Quality Improvement

Adrian BoyleChair of the Quality Emergency Care

Committee@dradrianboyle

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 harmedTimely Within an appropriate time frameEffective Evidence based guidelines are Efficient Avoids wasteEquitable People aren’t discriminated

againstPatient 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

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

RCEM Audits: Standards

FundamentalDevelopmental 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 exercisePerformed by temporary staff Lack of feedback loopsCareer advancement rather than care advancementLack of collective responsibilityStrangled with red tape

Fractured Neck of Femur Patients Receiving Analgesia within One Hour

%

Quality Assurance

Quality Improvement

Motivation Measuring compliance Continuously improving processes to meet

standards

Means Inspection PreventionAttitude Defensive Chosen, proactiveFocus Outliers Processes Scope Medical Provider Patient careResponsibility Few All

The Anatomy of an Audit

StructureDoes 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 BenchmarkingNational Picture

Safety of sedation in UK EDsTimeliness of psychiatric assessment

Aggregation of less common cases

Status Epilepticus

The Future of the Audit Program

Rapid cycle methodology (?2016-17)Initial performanceInterveneQuick repeat of failed standards on a smaller

groupIncreased Consultant and team ownershipEndorsement by relevant bodiesPublic domainNarrative for adverse outcomes

Public Domain

Accessible to allEasily 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 nurseInfection ControlPresenting ComplaintAVPU assessmentDecides on placement

Initial Assessment by pre-reg nurseInfection ControlPresenting ComplaintAVPU assessmentDecides 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

Ambulance staff

Ambulance staff

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/ Urinary Catheter

Bloods/ Urinary Catheter

Bloods

PA cubicle

SpR/

Consultant

Porter

Medical Assessment

Medical Assessment

SpR / Consultant

Junior Doctor

Junior Doctor

SpR / Consultant

Medical Assessment

Junior Doctor

SpR / Consultant

Medical Assessment

Junior Doctor

Porter

Porter

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

Porter Receptionist

HCA / Cubicle nurse

Ops centre person

Ops centre person

Radiographer

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