DHFPresentations 2004 to 2008

+44(0)1423 506 848+44(0)789 907 4881

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Non ApprovedColleges RCs

Specialist Specialist RegistrationRegistration

UKGraduates

EUGraduates

ApprovedColleges

NewProvider Bid

NCSC

TCTC

GM

C FullFull RegistrationRegistration

SurgeryTraining with Supervision

GMC

Performance Management & KPIs

KPIs

SUIs

Outcome measures

DHF

CSS v CPS

The CSS contains everything that should help us specify our procurement safely for the NHS

The CPS only contains that which we consider essential to the ITT and which will deliver a VFM bid

Input and process specifications

So the sponsor can integrate ISTC care with the rest of the health economy.· e.g. what is expected from the provider may differ between one

cholecystectomy package (with a very limited follow up) and another.

When things go wrong

Difficult to justify protocols which are contrary to UK best practice (without evidence base) which leads to unnecessary conflict with national standards organisations· when (not if) there are unacceptable fatalities · legal consistency across England (Clapham Omnibus)

Input and process specifications

Some procedures require specific data for national registers and these have to be specified · e.g. NCEPOD· Cataract National Dataset· e.g. National Joint Registry

Outcomes

The difficulty with outcome(s) is that the results should be attributable to the treatment

Measures

KPIs· 25 ISTCs· NHS TCs

Outcome Measures· NHS TCs· ISTCs

Fear of clinical incompatibility

Personal habit

Agreed team practice

/S Agreed local customs

P/S Nationwide custom

P/S Nationwide best practice

P/S International best practice

P/S Robust evidence practice

/S Legal requirement

KPIs, Clinical Outcomes and JSR process

Commercial KPIs devised by commercial and clinical team working with commercial lawyers

Hence strong clinical element

Consultation with, support of (not approval)• PCLs• RCLs• SHAs• JCC

Cleared in house & sent to be incorporated in contract July 2004

Clinical Outcome measures

• Indicators invited from – RCs– Other professional bodies– Providers– SHAs

• Indicators trawled from literature• Collated set discussed with stakeholders• Final set to stakeholders including JCC• Agreed by board of ISTC programme

Quality

Surgeons and accreditation

Moving on to post-operative care

Pathways, continuity and CPS

Credentialing

•People

•Facilities

•Organisation

•GMC•Specialist Register

•Training

•Buildings, equipment, consumables

•systems, information, registration•HCC

Governance

OCT’s & ISTC’s

Local ad hoc schemes

Note to Table 1 – the presence of an asterisk in the first column denotes that the relevant Performance Indicator is a Starred Performance Indicator

Ref Performance Indicator (measured over preceding Quarterly Period) in respect of [the] [each] Facility

Quarterly Threshold for Joint Service Investigation in respect of [the][each] Facility

1 Incidence of inpatient and/or daycase Activities not commenced because of DNAs as percentage of all Activities

>2% or performance of highest decile for all IS-TCs (for which data is available) if higher

2 Procedures cancelled by the Provider for non-clinical reasons on or after day of Admission; for the purposes of the Performance Threshold measured as a percentage of all Patients Admitted in the Facility

>0.5% or performance of highest decile for all IS-TCs (for which data is available) if lower

3 Procedures cancelled by Provider for clinical reasons on or after day of Admission. For the purposes of the Performance Threshold measured as a percentage of all Patients Admitted in the Facility

>0.65% or performance of highest decile for all IS-TCs (for which data is available) if lower

4 Patient returning to operating theatre for Procedure which was unforeseen at the time the Patient's previous Procedure was Completed as a percentage of all Patients Admitted in the Facility

>0%

5 In relation to each Activity Group, the conversion rate i.e. the percentage of Patients who go on to be given a Patient Appointment for a Procedure following an outpatient assessment

Greater or less than the rate in the Sponsor’s whole population of Referrals by non-consultants by a factor greater than one standard deviation around a proportion (binomial distribution)

