Benchmark for out of hours
How to make sure that the benchmark figures align with
yours….
Henry Clay 07775 696360
henry.clay@primarycarefoundation.co.uk
Agenda – and thank you!
 Some very detailed and specific points
 …and perhaps a more general discussion about how
we try to ensure comparability
 Time to definitive assessment
 Coding
 Inconsistent use of the system
© Primary Care Foundation
I know that there are difficulties…
 Wide range of staff, some working irregularly
 By definition staff work awkward hours so may be seen
infrequently
 Difficult to get staff together for training
 Not everyone reads the messages or notes issued
 Many Adastra systems have legacy coding structures
from when the system was less capable than now
 There is often little headroom in the contract price to
allow these things to be fixed
..but the aim is to highlight some of the issues and point you
towards solutions
© Primary Care Foundation
Time to definitive assessment
Some specific points
Time to definitive clinical
assessment – the standard
Definitive Clinical Assessment
Providers that can demonstrate that they have a clinically safe and effective system
for prioritising calls, must meet the following standards:

Start definitive clinical assessment for urgent calls within 20 minutes of the call
being answered by a person

Start definitive clinical assessment for all other calls within 60 minutes of the
call being answered by a person
Providers that do not have such a system, must start definitive clinical
assessment for all calls within 20 minutes of the call being answered by a person.
Outcome
At the end of the assessment, the patient must be clear of the outcome,
including (where appropriate) the timescale within which further action will be
taken and the location of any face-to-face consultation.
Definitive clinical assessment is an assessment carried out by an appropriately trained
and experienced clinician (not a call-handler) on the telephone or face-to-face. The
adjective ‘definitive’ has its normal English usage, i.e. ‘having the function of finally
deciding or settling; decisive, determinative or conclusive, final’. In practice, it is the
assessment which will result either in reassurance and advice, or in a face-to-face
consultation (either in a centre or in the patient’s own home).
© Primary Care Foundation
This slide shows the differences in measuring
time to definitive assessment
Standard process for a base visit
Green
istime
the time
to clinical
Green
is the
to definitive
Green
is
the
correct
way todoes
assessment,by
but
the
standard
assessment
the
standard,
calculatecall
time
to definitive
notred
recognise
streaming.
Because
as measured
by most
assessment
if
there
are
two
of
the possible
long
wait the
before the
services.
Yellow
shows
assessments.
Red
is
as
patient
talks
with to
a clinician
it is vital
time
to
face
face
measured
by
most
providers
that processes
for making and
consultation.
reviewing call-handler decisions are
robust. In our analysis these cases
are excluded from the main measure
of time to assessment
Walk in patient or Call streaming to a base visit – clinical assessment is part of face to face consultation
Standard process for a base visit with two assessments (say by a nurse then a doctor)
Standard process for a home visit with one assessment but a call by doctor on the way or locked case
Key
Initial call or contact
Telephone assessment
© Primary Care Foundation
Face to face consultation
How to set up to report in line with the
standard (1)
Set these to Y
© Primary Care Foundation
How to set up to report in line with the
standard (2)
Set these to Y
© Primary Care Foundation
Locking telephone advice calls
This puts them back in the advice queue – so
they still count as awaiting assessment
Lock cases if the assessment is not complete or you are checking
something – for example
● The mobile phone signal dropped and you haven’t immediately reconnected
● You need to check if there is a bed available
● You need to check with the poisons specialists
● You need to check with the district nurse before ringing again
Do NOT lock the cases if you spot two or three duplicate cases for the
same patient
Do NOT lock the case if you have finished the assessment, even if
● You plan to ring again later (comfort call)
● You are interrupted and know that you have yet to complete the notes
© Primary Care Foundation
Suggested solutions…
Speak to the Adastra consulting team but look at…
 A standard process for dealing with multiple cases to look through
them, close all except the earliest without entering any consultation
details and record the phone assessment on the first case
 Setting up a separate case type and queue for comfort calls
 Looking at other case flow methods with your Adastra consulting
team such as…..
 Using delayed messaging capability as a reminder about a comfort
call that is needed
 Adopting a standard practice of completing notes promptly in every
case (but when this is impossible, closing the case and completing
the notes using by editing them)
© Primary Care Foundation
Coding
The sorts of problems we see…
Coding
Coding – typical issues
 Codes where completion is not mandatory so obvious
gaps in the record
 Drop-down lists with
● insufficient options to cover all possibilities
● so many that users have difficulty
 Codes that are confusing and interpreted inconsistently
by users
 Fields that are used for more than one thing, making
use and analysis problematic
© Primary Care Foundation
Informational outcomes – 106 of them…and
they mix condition and outcome
Diabetic Related Call
Nose Bleed
Diarrhoea
Other (Please Add Comments)
Diarrhoea & Vomiting
Outside LSL
Dizziness
PV/PR Bleeding
Earache/Infection
Parkinson's Disease
Emergency Ambulance Called
Patient Gone To Hospital.
