Measurement of Quality Outcomes Making Sure Your Urgent Care Delivers April 2011 David Carson 07703 025775 [email protected]

Measurement of Quality OutcomesMaking Sure Your Urgent Care Delivers

April 2011David Carson 07703 [email protected]

mailto:[email protected]

© Primary Care Foundation

The Primary Care Foundation has looked urgent care from a number of angles

Reports for Department of Health

● Primary Care in A&E

● Urgent Care in general practice

● Benchmark of out of hours services

● Urgent care centres (report with DH)

Various projects for:

● Hospital Trusts

● PCTs

● PBC Groups

● Commercial and mutual provider organisations

URGENT CARE

a practical guide to transforming same-day care in general practice

Supported by the Department of Health

lth


A whole system perspective:urgent & emergency care components Patient

Self careEpisode complete

From any of the above

Each component must work well - separately and as part of the

whole

Hospital

From clinicians


Topics that I aim to cover...

● General Practice In and Out of Hours

● A&E

● Acute Services


ReviewingUrgent Care inGeneral Practice

URGENT CARE

a practical guide to transforming same-day care in general practice

Supported by the Department of Health

lth


Some of our key findings

● Speed of initial response – or ensuring patients can get through - matters

● Review and understand your number of appointments and the proportion that can be booked same day

● Managing peaks in demand - such as Monday mornings – is important

● Practice staff need to recognise what is potentially urgent and agree how to respond

● Rapid clinical assessment is important – especially of requests for home visits

● Telephone consultation can play a useful role


Acute Admission Timeline

8.30 11.30 13.30 17.30

3 Hours 2 Hours 2 (often 4) Hours

8.30 8.45 09.45 10.45

15 Minutes 1 Hour 1 Hour

Just as hospital staff go home!

In time to set up alternative to hospital

Early enough to avoid risk of deterioration


●Currently developing a web based planning and monitoring tool. Focuses on:●Telephony – checking the capability to answer the

phone promptly

●Capacity in terms of appointments to meet the demand from patients

●Recognition of potentially urgent cases

●Response to urgent cases

●Brings together practice data and patient experience to give a strong evidence base for making changes

●Practices are able to benchmark their own system and process against other local practices and across England

A new approach


Better evidence supporting change●Range of indicators provide a rounded picture of

what is happening in the practice, including:

● staffing by hour answering phones compared to what is needed for an effective response (Erlang Formula)

●consultation rate, weighted for age, compared to national average

●Detailed report builds on how the practice understands its processes with analysis of data and options for change

●Tweaking process will not work if people can’t get through on the phones or there are too few appointments

●Once these issues are addressed, there are a range of options – the practice will need to identify what works for them



Outcome of intervention

● Cons rate of 10 last July● Could not get through on phone● Difficult to see doctor of choice

● January● Cons rate 6● Less pressure● Continuity improved● Quality improved

GP Out of Hours



The CQC investigation highlighted shortcomings in commissioning

● Out-of-hours services were low priority at the time and the PCTs had limited understanding of these services.

● There was a lack of leadership in commissioning and monitoring services as part of an integrated urgent care service.

● There was a lack of experience in the PCTs in contracting with a commercial organisation.

● Staff did not fully understand the national quality requirements or TCN’s reports on activity and performance

● The PCTs did not have a high standard of commissioning or contract monitoring in out-of-hours - these contracts should have been monitored more thoroughly.

● Not highlighted in national targets and finances – so not seen as a priority for SHAs or PCTs.


The Health secretary believes that GP Commissioners will fix it!


Key message – you get what you insist onAlternatively, you get what you deserve

● You need a wide range of measures – and making comparison is vital

● Services have to manage clinicians if they are to perform effectively and consistently

● Each part must work well if you are to have a hope of joining different parts – and a similar wide range of measures is needed

● You will need to look at how practices deliver their share of care

● Look to establish contracts for longer and to drive improvements over a period


What qualities should data about a clinical service exhibit?

