Cwm Taf Health Board Visit to Salford & AQuA October 2011 DR D M CASSIDY AMD for Quality Improvement Cwm Taf Health Board

What is AQuA? Advanced Quality Alliance : established 2010/11 An improvement agency for health and social care Stimulate innovation Spread best practice Support local improvements

AQuA Work Programmes Reducing Mortality Collaborative Acute Myocardial Infarction CABG HF Hip & knee replacements Community acquired pneumonia Stroke Psychosis Dementia

AQuA’s Work Programme 2011/12 1.Harm Free Care 2.Improved Management of Long Term Conditions 3.Shared Decision Making 4.Eliminating Waste and Improving Productivity

Harm Free Care Safety Express Plus : reducing harm from VTEs/Falls/PU/CAUTI’s Reducing Mortality Collaborative Mental Health Safety Programme Patient Safety Ambassadors

Improved Management of Long Term Conditions AQUA developing a diagnostic tool to assess priorities and review existing successes Support operational phase of DH Long term Conditions QIPP programme Develop a Dementia Programme AQUA /ADASS Re-ablement Programme Care Domain Work Books Kings Fund Partnership Advancing Quality Along Care Pathways

Shared Decision Making Clinical engagements events Embed shared decision making into ERAS Shared decisions making in long term conditions Use King’s Fund & Health Foundation to access optimal expertise Reduce variation

Eliminating Waste and Improving Productivity AQUA Enhanced Recovery programme Productivity Leaning Exchange aimed at optimising efficiency AQUA Lean Network & Training aimed at driving up quality and reducing costs AQUA observatory: Productivity Bench Marking Integrated care to improve Health at lower costs

AQUA Programme Delivery AQuA Observatory – access to best evidence AQuA Action – engaging front line staff AQuA Partnerships AQuA Academy – to promote improvement

AQUA North West Mortality Collaborative 1 8 Hospitals in the NW plus 1 in Yorkshire Commenced April 2010 Aim to reduce adjusted Mortality by 10 points by April 2011as measured by CHKS/ Dr Foster Steering group established Driver Diagram developed Secondary drivers – Primary Drivers - Good

NW Collaborative Participants Calderdale & Huddersfield Stockport Manchester Tameside Blackpool Mid Cheshire Bolton Pennine E. Lancs Various approaches and focuses

AQUA North West Mortality Collaborative 2 Primary Drivers Clinical Care – provide safe, evidence – based care by implementing care bundles/patient pathways End of Life care – provide patients an excellent experience at the end of life in a setting of their choosing Documentation & Information - Patient documentation and coding is accurate, include all relevant clinical information and is used effectively to improve care -Leadership -The organisation has the data reporting and leadership skills it needs to manage and improve standardised mortality

AQUA North West Mortality Collaborative 3 Secondary Drivers Implement evidence – based care for leading causes of death Implement a strategy to eliminate HAI Identify and overcome barriers to implementation Increase community delivered palliative care Determine ceiling of care Understand standardised mortality data Improve quality & depth of coding & training & review Clinicians take responsibility for processes & outcomes Board level reporting and engagement

AQUA North west Mortality Collaborative 4 1 ST Step: Understanding Mortality calculations Mortality for high volume diagnoses and high RAMI Improving Mortality begins with improving care Identify top ten causes of death Focus on two Pneumonia/septicaemia/CHF/NOF/COPD/CVA/ AMI High Adjusted Mortality

AQUA North west Mortality Collaborative 5 Data quality and clinical coding inaccuracies a consistent theme Improving clinical re by introducing clinical bundles - multidisciplinary action: Working together - testing changes: real time data collection, PDSA cycle -Clinical engagement: clinical ownership & leadership -Measurement: frequent review and feedback -Education & Training: cascade training -Leadership: strategic priority Improved RAMI for condition (s)

AQUA North west Mortality Collaborative 6 Improving Documentation & Coding Clinical documentation must be complete and accurate Co- morbidities coded per clinical episode increased Inverse relationship to RAMI Changing coding practice improves RAMI Liaison between coders and clinical teams Accurate palliative care coding Avoid “Septicaemia unspecified”

AQUA North west Mortality Collaborative 7 Results NW Mortality Collaborative on average 9.5 point reduction (92.5 to 83) in RAMI vs 5 – 7 points nationally Attributed to – improvement accuracy of palliative care coding – increased coding of co-morbidities 3 – 15% ? Impact of clinical care bundles Small impact on conditions – specific unadjusted mortality Key to success: - clinical engagement - Executive Engagement and Leadership

Cwm Taf HB Mortality Audit Programme 1 October 2010 – September % deaths reviewed Predominantly with high RAMI and low predicted mortality as defined by CHKS Methodology: 12 point questionnaire + GTT Major causes of death: Septicaemia Cardiovascular Bronchopneumonia Malignancy

Cwm Tag HB Mortality Audit Programme 2 CHKS signpost summary Mortality Report 2010 – RAMI overall downward trend over 2 years -But higher than peer -Increase in non-specific diagnosis -High rate of signs & symptoms code -Depth of coding issues -High rate of procedure non – specific

Cwm Taf HB Mortality Audit Programme 3 CHKS Clinical Coding Mortality Review -Clinical Coding staffing levels/qualification -Training -Uncoded co-morbidities -Raise clinical awareness CHKS T & O data & General Medicine data -Average diagnosis per coded episode -Blank primary diagnosis -Diagnosis non-specific -Procedure non specific

Lessons for CTHB Findings similar to NW Clinical coding depth, quality, non specific diagnoses, co-morbidities, palliative care coding Improving clinical engagement Improving executive understanding Addressing clinical coding Resource and utilisation issues