6 In respect of [the] [each] Facility the rate of Rejection by the Provider in respect of Patients referred within the Referral Protocol (Schedule 3) as a percentage of all Patients who are Referred

Above level to be agreed with Sponsor

7 For day cases, inpatient Admission to the Facility or other provider's facilities (including NHS providers) which was unforeseen at the time of Admission; for the purposes of the Performance Threshold as a percentage of all day cases in the Facility

>2.0%

8 Transfers of Patients to another provider for inpatient Treatment which was not in the management plan[1] for that Patient upon Admission to the Facility; for the purposes of the Performance Threshold as a percentage of all inpatients in the Facility for:i) ophthalmology and minor surgery;ii) orthopaedics;iii) other Procedures

i) >0% for ophthalmology and minor surgery ii) >1.8% for orthopaedics iii) >0.8% for other Procedures

9 Emergency Admissions/ Readmissions of Patients who have received inpatient Treatment and have been Discharged within 29 days of such Discharge where such Admission or Readmission is related to or arising from the relevant inpatient Treatment. For the purposes of the Performance Threshold measures by HRG as a percentage of all Patients Discharged

Highest decile for performance of all IS-TCs (for which data is available)

[1] Management plan requirements to be set out in Schedule 3

10 Average length of stay in hours for day cases by HRG measured from the time of Admission to the time of Discharge

Lowest and highest decile of performance for all IS-TCs (for which data is available)

11 Average length of stay by HRG measured in inpatient days measured from the time of Admission to the time of Discharge

Lowest and highest decile of performance for all IS-TCs; lowest and highest decile of performance on previous year’s NHS performance if higher or lower (respectively) (all in so far as data is available)

12 Average Procedure time by HRG broken down by:i) induction;ii) time on operating table;iii) recovery measured from [] to [][1]

Lowest and highest decile of performance for all IS-TCs (for which data is available) in respect of (i), (ii) and (iii)

13 Patient receives or is listed or recommended for a further Procedure to put right any aspect of the original Activity less than 5 years from date of Discharge. For the purposes of the Performance Threshold measured as a percentage of all Procedures carried out at the Facility

Highest decile for all IS-TCs (for which data is available)

[1] e.g. Anaesthesia Start – Time when a member of the anaesthesia team begins preparing the patient for an aesthetic.Procedure/Surgery Start Time – Time the procedure is begun (e.g., incision for a surgical procedure, insertion of scope for a diagnostic procedure, beginning of examination for an EUA, taking x-ray for radiologica procedure).Procedure/Surgery Finish – Time when all instrument and sponge counts are completed and verified as correct; all post-op radiological studies to be done in the operating theatre are completed; all dressings and drains are secured; and the surgical team have completed all procedure-related activities on the patient.Discharge from Post Anaesthesia Care Unit – Time patient is transported out of PACU (for inpatients).ORDischarge from Same Day Surgery Recovery Unit – Time patient leaves SDSR, either to home or other facility (for day cases).

14 Percentage of Procedures carried out under local or regional anaesthetic (i.e. other than general) anaesthetic by HRG as a percentage of all Procedures

Lowest and highest deciles of performance for all IS-TCs (for which data is available)

15 Clinical outcomes specified, by Procedure by reference to the PCPs[1]

Lowest (undesirable) or highest (desirable) decile of performance for all IS-TCs (for which data is available)

16* Timeliness, completeness and accuracy of Provider Performance Data provided to the Joint Service Review and/or to Sponsors

Any material

17 Timeliness, completeness and accuracy of Provider clinician reporting to Referring Health Service Body's clinician

Any material

18 Patient/Customer Satisfaction (by survey) based on a survey of 10% of all Patients at each Facility in each [Contract Month]

>20% of Patients surveyed are dissatisfied with any aspect.

