HQIP: New resources available for trainee doctors

Health Quality Improvement Partnership | December 2021 | New resources available for trainee doctors

Trainee doctors now have access to a range of information to help them navigate quality improvement (QI) via a dedicated section of the HQIP website.

The resources for trainee doctors webpage has everything trainees need to help them carry out clinical audits or QI projects, including a Top Tips document to help them understand the ways in which they can get involved with national clinical audits.

There is also a brand new eLearning package, providing key information about NCAPOP and how trainees can get use the programme to support improvement. The course has two modules and covers a range of topics such as how to find National Clinical Audits, how to prioritise topics, accessing data and much more.

These new resources are the brainchild of former Clinical Fellow, Dr Hannah Wright, as part of a project to improve awareness of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) amongst trainee doctors.

Full details are available from HQIP’s dedicated webpage

Increasing oxygen prescribing during the COVID-19 pandemic

Sahota, R. & Kamieniarz, L. | 2021 | Increasing oxygen prescribing during the COVID-19 pandemic | BMJ Open Quality |

Prior to the start of this quality improvement project (QIP), it was evident that many patients at North Middlesex University Hospital (NMUH) receiving oxygen did not have a valid prescription. This became even more noticeable during the COVID-19 pandemic when almost every hospital patient was being administered oxygen as part of their treatment for COVID-19.

The aim of this QIP was to improve the proportion of hospital patients on two medical wards with a valid oxygen prescription over a 6-week period to 95%, in line with British Thoracic Society (BTS) national improvement objectives.

Unfortunately, this QIP did not achieve its aim of 95 per cent of patients having a valid oxygen prescription, in line with BTS guidelines.1 By the end of the project, 70 per cent of patients had a valid oxygen prescription, up from the baseline measurement of 0 per cent. All of the individual interventions were shown to work to a different extent, with the email sent to nursing staff proving to be the most successful. Each intervention provided incremental improvement in the process measure; at baseline 6 per cent of patients were within their target saturation range, this was 80 per cent at the end of the project, showing that the interventions were contributing towards a positive change in practice.

Abstract

Valid oxygen prescriptions for hospital inpatients have been a long-standing problem and have been described extensively in BMJ Open Quality with numerous quality improvement projects (QIPs) with the aim of improving compliance with oxygen prescribing.

The British Thoracic Society recommends that all inpatients should have oxygen target saturation set on admission: this is motivated by risks of both undertreatment and overtreatment with oxygen. The discrepancy between the recommendation and the reality produced a number of interventions studied in QIPs over the past years, all aiming at bringing the local ward teams closer to the target. This has become even more important during the COVID-19 pandemic, where non-standard oxygen saturation targets and oxygen scarcity led hospital systems to rethink their internal guidelines on the subject.

We propose three novel interventions to improve compliance: a remote, personally directed email communication to a ward pharmacist, a similar communication to ward nurses, and a remote, personally directed WhatsApp communication to junior ward doctors. We undertake a QIP which compares novel interventions developed in-house with the most successful interventions from oxygen prescribing initiatives that have previously been published by BMJ Open Quality. The main outcome measure was the proportion of patients with valid oxygen prescription on a ward.

The series of novel interventions in three plan, do study, act cycles led to improvement in the outcome measure from 0 per cent at baseline to 70 per cent at the end of the QIP. The successful interventions from previous QIPs were ran in parallel on a similar ward and achieved improvement from 17.9 per cent at baseline to 55.6 per cent at the end of the QIP.

This QIP demonstrates adapted interventions performed in context of social distancing aimed at members of multidisciplinary team which achieve superiority in increasing proportion of patients with a valid oxygen prescription, when compared with previously described methods from BMJ Open Quality.

Increasing oxygen prescribing during the COVID-19 pandemic

Listening to bereaved relatives and carers

Kent Community Health NHS Foundation Trust | nd | Listening to bereaved relatives and carers

This project is summarised on this accompanying page Listening to bereaved relatives and carers

Click to access Bereavement-Packs-Project-on-a-Page-v3.0-FINAL-1.pdf

Reframing the Patient Experience: A new scorecard for healthcare leaders

Siemens | December 2021 | Reframing the Patient Experience A new scorecard for healthcare leaders

This publication builds on the earlier “Reframing the Patient Experience, released in 2018. It builds on the foundation laid by the paper and explores and applies the lessons learned during COVID-19. It also contains an updated scorecard. Shaped by the pandemic, this scorecard is more detailed and comprehensive, reflecting what must be the new reality in healthcare.
Perhaps its most interesting feature is the evolution of what patients expect from providers and what goes into
creating what will be perceived as a positive patient experience. From lower costs to easier access to greater
convenience, patients are very clear that these are no longer aspects of their experience on which they are
prepared to compromise. And more than ever before, patients are making it clear that they want to be treated
with humanity. They want respect, they want to be communicated to clearly, consulted on and included.
They want to feel safe and cared for (Siemens).

