Presentation on theme: "ED Quality Framework – a stock take of implementation to date Lynette Drew Senior Advisor, System Integration Group Former Ministry Locus (without a t)"— Presentation transcript:
ED Quality Framework – a stock take of implementation to date Lynette Drew Senior Advisor, System Integration Group Former Ministry Locus (without a t)
Background In Taupo 2012, the ED community started to develop quality markers to wrap around the shorter stays in emergency departments health target. “A Quality Framework and Suite of Quality Measures for the ED phase of acute patient care in New Zealand” was launched in March 2014 DHB’s committed to implementation from 1 July 2014 through District Annual Plans 2014/15
2015/2016 Continue measuring mandatory measures, and start to learn from findings – holding actions to account Focus on prioritising non-mandatory measures to evaluate.
How’s it going? Survey results and discussion on the mandatory measures
9 DHBs responded 2 small 1 medium 5 large Disappointing that some National ED Advisory Group member’s DHBs didn’t respond – you know who you are!
Do you have a quality framework in place in your ED? 8 DHBs do 1 didn’t record Great to hear that all 9 DHBs are measuring both the mandatory and non mandatory measures – at varying degrees. 1 DHB is using the ACEM Framework 1 DHB has added other measures too.
Clinical Profile 1. ED LOS – all measuring, 4/9 responding to findings. How findings are being resolved: Large: Beginning to struggle to achieve and so have requested additional staff & project swift and localities. Small: Reduced compliance
3. Waiting time from triage – All measuring 5/9 DHBs responding to findings (medium 1/5, large 2/5, small 2/5) How findings are being resolved Large: Predominately focussing on improving TC2 seen by times, introduced CNS role in 2010, and have expanded FTE. Medium: This was evidenced by the reporting of this measure as well as looking at our "breach" times. An improvement project has now commenced encompassing all aspects of triage including resourcing, facilities and processes. Improvements already commenced include a third doctor on duty overnight. This enable all patients to be seen before morning shift commencement.
6. ED overcrowding – 6/9 (medium 1/6, large 3/6, small 2/6). 3 DHBs are responding to the findings How findings are being resolved Large: We have significantly reduced the incidence of corridor medicine. Still some corridor time in monitored EC but it is minimal and not for a lengthy time. Have introduced and are monitoring incidence of WRB (patients in waiting room who should be in assessment). Actually measuring number of corridor events. Can easily measure LOS in these areas. We do not measure ED occupancy. Small: Need to build new ED / ADU. Interim plan in development.
11. Unplanned representation rates within 48 hrs – 7/9 measuring (medium 1/7, large 4/7, small 2/7) 3 DHBs are responding to the findings Large: Using all rather than unplanned Needs more clarification on what ‘unplanned’ means – one item for discussion in the afternoon session. 12. Mortality and morbidity review – 6/9 (medium 1/6, large 3/6, small 2/6) 4 DHBs are responding to the findings Large: Monthly case presentation at combined seniors meeting Discussed monthly, reported to larger group quarterly
13. Sentinel events review process – all measuring 6/9 responding (medium 1/6, large 3/6, small 2/6) Large: Discussed monthly, reported to lager group quarterly if suitable, pathways altered as required. Case by case basis Medium: Reported on at line and governance / management level with appropriate reviews completed as per four organisations Serious and Sentinel events policy. A summarised quarterly report is also presented to our Hospital Advisory Committee and the Hospital Board meeting.
14. Complaint review and response – all measuring 6/9 responding (medium 1/6, large 3/6, small 2/6) Large: Annual review of trends Discussed monthly, reported to larger group quarterly Medium: Reported on at line and governance / management level with appropriate reviews completed as per four organisations Serious and Sentinel events policy. A summarised quarterly report is also presented to our Hospital Advisory Committee and the Hospital Board meeting. 15. Staff experience evaluations – 3/9 (medium 1/3, large 1/3, small 1/3). 1 small, 1 large DHBs are responding to the findings 16. Patient experience evaluations 4/9 (medium 1/5, large 3/5, small 1/5). The small DHB is responding to the findings.
18. Proportion left before seeing decision making clinician – all measuring, 4 DHBs are responding to findings (2=large, 2=small) Large: Low numbers. All patients who self - discharge are followed up within the next 24 to 48 hours by the Charge Nurses Small: Development of ambulatory care stream is expected to improve this aspect. 20. Mortality rates for specific conditions – 1/9 measuring (1 small, 1/ 9 not applicable (paed) Question to the floor, should this measure be discussed this afternoon: A lot of DHBs are waiting for the Ministry audit tools (Peter Jones section) 1 DHB feels it’s a useless indicator, so are not measuring it.
21. Time to thrombolysis - 6/9 measuring, and 3/6 DHBs responding to findings (1/6 large), 2/6 small, 1/9 not applicable (paed) Large: Measured monthly and we are working closely with St John to improve transmission out of hours 22. Time to adequate analgesia 6/9 measuring (1 medium, 3 large, 2 small) 3/6 DHBs responding to findings Large: We measure and report this on a monthly basis. We have improved our performance through early identification at triage. Delays in nursing assessment due to high volumes of patients has had a negative impact.
