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"I have learned so much from this course; I knew very little about RCA (Root cause analysis) until this.  Although initially I thought it would not be applicable to my role... I was totally wrong.  The systems I have learned will be of great help to me."

Using: CHKS Consultancy

Services: Root cause analysis training; policy and process development; compliance review

Key objectives

• Train a group of senior managers and clinicians to conduct structured investigation and root cause analysis (RCA)
• Identify key failings and potential solutions relevant to real incidents
• Develop a policy for the NHS standard: ‘Learning from Experience'

Key results

• Key personnel understand the value, nature and application of investigation of incidents
• A formal process for conducting effective investigations and how to use the information to drive improvement
• A compliant ‘Learning from Experience' policy and process, with buy-in from staff across the ISTC

Background

Having worked on the development of the NPSA e-learning toolkit and with a wealth of experience delivering RCA training to health and social care personnel across the UK and Ireland, an ISTC needed to understand how it could use the NPSA's RCA tools to help it understand and improve incident investigations and learning.

Our solution

We provided a two day training programme at one ISTC, followed by a further course for senior manager and clinicians from across the ISTC Group.  We also revised their incident policy to ensure compliance with the NHSLA standard on Learning from Experience.

The training programme

Working with the Director of Nursing, we designed an interactive programme which provided a combination of information giving, reflection, group exercises and discussion:

• an introduction to a range of tools and techniques used in structured RCA
• guidance to ensure the selection of appropriate tools to the different situations or tasks
• identifying the optimum means for identifying practical recommendations and ongoing monitoring

Using external case studies and real examples from the ISTC group, we covered the selection of appropriate tools and techniques and how to use them, in a controlled environment.  This allowed participants to identify common themes, failings and potential for failings within the organisation and to develop solutions.  By facilitating discussion, the group shared experiences and discussed live issues around investigation and incident review.

Policy and process development

The review of policy and process involved two pieces of work:

• a workshop with senior managers and subsequent proposals for revising incident reporting and investigation processes and documentation
• revising the Learning from Experience policy and process in line with the results from the workshop and to achieve compliance with NHSLA requirements

We facilitated discussion around the benefits of transforming the incident and investigation processes to ensure that learning took place and could be demonstrated. We also provided practical recommendations for a new incident and investigation process included a flow diagram, new incident report form, categories for reports and a suite of investigation report templates. A pilot process and timeframes were also agreed for the new process and documentation.

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Welsh Risk Pool (WRP) - Risk management standards and advice

Using: CHKS Consultancy

Risk managenent advice and active support in the development and implementation of risk management initiatives in NHS Wales.

Key objectives

• Provision of expert advice for the resolution of claims


• Identification of development opportunities for staff of the WRP


• Provision of advice for senior staff of the WRP


• Development and implementation of initiatives to improve healthcare risk management in Wales


• Support of assessors during audit work
  
• Provision of training for member organisations of the WRP.

Key results

• Robust process for identifying and assessing those issues which are critical to the provision of safe care and the reduction of risk.
• Development of all levels of WRP staff.

Background

The Welsh Risk Pool (WRP) is the body which indemnifies Welsh healthcare organisations against losses.  It performs an essential function for its members in both: 

• Managing the claims reimbursement process effectively
  
• Seeking to support the NHS in Wales in improving risk management and thus enhancing patient safety.

CHKS Consulting has been working with the WRP since 1996 providing both risk management advice and active support in the development and implementation of risk management initiatives in NHS Wales.

WRP chose us to be its risk management partner because of our outstanding track record in Health and Social Care expertise, gained in England, Wales and Northern Ireland. WRP was also impressed with our comprehensive risk management credentials and our ability to mentor and coach their staff.

WRP operates in an environment where frequent regulatory changes demand up to date risk expertise and advice coupled with the ability to devise and implement ‘fit for purpose' strategies. In order to ensure the pool is supported by high quality standards and advice, the WRP set Capita Consulting specific goals:

• Provision of expert advice for the resolution of claims
  
• Identification of development opportunities for staff of the WRP
  
• Provision of advice for senior staff of the WRP
  
• Development and implementation of initiatives to improve healthcare risk management in Wales
  
• Support of assessors during audit work
  
• Provision of training for member organisations of the WRP.