Image source: Siemens

Siemens Reframing the Patient Experience: A new scorecard for healthcare leaders

CVDPREVENT – First Annual Audit Report published

NHS Benchmarking Network | nd | CVDPREVENT – First Annual Audit Report published

The CVDPREVENT audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) and funded by NHS England & NHS Improvement, aims to support professionally-led quality improvement in primary care for the prevention of cardiovascular disease (CVD) in England. The audit is delivered by the NHS Benchmarking Network, the Office for Health Improvement & Disparities (OHID) – National Cardiovascular Intelligence Network (NCVIN) team, and NHS Digital.

The CVDPREVENT audit is part of a broader strategic objective outlined in the Long Term Plan to prevent 150,000 strokes, heart attacks and cases of dementia over the next ten years. The audit will prioritise working with system partners to drive CVD quality improvement at individual GP, PCN, CCG and ICS level

The First Annual Audit Report and Data & Improvement Tool has now been published, it makes the following points

• About 4 in 10 people with recorded hypertension also had obesity. Prevalence of obesity is correlated with deprivation, and hence wider efforts to address health inequalities and rising levels of obesity would contribute to reducing CVD.
• Those diagnosed with hypertension in the working age population, particularly males, could be better managed. A focus is needed on people BME groups in the management of hypertension.
• Initiatives to improve the management of atrial fibrillation (AF) could be targeted at females, particularly in the 40 to 59 age group, and non-White ethnic groups.
• The audit results suggest under recording of familial hypercholesterolaemia (FH) in England and missed opportunities to identify people with this genetic condition at a younger age.
• A high proportion of those with CVD have been prescribed lipid lowering therapy, however, an area of focus for improvement may be females, with CVD, aged 40 to 59 years.
• The proportion of those with chronic kidney disease (CKD) prescribed lipid lowering therapy (for either primary or secondary prevention of CVD) was lower than for those with CVD. As for the CVD cohort, females, in this case in all age groups, were less likely to receive lipid lowering therapy and may therefore be a focus for more active management.

CVDPREVENT First Annual Audit Report published

Systems engineering analysis of diagnostic referral closed-loop processes

Nehls, N. et al | 2021| Systems engineering analysis of diagnostic referral closed-loop processes | BMJ Open Quality | 10 | e001603| doi: 10.1136/bmjoq-2021-001603

The authors of this paper set out to explore current diagnostic closed-loop processes in a small urban community-based health centre and a teaching practice within a large academic medical centre. To this end they conducted a formative SE analysis of processes for ordering and completing diagnostic referrals (‘closing diagnostic loops’) both in general and with dermatology referrals as a specific use case. Key insights gained from their analysis include over-reliance on low-reliability design characteristics alone, variation in non-standardised work processes, inefficient push systems, serial queues, list management systems resulting in excessive delayed and unnecessary work, and consequently excessive amounts of non-value-add activities.

Abstract

Background 

Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65 per cent–73 per cent failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes.

Objective

 Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case.

Methods

 An interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a teaching practice within a large academic medical centre. Results were used to conduct an engineering process analysis, assess variation within and between practices, and identify common failure modes and potential solutions.

Results

 Processes to complete diagnostic referrals involve many sub-standard design constructs, with significant workflow variation between and within practices, statistical instability and special cause variation in completion rates and timeliness, and only 21 per cent of all process activities estimated as value-add. Failure modes were similar between the two practices, with most process activities relying on low-reliability concepts (eg, reminders, workarounds, education and verification/inspection). Several opportunities were identified to incorporate higher reliability process constructs (eg, simplification, consolidation, standardisation, forcing functions, automation and opt-outs).

Conclusion

 From a systems science perspective, diagnostic referral processes perform poorly in part because their fundamental designs are fraught with low-reliability characteristics and mental models, including formalised workaround and rework activities, suggesting a need for different approaches versus incremental improvement of existing processes. SE perspectives and methods offer new ways of thinking about patient safety problems, failures and potential solutions.

