1. Data set backgrounder

2. SENTINEL STROKE NATIONAL AUDIT PROGRAMME (SSNAP)

3. Aims of SSNAP clinical audit The SSNAP clinical audit collects a minimum dataset for every stroke patient, including acute care, rehabilitation, 6-month follow-up, and outcome measures in England, Wales and Northern Ireland The aims of the audit are: to benchmark services regionally and nationally to monitor progress against a background of organisational change to stroke services and more generally in the NHS to support clinicians in identifying where improvements are needed, planning for and lobbying for change, and celebrating success to empower patients to ask searching questions

4. Organisation of the audit This audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) and run by the Clinical Effectiveness and Evaluation unit (CEEu) of the Royal College of Physicians, London Data were collected at team level within trusts (or Health Boards in Wales) using a standardised method. Clinical involvement and supervision at team level is provided by a lead clinical contact in each hospital who has overall responsibility for data quality The audit is guided by a multidisciplinary steering group responsible for the RCP Stroke Programme – the Intercollegiate Stroke Working Party (ICSWP)

5. Evidence based standards and indicators SSNAP is the single source of data for stroke in England and Wales It provides the data for all other statutory data collections in England including the NICE Quality Standard and Accelerating Stroke Improvement (ASI) metrics and is the chosen method for collection of stroke measures in the NHS Outcomes Framework and the CCG Outcomes Indicator Set. SSNAP metrics are aligned with those in the Cardiovascular Disease Outcomes Strategy SSNAP data are being used as risk indicators for Care Quality Commission’s Intelligent Monitoring and for the Stroke Care in England NHS Marker

6. Eligibility and audit scope SSNAP aims to measure the quality of stroke care along the patient pathway from initial admission, through all subsequent locations, up to and including six month assessment. Teams which treat at least 10 stroke patients a year at any point up to six months are eligible to participate Data are therefore collected by different types of teams along the stroke pathway

7. Eligibility and audit scope These include: – Routinely admitting acute teams (teams which admit stroke patients directly for acute stroke care) – Non-routinely admitting acute teams (teams which do not generally admit stroke patients directly but continue to provide care in an acute setting when patients have been transferred from place of initial treatment) – Non-acute inpatient teams (teams which provide inpatient rehabilitation in a post-acute setting e.g. community hospitals) – Post-acute non inpatient teams (These teams include early supported discharge and community rehabilitation teams) – Six month assessment providers – 100% of routinely admitting teams and non-routinely admitting acute teams in England, Wales, Northern Ireland, and the Islands are registered on SSNAP – Recruitment of non-inpatient teams and teams providing six month assessments is continuing

8. Key indicators, domains and scoring 44 Key Indicators have been chosen by the ICSWP as representative of high quality stroke care. These include data items included in the CCG Outcomes Indicator Set and NICE Quality Standards (covering England only) The key indicators are grouped into 10 domains covering key aspects of the process of stroke care. Both patient- centred domain scores (whereby scores are attributed to every team which treated the patient at any point in their care) and team-centred domain scores (whereby scores are attributed to the team considered to be most appropriate to assign the responsibility for the measure to) are calculated

9. Key indicators, domains and scoring Each domain is given a performance level (level A to E) and a total key indicator score is calculated based on the average of the 10 domain levels for both patient-centred and team centred domains A combined total key indicator score is calculated by averaging the patient-centred and team- centred total key indicator scores – This combined total key indicator score is adjusted for case ascertainment and audit compliance to result in an overall SSNAP level.

10. Key indicators, domains and scoring Domain 1: Scanning Domain 2: Stroke unit Domain 3: Thrombolysis Domain 4: Specialist assessments Domain 5: Occupational therapy Domain 6: Physiotherapy Domain 7: Speech & language therapy Domain 8: MDT working Domain 9: Standards by discharge Domain 10: Discharge processes

11. Casemix data Casemix describes the characteristics of the group (or cohort) of stroke patients treated by a team It includes demographics and type of stroke Includes the following questions – AF before stroke? – If patient is in Atrial Fibrillation, was the patient on antiplatelet medication prior to admission? – If patient is in Atrial Fibrillation, was the patient on anticoagulant medication prior to admission? – If patient is in Atrial Fibrillation, what combination of anticoagulant and antiplatelet medication was the patient on prior to admission?