The long-standing relationship between us and the WRP is based on a close working partnership, centred upon education and the transfer of knowledge and skills to WRP staff.

Our first task, fundamental to the achievement of all WRP's goals, was the production of robust risk management standards. We developed a standards format and agreed the key areas to be covered with the WRP. By holding one to one meetings with practitioners and external bodies and using best practice gained on other assignments, We developed, in liaison with the appropriate specialists, a set of agreed, high quality standards for the WRP, which were subsequently used to assess each pool member.

In order to review claims, the Advisory board meets every six weeks. We add value to these meetings by providing expert advice and where necessary works on specific questions, drawing on our significant healthcare risk management expertise.

Not only do we provide specific advice to the WRP, we also facilitate the Senior team and assist with the development of strategy and process to fulfil organisational goals. The UK-wide Healthcare Risk and Patient Safety Forum, ran by CHKS Consulting, is just one example of the valuable networking and educational opportunities we provide to the WRP.

To ensure constant improvement and adherence to new standards, we develop and implement learning sets for staff of all levels, including pool members, senior staff welcome the coaching and mentoring offered by CHKS Consulting and the support of assessors during the key audit work.

WRP has reaped significant benefits from their relationship with over the years. Most importantly, the WRP has developed with the help of CHKS Consulting, a robust process for identifying and assessing those issues which are critical to the provision of safe care and the reduction of risk.

The WRP has the ability to network with other trusts around the UK by means of the CHKS Consulting Healthcare Risk and Patient Safety Forum, facilitating peer to peer education and furthering support for good risk management in Wales.

We have been instrumental in developing all levels of WRP staff, which in turn has allowed the WRP to enhance the provision of effective risk management in Welsh healthcare.

"We have worked with Capita for over a decade and have our confidence in them reinforced every time we go out to tender for renewal of the service when their knowledge of healthcare risk management and their professionalism is exemplified. This breadth of knowledge, experience and links to an international organisation is invaluable to us on a day to day consultancy basis but is also of major benefit in developing staff and keeping them up to date through the Forum and learning sets".  John Bowles, Welsh Risk Pool Manager.

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Review of Care

Using: CHKS Consultancy

We were engaged by a large provider of nursing and residential care homes in the UK to undertake an independent review of the care provided for a specific client. The review was commissioned by the service provider after an investigation by the local Primary Care Trust and following requests for further information from the client's relative. The scope of the review covered the quality of care delivered to the client and also the standard of services in place at the time of the review.

These were benchmarked against the Care Quality Commission (CQC) standards (previously CSCI). A critical goal for the review team was to determine whether the care home provider had learned the right lessons from the care episode in question, and whether there was scope for further improvements in care home management and care delivery. We were chosen to carry out this specialised review because of its independent status, proven track record in carrying out similar reviews and extensive clinical expertise and knowledge of the independent nursing and residential care home sector.

Challenges and Goals

Our extensive remit covered:

• Identification of any deficiencies or non compliance with national and professional standards in the assessment, care planning and delivery of care to the client


• Identification of areas of good practice and compliance with the appropriate local and national standards


• In light of the above, review of the current practices at the care home. The client's relative asked specific questions regarding care provision and also sought assurance that any recommended improvements would be implemented.
  

Our approach

We set up a multi disciplinary review team and applied a Root Cause Analysis approach to the review. This involved meticulously gathering all necessary data and interviewing key members of staff.

In order to understand the precise details of the client's care, we formulated a tabular timeline informed by the client notes, interviews, policies and site visit. Visits to the care home were undertaken by our specialist team on three occasions to meet and interview staff employed at the time of the client's care episode and those currently employed. Our expert team carefully examined the facilities, resources and services available at the care home including a number of care home policy documents.

Not only did we compare procedures in place at the time of the incident and at the time of the review regarding client care to national and professional standards, it also analysed information regarding the recruitment and selection, induction and performance management of the staff including the Home Manager. Furthermore, the review examined a variety of management information documents and correspondence and contract documents relating to service provision by the General Practitioner.

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North and West Belfast Health and Social Services Trust (Now Belfast Health and Social Care Trust)

Using: CHKS Consultancy

Root cause analysis review - A review of the circumstances of an incident using causal analysis techniques

Client goal / objective:

North and West Belfast Health and Social Services Trust had received a letter of complaint from the family of one of their clients who had been subject to alleged inappropriate behaviour from one of his fellow residents. The family were keen to know what the Trust was doing to ensure this would not happen again.  An internal investigation had already taken place but this had not used a causal analysis approach.

