Using Quality Standards on Stroke in Quality Accounts

As part of the Quality Accounts, for each improvement priority the trust had to identify where they are now, what they plan to do, and how this will be monitored. This has been done for the statements in the quality standard relating to the inpatient stroke rehabilitation service. - To take advantage of the clearly defined statements in the NICE QS to prioritise and direct service improvement in line with identified best practice.
- To make use of the data collected to demonstrate achievement of the QS for benchmarking purposes with the aim of being able to highlight the quality of our services to commissioners and service users as part of the Quality Accounts.

The Governance team approach business units (clinical directorates) each year to support their improvement priorities for the coming year. Ideas are tabled from both sides (often drawing on a locally maintained horizon scanner which the governance team maintain with reference to the NICE Forward Planner). The NICE quality standard for stroke was discussed in depth at the Business Unit Sub-Committee, chaired by the relevant Associate Director. Because the Governance team had alerted the team to the development of the stroke quality standard at an early stage, they had seen the draft standard at the consultation stage. This ensured they were fully aware of the content prior to publication and meant they had already done some initial preparation work in advance. They were also already auditing against the NICE guideline for Stroke.

The QS statements were reviewed in order to decide which would apply to the local rehabilitation service. Four of the statements were immediately seen to be relevant, and two others added after discussion on their implications for practice. Agreement on using the quality standard for stroke as a trust improvement priority was also sought at the Clinical Standards Committee which is chaired by the Chief Operating Officer and the Medical Director.

Once agreement was reached on which statements from the quality standard would be selected, they were added to the trust Quality Accounts. The content of the Quality Account was then consulted upon (via the Chief Operating Officer) with GP Consortia, the Local Authority, Joint Commissioners, LINKS and local patient and public involvement forums.

Stroke was chosen as a clinical improvement priority because: - It was already a high priority locally as they had recently participated in a CQC review and worked with NHS Improvement on this topic - The Quality Standard provided a driver to build on progress to date and sustain improvement - Through previous work there was an existing baseline to build on - Although some were challenging, the statements were felt to be achievable - There were clear statements in the quality standard on stroke that were highly relevant and applicable - The service was enthusiastic and keen to demonstrate that they are providing a high quality service There is a stroke register for Camden and all patients on the register are reviewed six monthly. Therefore it is relatively easy to identify patients. This would be harder in general community services where several quality standards will apply to the caseload of one team. There will be quarterly monitoring of the quality standard statements. Currently data collection has to be carried out manually by clinicians using a record sheet in the front of the paper notes on a quarterly basis. It is hoped that this could be done from a back end report from Rio in future. The trust's Quality Accounts are reviewed annually. Camden Provider Services recently integrated with Central and North West London NHS Foundation Trust, along with Hillingdon Community Health. For next year the improvement priorities will need to be reviewed across the whole of the new organisation. Some additional costs would be incurred to meet the standards. For example extra resource in speech and language therapy was identified to meet one of the statements. Because they had been aware of the quality standard at an early stage, these costs had been considered and incorporated into the strategy and planning of the business units, which is attended by finance and business planning staff. Costs were also addressed during the consultation period.

Data on the agreed measures has been collected for the first 3 quarters of the 2011-12 financial year. The most recent data shows that achievement of the measures has continued to rise throughout the year with the biggest improvements noted in patients being allocated keyworkers to act as a central point of contact and patients having access to all appropriate therapies (quarter 3 data shows that 91% patients are receiving physiotherapy, 90% occupational health and 76% speech and language therapy for 45 minutes a day, 5 days a week). These have been incorporated into metrics and targets for the service which are being reported to local commissioners as performance data. In addition, Camden's Stroke ESD team recently published a case study as part of NHS Improvement's Mind the Gap review which demonstrated 90% of patients receiving all appropriate therapies as part of our early supported discharge programme.

For extended results and evaluation information, please see the supporting material

- It was valuable to have been aware of the quality standards during the development and consultation stage and highlight these to the relevant clinical team. This meant that they were aware of the content and had done some initial preparation work.
- It was helpful to use the statements in the quality standards rather than the key priorities for implementation in the guideline. The numerators and denominators are clearly defined, and they felt they were able to clearly and quickly identify the descriptors of a high quality service.
- There will be real value in benchmarking against others. Incorporating NICE quality standards into the Community Information Dataset or national data would be welcomed.