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East Kent Hospitals University NHS Trust

Using: Signpost

 All clinicians are wary of data and those at East Kent Hospitals University NHS Trust are no exception. For managers at the trust, ensuring clinicians are presented with credible data that they can have confidence in is a key challenge.

Inproving data quality

Improving data quality is the first step in developing relevant and meaningful clinical metrics and the trust's Clinical Coding Programme, with its focus on improving training for clinical coders, is resulting in higher standards. Running alongside the Clinical Coding Programme is the trust's Patient Safety Programme where CHKS is playing a key role in delivering information and providing strategic advice.

Led by medical directors, associate medical directors and clinical leads, the objectives of the Patient Safety Programme are to monitor clinical metrics, to provide assurance on patient safety and to champion the drive for continuous improvement in quality of care.

Clinical coding information is delivered to the Patient Safety Programme through Signpost, the CHKS corporate reporting and clinical management system. With the support of CHKS consultants, the trust is then able to analyse and highlight areas of variation where data may be impacting on clinical metrics, for example in mortality, re-admissions, complications and misadventures.

Engaing clinicians with their data

CHKS is providing the trust with a mechanism to allow clinicians to see for themselves how episodes have been coded and how information has been presented to clinical coders to interpret into the coding process.  Through the Patient Safety Programme, clinicians at East Kent Hospitals University NHS Trust can understand data quality and its impact on the outcomes presented in clinical metrics.

Addressing patient safety

Dr Neil Martin, medical director at the trust says: "Patient safety is the highest priority for East Kent Hospitals University Trust. To be able to adequately judge progress in this area, measurement of harm events and mortality is essential. We have found significant advantage from being able to triangulate data from several sources - including CHKS - to give us the reassurance that we are moving in the right direction."

Dr Martin adds: "In particular, the Risk Adjusted Mortality Index (RAMI), which includes all deaths and excludes zero length of stay, is a powerful tool. We have also valued the expert analytical support offered by CHKS as this is not always easy to obtain in-house."

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NHS South East Coast Dementia Programme

Using: Bespoke analysis

Relevant and meaningful information supports the commissioning of dementia services and is a key priority for the South East Coast Strategic Health Authority. The NHS Information Centre has been instrumental in supporting the SHA's work in this area. It worked in partnership with CHKS and the SHA to turn health needs assessment into a tangible entity by defining clinical metrics using existing data that are relevant and meaningful to clinicians and practitioners.

Analysing the evidence

Using a range of evidence-based data sources, for example the National Audit Office report on the predicted population demands for dementia services, this evolving programme of work allows the SHA to focus on some key commissioning issues. Analyses undertaken so far include; admissions and length of stay, predicted dementia prevalence by GP practice compared with the number of patients on dementia registers, QOF data relevant to dementia, access measures and spend on dementia.

 Crossing the boundaries

Samantha Riley, Head of Knowledge Management at South East Coast Strategic Health Authority, says: "Meeting the challenge of world class commissioning means moving towards a pathway of care that is driven by the needs of patient and carer and that crosses the boundaries between primary, social and secondary care. The CHKS programme provides us with the mechanism to focus on the key drivers to variation between commissioners."

 The result

The programme output has highlighted some significant questions that can now begin to be addressed. "The information on prevalence is of particular interest since we can see that most GP practices have significantly fewer patients on their dementia registers than expected," Riley says. "This could present a real issue for commissioners. For example, if patients are not on dementia registers can we be confident they are receiving appropriate care?  What would the financial implications be if PCTs had 100 per cent of expected patients on dementia registers?"

Riley expects the programme to throw up further questions as it evolves. She says: "Armed with the information from the CHKS work, our clinicians on the ground will be able to provide the local context and initiate local discussion to start providing the answers to these important questions."

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Dartford Hospitals NHS Trust

Using: Signpost 

There were three factors driving Dartford Hospitals NHS Trust's decision to use the Signpost corporate reporting and clinical management system. First, the national standards and targets used by the Healthcare Commission's Annual Health Check; second, the requirements of Foundation Trust status; and finally, the need to demonstrate efficiency to primary care trusts and others. All of these meant the Trust needed a comparative tool to assess clinical performance, outcomes and productivity.

Mike Thompson, Assistant Director of Performance at the Trust, says: "We had been working with CHKS for some time before migrating to the Signpost system which we are using across a wide range of applications."

Two examples demonstrate the way in which the Trust is taking advantage of the scope the Signpost system is able to provide. At one level one of the Trust's clinical directors is using Signpost to monitor clinical performance at speciality level. Within a different context, the Trust is using Signpost to regularly report key indicators, for example length of stay, to the Trust Board.

Engaging clinicians and managers
A range of clinical and non-clinical staff, including clinical directors and general managers, has been trained to use the Signpost system. Mike Thompson says: "We have identified measurable benefits from using Signpost. For example reporting comparative information and present trends at Trust, speciality and HRG level is easier than in the past." He continued: "The web-based system is accessible to a wider range of staff and the information presented is more user-friendly."

Signpost is also helping the Trust with service performance improvement initiatives driven by the need to use resources more effectively. A project aimed at reducing non-elective average length of stay by one day is underway and another to improve day case rates is planned.

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Improving Performance

Using: Signpost

Signpost has given a significant boost to the drive for improvements in data quality at East & North Hertfordshire NHS Trust. The Trust is using Signpost through its clinical efficiency work streams to spotlight areas where improvements could be made. The Trust?s coding department is also using Signpost to measure performance against the Depth and Data Quality index.