We were commissioned to facilitate a further review of the circumstances of the incident using causal analysis techniques.

The client priorities were to:

• Involve key staff in looking at the events surrounding the incident
• Identify the key problems that occurred and the underlying issues which contributed to them
• Identify what can be done to deal with those issues.

Our approach:

The methodology of the root cause analysis review involved:

• A pre-meeting between the review facilitators, and key staff from the Trust
• Preparation of a timeline of events, drawn from the Investigation report
• A workshop held with concerned staff
• A post-meeting (as pre-meeting) to agree actions to address the key problems identified at the workshop
• Application by the facilitators of root cause analysis to the key problems identified to illustrate the underlying issues highlighted at the workshop
• Production, consultation and issue of a final report participants.

Client benefits:

The Trust was provided with a report which clearly outlined the methods used and identified key areas for improvement and a number of areas where good practice had been demonstrated. From this the Trust was able to draw up an action and implementation plan which they could share with the client's family to provide them with reassurance that as far as possible this incident would be prevented from occurring again.

"The review team from Capita were enormously helpful in ensuring a structured approach to our root cause analysis review and acting as independent facilitators for the review workshop. Their use of root cause analysis tools to get to the underlying issues of the incident resulted in some key areas of improvement for the Trust to take forward. The resulting comprehensive report enabled shared learning across all areas of Trust business".  Ian Jamison, Assistant Director of Corporate Services, North and West Belfast Health and Social Services

We are delighted to be sitting on two new DH working groups, set up by the National Quality Board.  Established to define an NHS-wide, standard HSMR and new patient safety indicators for use in England, the groups plan to have agreed the new methodologies by June 2010. 

Patient safety working group
Focusing on developing patient safety indicators (with the exception of HSMRs) for England, the group met for the first time on 26^th March.

NHS Medical Director, Professor Sir Bruce Keogh, explained the brief to agree a set of indicators (5-15) to be used as the NHS standard and the scope and criteria to evaluate them.

HSMR working group
Set up to agree a standard HSMR (Hospital Standardised Mortality Rate) for use in England.  The group includes key interested parties like Monitor and CQC as well as leading academics.

At the first meeting on 30^th March, chaired by Ian Dalton, NHS North East Chief Executive, the group agreed to establish two sub-groups:

• A technical group, to be chaired by Prof Paula Whitty (Director NE Quality Observatory) and
• A second group to focus on the communication and presentation issues surrounding an HSMR

Defined methodologies for both the HSMR and patient safety indicators are due by June 2010.

We will keep you posted on developments, but please speak to your CHKS consultant or business manager for progress updates.

The quality mark will be awarded to those practitioners and clinics that have been accepted on to the register.  CHKS' expertise has been called on by IHAS to help with the assessment process and the registration of applicants. Its trained IRCA lead auditors have a wide range of experience of supporting healthcare organisations.  Organisations and practitioners can apply for registration through the website: www.treatmentsyoucantrust.co.uk.

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Aneurin Bevan Health Board

Outcome:
The risk adjusted mortality ratio at Aneurin Bevan Health Board is now 72 compared with a risk adjusted mortality ratio average of 99 for all hospitals in Wales¹. The trust believes that the success of this initiative can be attributed to ensuring that the reported data is a true reflection of activity within the trust but also at individual clinician level.

Starting point:    
Following the introduction of the Saving 1000 lives campaign across Wales the clinical teams at the Aneurin Bevan Health Board recognised that in order to report accurate data (including risk adjusted mortality index) a comprehensive review of the data quality and clinical coding for all deaths needed to be undertaken.

The focus and drive for this effort came from the clinical teams supported by the informatics and coding teams. They introduced a range of initiatives to ensure consistency and a clinically audited reporting measure.

Service response:
The small backlog of uncoded deaths was cleared and this was then followed by the introduction of a "fast track", or "express" system, for coding of case notes where a patient had died. This enabled the informatics team to produce individual mortality reports for each consultant identifying each patient with the coded diagnoses and procedures.  These lists were then reviewed and if necessary discussed with a dedicated Audit Team. If required the electronic records were then re-coded to ensure both completeness and accuracy.