● Competently collected and collated● Correct● Clear, well presented information● Consistent – to allow comparison within the data set and over time

● Complete – it should provide a full picture of all aspects● Compare and contrast outcomes – so we can understand the cause

of differences and which innovations work● Collaborative - to secure the information and to engage stakeholders● Communicate – so that users can understand what it means● Convincing – if users are to change what they do based on the

evidence● Challenge or corroborate assumptions about clinical practice and

outcomes● Costed – because of the requirement for efficiency we need this too


A wide range of measures to give a rounded picture is needed if perverse incentives are to be avoided

Out of Hours benchmark

● % definitively assessed in 20 and 60 minutes

● % answered in 60 seconds

● % with face to face consultation in 1, 2 and 6 hours

● % of urgent cases

● Patient experience

● % of patients going to 999/hospital

● Cost per case, cost per head

● Productivity


There are big differences between services delivering out of hours care (this looks at QR9 for urgent cases in 20 minutes….)

Services ranked by % of urgent cases started definitive assessment in 20 minutes:Average across all services is ranked 41 out of 98

Red shows % where definitive assessment starts in 20 minutes. Green shows the figure where a first attempt to assess was begun in 20 minutes. Average across all services is at 79.6% (definitive) plus 8.3% (to first attempt)

ALL 7

9.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Showing the % of urgent cases started definitive assessment in 20 minutes against the % of urgent cases on receipt for different services

Those answering the calls for Average across all services identify 22% of cases as urgent on receipt and 79.6% of urgent cases are definitively assessed in 20 minutes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 10% 20% 30% 40% 50% 60% 70%

Perc

enta

ge o

f urg

ent c

ases

defi

nitiv

ely

asse

ssed

in 2

0 m

ins

Percentage urgent on receipt

..and there are big differences in what they identify as urgent

Those with higher levels of urgent on receipt find it difficult to better 90% definitively assessed in 20 minutesThese have low %urgent on receipt

but have a low percentage of urgent cases assessed in 20 minutes


In general it costs more to provide OOH cover in a rural PCT than an urban one (but there are wide variations within any band)

£2.00

£4.00

£6.00

£8.00

£10.00

£12.00

£14.00

£16.00

£18.00

0.00 20.00 40.00 60.00 80.00 100.00 120.00Population density

Co

st p

er h

ead

Rural City/UrbanMixed


There is a clear relationship between IPSOS Mori respondent’s view of speed of response and the rating for the care received

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

40% 45% 50% 55% 60% 65% 70% 75% 80% 85%

How quickly care was received % About right

Rat

ing

of

care

rec

eive

d e

ith

er g

oo

d o

r ve

ry g

oo

d


The majority of services give telephone advice in 40 to 50% of cases and offer home visits to 10 to 17%.

% Advice

% Home visits

0%

10%

20%

30%

40%

50%

60%

70%

80%

0%

5%

10%

15%

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25%

30%

A&E


A&E Proposed Measures

● Ambulatory care● Unplanned re-attendance● Total time spent● % leaving before being seen● Patient experience● Time to initial assessment● Time to treatment● % with consultant sign-off


There are big differences between services (four A&E departments looking at % discharged by 10 minute slots)

22.7% admitted

13.9% admitted

19.6% admitted

30.7% admitted


What do people often focus on?

● Numbers of attendances● Admission avoidance

● Quality = Volumes (or lack of them)

● What about people who need hospital


Process integrated and not competativeGPs are part of the process – Not in front of it

Unstable Patient

Acute arrival stable

AmbulanceInc GP Referral

Walk In Patient

Rescuciation

Admission Acute

AssessmentDischarge

Follow Up Appointment Discharge

Demographics - Patient Given Information / advice to Choose Stream

Major A&EInitial Assessment (Frame Case by Senior) 15 Mins within 15 Mins Arrival

Decision Assessment 120 Minutes (Senior)

Injuries Service30 Mins Max Wating

Average Episode Time 60 Mins

Primary Care +30 Mins Max Waiting

Paediatrics30 Mins Max Waiting

Nurse Assessment ???????

When Required Patients Move Between Areas


Acute care

● Ambulatory sensitive conditions – Outcomes● Percentage discharged same day● Process and timely care – Rapid Care is often good care● Readmission rates● Time to theatre for # NOF● Stroke – compliance with pathway● Etc etc


So what have we been missing?

● Professionals and organisations have been competing● GPs - we manage risk better than A&E● A&E - We deliver detailed and proper assessment● Etc etc

● Each group has specific and valuable expertise● Build a system in which the expertise is complementary

and cooperative and not competitive

● I have never ever met a clinician who was admitting a patient because the trust would get a tariff payment!

Documents

Measurement of Quality Outcomes Making Sure Your Urgent Care Delivers April 2011 David Carson 07703 025775 [email protected]