Using qualitative data to support improvements in
care and service delivery:
a confidential enquiry approach
Marisa Mason
Chief Executive NCEPOD
www.hqip.org.uk
What is a confidential enquiry
• History of the Enquiries
• What NCEPOD is/does
• National improvement
• Local improvements
Enquiry history
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CESDI/CEMD - CEMACH - CMACE
MBRRACE-UK
CHILD HEALTH-UK
NCISH
CIPOLD
NRAD
CEPOD – NCEPOD
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DH
NICE
NPSA
HQIP
1982
• Mortality Associated with Anaesthesia
• Lunn and Mushin 1982
• The Nuffield Provincial Hospitals Trust
1987 CEPOD
• The Report of a Confidential
Enquiry into Peri-operative
Deaths.
• Buck, Devlin & Lunn 1987
The Nuffield Provincial
Hospitals Trust
• Emphasis on Quality of Care
Not Causation
What we do
• We review medical, surgical and anaesthetic
practice
• We make recommendations to improve the
quality of the care delivered
• Use qualitative methods
Types of qualitative data methods
• Literature reviews
• Story telling
• Consensus exercises – Delphi etc
• Interviews
• Focus groups
• On-line surveys
• Observations
• Questionnaires
• Case study – note review
How we do it
How we do it
• Call for topics
• Topics chosen by the professions/funding bodies
• Study Advisory Group
• Multidisciplinary and includes lay representatives
• Define protocol, questionnaires and assessment
form
• Retrospective/prospective
• Questionnaire completion
• Photocopied extracts of the case notes
How we do it
• Case note review meetings
• Peer review – multidisciplinary coal-face health
care professionals
• Organisational data
• Qualitative and quantitative analysis
• Simple report – no statistics
• Case studies are used to example good and
poor care – ‘crimewatch reconstruction’
How we do it
• Case note review meetings
• Peer review – multidisciplinary coal-face health
care professionals
• Organisational data
• Qualitative and quantitative analysis
• Simple report – no statistics
• Case studies are used to example good and
poor care – ‘crimewatch reconstruction’
Example case study
An elderly patient complained to their GP of a severe
headache for 24 hours that had not responded to analgesia.
Severe spasm and pain in the neck muscles were noted by
the GP. The patient also complained that light was upsetting
but this was not considered to be “true” photophobia. The
next day the patient telephoned the surgery as they were
no better, after attending surgery that evening the patient
was referred to the local hospital where their management
was exemplary and the aneurysm successfully treated.
Despite classical symptoms and signs of a SAH the patient
was not admitted to hospital for 36 hours and calling for
guidelines on the management of severe headache to be
circulated widely in primary care.
Example case study
A 52 year old patient had a series of 22 alcohol-related
admissions over a two year period. The documentation on
each occasion made detailed assessment of the patient’s
alcohol intake including the risk of withdrawal. Assessment
tools were used. There was good documentation of
continued offers of support and referral to support services
presented in a language that was easy to understand.
The Advisors’ view was that this was an example of good
practice. The notes reflected teams who maintained good
standards of care and tried very hard on behalf of the patient
who despite this continued to drink.
Example case study
Following investigation with a barium enema and
endoscopy, a carcinoma of the colon with complete
obstruction was diagnosed. Two weeks later the patient was
admitted with lower abdominal pain and constipation. The
previous notes and X-rays were not available nor was the
patient clear about their condition. The surgical team caring
for the patient on this occasion was therefore unaware of
the diagnosis and no operation was performed. A few days
later the patient perforated their bowel and was taken to
the operating theatre but the clinicians had still not seen
the original notes or X-rays.