Emergency Contraception Request
Patient To Register At EAC
Epilepsy/Seizures
Period Pain
Eye Problems
Post-Natal Symptoms/Illness
Fall
Pregnancy Related Call
Fever
Psychiatric Patient
Flu Related Illness
Pt Advised To Attend A & E
Fungal Infection
Pt Advised To Call 999
GP To Contact Patient
Pt Referred To A&E By Dr.
Gastroenteritis
Pt To Contact Own Gp
General Advice Call
Rash Related Call
Groin/Genital Problems
Referred / Admitted To Hospital
Haemorhoids
Referred Back To Own Gp
Headache Related Call
Referred To DN
High Temperature
Related Joint/Limb Problems
Home Visit - Base Cancelled
Repeat Prescription
Home Visit - Patient Cancelled
Routine - Case Completed
Hypertension/High BP
Run Out Of Medication
Injuries
SWINE FLU RELATED CALL
Insect Bite
See Own Dentist
Life threatening emergency detected
Sickle Cell Crisis
Mastitis
Teething
Medication Advice
Tonsillitis/Throat Problems
Migraine
Treatment Centre - Base Cancelled
Mumps
Treatment Centre - Patient Cancelled
Muscle Pain
URTI
© Primary Care Foundation
No Follow Up
Ulcer
Condition
Urine Infection/UTI
Vertigo
Viral Infection
Visit - Patient Confrimed Deceased
Vomiting
Wheezing
Wounds
Outcome
Informational outcomes – some shorter lists
Admission or
referral?
A&E Admission
Admitted To Hospital
Ambulance Call
Call Again If Needed
District Nurse
ENT
Emergency Department Admission
MIU Redressing Needed
Maternity
Mental Health
No Follow Up - Call Again If Needed
No Follow-Up
Orthopaedics Admission
Other
Paediatric Admission
Patient Advised Must See Own G.P
Patient Deceased
Patient Did Not Attend
Patient Left Before Consultation Complete
Patient Stayed At Home
Princess Royal Hospital
Surgical Assessment Unit
Outcome
Difference?
Different to
A&E?
Condition
By service or
GP?
What does this
tell us?
Advise Own GP
Call Back If No Better
Compaint Organisational
Contact Own GP
For Follow Up
GP To Ring Patient
Life threatening emergency detected
Passed To District Nurse
Patient Deceased (Expected)
Patient Deceased (Unexpected)
Patient To Ring GP
Refer To Hospital
Refer To Social Worker
Repeat Prescription
Swine Flu
© Primary Care Foundation
999 Ambulance Called
A&E Referral Or Amb Called
Active Followup By Own GP
Admission DGH
Asthma Problems
Breathing Diffs
Collapse
Death - Expected
Death - Unexpected
Diabetic Issues
Discharged To Own GP
DVT Followup
Fall
Fitting
No Further Anticipated Action
Not Applicable
Other Illness
Patient Deceased (Expected)
Patient Deceased (Unexpected)
Psychiatric Problems
Refer To Own GP
Refer To Social Services Other
Refer To Social Services Vulnerable
Referred To GU Clinic
Repeat Scan
Satisfied With Treatment
A suggested approach for coding informational
outcomes
 Completion of the code is
made mandatory
 Use field for one thing only to report next contact with
NHS
 Staff trained to respond
consistently
 List is comprehensive (to
cover each situation) but..
 …short enough to be easy to
choose
 Structured in a logical order
Example:
 Ambulance/999
 GP follow-up recommended
 Hospital - A&E
 Hospital - for admission
 Hospital – for assessment
 Hospital – patient choice
 No further contact expected
 Primary Care – see own GP
 Primary Care – WIC/MIU
 Primary Care – Other service
© Primary Care Foundation
Coding – further examples where services
confuse themselves (and me!)
Call origin
 A&E referral
 Ambulance call
Case type
 A&E referral
 Ambulance call
Agreed: These
were referred FROM
A&E and Ambulance
service
Confused: Were
they from or to A&E
and Ambulance
service?
Case type
 Admitted to hospital
 999 Ambulance
 Asylum seeker
© Primary Care Foundation
But were these
cases assessed by
phone or seen face
to face?