Resources used and productivity gain:
The success of this initiative was due in a large part to the clinical teams' willingness to ensure reported data was a true reflection of both the trust's but more importantly their individual performance. The commitment and collaborative working of the three groups; clinical teams, Saving 1000 lives team and the informatics and coding team was vital. 

The initiative has provided the assurance to the trust, the local community and to the Welsh Assembly that the Aneurin Bevan Health Board is not reporting unexpected deaths. It has also helped to identify areas of potential risk when it comes to making further improvements to the care and treatment of future patients.

Notes to editors:
1. A risk adjusted mortality ratio of 100 means the number of observed deaths equals the number of expected deaths, allowing for variations in cases treated. A ratio of 72 means that there were 28 per cent fewer deaths than were expected.

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Accreditation at Cappagh National Orthopaedic Hospital

Using: Accreditation

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Dartford and Gravesham NHS Trust

Using: Consultancy

Dartford and Gravesham NHS Trust wanted to improve length of stay and ensure it provided the most appropriate and effective care for the patients being treated in the medical directorate.

Identifying the problem

Using Signpost, our online corporate reporting and clinical management system, we identified where that patients had an underlying diagnosis of dementia, their length of stay increased substantially.

More detailed analysis showed that it was not the patients who were discharged to a care home, but those whose dementia did not warrant a specific residential care package. A core element of the DH's Dementia Strategy is that dementia patients are best placed in their own environment, be it in their own home or in other appropriate care settings.

Key Findings

Physicians were reluctant to discharge patients as they were uncertain of continuing care provision

The high number of patient admitted was due to the pressure on A&E, CDU targets and high demand, which resulted in limited time for apprporiate pre-assessment, increasing the likelihood of admission

Whilst the acute needs of the patients were effectively managed, the physicians' skills in managing dementia were limited 

Tackling the problem

We facilitated a multi-agency workshop to identify the failure points in the patient pathway.  The workshop looked at the interrelationships between carer and providers; and the need for better awareness, communication, training and skills.  Involving the whole health economy, care agencies, patients and carers is crucial for implementing the Dementia Strategy effectively. By identifying the key failure points, the Trust can significantly reduce length of stay, improving quality of care, outcomes and patient experience, as well as driving productivity and efficiency savings.

We then defined a series of metrics to evaluate, monitor and improve the care pathway.  Like Dartford and Gravesham NHS Trust, by using combined CHKS products and services, healthcare organisations are working more innovatively to improve the quality of care, enhance the patient experience and increase efficiencies.

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This supplement celebrates the achievement of the hospitals that have won awards in this year's CHKS 40Top Hospitals programme. The programme was started in 2000 and has since grown to include awards that are open to all hospital trusts in the UK, in the important areas of patient safety, quality of care and data quality.

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County Durham and Darlington NHS Trust

Using: CHKS Accreditation

At County Durham and Darlington NHS Foundation Trust, the CHKS Accreditation Programme was one of the indicators that had a direct impact on the results of the Trust's 2007/8 Annual Healthcheck when it was rated ‘excellent' for both services and use of resources. By mapping where Standards for Better Health had been used within the accreditation criteria, the Trust was able to use this as an external assurance when determining compliance with the Healthcare Commission standards.

Guiding newly-merged trusts

The Trust began the process of accreditation as a new organisation, created through the merger of South Durham and North Durham acute trusts. Now one of the largest acute trusts in England, healthcare facilities are provided on three major acute sites and two community hospital settings. The Trust is also in the unusual position of having three key units as PFI provider sites.

Stuart Lonie, Governance Manager at the Trust, says: "Several factors led us to take a ‘slow but steady' approach to the accreditation programme. It takes about six hours and a 165 mile round trip to visit all our sites. Also, while one half of the newly-merged trust had been familiar with accreditation processes, the other half had not been externally assessed and accredited by CHKS before."

He continues: "Our first challenge was to educate the Trust as a whole about the accreditation process. Once this was achieved, the assessment process from launch to the external peer review survey took 20 months."

Streamlining process and procedures

For a newly-merged organisation, the process of accreditation has had many benefits. Newly-formed teams have been able to review practice, policy and procedures and identify where change could be introduced. With closer links developed within and between teams, trust-wide policy and practice change has been allowed to flourish.

