Advancing Quality Progress Report. Linda Smyth, Head of Quality Improvement. Approve Adopt Receive for information

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1 Trust Board Agenda Item 20 Date: 30 th November 2011 Title of Report Purpose of the report and the key issues for consideration/decision Advancing Quality Progress Report To update the Board on Year 3 (2010/11) performance in the AQ measure sets and details the actions in place to bring about necessary improvement. Prepared by: Name & Title Presented by: Linda Smyth, Head of Quality Improvement Gill Harris, Deputy Chief Executive/ Director of Nursing & Performance Action Required (please X) Strategic/Corporate Objective(s) supported by this paper Approve Adopt Receive for information CQUIN x Is this on the Trust s risk register? No Yes If Yes, Score Which Standards apply to this report? CQC NHSLA BAF Objectives 11/12 Have all implications related to this report been considered? Finance Revenue & Capital National Policy/Legislation NHS Contract Human Resources Consultation/Communication Other: Equality & Diversity Patient Experience Governance & Risk Management Terms of Authorisation Human Rights Carbon Reduction Previous Meetings Please insert the date the paper was presented next to the relevant group Meeting Point Audit Committee Gov & Risk Committee Finance & Investment Committee Management Board NED Other Page 1 of 15

2 Advancing Quality Progress Report for Trust Board, November Purpose The purpose of this report is to provide the Board with an update on progress with the Advancing Quality Programme which is now in its fourth year. Details of year 3 (2010/11) performance are provided which demonstrate that the Trust has surpassed the target threshold required for payment under the CQUIN scheme in 3 of the 5 measure sets within the programme. The report contains details of the plans which are in place to bring about further improvements in each of the measure sets during 2011/ Background Advancing Quality (AQ) aims to drive up qual ity and s afely reduce costs through the delivery of standardised clinical process measures which in turn should reduce complications, readmissions and length of patient hospital stays. The programme is now operating in 5 c linical treatment areas relevant to Wrightington, Wigan & Leigh NHS Foundation Trust: Acute Myocardial Infarction (AMI) Heart Failure Pneumonia Hip and knee replacement surgery Stroke (new measure set for 2010/11) /11 Performance Year 3 of the AQ Programme relates to the 2010/11 financial year and specifically to those patients discharged between 1 st April 2010 and 31 st March Preliminary results for the year were released in September 2011 and are summarised below: a. Acute MI The Trust achieved a composite quality score of 98.97% and therefore surpassed the threshold for payment under CQUIN (95%). The area for improvement within this measure set continues to be the need to get it right for every patient every time. b. Heart Failure The Trust achieved a composite quality score of 84.67% representing a marginal (1.11%) improvement on t he previous year but failing to achieve the CQUIN payment threshold of 91.28%. The main area of concern continues to relate to discharge instructions Page 2 of 15

3 (64.62% compliance) despite the specialist heart failure nurse making changes to her work pattern in order to address this issue. It continues to be a pr oblem that patients with heart failure are often admitted to non cardiac wards or may only be br iefly admitted meaning that the specialist team are often not made aware of them prior to discharge. It is anticipated that the development of the new cardio-respiratory unit on Ince & Winstanley wards will at least partially assist in addressing this issue. It is noted that other Trusts experience similar difficulties with this measure set and di scussions about the discharge instructions measure have recently taken place at a collaborative group meeting. c. Community Acquired Pneumonia The Trust achieved a c omposite quality score of 82.16% which demonstrates an improvement (4.58%) on previous performance and surpasses the threshold of 78.41% for CQUIN payment. Scope for improvement lies predominantly within the following measures: (i) (ii) (iii) initial antibiotic selection blood cultures performed prior to antibiotics initial antibiotic within 6 hours of arrival It is notable that the measures largely occur in the emergency care setting and some staff from that setting have attended collaborative learning events in an attempt to promote their engagement, further awareness training is to be provided to emergency care staff. The respiratory sub speciality within the division of medicine is undertaking further improvement in order to achieve future thresholds. d. Hip & Knee Surgery The Trust achieved a c omposite quality score of 92.98% which represents an improvement (4.1%) on the previous year and surpasses the 75.8% CQUIN threshold. Greatest scope for further improvement is within 2 measures: Prophylactic antibiotics within 1 hour prior to surgery Timely VTE prophylaxis The MSK Division has an action plan in place which is aimed at achieving 100% compliance across all measures: Staff at RAEI site now input data directly onto the theatre Ormis system in order to ensure accurate recording of surgical start and finish times as well as the initial induction dose of antibiotics, on both hospital sites. All consultants now adhere to VTE selection and t herefore an improvement in the VTE measures should be seen by this action alone. Advancing Quality results for hip and knee are presented at clinical audit on a r egular basis. A monthly report is also now made available Page 3 of 15

