Supporting NHS Wales to Deliver World Class Healthcare All Wales Stroke Services Improvement Collaborative

Supporting NHS Wales to Deliver World Class Healthcare

All Wales Stroke Services All Wales Stroke Services Improvement CollaborativeImprovement Collaborative

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All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative

Mike DavidgeSenior Improvement Advisor

NHS Institute for Innovation & Improvement

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The Model for ImprovementThe Model for Improvement

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Types of measureTypes of measure

Time from onset of symptoms to admissionTime from onset of symptoms to stat aspirinTime from admission to stat aspirinTime from admission to ROSIER assessmentTime from symptom onset to CT scanTime from admission to CT scanTime from admission to admission to a specialist stroke wardCrude mortality rate Per 1000 patientsLength of Stay% return to usual place of residenceAverage change in function score% of patients readmitted within 30 days% eligible patients who have thrombolysis within 3 hours of admission% patients who have CT scan within 24 hours of symptom onset% compliance with First Hours bundle% compliance with First Days bundle% compliance with First 3 Days bundle% compliance with First 7 Days bundle

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The care bundlesThe care bundles

• First hours bundle (Rapid recognition)

• First day bundle(Emergency treatment)

• First 3 day bundle(Early mobilisation)

• First 7 day bundle(Specialist care)

• % patients who receive stat aspirin• % patients who have diagnosis screen with ROSIER• % patients who have diagnosis confirmed by clinician• % patients who have CT scan within 24 hours of admission• % patients who have swallow assessment within 24 hours of

admission• % eligible patients who start regular aspirin within 24 hours of

admission• % patients admitted directly to stroke ward• % patients who have a manual handling assessment in first 72 hours• % patients with physiological signs monitored for first 72 hours• % patients who have their nutritional screening reported in first 72

hours• % patients who have their physiotherapy assessment in first 72

hours• % patients who were sat out of bed or mobilised in first 72 hours• % patients who have an OT assessment in first 7 days• % patients who have goals set and agreed in first 7 days• % patients who receive care information in appropriate format in first

7 days• % patients who are notified of an estimated date of discharge within

7 days

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CCollect – the right data in a

sustainable way

AAnalyse – the right measures

presented in a helpful

way

RReview – whether your changes are

having the desired effect

Measurement is a processMeasurement is a process


CCollectollect


The process of measurement The process of measurement at Luton & Dunstable Hospitalat Luton & Dunstable Hospital

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Why we wanted to do thisWhy we wanted to do this• Measurement is vital

• Regular and consistent measurement is a vital part of service improvement

• It is used to demonstrate that progress is being made or sustained

• It can tie process changes to improvements in performance across the pathway

• But its an add-on• Despite these obvious advantages, measurement for

improvement is often tacked on to existing workloads of staff who do not necessarily have the relevant information skills with the result that it is time consuming and seen as something of a chore

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What we were hoping to achieveWhat we were hoping to achieve• The team will be able to get everything they need to

present the chosen measures from the hospital systems• not needing therefore to get the information from a book or

an independent database, from the patient’s notes or by entering batches of NHS numbers by hand as a special effort.

• The systems include iPM with theatre module, Footman Walker and CRIS (radiology)

• Both data extraction and analysis will be automated

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How we went about itHow we went about it• Decide measures

• We started with a set of measures for the existing stroke pathway.

• Identify data• We worked backwards to identify all the steps in the

process that creates these measures to the point where data is first captured and entered into an IT or manual system.

• Map current process• We described and evaluated the current process.

• Create new process• We discussed the potential for a new more automated

process with the relevant staff.

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The measures usedThe measures used

• % having CT scan <24 hrs• % direct to Ward 17 (ASU)• Change in Bartel score• % mortality in hospital• % thrombolysed• Length of stay• % discharged to usual residence• Time in A&E• Nr ward moves• % cared for in stroke ward > 50% of time

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Required data itemsRequired data items

• Admission source• Admitting Bartel score• Date of admission/transfer

to stroke unit• Date of discharge/death• Date of discharge/transfer

from stroke unit• Date of thrombolysis• Date/Time of admission

• Date/Time of arrival in A&E• Date/Time of departure

from A&E• Date/Time of scan• Discharge Destination• Discharging Bartel score• Discharge reason• Procedure code used• Ward of admission

