Restructuring to bring together audit and QI: One year on

Aneurin Bevan Health Board

Kate Hooton

– Assistant Director: Quality & Patient Safety

Rachel Fletcher

– ABCi Lead – Project Support Team

A potted history

Traditional Clinical Audit Model predominantly supporting directorate level audit

2007 - Safer Patients Initiative

2008 - 1000 Lives Campaign

2010 - 1000 Lives Plus Programme

What did we learn?

Evidence based way to introduce change Model for Improvement – rather than ‘Spray and Pray!’

Effective way to measure improvement realtime –statistical process control

Need to support clinicians to measure process and outcome

2009/10 Clinical Audit Report

248 Clinical Audits

61% Audits led to agreed actions/shared learning

28% re-audits – difficult to assess actual improvements

1000 Lives - 143 series reported across 52 measures at either organisational, hospital or ward/theatre level

61% statistical improvement in outcome measures

64% statistical improvement in process measure

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in

improvement?

The Model for Improvement

Act Plan

Study Do

Model for Improvement

• Measurement a key component

• Employs Statistical Process Control Techniques

Measurement

Audit Posters

International Forum for Quality & Patient Safety 2013

Process & System

Improvement Posters

International Forum for Quality & Patient Safety 2013

Clinical Audit often aggregates data

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Before and After

SPC plots data over time as Runcharts or Control Charts

What did we do?Q&PSC development session – priorities

National priorities

1000 Lives Plus

Divisional priorities – highest risks, patient experience, focus on demonstrable improvement

Staff engagement workshops

Visits to all Audit Leads

Restructured workloads

Divisional working, engaged with QPS groups

No longer secretariat for audit meetings

Provide support only for priority projects

New job descriptions

Staff training

Clinical Effectiveness Group chaired by Medical Director responsible for ensuring: Overview of NCA&OR Plan at ABHB

Clinical Lead for each audit

Register of National Audits

Feedback re: each audit to CEG

Priority audits full presentation

Other audits via feedback template

Timetable of feedback devised

Learning and Action as a result of audit

Annual Report drafted to go to Q&PS Committee in October

Positive visit from NCA&OR Advisory Group

National Clinical Audit and Outcome

Review Plan – ABHB progress

1000 Lives PlusCoordinators supporting teams:

Acute Stroke

Stroke Rehabilitation

Life After Stroke

Chronic Heart Failure (CHF)

Hospital Acquired Thrombosis (HAT)

Leadership Walkrounds

Transforming Maternity Services

Mouthcare

Enhanced Recovery After Surgery (ERAS)

Catheter Associated Urinary Tract Infection (CAUTI)

Theatres

Community Falls

Through:

Care Metrics & Fundamentals of Care

Supporting clinicians in gathering, collation, analysis, interpretation, reporting and feeding of progress and data

Liaising with agencies to gather routine data eg. WHAIP, 1000 Lives central team

Regular feedback to clinical teams

High Level Data to Board as part of QI Report

Mortality Reviews

GTT Reviews

BoardData

Frontline data

Directorate data

Divisional data

Support & Leader-ship for

work

Data to Directorate Quality Imp./Audit Meetings

Locally held 1000 Lives spreadsheets/audits

Reports to Divisional Quality & Patient Safety Groups

QI Report of 1000 Lives measures to Q&PS Committee

Q&PSIMDept Support for data reports

1000 Lives Data - Aims

BoardData

Frontline data

1000 Lives Data – ABHB last year

- QIReports- Aims to reduce mort.

and harm- Driver Diagrams

-Local easy to use 1000Lives spreadsheets

-local run-chartsBUT difficult to aggregate

data for upwards reporting

BoardData

Frontline data

Directorate data

Divisional data

Support & Leader-ship for

work

X Drive for locally held 1000 Lives Spreadsheets

Developing regular reporting for Scheduled, Unscheduled, Family & Therapies

QI Report of high level 1000 Lives data toQ&PS Committee

Q&PSIMDept Support for data reports

1000 Lives Data – ABHB today

Ad hoc Support for clinicians to present directorate level data

Divisional QI Projects

Working with divisions to set up Quality Improvement Programmes

Eg. O&G QuIP Programme, priorities for division, QuIP teams leading each project

Aim to incorporate divisional priorities, national audits and 1000 Lives work

But…not all plain sailing!

ABCi Project Support Team

Dept transfer to ABCi

Project team workshop held

All staff undertaken Bronze IQT as part of Wales pilot

2 staff undertaking Silver IQT as part of Wales Pilot

All projects to be discussed at ABCi Operational Group

Project Initiation Document

25 Projects so far

Bringing together expertise from across the health board

Clinicians

Improvement managers

Clinical audit

To support divisions with their QI programmes Director met with divisions re QI

Projects/Programmes

5 arms – ABCi Project Support Team

Meeting new people and learning from each other

Project Support Team

ABCi Coordinators involved in:Shadowing patients through A&E (Safe Emergency Care workstream)

Self Administration of Analgesia Pilot

Everyday Counts for Megan

#NOF workgroup

Reducing Cellulitis Primary Care Pathway

Implementing core specification for health visiting pilot

COPD Discharge Bundle

Endoscopy JAG accreditation

ABCi Assistants involved in:helping to develop simulation game to express flow

Assistants supporting Wales Harm Study

Next steps:

Integrating QI into national audits

All staff trained to Silver IQT level

Deliver Silver training locally

Engage with patients eg. Shadowing, PFCC, EBD, PROM

Learning and developing further

Some final thoughts…

Revalidation2 of 6 - Quality Improvement Activity

Evidence of effective participation in clinical audit or an equivalent quality improvement exercise that measures the care

Royal College of AnaesthetistsRaising the Standard: a compendium of audit recipes for continuous quality improvement in anaesthesia 2012

Quality improvement in anaesthesia

International forum Q&PS 2013Emphasis on QI training

Change in direction/culture –compounded by experiences and discussions at international forum

Prof. Nick Black, Chair National Advisory Group for Clinical Audit & Enquiries (DOH)Black calls for ‘Quality’ not ‘Audit’ Departments

Consultation on Future of Audit staff in Trusts

Proposals include:Distinguishing between quality assessment and quality improvement

Quality Departments integrating clinicians, managers and clinical audit staff

Training in technical skills such as Improvement Science and Behavioural Skills

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Real-time monitoring of

performance over time.

Interventions for change are

implemented and their effects

assessed almost immediately

QI – Model for

Improvement SPC

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Snapshot in time of overall

performance. Checks that

standards are maintained

and improved where

necessary

Re-AuditClinical Audit

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Standard A

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Standard B

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Standard C

Snapshot in time of overall

performance compared to

evidence based standards.

Highlights where there are

deficiencies in practice

Integrating Clinical Audit with QI

The Clinical Audit Gap

Clinical audit doesn’t give

us methods to make change

Clinical Audit doesn’t measure during the process of change

Thankyou

Rachel.fletcher@wales.nhs.uk

Twitter @rachelnfletcher

Follow on Twitter @ABCiAb