Furness General Hospital Royal Lancaster Infirmary Westmorland General Hospital Dr Pradeep Kumar, Consultant Physician Pradeep.Kumar@mbht.nhs.uk 12th October 2012

About our hospital University Hospitals of Morecambe Bay NHS Foundation Trust Furness General, Royal Lancaster Infirmary, Westmorland General Hospital (an hours drive from FGH – RLI) Three outpatient centers Population of 350,000 approx. Geographical area of over 1,000 square miles 6000 staff

How we acted on the results: The results were disseminated to various stakeholders Presented at the cross-bay medical audit meeting Cardiac & Stroke network meeting Trust Board

These were some of the results of the 7th round of the sentinel audit (2010) Bearing in mind the audit was retrospective and only looked at some case notes Therefore quality of the audit was debatable Yet important learning points

SUMMARY OF PROCESS OF CARE - Key 9 process indicators National (median) FGH RLI 90% of stay in stroke unit 62.2% 67% 41% Swallowing disorder screen <24 hours since admission 84.1% 94% 87% Brain scan <24 hours since stroke 70.5% 63%

SUMMARY OF PROCESS OF CARE - Key 9 process indicators National (median) FGH RLI Aspirin by 48 hours since stroke 94.1% 95% 88% Physio assessment <72 hours 93.0% 98% 80% OT assessment <4 working days since admission 87.1% 73%

SUMMARY OF PROCESS OF CARE - Key 9 process indicators National (median) FGH RLI 90% of stay in stroke unit 62.2% 67% 41% Swallowing disorder screen <24 hours since admission 84.1% 94% 87% Brain scan <24 hours since stroke 70.5% 63%

Sequence of events: Took part in the 90:10 Northwest stroke project, subsequently also entered the next round of the national sentinel stroke audit 2010 Figures significantly fell in that round (chart) We won’t go into the reasons behind it as it was due to a variety of factors

Where are we now since the peer review:

What went wrong Our key indicators started falling well below national average There were a number of reasons behind this Perhaps best not dwell on it Best if I start to say how we started progressed

What is a national clinical audit Health care across the country is involved Improve the quality of clinical care for patients Improve patient outcomes Prospective Based on national clinical guidelines Based on evidence Includes patient involvement

Next steps: Close working relationship with the cardiac & stroke network Understanding the reasons for poor results Put in place processes to improve performance External peer review of stoke services presented by RCP & BASP

External stroke peer review Close working with cardiac and stroke network. Organised external peer review conducted by joint Royal College of Physicians and British association of Stroke Physicians End of the review there was a presentation by the peer review –with recommendations A comprehensive review and recommendations were sent to the Clinical Lead and the Trust chief executive and to the cardiac and Stroke Network

Key recommendations from external peer review: Better engagement of the management team with the clinical team (service re-alignment) Identify Executive Champion (Medical Director) Review overall stroke care pathway Robust high quality data capture system

Key recommendations A constructive and open dialogue with the commissioners –formulate a cohesive local strategy Acute stroke care pathway with agreed goals and targets time frames Establish an acute stroke unit for the first 72 hours as a matter of urgency Identification of a “stroke champion at the board level Forming a strategic working group to focus on key priorities and recommit to the provision for acute stroke as a “core business”

Steps to implement the process As a priority a task group was established This involved key stakeholders from the Trust and the commissioners At the Trust board level –Programme Management Office for stroke set up Identified key stake holders to represent this Office Highlighted the key recommendations of the peer review Established the key performance indices (KPIs)

Steps to implement the process Incorporated all these info into the SharePoint Clear time frames and targets and ways to progress Traffic light system Share point updated on a weekly basis by the members of the task group

Steps to implement the process Weekly meetings Discuss the progress of the project Highlight areas of concern or where no progress made and have clear action plans and time scales celebrate the achievements within the group and all the staff involved in the delivery of the stroke care engage the senior management team at the board level and constantly updating our progress of the project Communicate! Communicate!! Communicate!!!

Data issues In previous years it was retrospective National sentinel audit We are now into SINAP ( Stroke Improvement Programme) – real time data for the first 72 hours of care The results of the data are published on a quarterly basis Public domain

Data issues An area of serious concern was the data quality and coding Inconsistent Poor quality Incomplete Poor grasp and focus on the pressing priorities for improvement of stroke service

Steps to implement the process Team effort Clinical audit team Information and technology Clinical lead for stroke Senior manager Senior nurse from the stroke unit Coding managers

Where are we now?

Operational changes 5 bedded acute stroke unit Dedicated stroke data collection clerk Business case for early supported discharge An executive “champion” at board level-medical director Regular audit meetings to discuss stroke mortality

Summary and conclusions National clinical audit Helped to implement local delivery process Have clear communication and discussions with the senior executives and better working relationship to improve service delivery Monitor progress and implement change Business planning Service development and service redesign

Summary and conclusions Evidence based quality care Benchmark against national standards Has hugh influence in the future direction of the services Provide information on re-commissioning Value for money CEQUIN AQ (North west)

Summary and conclusions Upmost satisfaction for the staff knowing that the local population are getting the best care Patient and public confidence as the results are now in public domain

We have a long way to go but it is a huge step in the right direction and the National Clinical Audit has been the key mechanism to drive change