Developing and implementing
clinical standards for seven day
services
Celia Ingham Clark
National Director:
Reducing Prema...
National seven day services Forum
• The national Seven Day Services Forum led by Bruce Keogh is
leading the approach to de...
Seven day services: Why?
• Illness happens seven days a week
• Currently outcomes differ at weekends
• Trainee feedback su...
Key themes
• There is often inadequate involvement of senior medical
personnel in the assessment and subsequent management...
Cause of the weekend effect - multifactorial
• Variable staffing levels in hospitals at the weekend
• Fewer senior decisio...
In London data shows higher mortality rates for
weekend emergency admissions than weekdays
Total
emergency
admissions
In h...
Similarly elective surgical mortality is higher
for weekend admissions
Day of week of procedure and 30 day mortality for e...
Seven Day Services – What?
• What we mean by Seven Day Services
• Emergency care Must Do
• Urgent care Should Do
• Electiv...
Seven day services: What?
9
True emergencies –
where minutes delay
can affect risk of death
• Cardiac arrest
• Ruptured ao...
Seven day services:
Not ‘should we’ but ‘how far should we go’?
10
• Care and services need to shift towards seven day ser...
11
Review of literature
and College reports
Develop case for
change
Develop
standards
Commission
standards
Audit acute hos...
London quality standards – overview
• Addressing the variations in service arrangements and patient outcomes
between weekd...
London quality standards: Key themes
• Admissions seen by consultant <12 hours
• Twice daily ward rounds for all acute pat...
London quality standards:
consultant-delivered care
• All patients seen and assessed by a consultant within 12 hours
of ad...
London quality standards:
consultant-delivered care
• All health professionals use unitary document for medical record
• E...
National approach
The National Seven Day Services Forum established by
Professor Sir Bruce Keogh in 2013 found that:
• Var...
Developing national clinical standards
A Clinical Reference Group (CRG) was convened with
representation from patients, pr...
18
Consultant review within 12/14 hrs
Availability of core MDT
Rapid access to diagnostics
Only 16% of hospitals
review al...
Seven Day Services Forum: clinical standards
The CRG developed 10 clinical standards based on the evidence
and recommendat...
Alignment with Academy of Medical Royal
Colleges
The clinical standards are deliberately aligned with the Academy of
Medic...
Clinical standard 1:
Patient experience
• Patients, and where appropriate families and
carers, must be actively involved i...
2: Time to first consultant review
• All emergency admissions must be seen and
have a thorough clinical assessment by a
su...
3: Multi-disciplinary team review
• All emergency inpatients must have prompt
assessment by a multi-professional team to
i...
4: Shift handovers
• Handovers must be led by a competent senior
decision maker and take place at a designated
time and pl...
5: Diagnostics
Hospital inpatients must have scheduled seven-day
access to diagnostic services such as x-ray,
ultrasound, ...
6: Interventions
Hospital inpatients must have timely 24 hour
access, seven days a week, to consultant-
directed intervent...
7: Mental health
Where a mental health need is identified following
an acute admission the patient must be assessed
by psy...
8: Ongoing review
• All patients on the AMU, SAU, ICU and other high
dependency areas must be seen and reviewed by
a consu...
9: Transfer to community, primary
and social care
• Support services, both in the hospital and in
primary, community and m...
10: Quality Improvement
• All those involved in the delivery of acute care
must participate in the review of patient outco...
Seven Day Services: Implementation
• Year 1 (2014/15) – local contracts should include an Action
Plan to deliver the clini...
Enablers for implementation
• NHS England Implementation Board and delivery sub-group
• Development of metrics to support ...
The wider context
Recognising relationships with other work including:
• Primary Care Transformation
• Urgent and Emergenc...
Patient perspective
• “I was lucky. Shouldn’t every one of us
have the best chance possible no
matter what time of day or ...
