Quality Improvement Adrian Boyle Chair of the Quality Emergency Care

Background Widespread dissatisfaction with clinical audit Quality Improvement Projects likely to become as part of FCEM Understanding quality improvement will be a necessary skill for NHS Consultants

Quality Safe Patients aren’t harmed TimelyWithin an appropriate time frame EffectiveEvidence based guidelines are EfficientAvoids waste Equitable People aren’t discriminated against Patient Respectful Centred

The Royal College of Emergency Medicine Safety Timeliness Equitable Patient Centred Efficient Effective

The Royal College of Emergency Medicine Safety Timeliness Equitable Patient Centred Efficient Effective

RCEM Audits 12 th Year Process and documentation audits Common, important conditions Across the life span Not audited well elsewhere Supported by HQUIP ‘Quality Accounts’

RCEM Audits: Standards Fundamental Developmental Aspirational

Fundamental Standards Fundamental standards of minimum safety and quality - in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations.

So which of your current standards are ‘fundamental’? ‘All patients with a hip fracture should receive analgesia within 4 hours’ ‘All patients with a hip fracture should be offered analgesia within four hours’

Why does audit fail to improve care? Tick box exercise Performed by temporary staff Lack of feedback loops Career advancement rather than care advancement Lack of collective responsibility Strangled with red tape

Fractured Neck of Femur Patients Receiving Analgesia within One Hour %

Quality Assurance Quality Improvement MotivationMeasuring complianceContinuously improving processes to meet standards MeansInspectionPrevention AttitudeDefensiveChosen, proactive FocusOutliersProcesses ScopeMedical ProviderPatient care ResponsibilityFewAll

The Anatomy of an Audit Structure Does your ED have a PLAN compliant room? Process Can your ED give analgesia promptly? Outcome Did a child die during a seizure in your ED?

The Anatomy of an Audit (2) Local Benchmarking National Picture Safety of sedation in UK EDs Timeliness of psychiatric assessment Aggregation of less common cases Status Epilepticus

The Future of the Audit Program Rapid cycle methodology (? ) Initial performance Intervene Quick repeat of failed standards on a smaller group Increased Consultant and team ownership Endorsement by relevant bodies Public domain Narrative for adverse outcomes

Public Domain Accessible to all Easily interpretable by all

Narrative and Hard Numbers ‘Hearts and Minds’ 52% of your hip fracture patients received analgesia within 60 minutes of arrival ‘An 86 year old lady with mild dementia fell at home and broke her hip. The triage nurse recorded her pain score at 9/10. She was assessed by a junior doctor who prescribed intravenous morphine at 180 minutes after arrival. This wasn’t administered until after arrival on the ward six hours after her fall.’

Improvement Science Industry developed Limited evidence of effectiveness in healthcare

Quality Improvement Approaches (1) Business Process Re-engineering – Fundamental rethinking of process from the centre ‘Visionary Leader’ Experience based co-design – Ask patients and staff to identify ‘touch points’ (the bits that matter)

Quality Improvement Approaches (2) Lean (Toyota) – Regulating flow – Reducing waste – Pull mechanisms to support flow Model for Improvement – PDSA Six Sigma – Customer defined defects

Quality Improvement Approaches (3) Statistical process control – Control charts for acceptable versus unacceptable variation Theory of constraints – Identify bottlenecks and targeting resource Total Quality Management – Philosophy

Basic Principles of all methods Measurement for improvement – Hypothesis can change throughout the project – Data has to be ‘good enough’, not perfect Process Mapping Improving reliability Demand, capacity and flow Empowering staff

Patient arrives at the ED by ambulance / police Patient arrives at the ED on foot Initial Assessment by PAT nurse Infection Control Presenting Complaint AVPU assessment Decides on placement Initial Assessment by pre-reg nurse Infection Control Presenting Complaint AVPU assessment Decides on placement Secondary Assessment by SAT nurse Presenting complaint Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box Patient registered by receptionist at bedside who returns to reception and then brings out front sheet back to nursing staff Patient registered by receptionist at reception. Card then placed by patient in box next to minors Assessment 1 Assessment 2 Resus Blue Chairs Waiting room Secondary Assessment by Minors nurse, pick up card from box Presenting complaint Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA Places card in Box Medical Assessment Arrive at an Inpatient bed SAT Nurse Receptionist PAT Nurse Junior Doctor ENP SpR / Consultant Porter Radiographer X-ray Ultrasound CT Cubicle nurse HCA Ambulance staff Nurse in Charge Ops centre person Minors Receptionist Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Physician’s Assistant Cubicle nurse Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box Secondary Assessment by nurse Presenting complaint /VS Analgesia / ECG / Sometimes x-ray Liaise PA Places Card in Box Ambulance staff Minors nurse Secondary Assessment by Minors nurse, pick up card from box Presenting complaint Analgesia / ECG / Sometimes x-ray / sometimes Liaise PA Minors nurse Cubicle nurse Secondary Assessment by Doctor Physician’s Assistant Physician’s Assistant Physician’s Assistant Bloods/ Urinary Catheter Bloods PA cubicle SpR/ Consultant Porter Medical Assessment SpR / Consultant Junior Doctor SpR / Consultant Medical Assessment Junior Doctor SpR / Consultant Medical Assessment Junior Doctor Porter Nurse Coordinator Update Jonah with x-ray request Paper back-up Co-ordinate transfers to ward and radiology Request bed on phone Co-ordinate treatments Telephone handovers Manage relatives Request specialty Doctors to review SpR / Consultant Nurse in Charge Discharge Nurse Coordinator Update Jonah with x-ray request Paper back-up Co-ordinate transfers to ward and radiology Request bed on phone Co-ordinate treatments Telephone handovers Manage relatives Request specialty Doctors to review In Patient Pharmacy CDU Nurse in Charge Update Jonah with x-ray request Paper back-up Co-ordinate transfers to ward and radiology Request bed on phone and Jonah Co-ordinate treatments Telephone handovers Check Treatments Check Coding Check VTE assessment Check swabs PorterReceptionist HCA / Cubicle nurse Ops centre person Radiographer Minors nurse Treatments Cubicle nurse Treatments Resus nurse Treatments Cubicle nurse Treatments Cubicle nurse Treatments Cubicle nurse Treatments Time Pre-Reg

Statistical Process Control

Run Chart

PDSA

Example: Rapid Cycle Methodology Analgesia for hip fracture patients – Consistently identified as delayed RCEM Audit standard – Identify a few failed standards that matter – Repeat weekly on a small number of cases – Feedback to whole staff, talk to staff about constraints – Repeat as necessary

Workshop Design a rapid cycle audit project – Focus on a few / single standards or problems – Measurement? – Think pragmatically about how this would work – Think what problems you might find – How you’d offer solutions

Close New ways of improving care Collective Continuous responsibility