How the Benchmark Improved Care for Patients: Three Case Studies
Case Study 1
Using the measurement of productivity to drive improvements in care – Urgent Care 24
One of the providers in an early pilot, Urgent Care 24, were broadly pleased with the overall pattern of performance, but were concerned by their comparatively low level of productivity. This led them to dig deeper in this area. They carried out a further review of productivity by each clinician (doctors and nurses) and found an even greater variation across the wide range of clinicians covering shifts in their out of hours service. They then fed back this information to all clinicians and met with all clinical staff to discuss the results and reflect on what this might mean for an individual’s practice. They also looked at other aspects of clinical behaviour. They found out that some GPs were logging onto the system late for shifts, others in remote Centres were not picking up telephone advice calls and were often inactive, while their colleagues undertaking triage at the main base were over-stretched. By addressing these and other issues they were able to improve performance, patient care and promote a culture of fairness for all staff.
The overall result was that productivity at peak times more than doubled, clinicians were happier that workload was more evenly spread and patient care improved. UC24 Clinical Director, Simon Abrams said “by making clinicians more productive - supporting them as necessary, sorting out the problems that they face and addressing one or two poor performers – it has improved care for patients because clinicians can focus on the job that they are there to do”. It also highlighted that variations in performance tend to be less about external factors (e.g. geography, demography) and more about how staff are supported and managed.
Case Study 2
Improving Patient Safety in response to comparative low level of urgent cases on receipt – Chorley Medics Ltd
Chorley Medics is a small out of hour’s provider, serving a population of 170,500 patients in Central Lancashire. They were very pleased with the overall feedback from the benchmark and their results on a range of measures, but noted a low level of urgent calls on receipt compared to other providers. Although the operational model employed at Chorley Medics facilitates a rapid face to face consultation regardless of urgency, the service wanted to ensure all steps were taken to make any delay for potentially urgent cases minimal.
Following the benchmark, a rigorous base line audit of calls taken and priority given was undertaken. Call handlers were clear and correct in identifying and dealing with life threatening calls and also cases to be referred to A&E (e.g. fractures, patients requiring sutures). However, specific areas were identified which could be addressed by training sessions for the call handling staff, which were led by the Clinical Nurse Manager in a manner designed to develop each call handler’s confidence and underpinning knowledge. Subsequently, the results of the post training audit is that the percentage of urgent calls has increased and is moving towards the national average, but more importantly has shown to be appropriate to each presenting case as evidenced by the end priority given by the consulting clinician. The process has supported and reassured call handlers, who have benefitted from the extra training and from being able to compare their work as individuals with others across the organisation.
Sue Pinder, the manager of Chorley Medics said “The benchmark highlighted an area that we should look at, to ensure that our service would be as safe as possible in all situations. The detailed comparison carried out by the Primary Care Foundation enables even well-respected services like ours the chance to compare and reflect on how to make the service even better for patients and as safe as possible”.
Case Study 3
Using the benchmark to drive improvements in commissioning out of hours care - NHS Bedfordshire
NHS Bedfordshire commissions services for a population of 380,000 people. They joined the Out of Hours benchmark in November 2008. The Head of Acute & Urgent Commissioning, Lynda Lambourne, who is managing out of hours services services, had found it difficult to make direct comparisons across three different providers. Each provider had a different service model, call handling was managed in different ways, some OOH services were community based while others were based within Acute trusts. Although all were monitored within the National Quality Requirements , they all seemed to do it in a slightly different way “it was confusing and difficult to make meaningful comparisons across different services”.
The reports have proved useful in a number of ways. As commissioners we meet regularly with all providers and the benchmark acts as a focal point for identifying what is being done well as well as identifying areas of comparative weakness “it makes a real difference that this data is not just ‘our numbers’ but that recognised experts were providing an external view of performance. It has also become clear that this is not just a stick to beat people with but a positive tool for service development. It is easier to see where we need to take action and areas where we can be confidently assured of performance and governance processes". Reports also go regularly to PBC leaders and Executive Directors at the Bedfordshire Commissioning Group and, more recently, regular reports to the Executive team and the Board. There has also been a recent major ‘peer review’ process for Out of Hours undertaken across the East of England SHA which was Chaired by Dr Agnelo Fernandes from the Royal College of General Practitioners. The information from the benchmark provided a good basis for demonstrating governance processes and improvement across providers and year on year.
There are some clear areas where the information in the benchmark has driven improvements. The clearest is on the key NQR measuring time to clinical assessment for urgent cases. Last year performance was variable and mixed, ranging from 64% to 91%. After focused effort in this area, all providers are now fully compliant with the national target of 95%. There were also concerns about the high percentage of calls identified as urgent when they are received by call handlers. There is now a better understanding of the significance and how it is likely to put a strain on the service and that addressing it can reduce clinical risk. Finally, one provider was identified as needing to improve its governance systems and took steps to formalize some of its processes. Another has recruited a risk manager and is exploring the introduction of datix and is organising staff training.
Information from the benchmark coupled with feedback from the Practice Based commissioning groups gave ample evidence that performance was good, with high patient satisfaction, suggesting that the PCT was getting value for money in line with QIPP.
“We now all understand what is happening in Out of Hours and I am much clearer about the questions I need to ask at Commissioning meetings. Clinicians can be very good at giving reasons why performance is actually better than it looks, but now that everyone is compared in the same way with everyone else – we can work together to sort out any issues. The benchmark has driven greater consistency across the different services across the patch”.