19 Rate of Patient Complaints ie number of complaints received as a percentage of all Patients Referred for:i) outpatient Treatment; orii) inpatient/daycase Treatment

Lowest and highest decile of performance for all IS–TCs (for which data is available)

[1] These need to be specified when PCPs completed eg for cataracts, visual acuity is likely to be a relevant clinical outcome.

20 Patient complaints handling – complaints not handled within relevant timescales set out in this Agreement

One incident

21* Incidents which are reportable to the NPSA or other statutory body

One incident

22 Additionality – NHS staff recruited in breach of Clause 9 of this Agreement

One incident

23 Condition of Facility measured by inspection by a Sponsor and/or the Provider and assessed against the requirements of the Facility Manual and Operational Procedures

Any material incident of failure to meet statutory requirements in relation to the condition of the Facilities and/or the requirements of the Facility Manual and/or Operational Procedures in respect of cleanliness, catering, environment, accessibility, maintenance, pest control, housekeeping and waste management.

24 Breach of security related to the Services where there is an identifiable risk of harm, loss or damage to people or property

More than one incident

25 Breach by the Provider of confidentiality and/or data protection requirements in the Agreement

One incident

26 Failure to meet Treat by Date One incident

Prostate: International Prostate Symptom Score [IPSS]

pre- and

post-op, · timings to be confirmed

[patient administration as good as physician administration (Plante M et al. Urology, 1996;26:326-328)]

Cataract: VF-14 Visual acuity

Cataract surgery· pre-op and · 6 weeks post-op

Note that ISTC providers are also required to collect and report the Cataract National Dataset

Cholecystectomy: Leeds Dyspepsia Questionnaire

@ pre-op

@ OP assessment), and

@ 3 months post-operative Questionnaire[1]

· Moayyedi S et al. The Leeds Dyspepsia Questionnaire: a valid tool for measuring the presence and severity of dyspepsia. Aliment Pharmacol Ther, 1998;12:1257-1262

Carpal Tunnel: CTS Questionnaire

CTSQ: · @ Pre op· @ Post op assessment· @ 1 year post-op

Pre-op scores provide information about thresholds at which listing decisions are made, (which may be relevant to PIs #5 and #6 conversion and rejection)· Carpel Tunnel Assessment Questionnaire[1]

[1] Bessette L et al. Comparative responsiveness of generic versus disease-specific and weighted versus unweighted health status measures in carpal tunnel syndrome. Medical Car,e 1998;36(4):491-502

Hip replacement: Oxford Hip Score

Clinical outcome to be before/after comparison

OHS: · @ Pre op· @ Post op assessment· @ 1 year post-op Pre-op scores provide information

about thresholds at which listing decisions are made, (which may be relevant to PIs #5 and #6 conversion and rejection)

ISTCs also to collect and report data on hip replacements as required by the National Joint Registry

National Joint Registry data: (8 February 2004)

Total number of individual patient episodes, submitted electronically: 45,214 records

Contributors since 1 April 2003:• NHS Trusts (England only): 126 • NHS Hospitals (England only): 162

TKR: Oxford Knee Score

Clinical outcome to be before/after comparison

OKS: · @ Pre op· @ Post op assessment· @ 1 year post-op

Pre-op scores provide information about thresholds at which listing decisions are made, (which may be relevant to PIs #5 and #6 conversion and rejection)

ISTCs also to collect and report data on hip replacements as required by the National Joint Registry

Diagnostic procedures

endoscopy, colonoscopy, arthroscopy etc. Questions:· whether a diagnosis was made· whether the diagnosis made was correct

10% sample of referring clinicians to be asked for views (post-discharge) as to: whether the diagnosis was made; whether, in the event, it was (or appears to have been) correct;

Note that: PI#17 captures timeliness, completeness and accuracy of provider clinician reporting to referring clinician

Excision biopsy

All procedures involving excision biopsy

Complete removal of tumour or % incomplete removal of tumour on histology report

All surgery: blood loss during surgery

blood loss during surgery

thresholds set by reference to average blood loss in restricted number of procedures

Overall achievement of objectives

To what extent did your treatment achieve what you expected from it?