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Developing and implementing clinical standards for seven day services

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Celia Ingham Clark National Director: Reducing Premature Mortality. Slides from Celia's presentation from the 7 Day Services events West Midlands 11th June and East Midlands 12th June 2014

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Developing and implementing clinical standards for seven day services

  1. 1. Developing and implementing clinical standards for seven day services Celia Ingham Clark National Director: Reducing Premature Mortality 11/12 June 2014
  2. 2. National seven day services Forum • The national Seven Day Services Forum led by Bruce Keogh is leading the approach to deliver seven day health care services • It initially focussed on the acute inpatient pathway, although there is recognition of the need for whole-system change. • As such, there is alignment with other national work including the Urgent and Emergency Care review, primary care transformation and the integrated care programme. • A clinical reference group reviewed the evidence base and developed clinical standards for acute inpatients, based on recommendations from professional bodies. • The NHS England Board has agreed to the inclusion of these clinical standards in the standard contract over the next three years 2
  3. 3. Seven day services: Why? • Illness happens seven days a week • Currently outcomes differ at weekends • Trainee feedback suggests variable consultant involvement in acute care out of hours • Hypothesis that patients admitted at weekends are sicker due to limited access to primary care • Importance of “failure to rescue” in defining the difference between hospitals with high and low mortality rates • Acute illness can occur at any time and patient expectations are rising as other sectors (e.g. banking and retail) have moved to offer seven day services 3
  4. 4. Key themes • There is often inadequate involvement of senior medical personnel in the assessment and subsequent management of many acutely ill patients, particularly at the weekend • Limited access to diagnostic services and allied health professionals at weekends to establish multi-disciplinary management plans and facilitate transfer out of hospital • Poor weekend emergency service provision is associated with an increased variation in outcomes such as: • Mortality rates • Patient experience • Length of stay 4
  5. 5. Cause of the weekend effect - multifactorial • Variable staffing levels in hospitals at the weekend • Fewer senior decision makers of consultant level skill and experience on site at the weekend • A lack of consistent support services, such as diagnostic and scientific services at weekends • A lack of community, primary and social care services which could prevent some unnecessary admissions and support timely discharge 5
  6. 6. In London data shows higher mortality rates for weekend emergency admissions than weekdays Total emergency admissions In hospital mortality following emergency admission In hospital mortality following emergency admission (%) Weekday 521,868 16,377 3.14 +0.32 Weekend 159,676 5,531 3.46 The 0.32% difference between weekday and weekend mortality equates to 520 potentially avoidable deaths London’s heart attack centres already operate a consultant delivered service seven days per week and no observed difference is found in mortality rates in the week and at the weekend, suggesting where systems are in place to respond seven days a week, there is a direct effect on mortality rates 6
  7. 7. Similarly elective surgical mortality is higher for weekend admissions Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics BMJ 2013;346:f2424 (Published 28 May 2013) 7
  8. 8. Seven Day Services – What? • What we mean by Seven Day Services • Emergency care Must Do • Urgent care Should Do • Elective care Could Do • ? All of the above 8
  9. 9. Seven day services: What? 9 True emergencies – where minutes delay can affect risk of death • Cardiac arrest • Ruptured aortic aneurysm • Acute MI • Extra-dural haematoma Services provided promptly • Emergency laparotomy • Fractured NOF (DH 2011 BPT to improve care) • “hot” cholecystectomy Routine services • Endoscopy • MRI scans Services not commonly provided at weekends now • Routine elective surgery • Routine GP consultations • Contact with specialist nurses • Routine outpatient appointments Similar spectrum applies to diagnostics and their reports: FBC, U&E, ECG, CXR, CT, USS and cardiac echo, spirometry, histopathology Spectrumofcare
  10. 10. Seven day services: Not ‘should we’ but ‘how far should we go’? 10 • Care and services need to shift towards seven day services to abolish differentials in: • Patient safety • Patient experience • Clinical effectiveness • Discussions underway: should this also address patient convenience?