Focusing on the patient

The Trust was keen to involve its patient representatives in the process and trained three to become internal surveyors. Stuart Lonie says: "CHKS is unique in that it focuses on patients, their experiences and outcomes. Our clinical teams were able to focus on the patient's perspective, gain patient opinion and, where required, change the service to focus more on patient expectations."

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Signpost

We asked a number of leading trusts to share their key tips on how they use it to inform strategic and local decisions from resource utilisation and service planning to clinician appraisal and performance management.

1. Set up a trust steering group
Led by your trust's Signpost champion, the group could include at least one clinical director/lead clinician, general/business manager, clinical governance lead and information manager. Meeting as little as twice a year, the group can stimulate interest and buy-in across your trust to ensure that all staff, from Board members and clinicians to governance managers and information specialists, get the most from Signpost.

2. Broaden use across your trust
Too often dissemination of information is left to a few individuals; so why not make Signpost available to more staff? As a web-based system, any designated user can access it from any computer across the trust. Following initial training from your CHKS consultant, all staff, from directorate leads to clinicians and governance to information managers, can use Signpost to extract the information they need to help them fulfil their daily responsibilities.

3. Join the CHKS User Group
Encourage a member of your trust's steering group to join the CHKS User Group. Aimed at information/governance directors and information managers, and meeting just three times a year, you could benefit from sharing innovation and best practice, as well as help us to refine existing products and inform new product development.

4. Get the most from your CHKS consultant
Involve your CHKS consultant in directorate and clinical audit meetings quarterly to present findings and discuss issues around performance improvement, deterioration and trends. By regularly reviewing progress with you, your CHKS consultant can help to identify emerging problems and areas that need targeted analysis, to facilitate timely remedial action and improvement.

 5. Ensure your staff know what support is available
All Signpost contracts include additional consultancy support. From product implementation training to bespoke analysis and interpretation, ensure that your staff understand the extent of support available, so that you use all your commissioned days effectively to support your trust's improvement.

6. Configure Signpost around your trust's directorate structure
Ask your CHKS consultant to establish a monitoring and reporting structure that reflects your trust's directorate structure. This will make the information more meaningful to staff and more easily applicable to informing solutions and changes in practice.

7. Targeted reporting
Review the needs of your trust and ask your CHKS consultant for more targeted, bespoke bi-annual reports. Instead of a trust-wide review across all performance indicators, why not focus on a small range of specialties or a trust-wide report focusing on a specific issue such as mortality.

8. Embed Signpost in your performance management processes
Recommend that the clinical leads and governance managers provide regular summary reports identifying performance on defined key indicators. This often encourages greater use of Signpost for monitoring performance as well as for managing their service.

9. Engage more clinicians
Set up more detailed Signpost or DAT analyses and demonstrate to clinicians that they can run bespoke reports and use this information to support their revalidation and certification process.

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Salisbury NHS Foundation Trust

Instilling a culture of safety throughout the organisation has been a top priority for Salisbury NHS Foundation Trust for a number of years. It is this commitment that led to the trust winning the CHKS Patient Safety Award in 2008.

Taking responsibility for patient safety is Director of Nursing Tracey Nutter. She explains: "We have introduced a number of projects including reducing hospital mortality and infection rates. While I have the overall responsibility for patient safety, the Chief Executive, other Executive Directors and the wider Trust Board take an active role in developing the safety agenda and the Medical Director leads on specific aspects of safety work, such as the mortality project."

Focusing on mortality

Five years ago a mortality group was set up to focus on reducing preventable deaths and helping patients expecting to die, to die with more dignity. The mortality group has played an important role in raising awareness of the importance of reducing mortality and associated issues with clinical staff. Tracey Nutter says: "The development of mortality groups at directorate level has resulted in more open discussion and learning taking place within and between clinical teams and across specialty areas."

Other projects include the implementation of the Early Warning Scoring System, which makes it easier for staff to assess when a patient's condition is getting worse and take action. This is currently achieving audited compliance of 96%. Other initiatives include a 24-hour Critical Care Outreach service to support ward staff in delivering care to cardiac arrest patients, improvements in handover to night teams, the introduction of the Global Trigger Tool that helps the trust understand the main causes of harm in the hospital and the introduction of VTE assessment for all patients admitted to hospital for which the Trust recently achieved exemplar status.

