All Wales Stroke Services Improvement
Collaborative
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
Mike Davidge
Senior Improvement Advisor
NHS Institute for Innovation & Improvement
Slide 2
All Wales Stroke Services Improvement Collaborative
The Model for Improvement
Slide 3
All Wales Stroke Services Improvement Collaborative
Process
Outcome
Flow
Types of measure
Slide 4
Time from onset of symptoms to admission
Time from onset of symptoms to stat aspirin
Time from admission to stat aspirin
Time from admission to ROSIER assessment
Time from symptom onset to CT scan
Time from admission to CT scan
Time from admission to admission to a specialist stroke ward
Crude mortality rate Per 1000 patients
Length of Stay
% return to usual place of residence
Average 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
All Wales Stroke Services Improvement Collaborative
The care bundles
•
•
•
•
First hours bundle
(Rapid recognition)
•
•
•
First day bundle
•
(Emergency treatment) •
•
•
First 3 day bundle
•
(Early mobilisation)
•
•
•
•
First 7 day bundle
•
(Specialist care)
•
•
•
Slide 5
% 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
All Wales Stroke Services Improvement Collaborative
Measurement is a process
Collect – the right data in a sustainable
way
Analyse – the right measures presented
in a helpful way
Review – whether your changes are
having the desired effect
Slide 6
Collect
Supporting NHS Wales to Deliver World Class Healthcare
The process of measurement
at Luton & Dunstable Hospital
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
Why 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
Slide 9
All Wales Stroke Services Improvement Collaborative
What 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
Slide 10
All Wales Stroke Services Improvement Collaborative
How 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.
Slide 11
All Wales Stroke Services Improvement Collaborative
The 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
Slide 12
All Wales Stroke Services Improvement Collaborative
Required 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
Slide 13
• 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
All Wales Stroke Services Improvement Collaborative
The current process mapped
Ward clerk
enters
admission
date/time and
source of
admission into
ward book
Patient
arrives in
A&E
Patient
departs
A&E
Patient
arrives in
ACU
A&E
Receptionist
enters arrival
date/time onto
F/W
A&E clinical
staff enter
departure
date/time onto
F/W
Ward clerk
enters
admission
date/time,
ward and
source of
admission
onto IPM
Slide 14
Stroke co-ord
enters scan
time into
stroke DB
Ward clerk
enters
admission
date/time into
ward book
Therapy staff
enter Bartel
scores into
notes
Patient has
scan
Patient
transfer to
stroke unit
Radiology
staff enter
scan date/time
onto CRIS
Ward clerk
enters transfer
date/time onto
IPM
Ward clerk
enters
discharge
date/time and
disposal
method/
destination
into ward book
Patient
discharge
from
stroke unit
Ward clerk
enters
discharge
date/time and
ward/ disposal
method/
destination
onto IPM
Post discharge
Clinical coders
add diagnosis and
procedure codes
to IPM record
All Wales Stroke Services Improvement Collaborative
Observations 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.
Slide 15
All Wales Stroke Services Improvement Collaborative
What 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 multidisciplinary meetings etc and displayed on ward ‘mission
control’ boards.