  11. 11. 11 Review of literature and College reports Develop case for change Develop standards Commission standards Audit acute hospitals against standards Follow up with acute hospitals Engagementwithkeystakeholders Development of the London acute care quality standards
  12. 12. London quality standards – overview • Addressing the variations in service arrangements and patient outcomes between weekdays and weekends was identified by the NHS in London as a key priority in 2012/13 and has remained as such. • Scope of the standards: 12 Adult emergency services (AES) Paediatric emergency services (PES) Maternity services Emergency departments Acute medicine Emergency general surgery Critical care Fractured neck of femur Emergency departments Emergency inpatient medicine Emergency general surgery Specific parts of the pathway requiring specialist acute care: - Labour - Birth - Immediate postnatal care
  13. 13. London quality standards: Key themes • Admissions seen by consultant <12 hours • Twice daily ward rounds for all acute patients • MDT plan within 24 hours including EDD • Timely access to diagnostics and reports • Timely access to interventions including theatre • Good information for patients and their carers • Timely transfer to next place of care 13
  14. 14. London quality standards: consultant-delivered care • All patients seen and assessed by a consultant within 12 hours of admission • Emergency admissions to be managed in MAU, SAU or Critical Care Unit • Rotas constructed to maximise continuity of patient care • Access to all key diagnostic services in a timely manner 24 hours a day, seven days a week to support clinical decision making • Access to Interventional Radiology 24 hours a day, seven days a week within 1 hour for critical patients • Access to comprehensive endoscopy 24 hours a day, seven days a week 14
  15. 15. London quality standards: consultant-delivered care • All health professionals use unitary document for medical record • EDD set within 24 hours of admission • All patients on MAU/SAU seen and reviewed by a consultant during twice daily ward rounds • All referrals to intensive care should have consultant involvement • Structured handovers should take place twice a day and at every handover between consultant teams Patient experience • Consultant-led communications and information to patients, including patient information leaflets • Patient experience data recorded, analysed and acted on 15
  16. 16. National approach The National Seven Day Services Forum established by Professor Sir Bruce Keogh in 2013 found that: • Variation in outcomes exists for patients admitted at the weekend, seen in mortality rates, patient experience, length of hospital stay and re-admission rates • Our junior doctors often feel clinically exposed and unsupported at weekends • Lack of many seven day services has an adverse effect on measurable outcomes in each of the five domains of the NHS Outcomes Framework: • mortality amenable to healthcare • quality of care for people with long term conditions • outcomes from acute episodes of care • patient experience • patient safety16
  17. 17. Developing national clinical standards A Clinical Reference Group (CRG) was convened with representation from patients, primary care, secondary care, social care and colleagues from Colleges and professional bodies to develop clinical standards on behalf of the Forum. The CRG was asked to: • Establish the clinical evidence base for providing NHS Services, 7 days a week • Defining standards of care that will help commissioners and providers to deliver a consistently high quality acute care service at all times of the week. 17
  18. 18. 18 Consultant review within 12/14 hrs Availability of core MDT Rapid access to diagnostics Only 16% of hospitals review all emergency medical admissions within 14 hours of arrival Nearly 80% have 5 or more MDT members during the week. This is just 30% at the weekend X-ray and CT availability is consistently high but other services vary considerably making informed decision making difficult Seven Day Services Forum: survey findings
  19. 19. Seven Day Services Forum: clinical standards The CRG developed 10 clinical standards based on the evidence and recommendations from Royal Colleges and expert bodies. These follow the patient pathway, apply seven days a week and aim to ensure: • Prompt access to consultant review and multi-disciplinary assessment • Availability of diagnostics to support decision-making • Timely treatment and interventions • Planned, safe and appropriate timing of transfers from hospitals All standards are based on existing recommendations from Royal Colleges and expert bodies and will cover the seven days of the week 19
  20. 20. Alignment with Academy of Medical Royal Colleges The clinical standards are deliberately aligned with the Academy of Medical Royal Colleges work on consultant-delivered care: • Consultant involvement: All hospital inpatients should be reviewed by an on-site consultant at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient's care pathway • Consultant supervision: Consultant-supervised interventions and investigations, and their reports should be provided, seven days per week, if the results will change the outcome or status of the patient’s care pathway before the next ‘normal’ working day – this should include interventions and investigations which will enable immediate discharge or a shortened length of hospital stay • Support services, seven days a week: Support services both in hospital and in the community and primary care setting should be available seven days per week to ensure that the next steps in the patient’s care pathway, as determined by the daily consultant review, can be taken20
