1. Supporting NHS Wales to Deliver World Class Healthcare All Wales Stroke Services Improvement Collaborative

2. Slide 2 All Wales Stroke Services Improvement Collaborative Mike Davidge Senior Improvement Advisor NHS Institute for Innovation & Improvement

3. Slide 3 All Wales Stroke Services Improvement Collaborative The Model for Improvement

4. Slide 4 All Wales Stroke Services Improvement Collaborative Types of measure

5. Slide 5 All Wales Stroke Services Improvement Collaborative The care bundles First hours bundle (Rapid recognition) First day bundle (Emergency treatment) First 3 day bundle (Early mobilisation) First 7 day bundle (Specialist care) % patients who receive stat aspirin % patients who have diagnosis screen with ROSIER % patients who have diagnosis confirmed by clinician % patients who have CT scan within 24 hours of admission % patients who have swallow assessment within 24 hours of admission % eligible patients who start regular aspirin within 24 hours of admission % patients admitted directly to stroke ward % patients who have a manual handling assessment in first 72 hours % patients with physiological signs monitored for first 72 hours % patients who have their nutritional screening reported in first 72 hours % patients who have their physiotherapy assessment in first 72 hours % patients who were sat out of bed or mobilised in first 72 hours % patients who have an OT assessment in first 7 days % patients who have goals set and agreed in first 7 days % patients who receive care information in appropriate format in first 7 days % patients who are notified of an estimated date of discharge within 7 days

6. Slide 6 All Wales Stroke Services Improvement Collaborative C Collect – the right data in a sustainable way A Analyse – the right measures presented in a helpful way R Review – whether your changes are having the desired effect Measurement is a process

7. Supporting NHS Wales to Deliver World Class Healthcare Collect

8. Supporting NHS Wales to Deliver World Class Healthcare The process of measurement at Luton & Dunstable Hospital

9. Slide 9 All Wales Stroke Services Improvement Collaborative Why we wanted to do this Measurement is vital Regular and consistent measurement is a vital part of service improvement It is used to demonstrate that progress is being made or sustained It can tie process changes to improvements in performance across the pathway But its an add-on Despite these obvious advantages, measurement for improvement is often tacked on to existing workloads of staff who do not necessarily have the relevant information skills with the result that it is time consuming and seen as something of a chore

10. Slide 10 All Wales Stroke Services Improvement Collaborative What we were hoping to achieve The team will be able to get everything they need to present the chosen measures from the hospital systems not needing therefore to get the information from a book or an independent database, from the patient’s notes or by entering batches of NHS numbers by hand as a special effort. The systems include iPM with theatre module, Footman Walker and CRIS (radiology) Both data extraction and analysis will be automated

11. Slide 11 All Wales Stroke Services Improvement Collaborative How we went about it Decide measures We started with a set of measures for the existing stroke pathway. Identify data We worked backwards to identify all the steps in the process that creates these measures to the point where data is first captured and entered into an IT or manual system. Map current process We described and evaluated the current process. Create new process We discussed the potential for a new more automated process with the relevant staff.

12. Slide 12 All Wales Stroke Services Improvement Collaborative The measures used % having CT scan <24 hrs % direct to Ward 17 (ASU) Change in Bartel score % mortality in hospital % thrombolysed Length of stay % discharged to usual residence Time in A&E Nr ward moves % cared for in stroke ward > 50% of time

13. Slide 13 All Wales Stroke Services Improvement Collaborative Required data items Admission source Admitting Bartel score Date of admission/transfer to stroke unit Date of discharge/death Date of discharge/transfer from stroke unit Date of thrombolysis Date/Time of admission Date/Time of arrival in A&E Date/Time of departure from A&E Date/Time of scan Discharge Destination Discharging Bartel score Discharge reason Procedure code used Ward of admission

14. Slide 14 All Wales Stroke Services Improvement Collaborative The current process mapped Patient arrives in A&E Patient departs A&E Patient arrives in ACU Patient has scan Patient transfer to stroke unit Patient discharge from stroke unit A&E Receptionist enters arrival date/time onto F/W A&E clinical staff enter departure date/time onto F/W Ward clerk enters transfer date/time onto IPM Ward clerk enters admission date/time and source of admission into ward book Radiology staff enter scan date/time onto CRIS Ward clerk enters admission date/time into ward book Therapy staff enter Bartel scores into notes Ward clerk enters discharge date/time and disposal method/ destination into ward book Ward clerk enters discharge date/time and ward/ disposal method/ destination onto IPM Ward clerk enters admission date/time, ward and source of admission onto IPM Post discharge Clinical coders add diagnosis and procedure codes to IPM record Stroke co-ord enters scan time into stroke DB

15. Slide 15 All Wales Stroke Services Improvement Collaborative Observations on current process Data in hospital systems not always used Although most of the required data items are entered into hospital systems, these are not used to generate many of the current measures. Instead a combination of manual and stand-alone systems are used. Result: duplicate data entry. Analysis is time consuming Charts are largely created manually from data re-entered into Excel. This approach wastes valuable staff time.

