Transcript Quality - Direct Health First

DHF
Presentations 2004 to 2008
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Non
Approved
Colleges
Specialist
Registration
New
Provider Bid
UK
Graduates
GMC
GMC
EU
Graduates
NCSC
TC
Full
Registration
Surgery
Approved
Colleges
Training with
Supervision
Performance Management & KPIs
KPIs
SUIs
Outcome measures
DHF
CSS v CPS
The CSS contains everything that should help us specify our procurement safely for
the NHS
The CPS only contains that which we consider essential to the ITT and which will
deliver a VFM bid
Input and process
specifications
So the sponsor can integrate ISTC care with the rest of the health economy.
· e.g. what is expected from the provider may differ between one
cholecystectomy package (with a very limited follow up) and another.
When things go wrong
to justify protocols which are contrary to UK
best practice (without evidence base) which leads to
unnecessary conflict with national standards
organisations
Difficult
· when (not if) there are unacceptable fatalities
· legal consistency across England (Clapham Omnibus)
Input and process specifications
Some procedures require specific data for national registers and these
have to be specified
· e.g. NCEPOD
· Cataract National Dataset
· e.g. National Joint Registry
Outcomes
The difficulty with outcome(s)
is that the results
should be attributable
to the treatment
Measures
KPIs
· 25 ISTCs
· NHS TCs
Outcome Measures
· NHS TCs
· ISTCs
Fear of clinical incompatibility
/S
P/S
P/S
P/S
P/S
/S
Personal habit
Agreed team practice
Agreed local customs
Nationwide custom
Nationwide best practice
International best practice
Robust evidence practice
Legal requirement
KPIs, Clinical Outcomes and JSR process
Commercial KPIs devised by commercial and clinical
team working with commercial lawyers
Hence strong clinical element
Consultation with, support of (not approval)
•
•
•
•
PCLs
RCLs
SHAs
JCC
Cleared in house & sent to be incorporated in
contract July 2004
Clinical Outcome measures
• Indicators invited from
– RCs
– Other professional bodies
– Providers
– SHAs
• Indicators trawled from literature
• Collated set discussed with stakeholders
• Final set to stakeholders including JCC
• Agreed by board of ISTC programme
Quality
Surgeons and accreditation
Moving on to post-operative care
Pathways, continuity and CPS
Credentialing
•People
•GMC
•Specialist Register
•Training
•Facilities
•Organisation
•Buildings, equipment,
consumables
•HCC
•systems, information, registration
Governance
OCT’s & ISTC’s
Local ad hoc schemes
Ref
Performance Indicator (measured over preceding Quarterly Period) in
respect of [the] [each] Facility
Quarterly Threshold for Joint Service Investigation in
respect of [the][each] Facility
1
Incidence of inpatient and/or daycase Activities not commenced
because of DNAs as percentage of all Activities
>2% or performance of highest decile for all IS-TCs
(for which data is available) if higher
2
Procedures cancelled by the Provider for non-clinical reasons on or
after day of Admission; for the purposes of the Performance
Threshold measured as a percentage of all Patients Admitted in the
Facility
>0.5% or performance of highest decile for all IS-TCs
(for which data is available) if lower
3
Procedures cancelled by Provider for clinical reasons on or after
day of Admission. For the purposes of the Performance Threshold
measured as a percentage of all Patients Admitted in the Facility
>0.65% or performance of highest decile for all IS-TCs
(for which data is available) if lower
4
Patient returning to operating theatre for Procedure which was
unforeseen at the time the Patient's previous Procedure was
Completed as a percentage of all Patients Admitted in the Facility
>0%
5
In relation to each Activity Group, the conversion rate i.e. the
percentage of Patients who go on to be given a Patient
Appointment for a Procedure following an outpatient assessment
Greater or less than the rate in the Sponsor’s whole
population of Referrals by non-consultants by a factor
greater than one standard deviation around a
proportion (binomial distribution)
6
In respect of [the] [each] Facility the rate of Rejection by the
Provider in respect of Patients referred within the Referral Protocol
(Schedule 3) as a percentage of all Patients who are Referred
Above level to be agreed with Sponsor
Note to Table 1 – the presence of an asterisk in the first column denotes that the relevant
Performance Indicator is a Starred Performance Indicator
7
For day cases, inpatient Admission to the Facility or other provider's
facilities (including NHS providers) which was unforeseen at the time of
Admission; for the purposes of the Performance Threshold as a
percentage of all day cases in the Facility
>2.0%
8
Transfers of Patients to another provider for inpatient Treatment which
was not in the management plan[1] for that Patient upon Admission to
the Facility; for the purposes of the Performance Threshold as a
percentage of all inpatients in the Facility for:
i)
ophthalmology and minor surgery;
ii)
orthopaedics;
iii)
other Procedures
i) >0% for ophthalmology and minor surgery
ii) >1.8% for orthopaedics
iii) >0.8% for other Procedures
9
Emergency Admissions/ Readmissions of Patients who have received
inpatient Treatment and have been Discharged within 29 days of such
Discharge where such Admission or Readmission is related to or arising
from the relevant inpatient Treatment.