Reducing on hospital-acquired infections

Improvements in hospital mortality have been mirrored in the trust's achievements in reducing hospital-acquired infections. "We have a target zero approach to both MRSA bacteraemia and C.difficile and managing the prevention and control of infection is viewed as everyone's responsibility", says Tracey Nutter. Infection control is monitored from the ward right through to the board and initiatives such as the "bare below the elbow" policy for all clinical staff and a change from the traditional nurse's uniform to "all scrubs" for nursing and therapy staff have led to significant improvements.

In the last three years, cases of MRSA have reduced from 21 to 7 per annum and are continuing to fall. Cases of C.difficile are currently reducing by 75%. This has put the Trust in the upper quartile performance for reducing infection rates and efforts continue to reduce rates and sustain improvements.

"Winning the CHKS Patient Safety Award was a welcome recognition of the hard work everyone at Salisbury has put into creating a safe environment for our patients" concludes Tracey Nutter. "The challenge now is to maintain our high standards through a continual programme of monitoring and improvement."

All the trusts are using Signpost, the CHKS corporate reporting and clinical management system, to highlight improvements that can be made in booking methods and identify where list scheduling may be affecting day case performance.

Paul Robinson, Head of Market Intelligence, CHKS Group said: "There are 25 procedures, identified by the Audit Commission, that trusts should be aiming to carry out as day cases. We are delighted that we have been able to help our clients in the North West achieve the highest levels of day case clinical productivity in the region."

To read the full document, please see here.

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East Kent Hospitals University NHS Trust

Using: Signpost

 All clinicians are wary of data and those at East Kent Hospitals University NHS Trust are no exception. For managers at the trust, ensuring clinicians are presented with credible data that they can have confidence in is a key challenge.

Inproving data quality

Improving data quality is the first step in developing relevant and meaningful clinical metrics and the trust's Clinical Coding Programme, with its focus on improving training for clinical coders, is resulting in higher standards. Running alongside the Clinical Coding Programme is the trust's Patient Safety Programme where CHKS is playing a key role in delivering information and providing strategic advice.

Led by medical directors, associate medical directors and clinical leads, the objectives of the Patient Safety Programme are to monitor clinical metrics, to provide assurance on patient safety and to champion the drive for continuous improvement in quality of care.

Clinical coding information is delivered to the Patient Safety Programme through Signpost, the CHKS corporate reporting and clinical management system. With the support of CHKS consultants, the trust is then able to analyse and highlight areas of variation where data may be impacting on clinical metrics, for example in mortality, re-admissions, complications and misadventures.

Engaing clinicians with their data

CHKS is providing the trust with a mechanism to allow clinicians to see for themselves how episodes have been coded and how information has been presented to clinical coders to interpret into the coding process.  Through the Patient Safety Programme, clinicians at East Kent Hospitals University NHS Trust can understand data quality and its impact on the outcomes presented in clinical metrics.

Addressing patient safety

Dr Neil Martin, medical director at the trust says: "Patient safety is the highest priority for East Kent Hospitals University Trust. To be able to adequately judge progress in this area, measurement of harm events and mortality is essential. We have found significant advantage from being able to triangulate data from several sources - including CHKS - to give us the reassurance that we are moving in the right direction."

Dr Martin adds: "In particular, the Risk Adjusted Mortality Index (RAMI), which includes all deaths and excludes zero length of stay, is a powerful tool. We have also valued the expert analytical support offered by CHKS as this is not always easy to obtain in-house."

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NHS South East Coast Dementia Programme

Using: Bespoke analysis

Relevant and meaningful information supports the commissioning of dementia services and is a key priority for the South East Coast Strategic Health Authority. The NHS Information Centre has been instrumental in supporting the SHA's work in this area. It worked in partnership with CHKS and the SHA to turn health needs assessment into a tangible entity by defining clinical metrics using existing data that are relevant and meaningful to clinicians and practitioners.

Analysing the evidence

Using a range of evidence-based data sources, for example the National Audit Office report on the predicted population demands for dementia services, this evolving programme of work allows the SHA to focus on some key commissioning issues. Analyses undertaken so far include; admissions and length of stay, predicted dementia prevalence by GP practice compared with the number of patients on dementia registers, QOF data relevant to dementia, access measures and spend on dementia.