Systems engineering analysis of diagnostic referral closed-loop processes [paper]

An Approach to Reducing Health Inequalities

NHS England | 1 November 2021 | An Approach to Reducing Health Inequalities

Core20PLUS5 is an NHS England and NHS Improvement (NHSESI) approach developed by the Health Inequalities Improvement Team to support NHS Integrated Care Systems (ICSs) to reduce health inequalities.

Core20PLUS5 offers ICSs a focused approach to enable prioritisation of energies and resources as they address health inequalities in the period 2021-2024.
NHSEI presents the Core20PLUS5 approach as the NHS contribution to a wider system effort by Local Authorities, communities and the Voluntary, Community and Social Enterprise (VCSE) sector to tackling healthcare inequalities – and aims to complement and enhance existing work in this area.
This document describes the Core20PLUS5 approach in more detail and outlines its role as a vehicle for building system capability to deliver the NHS Long Term Plan commitments to reducing healthcare inequalities in England, which will contribute towards the overall government goal of increasing healthy life expectancy by five years by 2035.

Core20PLUS5 An Approach to Reducing Health Inequalities Supporting document to enable the completion of the Engage online survey on Core20PLUS5

More information on Core20PLUS5 is available from NHS England

Public health and integrated care reform: doing the knitting

The King’s Fund | November 2021 | Public health and integrated care reform: doing the knitting

All aspects of the health and care system are caught up in far-reaching reform. Public Health England has been abolished and replaced by two new successor organisations, the Office for Health Improvement and Disparities and the UK Health Security Agency. There is a landmark Health and Care Bill in parliament that will reform both the NHS and the way the NHS works with key partners including local government and the voluntary sector

This new and evolving health and care system holds the potential to hard wire the public health system’s contribution more coherently alongside the NHS and the wider care system in order to finally put population health as its core goal at local and regional level. Yet there remain deep challenges to realising this potential. This long read from The King’s Fund looks at the opportunities ahead, identifies the remaining missing pieces for public health in the health and care architecture, and concludes with the remaining key challenges (Source: The King’s Fund).

Public health and integrated care reform: doing the knitting [read online]

The challenges of developing integrated care partnerships (ICPs): a discussion

NHS Confederation | November 2021 | The challenges of developing integrated care partnerships (ICPs): a discussion

Following the publication of the national ICP engagement document, the ICS Network hosted a ‘Spotlight’ session with the Department for Health and Social Care, providing ICS leaders with an opportunity to discuss and ask questions about ICP establishment. This briefing summarises the key issues covered.

Key points

• All integrated care systems (ICSs) are at different stages in their development and establishing ICPs brings different challenges depending on size, relationships and other local circumstances within systems.
• It will be important to build on the structures and relationships already in place locally and to bear in mind the important role existing partnerships and health and wellbeing aoards play.
• The permissiveness of the health and social care bill in allowing ICSs to develop in a way that suits local needs is vitally important when it comes to setting up ICPs that will work.
• ICPs are not just about ‘seats around the table’: they are intended to actively drive integrated working between partners across a system. (Source: NHS Confederation)

See NHS Confederation for further details and the full Q & A

Leading the Spread and Adoption of Innovation and Improvement: A Practical Guide

NHS Horizons | November 2021 | Leading the Spread and Adoption of Innovation and Improvement: A Practical Guide

This guide offers seven interconnected principles and a way of leading to apply them in practice, developed from knowledge and experience. The content is practice focused; it has been tested via multiple presentations and prototype demonstrations at local, regional and national levels and modified based on the feedback shared with NHS Horizons.

These principles are summarised below with more detail and explanation in the linked blogs and in the Guide.

• Complexity – understanding complexity and the implications for your work. Spread and adoption in health and care is often not straightforward, but an activity that requires managing many interdependencies. Read more in this blog
• Leadership – an enabling leadership style – to give people the space to connect and engage – is needed. Read more in this blog.  
• Individual – the perspective of the individual – patient, carer, staff member – is pivotal to enable behaviour change. Read more in this blog.
• Benefit – focus on the benefit rather than the innovation, the ‘why’ not the ‘what’. Read more in this blog.
• Adopter focus – support adopters so they have a sense of agency and feel energised about the work 
• Networks – build communities, energising and connecting individuals 
• Learning – build a learning system and habit of learning, sharing with and seeking knowledge from others  

The practical tools and methods, and case studies pages will help you apply these to your work along with the further information pages which provide a depth of detail and knowledge

Image shows the 7 principles to consider for spread an adoption (as listed above). Image is from Horizons NHS

Leading the Spread and Adoption of Innovation and Improvement: A Practical Guide

There are a number of resources, case studies and blogs about spread, adoption and system convening available from NHS Horizons