4 to the management team detailing the individual consultant activity. This report is also sent to the individual consultants so that they can review their own outcomes and in turn review their activity, making them aware of their results and t he actions that need to be communicated within their teams, to improve their outcomes. e. Stroke The AQ measure set for stroke went live in October The data presented in the appendix demonstrates that improved compliance is required against all measures. An overall composite quality score of 74.15% was achieved against a threshold of 90%, thus payment was not achieved. The stroke team have encountered a number of difficulties with regard to AQ processes and this may have had an adv erse impact on the reported results and may not therefore reflect actual practice. The stroke team undertook a risk assessment in July 2011 with regard to the potential failure to achieve AQ standards and applied a number of control measures: A weekly control meeting takes place and all stroke patients pathways are examined to ensure all care bundles are applied and documented and s ubsequently recorded correctly on t he database. A daily white board meeting cross references and ensures that bundles have been completed in the correct time frame. The stroke team meet and greet patients 7 days a week and track and support quick access to the stroke ward and commence care bundles in A+E. An education programme has been developed to ensure that all members of the emergency care team (nursing and medical) are aware of the correct stroke pathway and c are bundles required. Root cause analysis is carried out on all cases where the stroke pathway is not adhered to. In addition, an action plan has been devised to analyse the problems and implement appropriate solutions to achieve the AQ targets (Stoke Improvement Plan). Full details of all measure sets, results and regional comparison data can be found in the appendices to this report. 4. Data & Coding Completeness Based on the data available from the monthly\quarterly and annual reports the indicative summary for AQ year 3 in relation to clinical coding and dat a completeness is that targets of 95% have been achieved with the exception of the stroke pathway where 80% data completeness was achieved. To date the Trust has not received a published report from Aqua\Clarity which Page 4 of 15

5 details the clinical coding and data completeness performance. The switch over from Premier to Clarity as the strategic partner has proved to be highly problematic for the Trust which has experienced a number of issues relating to the submission\upload of the extracts. The business intelligence team continue to work with Aqua and Clarity to resolve these. In the interim, relevant changes have been applied manually to ensure that the published performance is unaffected. This has had an adverse impact on resources for the clinical teams and business intelligence. 5. Patient Experience Measures During year 3 the AQ programme reviewed its approach to the measurement of patient experience. From April 2011 a survey consisting of a single question has been administered to patients on the day of discharge: On reflection, did you get the care that mattered to you? Results of these surveys will be a vailable in future reports. 6. Patient Reported Outcome Measures (PROMs) Participation in PROMs applies only to the Hip and Knee pathway in AQ. The Trusts response rate is below the national average and plans are in place to meet with the national team to review the current systems and processes to determine whether inclusion rates can be i mproved. The Trust is aware of the ongoing discussions within the National Team to increase the scope of PROMs to include all elective procedures from April Conclusions and Recommendations In conclusion, the AQ results for Year 3 demonstrate that high compliance in the AMI measures has been sustained and that improvements have been achieved in the remaining 3 established AQ measure sets (heart failure, pneumonia and hip & knee surgery) although such improvement has been inadequate to the meet payment threshold for heart failure. Stroke has been added to the AQ programme for quarters 3 & 4 and the results demonstrate that significant improvement is required; it should be noted that difficulties with AQ administrative processes may account for some of the shortfall in compliance. The Trust Board is asked to note the results and the plans that each speciality team has put in place to bring about the required improvements in Year 4. Page 5 of 15

6 Appendix 1 Acute Myocardial Infarction Data Year 3 Comparison to North West Trusts Page 6 of 15

7 Trust Performance Figures by Individual Measure Page 7 of 15

8 Appendix 2 Heart Failure Data Year 3 Comparison to North West Trusts Page 8 of 15

9 Trust Performance Figures by Individual Measure Page 9 of 15

10 Appendix 3 Community Acquired Pneumonia Data Year 3 Comparison to North West Trusts Page 10 of 15

11 Trust Performance Figures by Individual Measure Page 11 of 15

12 Appendix 4 Hip and Knee Replacement Surgery Data Year 3 Comparison to North West Trusts Page 12 of 15

13 Trust Performance Figures by Individual Measure Page 13 of 15

14 Appendix 5 Stroke Data Year 3 Comparison to North West Trusts Page 14 of 15

15 Trust Performance Figures by Individual Measure Page 15 of 15