 Crossing the boundaries

Samantha Riley, Head of Knowledge Management at South East Coast Strategic Health Authority, says: "Meeting the challenge of world class commissioning means moving towards a pathway of care that is driven by the needs of patient and carer and that crosses the boundaries between primary, social and secondary care. The CHKS programme provides us with the mechanism to focus on the key drivers to variation between commissioners."

 The result

The programme output has highlighted some significant questions that can now begin to be addressed. "The information on prevalence is of particular interest since we can see that most GP practices have significantly fewer patients on their dementia registers than expected," Riley says. "This could present a real issue for commissioners. For example, if patients are not on dementia registers can we be confident they are receiving appropriate care?  What would the financial implications be if PCTs had 100 per cent of expected patients on dementia registers?"

Riley expects the programme to throw up further questions as it evolves. She says: "Armed with the information from the CHKS work, our clinicians on the ground will be able to provide the local context and initiate local discussion to start providing the answers to these important questions."

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Dartford Hospitals NHS Trust

Using: Signpost 

There were three factors driving Dartford Hospitals NHS Trust's decision to use the Signpost corporate reporting and clinical management system. First, the national standards and targets used by the Healthcare Commission's Annual Health Check; second, the requirements of Foundation Trust status; and finally, the need to demonstrate efficiency to primary care trusts and others. All of these meant the Trust needed a comparative tool to assess clinical performance, outcomes and productivity.

Mike Thompson, Assistant Director of Performance at the Trust, says: "We had been working with CHKS for some time before migrating to the Signpost system which we are using across a wide range of applications."

Two examples demonstrate the way in which the Trust is taking advantage of the scope the Signpost system is able to provide. At one level one of the Trust's clinical directors is using Signpost to monitor clinical performance at speciality level. Within a different context, the Trust is using Signpost to regularly report key indicators, for example length of stay, to the Trust Board.

Engaging clinicians and managers
A range of clinical and non-clinical staff, including clinical directors and general managers, has been trained to use the Signpost system. Mike Thompson says: "We have identified measurable benefits from using Signpost. For example reporting comparative information and present trends at Trust, speciality and HRG level is easier than in the past." He continued: "The web-based system is accessible to a wider range of staff and the information presented is more user-friendly."

Signpost is also helping the Trust with service performance improvement initiatives driven by the need to use resources more effectively. A project aimed at reducing non-elective average length of stay by one day is underway and another to improve day case rates is planned.

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East & North Hertfordshire NHS Trust

Using: Signpost

Signpost has given a significant boost to the drive for improvements in data quality at East & North Hertfordshire NHS Trust. The Trust is using Signpost through its clinical efficiency work streams to spotlight areas where improvements' could be made. The Trust's coding department is also using Signpost to measure performance against the Depth and Data Quality index.

Improving Length of Stay

Keith Broughton, Data Quality Improvement Manager, says: "We have particular issues surrounding length of stay across all specialties. Patients staying in hospital any longer than necessary means ward beds are not being used to optimum capacity. Signpost is helping us to analyse the length of time patients spend in hospital and identify where the length of stay can be reduced. The result is that more patients can be treated and discharged."

Signpost is used at different levels across the Trust, providing easy access to user-specific information for consultants, clinicians, managers and information analysts. Analysis of clinical coding ensures the correct coding is input to produce the corresponding HRG, which is reflected in the trim point. Signpost is also informing staff training, for example in the use of the Estimated Discharge Date.

Keith Broughton says: "We have found that Signpost is easier to use compared with comparable products. Data updates can be achieved after correcting incorrect data. It is not fixed to secondary user service updates and freeze dates. Also, data can be sent at any time to update historic data. Signpost is also providing our Clinical Coding Manager with vital support in ensuring coding is of the highest standard and depth."

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East Sussex Downs and Weald, and Hasting and Rother PCTs and East Sussex County Council

Using: Joint Strategic Needs Assessment

Producing a joint strategic needs assessment within a twelve week timeframe is hard work for any PCT. Faced with this task, East Sussex Downs and Weald and Hastings and Rother PCTs and East Sussex County Council realised that they needed outside help and in July 2007 went out to competitive quotation for the work.