Mis-use of the system
…often with the best of intentions!
Clinicians phone a patient when sent a home
visit
Reasons for the phone call
 To confirm likely arrival time, check priority, reassure
 Because the doctor thinks that the case can be closed
as phone advice
 Because the organisation has built it in as part of the
process
 Appears to be more prevalent where two services are
involved or nurses send cases to home visits
But it means that you report incorrectly on QR9 and12…
…and you say you will visit a patient but then don’t.
© Primary Care Foundation
Here is an extreme example – this is a random
selection of case type home visit but 7/10 have
two home visits recorded on the system
1stConsultationEndDateTime
1stConsult Cons1Lock 1stConsult 2ndConsultationStartDa 2ndConsul Cons2Lock 3rdConsultationStartDat 3rdConsult Cons3Lock
ationType ed
Notes
teTime
tationType ed
eTime
ationType ed
30/03/2009 23:17:06
Advice
FALSE
37 TAPES 30/03/2009 23:53:50
STREET
30/03/2009 20:07:01
Advice
FALSE
04/04/2009 13:23:05
Home Visit FALSE
PAIN
MON IN
19-R
57
S/W/MUM -spoke
CHILDto 04/04/2009 15:40:00
Home Visit FALSE
31/03/2009 00:58:00
Home Visit FALSE
Home Visit FALSE
05/04/2009 13:42:24
Home Visit FALSE
Home Visit FALSE
04/04/2009 16:36:00
Home Visit FALSE
Home Visit FALSE
05/04/2009 10:53:22
Advice
FALSE
04/04/2009 14:24:34
Advice
FALSE
patient ,
unwell for
1 week,
very
deaf 05/04/2009 11:04:46
gentleman
, unable to
get much 04/04/2009 14:38:02
PALALISE
FALSE
D PT
FROM
NECK
Spoke to
03/04/2009 21:27:18
Home Visit FALSE
04/04/2009 00:07:00
Home Visit FALSE
FALSE
Son. Has
been
coughing
Spoke to
04/04/2009 12:38:22
Home Visit FALSE
04/04/2009 13:20:00
Home Visit FALSE
FALSE
pt's wife.
Suffers
with heart
03/04/2009 21:23:00
04/04/2009 12:17:12
Advice
Advice
Advice finishes at
14.24
01/04/2009 06:45:26
Home Visit
First ‘home visit’ at
14.38
SPOKE TO
NURSE
SPOKE TO 01/04/2009 21:33:20
NURSE;T
38.7,BP
HIGH,P
91yrs
04/04/2009 19:26:52
Second home visit
at 16.36
Adastra reports measure QR12 from the end of the advice
call to the start of the first hoe visit – which is right….
..but only if it was a home visit!
01/04/2009 20:43:13
Advice
FALSE
04/04/2009 18:36:09
Advice
FALSE
old,sharon
, carer
Home Visit FALSE
01/04/2009 22:17:38
Home Visit FALSE
Home Visit FALSE
05/04/2009 00:10:00
Home Visit FALSE
© Primary Care Foundation
Suggested solution….
 Ban doctors from re-assessing cases once a decision
has been made for a home visit
 Focus your attention on making sure that the right
decision is made first time
 Enter details of any extra phone call not as if they were
the home visit consultation, but as case notes HOW?
 And, for the rare occasions where a home visit has to
be changed to an advice call, speak to the Adastra
consulting team about setting up an informational
outcome as ‘given advice – no visit needed’ and set this
up to change the case type
© Primary Care Foundation
Converting a planned base visit to advice
when closing a DNA
Reason for doing this
 Good safety precaution that a clinician should check the case if the
patient does not attend – may or may not phone the patient
Problems
 Clinician goes into case and makes a note – but the system
records it as a base visit
 Case is changed to advice – but it looks as if it is a second advice
call – so time to definitive assessment is wrong
Solution
 Speak to the Adastra consulting team about setting up an
informational outcome as ‘DNA - given advice’ and set this up to
change the case type
© Primary Care Foundation
Failure to count all the cases you have dealt
with…
 Call-handlers who refer a patient without capturing any details –
‘we don’t have X-ray so you would need to go to A&E’
 Solution – training!
 Providers who filter all their reports by doctors operating group
(say) forgetting that there are some cases where this field is not
completed
 Solution – check your filters carefully and make sure that you
populate the field correctly
 Providers where the mapping of practices to PCTs does not reflect
the CfH list
 Solution – check mapping periodically against latest versions
© Primary Care Foundation
Discussion and questions….