CHKS RSS Feed

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.

CHKS RSS Feed

Accreditation at Cappagh National Orthopaedic Hospital

Using: Accreditation

CHKS RSS Feed

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.

CHKS RSS Feed

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.

CHKS RSS Feed

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."

CHKS RSS Feed

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.

CHKS RSS Feed

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.

CHKS RSS Feed

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."

CHKS RSS Feed

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."

CHKS RSS Feed

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.

CHKS RSS Feed

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."

CHKS RSS Feed

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.

CHKS RSS Feed

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."

CHKS RSS Feed

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.