12. HOSPITAL EPISODE STATISTICS

13. HES Data Overview HSCIC apply a strict statistical disclosure control in accordance with the HES protocol, to all published HES data. This suppresses small numbers to stop people identifying themselves and others, to ensure that patient confidentiality is maintained. HES information is stored as a large collection of separate records - one for each period of care - in a secure data warehouse. It is a records-based system that covers all NHS trusts in England, including acute hospitals, primary care trusts and mental health trusts. HES data is designed to enable secondary use, that is use for non-clinical purposes, of this administrative data. This data is collected during a patient's time at hospital and is submitted to allow hospitals to be paid for the care they deliver HES is a data warehouse containing details of all admissions, outpatient appointments and A&E attendances at NHS hospitals in England

14. HES data overview “HES data underpins the decisions made by commissioners and managers across the health service, HES has been used in tens of thousands of audits and peer –reviewed research studies.” Dr Geraint Lewis – Chief Data Officer NHS

15. HES data overview HES is a unique data source, whose strength lies in the richness of detail at patient level going back to 1989 for inpatient episodes, 2003 for outpatient appointments and 2007 for A&E attendances. HES data includes: – Specific information about the patient, such as age, gender and ethnicity – Clinical information about diagnoses, operations and consultant specialties – Administrative information, such as time waited, and dates and methods of admission and discharge – Geographical information such as where the patient was treated and the area in which they live.

16. HES data overview The principal benefits of HES are in its use to: monitor trends and patterns in NHS hospital activity assess effective delivery of care and provide the basis for national indicators of clinical quality support NHS and parliamentary accountability inform patient choice provide information on hospital care within the NHS for the media determine fair access to health care develop, monitor and evaluate Government policy reveal health trends over time support local service planning

17. UK comparisons Separate collections of hospital statistics are undertaken by Northern Ireland, Scotland and Wales. There are a number of important differences between the countries in the way that data measures are collected and classified, and because of differences between countries in the organisation of health and social services. For these reasons, any comparisons made between HES and other UK data should be treated with caution

18. NHS Data Types Primary User Data – Information used directly for clinical care Secondary User Service Data (SUS) – is primarily a data warehouse that provides access to patient-based data for purposes other than direct clinical care, it groups clinical codes into HRGs and calculates a payment healthcare planning, commissioning services, public health, national policy development Hospital Episode Statistics (HES) – The Health and Social Care Information Centre (HSCIC) produces HES Extracts from SUS data. – HES extracts are taken from the Secondary Uses Service (SUS) data warehouse on a monthly basis, at pre-arranged dates during the year. HES data has been collected this way since April 2008 – It is Pseudonamised SUS data

19. Payment By Results Key Terms ICD10 International Classification of Disease V10. Each HES episode has one primary diagnosis and may have up to 19 secondary diagnoses recorded. The primary diagnosis is the main reason the patient is receiving care in hospital, while the secondary diagnoses are relevant co- morbidities and external causes if these have been identified. For example a patient may be treated for a broken leg, may have diabetes which would be relevant to their care, and may have broken their leg in a traffic accident

20. Payment By Results Key Terms OPCS-4 Code Office of Population, Censuses and Surveys Classification of Surgical Operations and Interventions (4th revision), translates operations, interventions and interventions carried out on a patient during a spell of care into alphanumeric code Each HES record can have up to 24 procedures or interventions recorded. The primary procedure is the most resource intensive procedure performed during the hospital episode, while the secondary procedures are available to capture further information about the primary procedure and any less resource intensive procedures performed during the hospital episode.

21. Payment By Results Key Terms Tariff The average elective /non-elective cost & length of stay for treating a specifically diagnosed patient in the previous year. CCG / Commissioner gets charged the tariff price for each spell for a patient registered with one of their practices

22. Payment By Results Key Terms Healthcare Resource Group The currency for admitted patient care and A&E is the healthcare resource group (HRG). HRGs are clinically meaningful groups of diagnoses and interventions that consume similar levels of NHS resources. With some 26,000 codes to describe specific diagnoses and interventions, grouping these into HRGs allows tariffs to be set at a sensible and workable level. Each HRG covers a spell of care, from admission to discharge

23. Calculating an HRG from Hospital Activity Diagnosis£ TariffLength of Stay Procedures

24. NHS Data Flows / Payment by Results Provider (hospital) Patient Record ICD10, OPCS4.5 etc PAS HRG Allocated PAS HRG Allocated BT SUS Warehouse CCGs/CSU Northgate Imperial College Harvey Walsh Patient IP/OP/DC SUS Data Validation AXON HES Intelligence NHS IC Dr Foster

25. What Goes Into An HRG cost? The HRG should include – Diagnostic investigations – Staffing costs – Consumables, prostheses, etc. – Accommodation and facilities costs – Drug costs during spell – if a drug is NOT on the High Cost Drugs List – Management overhead – A contribution towards complex cases

26. How does PBR work? Under PbR In-patient activity is measured in Spells and Excess Bed Days Spell = The total continuous stay of a patient using a bed on premises controlled by a health care provider during which medical care is the responsibility of one or more consultants. Each period of care = Finished Consultant Episodes (FCEs) FCE 1 e.g. COPD FCE 2 e.g. Heart Attack FCE 3 e.g. Speciality rehab Patient Admitted Patient Discharged Spell Provider Trust

27. PBR Summary A Hospital spell is the time from diagnosis through treatment with drugs and procedures to discharge Hospital Coders match an HRG code (Health Resource Group) that best fits what was done to you during your spell This is linked to a national tariff cost or price for that HRG The national tariff price is the average national cost for that code in the previous year The commissioning organisation gets charged the tariff price for each spell for a patient registered with one of their practices Providers send HRGs to BT SUS (secondary User Services) and then on to the CCGs for validation & Payment but also HSCIC.