For the purposes of the
Performance Threshold measures by HRG as a percentage of all Patients
Discharged
Highest decile for performance of all IS-TCs
(for which data is available)
[1] Management plan requirements to be set out in Schedule 3
10
Average length of stay in hours for day cases by HRG measured from
the time of Admission to the time of Discharge
Lowest and highest decile of performance for all ISTCs (for which data is available)
11
Average length of stay by HRG measured in inpatient days measured
from the time of Admission to the time of Discharge
Lowest and highest decile of performance for all ISTCs; lowest and highest decile of performance on
previous year’s NHS performance if higher or lower
(respectively) (all in so far as data is available)
12
Average Procedure time by HRG broken down by:
i)
induction;
ii)
time on operating table;
iii)
recovery measured from [] to [][1]
Lowest and highest decile of performance for all ISTCs (for which data is available) in respect of (i), (ii)
and (iii)
13
Patient receives or is listed or recommended for a further Procedure to
put right any aspect of the original Activity less than 5 years from date
of Discharge.
For the purposes of the Performance Threshold
measured as a percentage of all Procedures carried out at the Facility
Highest decile for all IS-TCs (for which data is
available)
[1] e.g. Anaesthesia Start – Time when a member of the anaesthesia team begins preparing the patient for an aesthetic.
Procedure/Surgery Start Time – Time the procedure is begun (e.g., incision for a surgical procedure, insertion of scope for a diagnostic procedure, beginning of examination for an EUA, taking x-ray
for radiologica procedure).
Procedure/Surgery Finish – Time when all instrument and sponge counts are completed and verified as correct; all post-op radiological studies to be done in the operating theatre are completed; all
dressings and drains are secured; and the surgical team have completed all procedure-related activities on the patient.
Discharge from Post Anaesthesia Care Unit – Time patient is transported out of PACU (for inpatients).
OR
Discharge from Same Day Surgery Recovery Unit – Time patient leaves SDSR, either to home or other facility (for day cases).
14
Percentage of Procedures carried out under local or regional
anaesthetic (i.e. other than general) anaesthetic by HRG as a
percentage of all Procedures
Lowest and highest deciles of performance for all
IS-TCs (for which data is available)
15
Clinical outcomes specified, by Procedure by reference to the
PCPs[1]
Lowest (undesirable) or highest (desirable) decile of
performance for all IS-TCs (for which data is
available)
16*
Timeliness, completeness and accuracy of Provider Performance
Data provided to the Joint Service Review and/or to Sponsors
Any material
17
Timeliness, completeness and accuracy of Provider clinician
reporting to Referring Health Service Body's clinician
Any material
18
Patient/Customer Satisfaction (by survey) based on a survey of
10% of all Patients at each Facility in each [Contract Month]
>20% of Patients surveyed are dissatisfied with any
aspect.