16. Slide 16 All Wales Stroke Services Improvement Collaborative What we proposed for the future Use hospital systems data Extraction of data will be performed by the information team in response to a brief and repeated on a regular agreed basis (maybe monthly). The output will be a set of patient level data Create Excel tool to analyse & display measures Patient level data will be cut and pasted into an Excel tool on a regular (monthly) basis. The tool will display weekly and monthly charts as required and can therefore be presented and discussed at multi- disciplinary meetings etc and displayed on ward ‘mission control’ boards.

17. Slide 17 All Wales Stroke Services Improvement Collaborative Issues Who is on the pathway? Identifying the right patients from hospital systems Add pathway identifier to IPM Bartel score only currently recorded in notes Add facility to enter Bartel scores into IPM Where do we get thrombolysis information from? Clinical coders confirm that they code as procedure (X292,X298) so can be obtained from IPM What about scan time? Info team will link CRIS, Footman Walker and IPM to create single record per patient containing all the right data components Where does this leave the stroke database? Info team have already designed an IPM module that could be used instead

18. Slide 18 All Wales Stroke Services Improvement Collaborative The principles involved Need to understand the patient pathway Need to understand where data is collected now and flag up any gaps

19. Slide 19 All Wales Stroke Services Improvement Collaborative First 7 days bundle First 3 days bundleFirst day bundleFirst hours bundle Stroke route via A&E Onset of sympto ms Contact GP Phone 999 Arrive at A&E Admit into bed Admit into ASU Screen diagnosis with ROSIER Administer stat aspirin Perform CT scan Perform swallow assessment Start regular aspirin Manual handling assessment Nutritional screening Physiology monitored Physiotherapy assessment Sat up or mobilised OT assessment Notified of EDD Receive appropriate information Goals set and agreed Confirm diagnosis with clinical examination

20. Slide 20 All Wales Stroke Services Improvement Collaborative Groupwork: What is your pathway? Draw your own timeline Are there any differences from our generic one? Do things happen in a specified order all the time? Record what happens most often Make a note of any issues you want to clarify back at base Be prepared to share your timeline

21. Supporting NHS Wales to Deliver World Class Healthcare Feedback and sharing

22. Slide 22 All Wales Stroke Services Improvement Collaborative Groupwork: Where is data collected? Refer to your timeline Start to complete the data collection planning sheet Who records this – the person or role responsible At what point – real time or how long afterwards Where is it stored – named hospital system, little black book etc How reliable – how many will be missing? Issues – things to check or actions to do Tackle ‘Who records this’ first Use ‘Not collected’ or ‘Not sure’

23. Supporting NHS Wales to Deliver World Class Healthcare Feedback on issues

24. Slide 24 All Wales Stroke Services Improvement Collaborative Planning your data collection How are you going to ensure you get the right data? How will you get hold of data already collected? How will you collect data items that you don’t currently collect? Plan to test with the next patient

25. Slide 25 All Wales Stroke Services Improvement Collaborative Postscript The Luton new system was delayed because of lack of information analyst time Moral: The more automated you make things, the more reliant you are on specialist informatics skills

26. Supporting NHS Wales to Deliver World Class Healthcare Analyse

27. Supporting NHS Wales to Deliver World Class Healthcare The type of presentation you use has a crucial effect on how you react to data

28. Slide 28 All Wales Stroke Services Improvement Collaborative DEPARTMENT % ABSENTEEISM BY DEPARTMENT

29. Slide 29 All Wales Stroke Services Improvement Collaborative Jobs on the line? At least we’re not as bad Nothing to worry about Who’s doing well?

30. Slide 30 All Wales Stroke Services Improvement Collaborative Take two numbers

31. Slide 31 All Wales Stroke Services Improvement Collaborative We have 2 quarterly data points - is this an improvement? Higher is better

32. Slide 32 All Wales Stroke Services Improvement Collaborative Are we assuming something like this?

33. Slide 33 All Wales Stroke Services Improvement Collaborative But it could be like this...

34. Slide 34 All Wales Stroke Services Improvement Collaborative Or this...

35. Slide 35 All Wales Stroke Services Improvement Collaborative Or this!

36. Supporting NHS Wales to Deliver World Class Healthcare How often you measure can also have an effect on how you look at the results

37. Slide 37 All Wales Stroke Services Improvement Collaborative Monthly data shows improvement The chart shows the average monthly length of time before patients got to the Stroke ward

38. Slide 38 All Wales Stroke Services Improvement Collaborative Weekly data tells a slightly different story

39. Slide 39 All Wales Stroke Services Improvement Collaborative Patient level data adds another level of understanding

40. Supporting NHS Wales to Deliver World Class Healthcare Spreadsheet Demo

41. Slide 41 All Wales Stroke Services Improvement Collaborative Groupwork Discuss how you will ensure the spreadsheet gets completed Hint: Put names in the frame!

42. Supporting NHS Wales to Deliver World Class Healthcare Review

43. Supporting NHS Wales to Deliver World Class Healthcare It is a waste of time collecting and analysing your data if you don't take action on the results

44. Slide 44 All Wales Stroke Services Improvement Collaborative Groupwork Discuss: Where you will display your measures When you will meet to review them Who needs to be there Use the Review Meeting Guide handout to prompt you

45. Supporting NHS Wales to Deliver World Class Healthcare Feedback

46. Slide 46 All Wales Stroke Services Improvement Collaborative Summary You have clarified your timeline Planned your data collection Agreed who will own the spreadsheet Decided how you will take action on the results Or... You know what you have to do to achieve all these