standards expressed from patient’s perspective. “You should expect… To be respected, involved, and kept well informed Care, treatment & support that meets your needs To be safe To be cared for by staff with the right skills The provider to routinely check the quality of their services Sub-categories within each of these – comprehensively coverthe patient’s experience. Providers must register with CQC(self-certified). Unannounced inspections. Powers toenquire. Can impose fines, stop admissions or even de-register
Clarity about ‘never events’ 25 Nationally-determined Never Events, such as: 325 of these 1. Wrong site surgery (70 in 2012) 2. Wrong implant/prosthesis (41 in 2012) reported in 3. Retained foreign object post-operation (161 in 2012) 2012 4. Misplaced naso or orogastric tubes (23 in 2012) 5. Wrongly prepared high-risk injectable medication 6. Maladministration of potassium –containing solutions Must be 7. Wrong route administration of chemotherapy reported to 8. Wrong route administration of oral/enteral treatment commissioners, 9. Intravenous administration of epidural medication national 10. Maladministration of insulin database & 11. Overdose of midazolam during conscious sedation 12. Opioid overdose of an opioid-naïve patient CQC. Internal 13. Inappropriate administration of daily oral methotrexate Enquiry + 14. Suicide using non-collapsible rails financial 15. Transfusion of ABO-incompatible blood components sanction 16. Transplantation of ABO or HLA-incompatible organs 17. Wrong gas administered 18. Failure to monitor and respond to oxygen satisfaction “Never should mean 19. Air embolism ‘never’. And learn 20. Misidentification of patients from these to better 21. Severe scalding of patients recognise near 22. Maternal death from post-partum haemorrhage after elective caesarian misses”
Commissioning Service providers are funded by contracts from ‘commissioners’ (local GP-led for most 2˚ care; National Commissioning Board for more specialised services and for 1˚care) Contracts set local volumes of service and desired changes in quality. NHS Outcomes Framework sets the scene for quality improvement. Price determined nationally Price increases below rate of inflation aim to force providers to seek productivity improvement. Quality improvement linked to financial incentives and sanctions. Much of this is very service-specific or even procedure-specific.
NHS Outcomes FrameworkFive domains; 38 specifics within them (metrics set locallyeach year). These specifics get translated into contracts,incentive payments and penalties.1. Preventing people from dying prematurely2. Enhancing quality of life for people with long term conditions3. Helping people to recover from episodes of ill-health or following injury4. Ensuring that people have a positive experience of care5. Treating and caring for people in a safe environment and protecting them from avoidable harm
Incentivising the Outcomes Framework Commissioning for Quality & Innovation (CQUIN) puts measurables and financial incentives onto some of the Outcomes Framework goals. For a typical Teaching Hospital with a contract with its local commissioner of £253m; CQUIN payments of £3.8m are available to be earned if goals met. Typically, 25-30 goals, with different weightings adding up to 100% of the CQUIN sum available. For example: Reduced death, disability or chronic ill-health from VTE: 10% Improved positive response rates in national Patient Survey (meeting patients’ personal needs): 10% Increased % of patients on home dialysis: 7.47% Better outcomes in trauma care: 6.67% Improved quality standards in hospital discharge letters: 4% Improved breast feeding prevalence: 1.41% Reduce number of emergency re-admissions: 4% Similar scheme for Primary Care (QOF) – 22 clinical domains: eg diabetes care; dementia; obesity; epilepsy; COPD; hypertension; cardiac; cancer; stroke/TIA etc
NHS Safety Thermometer – a new element in CQUIN The ‘Safety Thermometer’ measures 4 high volume ‘harms’: Pressure ulcers Falls Urinary tract infections in patients with catheters New VTE Monthly snapshot surveys (<10 minutes per patient) Between April to December 2012 proportion of patients suffering these harms fell from 4.6% to 3.3% CQUIN payments quarterly based on three consecutive months data
Intra-hospital clinical governance processes Committee structures – usually a Quality Committee underpinned by a range of sub-committees on clinical audit; risk management; maternity and peri-natal standards; radiological safety; medicines safety; control of infection etc) Board responsibility (very variable in practice) Organisational support for clinical audit activity Coming soon – revalidation of clinicians’ fitness to practise (will be locally grounded but overseen independently) (Sometimes) practical expert support in change management (Primary care much less well-developed in having equivalent arrangements)
NHS Litigation Authority – reinforcing the intra-hospital processes NHS-wide scheme for sharing the costs of litigation risk. Subscription-based, with amount of subscription based on 3 yearly self-certification & inspection to check effectiveness of intra-hospital processes: Governance arrangements Arrangements for learning from experience – clinical audit; following NICE guidance; reporting systems etc Competent & capable workforce Safe environment At clinical service level – training; consent; diagnostic procedures; transfusion; medicines management; etc
So, there’s a massive superstructure pushing for change and improvement – who delivers it? Usually, the clinicians and service managers at individual specialty level. Sometimes seen as good project experience for trainees or for junior staff with potential Sometimes ad hoc project teams coordinating across several services or departments Supported by clinical audit and risk management staff and, sometimes, specialist change agents