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The current process mappedThe current process mapped

Patient arrives in

A&E

Patient departs

A&E

Patient arrives in

ACU

Patient has scan

Patient transfer to stroke unit

Patient discharge

from stroke unit

A&E Receptionist enters arrival

date/time onto F/W

A&E clinical staff enter departure

date/time onto F/W

Ward clerk enters transfer date/time onto

IPM

Ward clerk enters

admission date/time and

source of admission into

ward book

Radiology staff enter scan

date/time onto CRIS

Ward clerk enters

admission date/time into

ward book

Therapy staff enter Bartel scores into

notes

Ward clerk enters

discharge date/time and

disposal method/

destination into ward book

Ward clerk enters

discharge date/time and ward/ disposal

method/ destination onto IPM

Ward clerk enters

admission date/time, ward and source of admission onto IPM

Post discharge

Clinical coders add diagnosis and procedure codes to IPM

record

Stroke co-ord enters scan

time into stroke DB

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Observations on current processObservations on current process• Data in hospital systems not always used

• Although most of the required data items are entered into hospital systems, these are not used to generate many of the current measures.

• Instead a combination of manual and stand-alone systems are used.

• Result: duplicate data entry.• Analysis is time consuming

• Charts are largely created manually from data re-entered into Excel.

• This approach wastes valuable staff time.

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What we proposed for the futureWhat we proposed for the future• Use hospital systems data

• Extraction of data will be performed by the information team in response to a brief and repeated on a regular agreed basis (maybe monthly).

• The output will be a set of patient level data

• Create Excel tool to analyse & display measures• Patient level data will be cut and pasted into an Excel

tool on a regular (monthly) basis.• The tool will display weekly and monthly charts as

required and can therefore be presented and discussed at multi-disciplinary meetings etc and displayed on ward ‘mission control’ boards.

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IssuesIssues• Who is on the pathway?

• Identifying the right patients from hospital systems• Add pathway identifier to IPM

• Bartel score only currently recorded in notes• Add facility to enter Bartel scores into IPM

• Where do we get thrombolysis information from?• Clinical coders confirm that they code as procedure

(X292,X298) so can be obtained from IPM

• What about scan time?• Info team will link CRIS, Footman Walker and IPM to

create single record per patient containing all the right data components

• Where does this leave the stroke database?• Info team have already designed an IPM module that

could be used instead

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The principles involvedThe principles involved

• Need to understand the patient pathway• Need to understand where data is collected now

and flag up any gaps

Patient arrives in

A&E

Patient departs

A&E

Patient arrives in

ACU

Patient has scan


Patient discharge

from stroke unit

A&E Receptionist enters arrival date/time onto

F/W


date/time onto F/W


IPM

Ward clerk enters



ward book


date/time onto CRIS

Ward clerk enters


ward book


notes

Ward clerk enters


disposal method/


Ward clerk enters



Ward clerk enters


Post discharge


record

Stroke co-ordenters scan

time into stroke DB

Patient arrives in

A&E

Patient departs

A&E

Patient arrives in

ACU

Patient has scan


Patient discharge

from stroke unit

A&E Receptionist enters arrival date/time onto

F/W


date/time onto F/W


IPM

Ward clerk enters



ward book


date/time onto CRIS

Ward clerk enters


ward book


notes

Ward clerk enters


disposal method/


Ward clerk enters



Ward clerk enters


Post discharge


record

Stroke co-ordenters scan

time into stroke DB

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First 7 days bundle

First 3 days bundleFirst day bundleFirst hours bundle

Stroke route via A&EStroke route via A&E

Onset of

symptoms

Contact GP

Phone 999

Arrive at A&E

Admit into bed

Admit into ASU

Screen diagnosis

with ROSIER

Administer stat aspirin

Perform CT scan

Perform swallow

assessment

Start regular aspirin

Manual handling

assessment

Nutritional screening

Physiology monitored

Physiotherapy

assessment

Sat up or mobilised

OT assessment

Notified of EDD

Receive appropriate information

Goals set and agreed

Confirm diagnosis

with clinical examination

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Groupwork: What is your pathway?Groupwork: What is your pathway?

