Developing and implementing a set of outcome measures incorporating NICE Standards across the whole stroke care pathway in Greater Manchester

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