How does all this feel if you are a clinician? Pressure from commissioners – External & may feel imposed Hospital management struggling to meet financial or waiting times targets – requires great finesse by management to avoid it feeling a clumsy imposition Pressure from Regulators – External & feels uncomfortable Insights gained from intra-hospital clinical governance – sometimes feelings of ambivalence, embarrassment, and frustration at bureaucratic nature of many governance processes NICE guidance – Respected, but is external & may feel top down Responding to increased service demand or bottlenecks – at least this is ‘our problem’ (although tendency to blame GPs, Social Services, other departments….) Clinicians’ own enthusiasms – hooray!! Enlightened hospital management working with clinicians to improve effectiveness, efficiency, safety – the gold standard…..but rare
Change management tools Too often people just try to muddle through – busy people not familiar with management theories or not adept at using them Some well-recognised techniques mostly borrowed from US or from Japanese-inspired approaches to quality improvement and change management LEAN (careful study of work flows, volumes, and timings and scope to change them for the better) Plan Do Study Act cycle (work of Don Berwick in the US). The PDSA cycle will often use locally practicable implementation of NICE guidance as its intended outcome. TQM methodologies are often regarded as too complex and based in an alien (non-clinical) culture Clinical decision support systems – harnessing evidence- based practice to real time decision-making and making data connections to highlight clinical risk factors. One to watch!
Plan, Do, Study, Act?PDSA cycle used to test an idea by temporarily trialling achange and assessing its impact. Often quoted inHealthcare news/professional magazines as ‘theapproach we used’ Plan – thinking through the change you want to test or implement Do – carry out the test or change Study – look at data for before and after the change and reflect on what was learned Act – plan the next change cycle or full implementation
Clinical decision support systems Many useful applications that enable the clinician to make efficient and effective clinical decisions, such as: Prescribing decisions, including drug interactions Appropriateness of diagnostics to be ordered Latest evidence on effectiveness of specific interventions Dietary guidelines Data mining & data connection allows otherwise disconnected pieces of information about a patient to be connected, contributing to risk profiling & providing alerts Key issue: stand alone or integrated into main EPR system?
The Power of Networks An effective way of engaging clinicians in the impulses for clinical service improvement. Use of comparative data; focus on evidence-based practice; focus on patient care realities or on research. Untainted by top-down identity. Examples: Cancer Networks – mandatory but clinically-driven and very patient-focussed AQuA – a voluntary alliance of hospitals in North West England which positively promotes shared learning between them and the consistent application of clinically proven interventions. AQuA supports collaboratives, sharing of data, face to face learning, e- learning. NHS QUEST is a new England-wide extension of this Academic Health Sciences Networks – where Universities, NHS, industry, work together to promote not only research but also application of its results into clinical practice or service delivery. AHSNs will coordinate numerous small research-oriented networks and partnerships.
Our messy system fails to recognisethe realities of change management Making change is difficult! Most projects fail to meet expectations. Inertias; vested interests; lack of concerted effort; people do not really ‘buy in’. Are the forces for change strong enough to shift the forces of resistance? Evidence of the need for change is not enough. Appeals to work in the ‘best interests of patients’ are not enough. ‘Top down’ instructions are not enough. Even sanctions are not enough. There is a huge literature on change management. If it can be summed up in two diagrams…….
Levers Mindsets Professional ethos and The capacity of, & The organisational practices (values & concepts interfaces between, cultureGuidance such as team work) primary & secondary care•Strategies/frameworks (big picture of what & how with injection of standards)•Evidence-based guidelines & their translation into protocols & pathwaysKnowledge, technologicalinnovations , smartimplementation tools &trainingIncentives & sanctions•Financial•Targets + sanctions for non-compliance•CompetitionMeasurement &comparison•Outcomes•Meeting standards forquality & safety
New evidence for change and/or response to failure Our strategy Future Present results for change resultsPresent practices, • Guidelines Future practices, processes & • Change processes & behaviours management tools behaviours Winning hearts and Present minds (emotional Future mindsets mindsets intelligence) Creating or interpreting the context for change – deep diving
You can have all the tools in the world,but leadership is the crucial ingredient Leadership is to be found everywhere, not just at ‘the top’, but it needs to be nurtured The current national leadership of the NHS is discredited but powerful The task for the leaders of hospitals (and in primary care organisations) is to nurture and inspire their local service- level leaders, interpret the demands that cascade down upon the hospital so that they make sense, and enable their organisation to respond to multiple demands rather than becoming paralysed or narrowly fixated on, say, finance or waiting times. Such leaders are in short supply.
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