1. Furness General Hospital Royal Lancaster Infirmary
Westmorland General Hospital
Dr Pradeep Kumar, Consultant Physician
12th October 2012

2. 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

4. 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

5. 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

6. 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%

7. 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%

8. 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%

9. 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

10. Where are we now since the peer review:

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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”

17. 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)

18. 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

19. 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!!!

20. 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

21. 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

22. 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

23. Where are we now?

27. 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

28. 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

29. 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)

30. 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

31. 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