19
Rate of Patient Complaints ie number of complaints received as a
percentage of all Patients Referred for:
i)
outpatient Treatment; or
ii)
inpatient/daycase Treatment
Lowest and highest decile of performance for all IS–
TCs (for which data is available)
[1] These need to be specified when PCPs completed eg for cataracts, visual acuity is likely to be a relevant clinical outcome.
20
Patient complaints handling – complaints not
handled within relevant timescales set out in this
Agreement
One incident
21*
Incidents which are reportable to the NPSA or other
statutory body
One incident
22
Additionality – NHS staff recruited in breach of
Clause 9 of this Agreement
One incident
23
Condition of Facility measured by inspection by a
Sponsor and/or the Provider and assessed against
the requirements of the Facility Manual and
Operational Procedures
Any material incident of failure to meet statutory requirements in
relation to the condition of the Facilities and/or the requirements
of the Facility Manual and/or Operational Procedures in respect of
cleanliness, catering, environment, accessibility, maintenance,
pest control, housekeeping and waste management.
24
Breach of security related to the Services where
there is an identifiable risk of harm, loss or damage
to people or property
More than one incident
25
Breach by the Provider of confidentiality and/or data
protection requirements in the Agreement
One incident
26
Failure to meet Treat by Date
One incident
Prostate:
International Prostate Symptom Score [IPSS]
pre- and
post-op,
· timings to be confirmed
[patient administration as good as physician
administration (Plante M et al. Urology,
1996;26:326-328)]
Cataract:
VF-14 Visual acuity
Cataract surgery
· pre-op and
· 6 weeks post-op
Note that ISTC providers are also required to collect and report the
Cataract National Dataset
Cholecystectomy: Leeds Dyspepsia Questionnaire
@ pre-op
@ OP assessment), and
@ 3 months post-operative Questionnaire[1]
· Moayyedi S et al. The Leeds Dyspepsia Questionnaire: a
valid tool for measuring the presence and severity of
dyspepsia. Aliment Pharmacol Ther, 1998;12:1257-1262
Carpal Tunnel: CTS Questionnaire
CTSQ:
· @ Pre op
· @ Post op assessment
· @ 1 year post-op
Pre-op scores provide information about
thresholds at which listing decisions are
made, (which may be relevant to PIs #5 and #6 conversion and
rejection)
· Carpel Tunnel Assessment Questionnaire[1]
[1] Bessette L et al. Comparative responsiveness of generic versus
disease-specific and weighted versus unweighted health status
measures in carpal tunnel syndrome. Medical Car,e 1998;36(4):491-502
Hip replacement: Oxford Hip Score
Clinical outcome to be before/after comparison
OHS:
· @ Pre op
· @ Post op assessment
· @ 1 year post-op Pre-op scores provide information
about thresholds at which listing decisions are made,
(which may be relevant to PIs #5 and #6 conversion and rejection)
ISTCs also to collect and report data on hip
replacements as required by the National Joint
Registry
National Joint Registry data: (8 February 2004)
Total number of individual patient episodes, submitted electronically: 45,214
records
Contributors since 1 April 2003:
• NHS Trusts (England only): 126
• NHS Hospitals (England only): 162
TKR: Oxford Knee Score
Clinical outcome to be before/after comparison
OKS:
· @ Pre op
· @ Post op assessment
· @ 1 year post-op
Pre-op scores provide information about thresholds
at which listing decisions are made, (which may be relevant
to PIs #5 and #6 conversion and rejection)
ISTCs also to collect and report data on hip
replacements as required by the National Joint
Registry
Diagnostic procedures
endoscopy, colonoscopy, arthroscopy etc.
Questions:
· whether a diagnosis was made
· whether the diagnosis made was correct
10% sample of referring clinicians to be asked for views
(post-discharge) as to: whether the diagnosis was made;
whether, in the event, it was (or appears to have been)
correct;
Note that: PI#17 captures timeliness, completeness and
accuracy of provider clinician reporting to referring
clinician
Excision biopsy
All procedures involving excision biopsy
Complete removal of tumour or % incomplete removal of tumour on
histology report
All surgery: blood loss during surgery
blood loss during surgery
thresholds set by reference to average blood loss in restricted number of
procedures
Overall achievement of objectives
To what extent did your treatment achieve what
you expected from it?