Examples of poor culture
“Our coroner does not permit communication between his
pathologist and the surgeon unless the surgeon has a specific
question”
“The consultant surgeon has a particularly arrogant
personality and creates a tense and unpleasant atmosphere in
theatre”
“I was not happy that the locum surgeon was good enough”
“The patient is still drinking so I will not accept them to my
ICU”
Why the approach works
• Confidential
• Simplicity of the method and easy to read reports
• Peer review – not ivory tower
• Independent in views
• Put into a report what people already suspect…
…reactions to the findings are assessed before
publishing
NCEPOD supporting bodies
• Faculty of Public Health Medicine
of RCP of UK
• Association of Anaesthetists
• Association of Surgeons
• Royal College of Anaesthetists
• Royal College of Radiologists
• Royal College of Ophthalmologists
• Royal College of Surgeons
• Lay Representatives
• IAG
• Funders
• Academy of Medical
Royal Colleges
• Faculty of Dental Surgery of RCS
• Royal College of Pathologists
• Royal College of Obstetricians &
Gynaecologists
• Royal College of Physicians
• Royal College of General
Practitioners
• Royal College of Nursing
• Royal College of Child Health and
Paediatrics
• College of Emergency Medicine
Structure
• 550+
Local reporters
• 100+
Ambassadors
• 10,000 hrs/yr
Clinicians providing input
Participation
• NHS Quality Accounts/NCAPOP
• Continued professional development – certificates
• Required under Good Medical/Surgical Practice
Reports
National improvements
Trauma: Who cares?
Emergency Admissions:
A journey in the right direction?
A report of the National Confidential Enquiry
into Patient Outcome and Death (2007)
A report of the National Confidential Enquiry into Patient Outcome and Death (2007)
Trauma
• Trauma: Who cares?
• 48% of patients received less than good care in the view
of the advisors
• Consultant involvement low
• Delays in treatment
• Avoidable deaths
• Patients received better care in centres that reported a
high volume of cases
Trauma
• Trauma: Who cares?
• Widely accepted report by the professions
• Timely in view of Ara Darzi’s reform of services
• Appointment of a new
National Director for Trauma care
Acutely Ill Patients
• 1500 patients
• Lack of consultant involvement
• Lack of recognition of illness
• Poor monitoring
• Poor supervision
• Lack of knowledge
• Failure to seek help / working outside
competence
Acutely Ill Patients
Acute kidney injury
• 1500 patients
• Only 50% of AKI care was considered good
• There was poor assessment of risk factors for AKI
• 20% of post-admission AKI was both predictable and
avoidable
• Only 12% of patients received RRT
• Treatment limitations were made in 52% of patients
Acute kidney injury
Cosmetic surgery
“You may be aware that Sir Bruce Keogh is
currently leading a review of the regulation
of cosmetic interventions in England, which
was requested by the former Secretary of
State for Health, Andrew Lansley, following
the events surrounding PIP breast implants.
We believe that the NCEPOD report, On the
face of it, is a key document for the
Committee's consideration, given its clear
evidence-base and incisive
recommendations.”
Local improvements
Are We There Yet?
"We had a complete review of all
children’s services, updated training
schedules and developed a change of
paediatric cover available (medical) at
the hospital."
Measuring the Units
"Because of this report I was able to
recruit an alcohol liaison nurse, the
funding for which I lost some years
ago and have been trying to get
back."
Time to Intervene
"This NCEPOD report has had a clear impact on the provision of resuscitation at
out hospital. Specifically, the recommendation on page 68 that "The use of
‘ceilings of care’ documentation would facilitate decision-making and clarity of
intent." Partly in response to this recommendation, the Hospital introduced a
combined DNACPR/Ceiling of Treatment (CoT) form in July 2012. We have seen a
significant improvement in the completion of these forms. Our cardiac arrest rate
has decreased from 1.57 per 1000 admissions in 2011-2012 to 1.29 per 1000
admissions in 2012-13 (P=0.20) - although not statistically significant as yet I am
expecting this cardiac arrest rate to continue to fall as a result of the CoT form."
Checklists
Audit tools
Benchmarking data
Qualitative data
“Does the manager of a department store need to
carry out a case control study to establish that staff
should be friendly, alert, supportive, well turned out
and punctual?“
Group work
At your table
Share one instance locally where qualitative work
(not necessarily an enquiry)
has led to an improvement in patient care
www.ncepod.org.uk