28. 30 Day Readmission Investing Savings – Commissioners must reinvest money they retain from not paying for emergency readmissions in post discharge services that support rehabilitation and re-ablement – A readmission threshold is agreed between provider & commissioner – Some readmissions are, in effect, ‘planned for’ and therefore should not be considered avoidable unplanned readmissions

29. HES data caveats HES data cannot be used to directly measure healthcare-acquired harm; there is no distinction between conditions acquired outside healthcare and those acquired after admission, and research indicates levels of recorded events that could be assumed to be usually healthcare related (e.g. pressure ulcers, surgical misadventure) are implausibly low. For many aspects of healthcare, interpretation of HES data is complicated by variations in coding practice between organisations and over time.

30. QUALITY OUTCOMES FRAMEWORK

31. What is QOF The national Quality and Outcomes Framework (QOF) was introduced as part of the new General Medical Services (GMS) contract on 1 April 2004. The QOF rewards practices for the provision of 'quality care' and helps to fund further improvements in the delivery of clinical care. Participation by practices in the QOF is voluntary, though participation rates are very high, with most Personal Medical Services (PMS) practices also taking part.

32. Where does the data come from / what is CQRS? Previously, the Quality Management and Analysis System (QMAS) was used for the extraction of QOF data. In July 2013, QMAS was replaced by the Calculating Quality Reporting Service (CQRS), together with the General Practice Extraction Service (GPES). Information in QOF 2013/14 was derived from the CQRS together with the GPES, national systems developed by the HSCIC. CQRS uses data from general practices to calculate their QOF achievement.

33. What is in QOF? What are 'domains'? The QOF has five main components, known as domains. Each domain consists of a set of measures of achievement, known as indicators, against which practices score points according to their level of achievement. The five domains are: – Clinical 93 indicators and 610 points – Public Health 9 indicators and 113 points – Public Health – Additional Services 9 indicators and 44 points – Quality and Productivity 9 indicators and 100 points – Patient Experience 1 indicators and 33 points

34. How do CQRS / QOF data relate to GP practice payments? Through the QOF, general practices are rewarded financially for aspects of the quality of care they provide. CQRS ensures consistency in the calculation of quality achievement and disease prevalence, and is linked to payment systems. This means that payment rules underpinning the new GMS contract are implemented consistently across all systems and all practices in England. For 2013/14 practices were paid, on average, £156.92 for each point they achieved.

35. How do CQRS / QOF data relate to GP practice payments? Users of data derived from CQRS should recognise that CQRS was established as a mechanism to support the calculation of practice QOF payments. QOF does not provide a comprehensive source of data on quality of care in general practice, but it is potentially a rich and valuable source of such information, providing the limitations of the data are acknowledged.

36. What is QOF exception reporting? Patients on a specific clinical register can be excluded from individual QOF indicators if a patient is unsuitable for treatment, is newly registered with the practice, is newly diagnosed with a condition, or in the event of informed dissent. ‘Exception reporting’ refers to the potential removal of individual patients from calculations of practice achievement for specific clinical indicators. Some exception reporting is applied automatically by the IT system, for example in respect of patients who are recently registered with a practice, or who are recently diagnosed with a condition. Other exception reporting is based on information entered into the clinical system by the GP. Practices may ‘exception-report’ (i.e. omit) specific patients from data collected to calculate QOF achievement scores within clinical areas. The GMS contract sets out valid exception reporting criteria.

37. What is QOF exception reporting? Patients on a specific clinical register can be excluded from individual QOF indicators if a patient is unsuitable for treatment, is newly registered with the practice, is newly diagnosed with a condition, or in the event of informed dissent. ‘Exception reporting’ refers to the potential removal of individual patients from calculations of practice achievement for specific clinical indicators. Some exception reporting is applied automatically by the IT system, for example in respect of patients who are recently registered with a practice, or who are recently diagnosed with a condition. Other exception reporting is based on information entered into the clinical system by the GP. Practices may ‘exception-report’ (i.e. omit) specific patients from data collected to calculate QOF achievement scores within clinical areas. The GMS contract sets out valid exception reporting criteria.