Slide 16
All Wales Stroke Services Improvement Collaborative
Issues
• 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
Slide 17
All Wales Stroke Services Improvement Collaborative
The principles involved
• Need to understand the patient pathway
• Need to understand where data is collected now and
flag up any gaps
Ward clerk
enters
admission
date/time and
source of
admission into
ward book
Slide 18
Patient
arrives in
A&E
Patient
departs
A&E
Patient
arrives in
ACU
A&E
Receptionist
enters arrival
date/time onto
F/W
A&E clinical
staff enter
departure
date/time onto
F/W
Ward clerk
enters
admission
date/time,
ward and
source of
admission
onto IPM
Stroke co-ord
enters scan
time into
stroke DB
Ward clerk
enters
admission
date/time into
ward book
Therapy staff
enter Bartel
scores into
notes
Patient has
scan
Patient
transfer to
stroke unit
Radiology staff
enter scan
date/time onto
CRIS
Ward clerk
enters transfer
date/time onto
IPM
Ward clerk
enters
discharge
date/time and
disposal
method/
destination
into ward book
Patient
discharge
from
stroke unit
Ward clerk
enters
discharge
date/time and
ward/ disposal
method/
destination
onto IPM
Post discharge
Clinical coders
add diagnosis
and procedure
codes to IPM
record
All Wales Stroke Services Improvement Collaborative
Stroke route via A&E
Perform CT
scan
Contact GP
Screen
diagnosis with
ROSIER
Onset of
sympto
ms
Arrive at
A&E
Phone 999
Confirm
diagnosis with
clinical
examination
Administer
stat aspirin
Perform
swallow
assessment
Start regular
aspirin
Admit into bed
Manual
handling
assessment
Physiology
monitored
Nutritional
screening
Physiotherapy
assessment
Sat up or
mobilised
OT
assessment
Goals set and
agreed
Receive
appropriate
information
Notified of
EDD
Admit into
ASU
First hours bundle
Slide 19
First day bundle
First 3 days
bundle
First 7 days
bundle
All Wales Stroke Services Improvement Collaborative
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
Slide 20
Feedback and sharing
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
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’
First hours
Phase Data item
Format Who records this
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
Slide 22
Yes/No
At what point
Where is it stored
How reliably do we
collect
Issues to resolve
Feedback on issues
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
Planning 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
Slide 24
All Wales Stroke Services Improvement Collaborative
Postscript
• 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
Slide 25
Analyse
Supporting NHS Wales to Deliver World Class Healthcare
The type of presentation you use has a
crucial effect on how you react to data
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
ABSENTEEISM BY DEPARTMENT
DEPARTMENT
%
Slide 28
All Wales Stroke Services Improvement Collaborative
Who’s doing well?
At least we’re not as bad
The % patients on CHD register who are being
treated with aspirin
February 2002
Jobs on the line?
100.0%
90.0%
80.0%
Average
70.0%
Nothing to worry about
60.0%
50.0%
A
Slide 29
B
C
D
E
F
G
H
I
J
K
All Wales Stroke Services Improvement Collaborative
Take two numbers
35
30
29
25
20
15
12
10
5
0
Q1
Slide 30
Q2
All Wales Stroke Services Improvement Collaborative
We have 2 quarterly data points - is this
an improvement?
Executive Time Series
Something Important
100
80
60
40
20
0
J
Higher is
better
Slide 31
F
M
A
M
J
J
Months
A
S
O
N
D
All Wales Stroke Services Improvement Collaborative
Are we assuming something like this?
Executive Time Series - linear trend
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
Slide 32
A
S
O
N
D
All Wales Stroke Services Improvement Collaborative
But it could be like this ...
Executive Time Series - no trend
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
Slide 33
A
S
O
N
D
All Wales Stroke Services Improvement Collaborative
Or this ...
Executive Time Series - seasonal dip
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
Slide 34
A
S
O
N
D
All Wales Stroke Services Improvement Collaborative
Or this!
Executive Time Series - one month blip
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
Slide 35
A
S
O
N
D
How often you measure can also have an
effect on how you look at the results
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
Monthly data shows improvement
3.5
Average length of pre-ward stay on Barnsley
Stroke Ward
from 01/2007 to 07/2007
3
2.5
2
1.5
1
0.5
0
1
2
3
4
Months
Slide 37
5
6
7
The chart shows
the average
monthly length of
time before
patients got to the
Stroke ward
All Wales Stroke Services Improvement Collaborative
Weekly data tells a slightly different story
Average length of pre-ward stay on Barnsley
Stroke Ward
from 01/2007 to 07/2007
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
Weeks
Slide 38
31
29
27
25
23
21
19
17
15
13
11
9
7
5
3
1
0.0
All Wales Stroke Services Improvement Collaborative
Patient level data adds another level of
understanding
Slide 39
Spreadsheet Demo
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
Groupwork
• Discuss how you will ensure the spreadsheet gets
completed
• Hint: Put names in the frame!
Slide 41
Review
Supporting NHS Wales to Deliver World Class Healthcare
It is a waste of time collecting and
analysing your data if you don't take
action on the results
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
Groupwork
•
•
•
•
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
Slide 44
Feedback
Supporting NHS Wales to Deliver World Class Healthcare
All Wales Stroke Services Improvement Collaborative
Summary
•
•
•
•
•
•
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
Slide 46