Measured on all patients, at 6 weeks post-surgery

at the same time as EQ5D

incorporated into patient satisfaction survey instrument when eventually agreed

providers be required to record the objectives of treatment agreed with the patient at the time informed consent

Problems

To what extent did your treatment cause problems you did not expect?

Measured on all patients, at 6 weeks post-surgery (at the same time as EQ5D and incorporated into patient satisfaction survey instrument when eventually agreed) Providers be required to record the advice on likely side effects and problems of treatment with the patient at the time informed consent

Unexpected need for medical attention

Did you need to contact the ISTC, your GP surgery, or other health facility/professional other than by prior arrangement?

Measured at 6 weeks (as above)

Compared to what you expected, did you have more:· discomfort?· pain?· leakage of fluid from the wound?· bleeding?· limitation of normal activities?

EQ5D

Diagnostics (direct access)

Discharge to NHS - GP - Intermediate

Care - Subsequent

necessary care

Essential OP follow- up as required

Acute Inpatient

Follow-up ?

Surgery & Recovery

Pre-op Assessment

OP Follow-up OP Consultation

NHS OP Consultation (and waiting

list)

A CB D

diagnostics+-

E

New Provider Assessments (Outpatients)

New Provider Surgery (FCEs)

(£A)

(£S)

ISTC ProgrammeTCs Patient Flow Diagram

diagnostics+ -

GP Consultation with Patient

anomalyidentified or

random records

sponsor andprovider jointlyreview case(s)

agree onproblem?

arbitrationN

Y

arbitrationremedial action

agreed?

care asagreed?

Y

N

no penaltyapplied

penaltiesagreed?

arbitration

remedial actiontaken?

N

N

Y

N

Y

f

Joint Service Reviews

actions agreed at previous meetings

routine data, identification of any problem areas, and agreed actions

ad hoc reports and the results of any investigations, identification of problem areas, and agreed actions

figures for the ISTCs concerned, compared with other ISTCs;

all findings from reviews of random case records

presentation by the provider to the sponsor of the results of their clinical audit

Source of data

Anomaly Example

Routine reports

Absolute statistical

Patients waiting longer than contracted maximum

Routine reports

Relative statistical

Procedure time in the highest decile of all comparable providers; visual acuity following cataract surgery in lowest decile of all comparable providers

Ad hoc reports

Significant event

Unplanned transfer of patient to NHS provider

Ad hoc reports

Complaints Patient had not understood proposed treatment when giving consent to surgical treatment

Review randomly from case records

----- -----

Triggers for review

Consequences of review

No problem detected

No penalty, but may be other consequence as per contract

A Provider to take remedial action within specified timescale; possibly increased level of monitoring

B Failure points, proportionate to issue(s)

C Financial penalties

D Contract termination

Perceptions of quality risk

National govt.

Local Govt.

Providers (new territories)

Investors (due diligence)

Professions (mixed interests)

Media

Public

What Procedures can be ‘safely’ performed in the

setting?

not associated w/ excessive blood loss &/or fluid shifts do not require higher specialized operating equipment or intensive post-op care; post-op pain manageabletake a “reasonable period of predictable time”the‘ultimate’ determinant: clinician comfort level

What Patients?

few standardized guidelinesno multi-centre studies; paucity of large prospective studiesMayo Clinic Study 1984: ASA III no higher risk in a Surgery CentreFASA 1987: survey of 87,000 patients, questioned relationship between pre-existing disease and peri-operative complicationsThere is some empiric evidence of certain “patients at risk”

Patients at Risk

“complex morbid obesity/complex sleep apnoea”potential for airway problems, dysmorphic facial features, severe rheumatoid arthritis, extreme age (?)poor physiologic condition: ASA III+/IVhistory of problems with anaesthesia (MH history)Acute substance abuse

The goal of any pre-op system

“Reduce the morbidity of surgery & return patient to normal functioning as

quickly as possible.”

