Kupu Taurangi Hauora o Aotearoa

Quality Safety Markers for Falls Richard Hamblin, Director of Health Quality Evaluation, HQSC Presentation 4 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC

Quality and Safety Markers QSMs are the way of keeping track on progress on the four priority areas – Falls – Infection Prevention and Control Hospital acquired infections Central line associated bacteraemia – Surgical Safety – Medication errors (on hold)

Quality and Safety Markers – the context Measurement and publication of measures of health service performance has a 20 + years history Ministerial enthusiasm for this Large literature which largely suggests that done well it can help incentivise change, but get it wrong and there are large pitfalls Big debate in this is between process enthusiasts and outcome evangelists Our aim to stimulate change in priority areas (process) but also demonstrate the benefit in reduced harm and saved $ (outcome) So our idea was to combine process and outcome into QSM sets

The QSM set Process measures – – practices that are shown to improve care – should (except for specific exclusions) always be undertaken – therefore set a national threshold to be achieved with differential trajectories agreed between NHB and DHBs – Under the control of the provider – Suitable for targets and league tables Outcome measures – – outcomes that should be related to changed practice – harm avoided, cost reduced – not directly under the control of the provide so no targets or league tables used for these – contextualise process measures – quantify effects at a national level

How outcome contextualises process Process But did it make any difference? “Hitting the target and missing the point” Failure to recognise improvement Gaming and other nasty things + - Elation Despair

How outcome contextualises process Process Outcome Looks to be working (but keep thinking!) ?Hitting the target and missing the point ?Is there a new problem ?What else is happening ?Regression to the Mean Get on with it!

Presentation in line with the principles New Zealand Quality and Safety Markers Select a DHB by clicking on the map Waikato DHB This year On track?Last year    Using the right processes 94%  80%   Infection Rate per 1,000 days 1.5 (New Zealand – 1.4)   How many fewer deaths? 2(New Zealand – 31)   How many $’000 saved? 100(New Zealand – $2.8m)  Click here  for more detail about the markers and expected performance Range of performance Why does this matter? Bacterial infections around central lines in Intensive Care Units greatly increase the risk of already seriously ill patients dying, and increase the amount of time they stay in the unit 1. It is estimated that each case costs $20,000 to treat 2. Following some simple rules at the time of inserting a line and regular checks thereafter are shown to minimise the risk of infection. This marker set looks at how regularly this good practice is followed and what the effects of this are. Performance v. target

Plus… Use existing data where possible Ensure support and understanding of sector Ensure fit with the 4 priority programmes Delivery baselines by December 2012

Progress Approach agreed with Minister late May Feedback sought from DHBs, National Health Board, the colleges and professional bodies June 15 deadline Finalising analysis of feedback and response now Feasibility testing and some detailed consultation on specifics with view to initial baselining in September

Feedback Response 16 DHBs 13 professional bodies or colleges and an international advisor to Surgical Checklist Advisory Group Surgical Checklist Advisory Group minutes Some feedback very brief and general Other in-depth relating to definitions, data collection, validity A few suggestions of new markers Offers to assist Commission in refining indicators and/or provision of references.

Falls QSM set Process markers Percentage of patients aged 75 and over that are given a falls risk assessment and implementation of appropriate falls prevention. - proposed national threshold 95% Percentage assessments that result in a positive intervention to manage the risk of fall. (a subset used to contextualise the primary marker – no national threshold) Outcome measures In hospital Fractured Neck of Femur (FNOF) per 1,000 admissions (age/sex standardised). Mortality following in-hospital FNOF (actual lives lost and rate per 1,000 admissions). Additional occupied bed days (OBDs) and associated cost following in hospital FNOF (actual OBDs and $s).

Specific feedback (1) Percentage of patients aged 75 and over that are given a falls risk assessment and implementation of appropriate falls prevention - proposed national threshold 95% Feedback Why 75+? – believe best balance between amount of activity and affect on falls Specify tool; specify timescale for use – we have sought not be prescriptive but advice sought on this Use bed days as a denominator – distorts result (OBDs per patient increase as FNOF does) Who should be excluded from the measure – clearly will be some instances where this might be inappropriate but what are they? advice sought on this Comparatively little disagreement with 95% of non excluded patients Strong view that data can only be collected through retrospective audit – we believe that this is both inaccurate and misses the point – your advice sought

Specific feedback (2) Percentage assessments that result in a positive intervention to manage the risk of fall. (a subset used to contextualise the primary marker – no national threshold) Purpose of this widely misunderstood so will give a clearer explanation and definition

Specific feedback (3) In hospital Fractured Neck of Femur (FNOF) per 1,000 admissions (age/sex standardised). Feedback Why just FNOF – this excludes a lot of other harms? This is a definite and routinely recorded measure which represents 50% of recorded falls with serious harm Risk standardisation essential for fair comparison. We are not comparing between DHBs we are looking for change over time. Some risk adjustment likely to be needed but we will look at options in feasibility testing Can this be captured from NMDS – feasibilty testing now but early analysis gives similar figures to SSE report – Can we use ACC data as a check? Use Northern region First do no harm or falls incidence measures. Not doing this to avoid corrupting powerful local improvement measures

Specific feedback (4) Mortality following in-hospital FNOF (actual lives lost and rate per 1,000 admissions). Feedback Cannot show causality between FNOF and death. Causality versus actuarial risk – a key concept to understand Need to risk adjust to show comparisons - We are not comparing between DHBs we are looking for change over time. Some risk adjustment likely to be needed but we will look at options in feasibility testing Are you looking only at in hospital deaths? Initially considered doing this but we do have out of hospital death data which can be linked to NMDS – could show all deaths within 30 days of admission – To be tested in feasibility testing

Specific feedback (5) Additional occupied bed days (OBDs) and associated cost following in hospital FNOF (actual OBDs and $s). Feedback There is already a preworked estimate of additional cost of $26k per FNOF – why not just use this. If its reliable that’s not a bad idea Your advice sought Complicated to calculate additional OBDS. Yes but not impossible – this to be tested in feasibility testing Are these two related indicators? Yes – however, we could consider going to one if the $26k figure works Your advice sought