Measured on all patients, at 6 weeks post-surgery
at the same time as EQ5D
incorporated into patient satisfaction survey
instrument when eventually agreed
providers be required to record the objectives of
treatment agreed with the patient at the time
informed consent
Problems
To what extent did your treatment cause
problems you did not expect?
Measured on all patients, at 6 weeks postsurgery (at the same time as EQ5D and
incorporated into patient satisfaction survey
instrument when eventually agreed)
Providers be required to record the advice
on likely side effects and problems of
treatment with the patient at the time
informed consent
Unexpected need for medical attention
Did you need to contact the ISTC, your GP surgery,
or other health facility/professional other than by
prior arrangement?
Measured at 6 weeks (as above)
Compared to what you expected, did you have
more:
·
·
·
·
·
discomfort?
pain?
leakage of fluid from the wound?
bleeding?
limitation of normal activities?
EQ5D
ISTC Programme
TCs Patient Flow Diagram
New Provider Assessments (Outpatients)
+-
Diagnostics
(direct access)
A
(£A)
diagnostics
OP Consultation
B
OP Follow-up
D
C
New Provider Surgery (FCEs)
+- diagnostics
GP Consultation
with Patient
Pre-op
Assessment
E
NHS OP
Consultation
(and waiting
list)
Essential OP followup as required
Surgery &
Recovery
(£S)
Acute
Inpatient
Follow-up ?
Discharge to NHS
- GP
- Intermediate
Care
- Subsequent
necessary care
anomaly
identified or
random records
sponsor and
provider jointly
review case(s)
agree on
problem?
Y
N
arbitration
care as
agreed?
Y
no penalty
applied
N
f
remedial action
agreed?
N
arbitration
N
arbitration
Y
N
penalties
agreed?
Y
remedial action
taken?
Joint Service Reviews
actions agreed at previous meetings
routine data, identification of any problem areas, and agreed
actions
ad hoc reports and the results of any investigations,
identification of problem areas, and agreed actions
figures for the ISTCs concerned, compared with other ISTCs;
all findings from reviews of random case records
presentation by the provider to the sponsor of the results of
their clinical audit
Triggers for review
Source of data
Anomaly
Example
Routine
reports
Absolute
statistical
Patients waiting longer than contracted maximum
Routine
reports
Relative
statistical
Procedure time in the highest decile of all comparable
providers; visual acuity following cataract surgery in
lowest decile of all comparable providers
Ad hoc reports
Significant
event
Unplanned transfer of patient to NHS provider
Ad hoc reports
Complaints
Patient had not understood proposed treatment when
giving consent to surgical treatment
Review
randomly from
case records
-----
-----
Consequences of review
No problem
detected
No penalty, but may be other
consequence as per contract
A
Provider to take remedial action within
specified timescale; possibly increased
level of monitoring
B
Failure points, proportionate to
issue(s)
C
Financial penalties
D
Contract termination
Perceptions of quality risk
National govt.
Local Govt.
Providers (new territories)
Investors (due diligence)
Professions (mixed interests)
Media
Public
What Procedures can be ‘safely’ performed in the
setting?
not associated w/ excessive blood loss &/or fluid
shifts
do not require higher specialized operating
equipment or intensive post-op care; post-op pain
manageable
take a “reasonable period of predictable time”
the‘ultimate’ determinant: clinician comfort level
What Patients?
few standardized guidelines
no multi-centre studies; paucity of large prospective
studies
Mayo Clinic Study 1984: ASA III no higher risk in a
Surgery Centre
FASA 1987: survey of 87,000 patients, questioned
relationship between pre-existing disease and perioperative complications
There is some empiric evidence of certain “patients
at risk”
Patients at Risk
“complex morbid obesity/complex sleep apnoea”
potential for airway problems, dysmorphic facial
features, severe rheumatoid arthritis,
extreme age (?)
poor physiologic condition: ASA III+/IV
history of problems with anaesthesia (MH history)
Acute substance abuse
The goal of any pre-op system
“Reduce the morbidity of surgery & return patient to
normal functioning as quickly as possible.”