Improving Length of Stay

Keith Broughton, Data Quality Improvement Manager, says: "We have particular issues surrounding length of stay across all specialties. Patients staying in hospital any longer than necessary means ward beds are not being used to optimum capacity. Signpost is helping us to analyse the length of time patients spend in hospital and identify where the length of stay can be reduced. The result is that more patients can be treated and discharged."

Signpost is used at different levels across the Trust, providing easy access to user-specific information for consultants, clinicians, managers and information analysts. Analysis of clinical coding ensures the correct coding is input to produce the corresponding HRG, which is reflected in the trim point. Signpost is also informing staff training, for example in the use of the Estimated Discharge Date.

Keith Broughton says: "We have found that Signpost is easier to use compared with comparable products. Data updates can be achieved after correcting incorrect data. It is not fixed to secondary user service updates and freeze dates. Also, data can be sent at any time to update historic data. Signpost is also providing our Clinical Coding Manager with vital support in ensuring coding is of the highest standard and depth."

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East Sussex Downs and Weald, and Hasting and Rother PCTs and East Sussex County Council

Using: Joint Strategic Needs Assessment

Producing a joint strategic needs assessment within a twelve week timeframe is hard work for any PCT. Faced with this task, East Sussex Downs and Weald and Hastings and Rother PCTs and East Sussex County Council realised that they needed outside help and in July 2007 went out to competitive quotation for the work.

Cynthia Lyons, Deputy Director of Public Health, says: "The Joint Strategic Needs Assessment underpins the three-year PCT Strategic Commissioning Plans and the Local Area Agreement and will play an important role in helping to reduce inequalities at a local level. It's a crucial tool that will inform the development of other local plans and strategies."

Meeting the Deadline
From the time CHKS was awarded the contract to delivery the timeframe had shortened to just six weeks. The PCT needed a lot of data collated an analysed quickly. "We had a clear idea of what we needed to produce and CHKS helped the vision become a reality in a very short space of time," says Lyons.

A Collaborative Approach
Standardised reporting format was discussed and agreed at an early stage. Common data templates were issued and responsibilities for collation and processing identified. This meant CHKS was able to produce a number of detailed reports. These included indicators for individual GP practices, practice-based commissioning consortia, electoral wards, local authority districts and County Council level.  Mapping of health data to local government areas (and vice versa) was achieved via algorithms based on electoral ward of residence assigned to patients registered with local GPs.

The Result
As a result, the partnership between CHKS and the PCTs and East Sussex County Council yielded an evidence-based Joint Strategic Needs Assessment well ahead of other PCTs. "It has given us a good foundation on which to build plans for the future. It was hard work but well worth it," says Lyons.

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Imperial College Healthcare NHS Trust

Using: Case Notes Audit

After a comparative coding analysis undertaken by CHKS for Hammersmith Hospitals NHS Trust (now part of Imperial College Healthcare NHS Trust) highlighted income concerns across four specialties, CHKS recommended a 200 case note audit in general surgery, plastic surgery, neurosurgery and neurology.

The case note audit revealed discrepancies between information in the case notes and the coded episodes and the impacted they had on income. Clinical coding needed to be improved and the audit suggested this could be achieved through greater clinical involvement.

Increasing Clinical Involvement

Carol Toogood, general manager of the Trust's west London renal and transplant centre, led the initiative to increase clinical involvement in coding within these four areas. She says: "In renal services we have clinician-led weekly coding meetings where coding is analysed by patient discharges. Clinicians are trained in using the system and add significant value to the coding process." She continues: "When we first started involving clinicians the meetings took up to three hours and involved a high level of coding amendments. Now, with clinicians supervising the meetings they last a maximum of one hour and coding amendments are minimal."

The Result

Ms Toogood believes that creating and maintaining gold standards in coding is essential for Imperial College Healthcare NHS Trust. "In terms of patient care, better documentation means better governance and less chance of problems for patients in the future. And as for our income position, accurate documentation reflects the true activity going through the Trust."

Ms Toogood is now working with colleagues to apply 'best-practice' clinician-led coding across the Trust. She concludes: "The CHKS audit has been invaluable, providing evidence in support of our plans for clinical involvement in coding for all specialties."

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Southport & Ormskirk Hospital NHS Trust

Using: Signpost

When a local newspaper reporter contacted Southport & Ormskirk Hospital NHS Trust investigating a potential 'bad news' story, a swift response was required to get the facts straight. According to a national study into the length of stay following major abdominal surgery, the Trust had performed particularly badly and the newspaper wanted to know why. Turning to Signpost, the CHKS corporate reporting and clinical management system, Trust managers were able to quickly extract key information to arm their response.

Getting the facts straight

The Signpost analysis showed that the results of the study were seriously misleading. Margaret Johnson-McDevitt, deputy director of performance at the Trust, said: "The study gave an average length of stay that was significantly higher at Southport & Ormskirk hospitals. When we looked at the Signpost data, however, we saw that there were only 11 cases of major abdominal surgery at the Trust during the time period of the study. One patient's length of stay was disproportionately higher due to clinical complications and this skewed the whole result." Ms Johnson-McDevitt added: "Taking this patient out of the equation revealed that the Trust's performance was amongst the highest in the country."

Helping managers respond to hostile media questions is one of the more unusual ways in which Signpost has been used by the Trust. On a day-to-day basis the system is used as a clinical benchmarking tool and to provide a framework for service improvements.

Clinical engagement is viewed as key to the successful application of Signpost throughout the Trust. Clinical directors use the system for peer reviews and consultant job planning while medical directors are able to examine specific areas in close detail to monitor performance and service improvements.