Risk Classification

Surgical Category

1

Surgical Category

2

Surgical Category

3

Surgical Category

4

Surgical Category

5

Anaesthesia Class

1

Anaesthesia Class

2

Anaesthesia Class

3

Anaesthesia Class

4

The Johns Hopkins Risk Classification System

Group of 606 patients, 386 chest x-rays ordered without indication…Among these patients, one with abnormality that ‘may’ have resulted in improved care….the existence of three patients with lung shadows led to three sets of invasive tests, including one thoracotomy, but no discovery of disease

After careful medical history, patients undergoing minimally invasive surgery have little benefit from testing…..30 day morbidity after surgery no different than living 30 days without surgery.

Schein OD, et al. The Value of Routine Preoperative Medical Testing Between Cataract Surgery. NEJM 2000; 342: 168-175

Roizen MF, et al. The relative roles of the history and physical examination, and laboratory testing in preoperative evaluation: the “Starling” curve in preoperative testing. Anesthesiol Clin North Am 5:15, 1987.

Narr BJ, et al. Outcomes of patients with no laboratory assessment before anesthesia and a surgical procedure. Mayo Clin Proc 72:505-509, 1997

18,189 elective cataract patients: no significance differences betweenthe no-testing & testing groups in the rates of Intraoperative events.

Pre-Op Testing: a sample matrix for minimally invasive surgery

NO T E S T ING

YE S

E K G w ith in 1 m on th :h /o C ard iac , D iab e tes

Na+ ,K + ,Bun/C r, G lucose(E lec tro lyte P an e l):

h /o D iab e tes , R en a l D isease ,D iu rec tic u se

C BC w / p la te le ts :h /o an em ia , recen t b lood loss ,(p o ten tia l fo r s ig n b lood loss )

L iver F unction T es ts :ra re ly req u ired

Blood T ype :m isc arriag es

C X R :ra re ly req u ired

se lec ltive tes ting

NO T hea lthy

E K G w ith in 6 m onths

NO , hea lthy but > 75

Is pa tient hea lthy & < 75(n o h osp ita liza tion o r m a jo r c h an g es in las t 6 m on th s )

Surgery Centre Pre-Op Testing: On-Site

ElectrocardiogramHaemoglobinGlucometerUrine Pregnancy Test

The process of the screening process is a crucial first step that allows for the provision of safe, effective, and efficient medical care……The development of preoperative evaluation systems in response to outpatient and same day admission surgery provides the challenge of organizing services into formal systems with guidelines formulated on the basis of mutual agreement and

established clinical practice……

it is imperative that the anesthesia staff reach a consensus on significant preoperative evaluation issues and adhere to them in dealing with patients and surgeons and

associated organizations. Conspicuous or consistent deviation from these practices will only serve to undermine the confidence of all the parties………

Anesthesiologists, in setting up their systems, are well advised to allow for a measure of flexibility.

While adhering to a strong standard of care, reasonable judgement in providing that care is preferable to unyielding policies.

Ambulatory Anesthesiology: A problem oriented approachL. Reuven Pasternak, M.D., Chapter 1, Screening Patients: Strategies and Studies.

On-Time Performance

Updated preference cards

On-site Sterile Processing

Standardize Case packs- supplies pulled day before

Patients walked to OR – short distance, no porters

Quick Prep & Anaesthesia Starts – minimize M.A.S.T.

Rapid turn around time (less than 10 minutes)

Simple Charting – report by exception, utilize checklists

OR flow closely monitored by the OR charge nurse & the charge anaesthetist: “vigilance”

Example Anaesthesia Service Quality Indicators:

Patient and surgeon satisfaction

Accuracy rate on clinical records

Same day cancellation and surgical cases delayed

Cost per case benchmarking

Prolonged post-op nausea/vomiting

Taking longer than 30 minutes in phase I

‘Reportable incident’ rates