The aim of the project was to bring together and update existing metrics into a single set of outcome measures for acute and community stroke care in Greater Manchester that would:

• Reflect the updated NICE Quality Standard for stroke (QS2)
• Be as evidence based as possible (i.e. include NICE and RCP guidelines)
• Reflect the whole patient journey
• Be balanced and include process and patient outcome/experience measures to better assess the impacts of stroke care, especially in the longer term
• Be implemented by all acute and community stroke teams to enable benchmarking of services locally
• Be manageable in terms of data collection, ideally reducing the existing burden of data entry for teams
• Utilise the SSNAP audit tool to collect any additional data using custom fields
• Provide information for a local dashboard to help identify areas of poor compliance/practice to inform improvement plans

Greater Manchester’s acute stroke units are part of a centralised pathway of care and work under a single service specification and associated quality standards (mostly SSNAP indicators). However, there is no shared specification and standards in community rehabilitation services resulting in considerable variation in the provision of post-acute care. Work is underway to improve this area, however, it has been hampered by a lack of reliable data to help understand the standards of community care being delivered across the city. Until there are a standard measures, it will not be possible to assess any impacts of change in community services.

The standard set of measures will apply to all acute and community teams managing stroke patients and will be implemented by inclusion as Key Performance Indicators (KPIs) into contracts between CCGs and providers. Data for some measures will be collected on a Greater Manchester basis (i.e. length of stay, mortality, readmission rates) by the GMSODN and will be added to information gathered by stroke teams to form a local dashboard.

By developing and implementing a standardised, evidence based set of metrics that incorporate all NICE standards for stroke across the region, there should be more effective and comprehensive assessment of the the care provided to stroke patients to inform improvement in services and ensure equity of access to high quality care.

Acute and community stroke teams currently contribute to the national audit for stroke (SSNAP). Assessing performance in acute stroke is well developed, and stroke units receive regular reports on the quality of their care across 44 indicators and compliance with the national audit is excellent within Greater Manchester. Acute care SSNAP indicators are process based, however, many have evidence that make them good proxies of care, and are based on NICE guidance and standards.

Data entry for SSNAP in community teams is less consistent and not all community teams take part. There are no formal indicators or dashboards of performance, which provides limited incentive for teams to contribute data. The data collected does not help support assessment of compliance against the updated NICE standards for stroke, which are mainly focused on post-acute care.

Single service specifications and quality standards for all stroke units in Greater Manchester were implemented following the adoption of a centralised acute care pathway in 2015. However, these standards were out of date with regards to the new NICE standards. Local community teams were found to be using a wide range of mainly process indicators, that also did not reflect the updated NICE standard and the variation prevented local benchmarking of community services.

It was agreed collectively that a single dashboard of outcome measures spanning hyper acute, acute and post-acute stroke care would be developed to enable the conurbation to more accurately assess the quality and impact of its care pathway. Centralisation of acute care in 2015 (following significant additional investment) has resulted in dramatic improvements for the 6000 cases of stroke each year. However, it is impossible to assess the quality of subsequent community care in a similar way, and potentially the gains made in acute care could be lost if post-acute care is not of a high standard.

Changes to community care led by the GMSODN are underway and a new standardised model is being implemented across the conurbation to reduce variation and improve quality. It will be critical to be able to measure the impacts of this change and to assess whether all NICE standards are being met.

The GMSODN Clinical Effectiveness Group (CEG) agreed in mid 2016 that a set of standard measures should be developed. A task and finish group was set up by the network and included a range of stakeholders from stroke units, community teams, commissioners and voluntary sector organisations. The group met on three occasions with email contact in between. There was no difficulty in gaining volunteers for the group who remained engaged throughout.

The task group initially reviewed possible measures across the care pathway including existing quality standards for stroke units, existing KPIs used in contracts with community teams, the 44 SSNAP indicators, NICE standards (current and previous) and other patient reported outcome and experience measures. The group also took relevant RCP and NICE guidance into account.

The group quickly decided to adopt all current NICE standards. It then considered other potential measures and assessed the availability of data and burden of collection, with priority given to measures that directly assessed outcomes and experience. Following this review, a sub set of measures were chosen and there followed a consultation with a much wider group of stakeholders.

A final set of measures was agreed and approved at the CEG in August 2016 and were provided to commissioners to incorporate into acute and community contracts for 2017/18. The GMSODN continued working on providing guidance on using the measures and also negotiating with the national SSNAP team to develop custom fields for additional data requirements.

The costs of the project included GMSODN staff time to:

• organise meetings (1/2 day NHS B4 Administrator)
• prepare and facilitate meetings (1 day NHS B8b manager)
• collate and share information (3 days NHS B8b manager)
• develop a dashboard and write guidance on data entry (2 days NHS B7 co-ordinator)
• liaise with RCP SSNAP team over implementing custom field (1/2/ day NHS band 7 co-ordinator)
• liaise with CCGs over inclusion in contracts (1/4 day NHS B8b manager)

The GMSODN is a provider funded organisation. The only other cost was the staff time for task and finish group member attending meetings and contributing to the work.

The network is a partnership of care providers, commissioners and other stakeholders such as the voluntary sector. Its successful engagement with these organisations and people prior to the project commencing resulted in excellent buy in from those involved, and a genuine sense of collective working towards a common goal i.e. the improvement in quality of stroke care.

The project has been successful in terms of reaching a collaborative agreement on a set out outcome measures involving two care settings that include all NICE quality standards for stroke. There was considerable involvement from NHS stakeholders, as well as the voluntary sector who helped ensure the measures selected focused on areas that mattered to patients and carers.

The measures are currently being incorporated into contracts and the network will commence collating and reporting on the data from 1/4/17.

• Engage and involve effectively – build on current relationships and forge new ones if necessary
• Ensure a wide range of stakeholders are included to help people take ownership of the work; improves successful implementation later on
• Clearly articulate the focus and goals of the project – ensure messaging relates to improving patient outcomes and quality of care to enthuse rather than put off
• Communicate progress regularly and to whoever it impacts
• Ensure there is clear leadership and ensure work is taken forwards in a timely fashion – engagement is more easily retained if progress is visible and feels at pace
• If there is no agreement then empower someone to make a decision to prevent deadlock, but communicate this properly to prevent alienating people
• Acknowledge that full consensus may never be reached on everything
• “Good enough for now” may be needed to ensure the project finishes in a timely way, but recognise that the work may evolve in time and this is not the final end point

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.