• Draw your own timeline• Are there any differences from our generic one?• Do things happen in a specified order all the

time?• Record what happens most often

• Make a note of any issues you want to clarify back at base

• Be prepared to share your timeline


Feedback and sharingFeedback and sharing

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Groupwork: Where is data collected?Groupwork: Where is data collected?• Refer to your timeline• Start to complete the data collection planning sheet• Who records this – the person or role responsible• At what point – real time or how long afterwards• Where is it stored – named hospital system, little black book etc• How reliable – how many will be missing?• Issues – things to check or actions to do

• Tackle ‘Who records this’ first• Use ‘Not collected’ or ‘Not sure’

Phase Data item Format Who records this At what point Where is it storedHow reliably do we collect Issues to resolve

Date of symptom onset Date

Time of symptom onset Time

Date of stat aspirin Date

Time of stat aspirin Time

Date assessed with ROSIER Date

Time assessed with ROSIER Time

Confirmed stroke Yes/No

Firs

t ho

urs


Feedback on issuesFeedback on issues

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Planning your data collectionPlanning your data collection

• How are you going to ensure you get the right data?

• How will you get hold of data already collected?• How will you collect data items that you don’t

currently collect?• Plan to test with the next patient

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PostscriptPostscript

• The Luton new system was delayed because of lack of information analyst time

• Moral: The more automated you make things, the more reliant you are on specialist informatics skills


AAnalysenalyse


The type of presentation you use The type of presentation you use has a crucial effect on how you has a crucial effect on how you

react to datareact to data

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DEPARTMENT

%

ABSENTEEISM BY DEPARTMENTABSENTEEISM BY DEPARTMENT

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The % patients on CHD register who are being treated with aspirin

February 2002

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

A B C D E F G H I J K

Average

Jobs on the line?

At least we’re not as bad

Nothing to worry about

Who’s doing well?Who’s doing well?

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Take two numbersTake two numbers

29

12

0

5

10

15

20

25

30

35

Q1 Q2

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We have 2 quarterly data points - is We have 2 quarterly data points - is this an improvement?this an improvement?

Executive Time Series

0

20

40

60

80

100

J F M A M J J A S O N D

Months

So

me

thin

g I

mp

ort

an

t

Higher is better

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Are we assuming something like Are we assuming something like this?this?

Executive Time Series - linear trend

0

20

40

60

80

100


Months

So

meth

ing

Im

po

rtan

t

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But it could be like this ...But it could be like this ...

Executive Time Series - no trend

0

20

40

60

80

100


Months

So

meth

ing

Im

po

rtan

t

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Or this ...Or this ...

Executive Time Series - seasonal dip

0

20

40

60

80

100


Months

So

me

thin

g I

mp

ort

an

t

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Or this!Or this!

Executive Time Series - one month blip

0

20

40

60

80

100


Months

So

meth

ing

Im

po

rtan

t


How often you measure can also have How often you measure can also have an effect on how you look at the resultsan effect on how you look at the results

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Monthly data shows improvementMonthly data shows improvement

Average length of pre-ward stay on Barnsley Stroke Ward

from 01/2007 to 07/2007

0

0.5

1

1.5

2

2.5

3

3.5

1 2 3 4 5 6 7

Months

The chart shows the average monthly length of time before patients got to the Stroke ward

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Weekly data tells a slightly different storyWeekly data tells a slightly different storyAverage length of pre-ward stay on Barnsley

Stroke Wardfrom 01/2007 to 07/2007

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31Weeks

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Patient level data adds another level of Patient level data adds another level of understandingunderstanding

Patient length of pre-ward stay on Barnsley Stroke Ward

from 01/2007 to 07/2007

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Patients


Spreadsheet DemoSpreadsheet Demo

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GroupworkGroupwork

• Discuss how you will ensure the spreadsheet gets completed

• Hint: Put names in the frame!


RRevieweview


It is a waste of time collecting and It is a waste of time collecting and analysing your data if you don't take analysing your data if you don't take

action on the resultsaction on the results

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GroupworkGroupwork

• Discuss:• Where you will display your measures• When you will meet to review them• Who needs to be there

• Use the Review Meeting Guide handout to prompt you


FeedbackFeedback

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SummarySummary

• You have clarified your timeline• Planned your data collection• Agreed who will own the spreadsheet• Decided how you will take action on the results• Or ...• You know what you have to do to achieve all

these

Documents

Supporting NHS Wales to Deliver World Class Healthcare All Wales Stroke Services Improvement Collaborative