  21. 21. Clinical standard 1: Patient experience • Patients, and where appropriate families and carers, must be actively involved in shared decision making and supported by clear information from health and social care professionals to make fully informed choices about investigations, treatment and on-going care that reflect what is important to them. This should happen consistently, seven days a week. 21
  22. 22. 2: Time to first consultant review • All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours of arrival at hospital 22
  23. 23. 3: Multi-disciplinary team review • All emergency inpatients must have prompt assessment by a multi-professional team to identify complex or on-going needs, unless deemed unnecessary by the responsible consultant. The multi-disciplinary assessment should be overseen by a competent decision- maker, be undertaken within 14 hours and an integrated management plan with estimated discharge date to be in place along with completed medicines reconciliation within 24 hours 23
  24. 24. 4: Shift handovers • Handovers must be led by a competent senior decision maker and take place at a designated time and place, with multi-professional participation from the relevant in-coming and out- going shifts. Handover processes, including communication and documentation, must be reflected in hospital policy and standardised across seven days of the week 24
  25. 25. 5: Diagnostics Hospital inpatients must have scheduled seven-day access to diagnostic services such as x-ray, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy, bronchoscopy and pathology. Consultant-directed diagnostic tests and their reporting will be available seven days a week: • within 1 hour for critical patients • within 12 hours for urgent patients • within 24 hours for non-urgent patients 25
  26. 26. 6: Interventions Hospital inpatients must have timely 24 hour access, seven days a week, to consultant- directed interventions that meet the relevant specialty guidelines, either on-site or through formally agreed networked arrangements with clear protocols, such as: • critical care • interventional radiology • interventional endoscopy • emergency general surgery 26
  27. 27. 7: Mental health Where a mental health need is identified following an acute admission the patient must be assessed by psychiatric liaison within the appropriate timescales 24 hours a day, seven days a week: • Within 1 hour for emergency care needs • Within 14 hours for urgent care needs 27
  28. 28. 8: Ongoing review • All patients on the AMU, SAU, ICU and other high dependency areas must be seen and reviewed by a consultant twice daily, including all acutely ill patients directly transferred, or others who deteriorate. To maximise continuity of care consultants should be working multiple day blocks • Once transferred from the acute area of the hospital to a general ward patients should be reviewed during a consultant-delivered ward round at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway 28
  29. 29. 9: Transfer to community, primary and social care • Support services, both in the hospital and in primary, community and mental health settings must be available seven days a week to ensure that the next steps in the patient’s care pathway, as determined by the daily consultant-led review, can be taken 29
  30. 30. 10: Quality Improvement • All those involved in the delivery of acute care must participate in the review of patient outcomes to drive care quality improvement. The duties, working hours and supervision of trainees in all healthcare professions must be consistent with the delivery of high-quality, safe patient care, seven days a week 30
  31. 31. Seven Day Services: Implementation • Year 1 (2014/15) – local contracts should include an Action Plan to deliver the clinical standards within the Service Development and Improvement Plan Section • Year 2 (2015/16) – those clinical standards which will have the greatest impact should move into the national requirements section of the NHS Standard Contract • Year 3 (2016/17) – all clinical standards should be incorporated into the national requirements section of the NHS Standard Contract with appropriate contractual sanctions for non-compliance. 31
  32. 32. Enablers for implementation • NHS England Implementation Board and delivery sub-group • Development of metrics to support the standards • Clinical Senates support • NHS IQ to introduce a large-scale transformational change programme to support the spread of seven day services • CRG continues to provide expert advice • In London – ongoing audit of implementation of Quality Standards, and lessons shared • Inspection and assurance – CQC hospital inspections to include assessment of seven day services implementation 32
  33. 33. The wider context Recognising relationships with other work including: • Primary Care Transformation • Urgent and Emergency Care Review • Integrated care programme • Reconfiguration proposals and service change plans • Productive elective care 33
  34. 34. Patient perspective • “I was lucky. Shouldn’t every one of us have the best chance possible no matter what time of day or day of the week it is?” • Rodney Partington, Patient representative 34

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