23. Time to antibiotics in sepsis – 6/9 measuring (1/6 medium, 3/6 large, 2/6 small), 3 DHBs responding (2/3 large, 1/3 small) Large: On a monthly basis we measure time to antibiotics, and we have raised awareness of sepsis both in EC and across the organisation 24. Procedural and other audits – 5/9 measuring (1/5 medium, 3/5 large, 1/5 small). 2 DHBs responding (1 small, 1 large) 25. Other clinical audits - 5/9 measuring (1/5 medium, 3/5 large, 1/5 small) 2/5 DHBs responding to findings (1 large, 1 small) Some DHBs are awaiting the Ministry audit tools before commencing (Peter Jones session)
26. Documentation and communication 8/9 measuring (1/8 medium, 5/8 large, 2/8 small) Large Also Part of CNM KPI's Audits have shown that for nursing the initial assessment is well documented but on-going documentation is an issue. Medical staff are also being audited and we are regularly feeding acknowledging findings both by staff group and individually. Small: Patient safety unit conducting ED specific and hospital wide audits Currently developing electronic document process. 28. Admission from unit to inpatient team – less than 20% (performance of SSU/Observation unit) 8/9 measuring (1/8 medium, 5/8 large, 2/8 small) 3 DHBs responding to findings (2 large, 1 small) Large - Admission from ASSU for ED patients is 8%. We are undertaking a full evaluation of the Medical assessment unit which opened in 2014.
Education and Training Profile 30. An appropriate orientation in to the ED – all measuring. 3 DHBs responding to findings (2/3 large, 1/3 small) 31. Departmental educational program 8/9 measuring (1/8 medium, 4/8 large, 3/8 small) 3 DHBs responding to findings (2/3 large, 1/3 small)
Administration Profile 47. A designated Quality Team presence within ED 8/9 measuring (1/8 medium, 4/8 large, 3/8 small) 3 DHBs responding to findings (2/3 large, 1/3 small)
What have you learned? Good outcomes, challenges, lessons learned that you want to share with others Medium: This process has highlighted that we are in our infancy when it comes to data collection and analysis. We are hindered by our current electronic reporting systems. That we had a 'person specific' system reliance for reporting of some data. This has now been reviewed and a new system based / team based process has been developed and is currently being implemented. Further strengthening our work has been a 'whole of team' ownership of not just our reporting measure but also a shared approach to learning's and improvement ideas.
Large: Challenge is to have a robust Audit programme It is important to keep your quality programme focused on a small number of objectives depending on the resources that you have. We fell into the trap of trying to do everything and have now devised a prgoramme that focussing on a number of key clinical objectives. While we regularly collect and monitor the ED quality framework indicators a number of these are operational rather than clinical and we are focussing our programme on the clinical aspects. There is much more discussion occurring about audits underway and staff are asking for topics to work on rather than the previous random audits that were either easy or of interest mainly to the auditor. It takes a lot of time to do with limited resources. A dedicated Quality FTE will be hugely helpful.
Small Needs a structured team. Good IT support. Input and designation of portfolio's from ED seminars A poor IT system we currently have in place and the need to upgrade. Challenges regarding a national system. Need to increase local HDU provision instead of ED being a default holding area.
What you have found, that you would like others to help you resolve Large hospital The constraints of the software system which we use. The robust training plan we have is not supported by DHB. Capacity and strategy Good robust IT support is essential in collecting and analysing the data. It is very difficult to keep track of the courses undertaken, conference attended and stages of audits in a large department. A webpage requiring only login and clicking on a check-box would help. Preferably a site that can generate feedback summaries for reporting on. Small hospital The importance of IT - working toward an electronic system. Convincing senior Doctors that data and audits will make a difference to patient care / outcomes. IT system. Need to consider a national benchmark for overload and benchmark for workforce RN ratios etc.
Is the DHB supporting the framework with appropriate resourcing eg skilled personnel. If no, what could be done to Yes n=3 (medium 1/3, large 1/3, small 1/3) No n=5 (large 4/5, small 1/5) Large No formal discussions outside of ED. No back fill for nursing orientation. There is little availability of hours to assist with this. No dedicated staff to assist with this. Small Lacking available/dedicated workforce to fulfil quality indicators. Hospital currently in overload which distracts a high profile focus on these.
Do you have information technology that enables real-time and continuous measurement? Yes n=4 (large 2/4, small 2/4) Small hospital Slowly awaiting installation of Clinical Portal which will hopefully help but we can't have an EDIT system currently. No n=4 (medium 1/4, large 2/4, small 1/4) Small hospital No, we have four different systems which are not all interconnected. Our current systems fail at times. Medium hospital With great difficulty. At this present moment in time, the only way we are able to monitor real time data is through the use of our hospital at a glance and Variance Response Measures. However, these only provide data for a very limited time/snapshot. Work is currently being done to develop our hospital operations centre and the use of real time data. Not answered n=1 (large) Excellent BA's working in confined systems