QUALITY FRAMEWORK – OUR START

QUALITY FRAMEWORK Disclaimers  Have not got this right ourselves yet  It is difficult to measure clinical outcomes  Labour or IT resources  Have tried to maintain a variety of types of measures Proposed national measures  Many are annual credentialing type measures  Difficult to know how to maintain momentum and visibility

INSTITUTE OF MEDICINE FRAMEWORK Widely used (not a bunch of physicians!) Ensures good spread of measures Is referred to in NZ document Operationalises quality within a framework of domains SafeEffectiveEfficient TimelyPatient-centredEquitable

SAFE Definition  Care should be as safe for patients in health care facilities as in their homes Measures  Medication errors  Hand hygiene  Handover quality

TIMELINESS Definition  Patients should experience no waits or delays in receiving care and service Not short on measures in this grouping!  Includes triage related metrics  Can include a number of clinical measures  Time to analgesia

EFFICIENT Definition  Care and service should be cost effective, and waste should be removed from the system Measures  Number of financial measures assess this in our organisations  Generic  Lab and radiology costs/patient presentation  Specific  Condition related resource

EFFECTIVE Definition  The science and evidence behind health care should be applied and serve as the standard in the delivery of care Measures  Following pathways of care  Representations  Screening completed

PATIENT CENTRED Definition  The system of care should revolve around the patient, respect patient preferences, and put the patient in control Measures  Did not wait  Satisfaction surveys  prem-tools  Complaints

EQUITABLE Define  Unequal treatment should be a fact of the past; disparities in care should be eradicated Practically  This can be implemented by stratification  Ethnicity  Deprivation score  Gender  ? Others

WORKLOAD Decided we needed to report on workload  Linked to other outcomes  Has been used as a departmental indicator for many years Include  Resuscitation  Procedural sedation  Midnight occupancy  Admission rates

WORKLOAD Workload Feb 2015 Other Month ED Attendancen2460 ED Attendance by ATS category Triage 1n26 etc ED Attendance By Ethnicity Prioritised Asiann666 Maorin235 Pacificn493 Othern1066 ED Attendance By Deprivation Scale Deprivation Scale 1nPending Deprivation Scale 2nPending Patients in Resus Area n 105 Median (mins) 68 Procedural Sedation n 95 ED Midnight Occupancy > 20n7 Admission Rate%24% Admission Rate By Ethnicity Asian%Pending Maori%Pending Pacific%Pending

Timely Feb 2015Other Month ED LOS Over 6Hr n124 %5.1% ED LOS By EthnicityMedian (mins)186 AsianMedian (mins)171.5 MaoriMedian (mins)213 PacificMedian (mins)193 OtherMedian (mins)187.5 Triage Waiting Time and Compliance various Triage 3 By Ethnic Group AsianMedian (mins)15 MaoriMedian (mins)16 PacificMedian (mins)15 OtherMedian (mins)17 ED CompletionMedian (mins)130 Referral to Specialist AssessmentMedian (mins)69 Specialist Assessment CompletionMedian (mins)101 Bed AllocationMedian (mins)18 Bed Allocation to ED DepartureMedian (mins)134 2 Hour Access Block%26.3% CSS%6.3% CSS LOS Under 12 Hrs (≥80%)%91.8% CSS to Admission (≤ 20%)%5.3%

Patient Centered Feb 2015 Other Month DNW Before Seen%1.0% n25 Left Before Care Completion%0.1% Discharge summary completion within 48 hours % 97% Consumer survey ("Excellent" or "Very good")% Manual Maori% Manual Pacific% Manual Asian% Manual Complaintsn 5 Asthma action plan provided% Manual

Safety Feb 2015 Other Month Medication errors reported n6 Hand hygiene audit score (all staff) %78% Handover related care failure %Manual Staff survey (Excellent/Very good)%Manual

Effective and Efficient Feb 2015 Other Month Representations to ED within 48 hours n78 %3% Representations to ED within 48 hours requiring admission nPending % Child Protection screening completed %65% Time to antibiotics in neonatal sepsisMedian minManual Time to FBC collect in febrile oncologyMedian minManual Time to salbutamol in acute asthma (TC 1 to 3)Median minManual MaoriMedian minManual PacificMedian minManual AsianMedian minManual Steroid use in acute asthma (age > 5 years)%Manual CXR use in acute asthma/bronchiolitis%Manual CT Head in discharged head injury%Manual Time to opiate analgesia in acute fracture (TC 1 to 3)Median minManual MaoriMedian minManual PacificMedian minManual AsianMedian minManual Unplanned fracture remanipulation (if manipulated in ED) %Manual Length of ED stay in patients requiring fracture manipulation Median minManual

SO …. We are in the process of ‘automating’ this  Some of it is possible currently  Some of it in preparation We have/are developing standardised definitions We can then allocate resource to ‘manual’ measures  SMO audit  RMO audit  Nursing audit  Other Department auditing us  Research assistants  Clerical team

IMPROVEMENT Monthly improvement focussed meeting  Review ‘performance’  Identify how to improve  Will also need to look to varying measures Visibility  Staff  Will need to include staff education  Patients and families