Risk Classification
Surgical
Category
1
Surgical
Category
2
Surgical
Category
3
Surgical
Category
4
Surgical
Category
5
Anaesthesia
Class
1
Anaesthesia
Class
2
Anaesthesia
Class
3
Anaesthesia
Class
4
The Johns Hopkins Risk Classification System
18,189 elective cataract patients: no significance differences between
the no-testing & testing groups in the rates of Intraoperative events.
Schein OD, et al. The Value of Routine Preoperative Medical Testing Between Cataract Surgery. NEJM 2000; 342: 168-175
Group of 606 patients, 386 chest x-rays ordered without
indication…Among these patients, one with abnormality that ‘may’ have
resulted in improved care….the existence of three patients with lung
shadows led to three sets of invasive tests, including one thoracotomy,
but no discovery of disease
Roizen MF, et al. The relative roles of the history and physical examination, and laboratory testing in preoperative evaluation:
the “Starling” curve in preoperative testing. Anesthesiol Clin North Am 5:15, 1987.
After careful medical history, patients undergoing minimally invasive
surgery have little benefit from testing…..30 day morbidity after surgery
no different than living 30 days without surgery.
Narr BJ, et al. Outcomes of patients with no laboratory assessment before anesthesia and a surgical procedure. Mayo Clin
Proc 72:505-509, 1997
Pre-Op Testing: a sample matrix for
minimally invasive surgery
Is patient healthy & <75
(no hospitalization or major changes in last 6 months)
YES
NOT healthy
NO TESTING
selecltive testing
NO, healthy but > 75
EKG within 6 months
EKG within 1 month:
Na+,K+,Bun/Cr, Glucose
h/o Cardiac, Diabetes
(Electrolyte Panel):
h/o Diabetes, Renal Disease,
Diurectic use
CBC w/ platelets:
Liver Function Tests:
h/o anemia, recent blood loss,
(potential for sign blood loss)
rarely required
Blood Type:
CXR:
miscarriages
rarely required
Surgery Centre Pre-Op Testing: On-Site
Electrocardiogram
Haemoglobin
Glucometer
Urine Pregnancy Test
The process of the screening process is a crucial first step that allows for the provision of safe,
effective, and efficient medical care……The development of preoperative evaluation systems
in response to outpatient and same day admission surgery provides the challenge of organizing
services into formal systems with guidelines formulated on the basis of mutual agreement and
established clinical practice……
it is imperative that the anesthesia staff reach a consensus on significant preoperative
evaluation issues and adhere to them in dealing with patients and surgeons and
associated organizations. Conspicuous or consistent deviation from these practices
will only serve to undermine the confidence of all the parties………
Anesthesiologists, in setting up their systems, are well advised to allow
for a measure of flexibility.
While adhering to a strong standard of care, reasonable judgement in
providing that care is preferable to unyielding policies.
Ambulatory Anesthesiology: A problem oriented approach
L. Reuven Pasternak, M.D., Chapter 1, Screening Patients: Strategies and Studies.
On-Time Performance
Updated preference cards
On-site Sterile Processing
Standardize Case packs- supplies pulled day before
Patients walked to OR – short distance, no porters
Quick Prep & Anaesthesia Starts – minimize M.A.S.T.
Rapid turn around time (less than 10 minutes)
Simple Charting – report by exception, utilize checklists
OR flow closely monitored by the OR charge nurse & the
charge anaesthetist: “vigilance”
Example Anaesthesia Service Quality Indicators:
Patient and surgeon satisfaction
Accuracy rate on clinical records
Same day cancellation and surgical cases delayed
Cost per case benchmarking
Prolonged post-op nausea/vomiting
Taking longer than 30 minutes in phase I
‘Reportable incident’ rates