Cynthia Lyons, Deputy Director of Public Health, says: "The Joint Strategic Needs Assessment underpins the three-year PCT Strategic Commissioning Plans and the Local Area Agreement and will play an important role in helping to reduce inequalities at a local level. It's a crucial tool that will inform the development of other local plans and strategies."

Meeting the Deadline
From the time CHKS was awarded the contract to delivery the timeframe had shortened to just six weeks. The PCT needed a lot of data collated an analysed quickly. "We had a clear idea of what we needed to produce and CHKS helped the vision become a reality in a very short space of time," says Lyons.

A Collaborative Approach
Standardised reporting format was discussed and agreed at an early stage. Common data templates were issued and responsibilities for collation and processing identified. This meant CHKS was able to produce a number of detailed reports. These included indicators for individual GP practices, practice-based commissioning consortia, electoral wards, local authority districts and County Council level.  Mapping of health data to local government areas (and vice versa) was achieved via algorithms based on electoral ward of residence assigned to patients registered with local GPs.

The Result
As a result, the partnership between CHKS and the PCTs and East Sussex County Council yielded an evidence-based Joint Strategic Needs Assessment well ahead of other PCTs. "It has given us a good foundation on which to build plans for the future. It was hard work but well worth it," says Lyons.

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Imperial College Healthcare NHS Trust

Using: Case Notes Audit

After a comparative coding analysis undertaken by CHKS for Hammersmith Hospitals NHS Trust (now part of Imperial College Healthcare NHS Trust) highlighted income concerns across four specialties, CHKS recommended a 200 case note audit in general surgery, plastic surgery, neurosurgery and neurology.

The case note audit revealed discrepancies between information in the case notes and the coded episodes and the impacted they had on income. Clinical coding needed to be improved and the audit suggested this could be achieved through greater clinical involvement.

Increasing Clinical Involvement

Carol Toogood, general manager of the Trust's west London renal and transplant centre, led the initiative to increase clinical involvement in coding within these four areas. She says: "In renal services we have clinician-led weekly coding meetings where coding is analysed by patient discharges. Clinicians are trained in using the system and add significant value to the coding process." She continues: "When we first started involving clinicians the meetings took up to three hours and involved a high level of coding amendments. Now, with clinicians supervising the meetings they last a maximum of one hour and coding amendments are minimal."

The Result

Ms Toogood believes that creating and maintaining gold standards in coding is essential for Imperial College Healthcare NHS Trust. "In terms of patient care, better documentation means better governance and less chance of problems for patients in the future. And as for our income position, accurate documentation reflects the true activity going through the Trust."

Ms Toogood is now working with colleagues to apply 'best-practice' clinician-led coding across the Trust. She concludes: "The CHKS audit has been invaluable, providing evidence in support of our plans for clinical involvement in coding for all specialties."

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Southport & Ormskirk Hospital NHS Trust

Using: Signpost

When a local newspaper reporter contacted Southport & Ormskirk Hospital NHS Trust investigating a potential 'bad news' story, a swift response was required to get the facts straight. According to a national study into the length of stay following major abdominal surgery, the Trust had performed particularly badly and the newspaper wanted to know why. Turning to Signpost, the CHKS corporate reporting and clinical management system, Trust managers were able to quickly extract key information to arm their response.

Getting the facts straight

The Signpost analysis showed that the results of the study were seriously misleading. Margaret Johnson-McDevitt, deputy director of performance at the Trust, said: "The study gave an average length of stay that was significantly higher at Southport & Ormskirk hospitals. When we looked at the Signpost data, however, we saw that there were only 11 cases of major abdominal surgery at the Trust during the time period of the study. One patient's length of stay was disproportionately higher due to clinical complications and this skewed the whole result." Ms Johnson-McDevitt added: "Taking this patient out of the equation revealed that the Trust's performance was amongst the highest in the country."

Helping managers respond to hostile media questions is one of the more unusual ways in which Signpost has been used by the Trust. On a day-to-day basis the system is used as a clinical benchmarking tool and to provide a framework for service improvements.

Clinical engagement is viewed as key to the successful application of Signpost throughout the Trust. Clinical directors use the system for peer reviews and consultant job planning while medical directors are able to examine specific areas in close detail to monitor performance and service improvements.