Background
Dartford and Gravesham NHS Trust offers a comprehensive range of acute hospital based services to around 270,000 people in Dartford, Gravesham, Swanley and Bexley. In 2010 Dartford and Gravesham NHS Trust was named as one of the CHKS 40Top Hospitals - an award for the 40 top hospital trusts amongst those working with CHKS, based on the evaluation of 21 key performance indicators.
The board of the trust, like many others, is determined that the organisation has a continuous improvement process in place to ensure that the quality of care provided is of the highest standard. At the same time, the board needs assurance that performance (using measures such as length of stay) across all the clinical directorates is within expected ranges.
Starting point
CHKS has been working with the trust since May 2009 to help it meet both these objectives. CHKS has achieved this by developing a dynamic programme called Quality Laboratory (Q-Lab). The idea behind Q-Lab is that it works across all clinical directorates as part of the clinical governance programme to review practice and outcomes and identify appropriate service improvement initiatives.
Q-Lab is not a one off project but a sustainable improvement programme. CHKS meets with specified directorates at the trust on a quarterly basis. Initially, CHKS uses Signpost, its online performance and clinical management system, to highlight areas where the data has revealed unexpected variations. CHKS then works with the multidisciplinary team, which includes clinicians and a clinical coding manager, to examine the data. The aim is to establish if there are aspects of care and treatment that may be driving the variation. Very often clinicians initiate the discussion by identifying areas where they would like further review.
The various issues are debated and actions agreed. This can often lead to clinicians carrying out a case note review. Above all it is an iterative process and the outcomes are included in the Audit Committee Board report.
Medical Director, Annette Schreiner, is very pleased with the impact Q-Lab has had in the trust.
“Q-Lab in itself cannot say whether outliers are good, bad or indifferent, but by being able to identify outliers we have the insight to proactively search for underlying reasons and if there are quality issues, we can address them. If outliers are due to benign causes, such as commissioning, no further investigation needs to be undertaken. It means we can look at any area of provision and then, using the insight from CHKS, look in-depth and work out whether there is an issue that needs to be addressed,” she says.
Service response
One of Q-Lab’s first successes has been in dementia care. Initial investigation into hospitalisation for patients with dementia showed that their average length of stay was longer than patient admitted for the same treatment but who didn’t have dementia. This was the catalyst for a review of the patient pathway: working on referrals for assessment pathways; recognising and providing training and education of acute staff in caring for dementia patients, changing the patient environment and working collaboratively to provide the best care with the many other health and social care agencies in the local health economy.
Readmission in orthopaedics is another area where Q-Lab intervention has delivered significant benefit. A review of readmissions was carried out and clinicians decided to look at case notes to establish whether they were emergency readmissions, or whether they were in fact planned admissions. It was established that coding could be improved. Clinicians and the coding team are now working together to ensure correct Healthcare Resource Group (HRG) attribution and the coding manager has a dialogue with clinicians on patient outcomes. Annette says that, in practice, the people who can make the most significant changes to quality and outcomes of healthcare are the clinical teams who deliver it.
“Successful patient safety performance and outcomes, cost effectiveness and efficiency must be based on sound evidence, including benchmarked metrics that use a credible data source that promotes clinical ownership and engagement. I’m pleased with Q-Lab because I know that when our chief executive or chair puts me on the spot, I know that we are not missing anything because we have a pro- active programme in place” she says.
Benefits of the programme
Process
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A process that links, activity, efficiency, outcomes and service improvement with the trust determining the agenda of the programme
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A cost-effective way in which to achieve engagement with the clinicians
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Quality and outcome reviews are undertaken in a consistent, systematic and sustainable way across the organisation
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Established links between clinical governance activities and the trust business processes Interactive workshops run by an experienced facilitator who is independent of the organisation
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Evidence-based information to inform the Board Assurance Framework.
People
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A process that the Medical Director can use to engage with the clinicians in reviewing the quality of care and outcomes
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An interactive programme that brings information to the clinicians developing their skills in its use and interpretation
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Systems that enable both a top down and bottom up approach and therefore provide assurance to the Board that issues are reviewed by clinicians.
Information
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Evidence-based, benchmarked indicators which enable outcomes to be put into context and provide direction on key areas of variation for subsequent review
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Direct linkage between outcomes and the patient cohorts to support case note audits
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The reviews provide insight on what is driving outcomes and therefore if it is within the control of the trust, or subject to external factors
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Provides opportunities to continually improve the quality of information through clinical engagement
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Underpinned by benchmarking to inform not only current outcomes but also if the improvement programme is delivering the desired effect.
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