The Kent, Surrey, Sussex, Academic Health Science Network (KSS AHSN) Enhancing Quality (EQ) Heart Failure programme was established in 2010 and refreshed in 2015.
The programme utilises the NICE guidelines (CG108, CG187), Quality Standards (QS9, QS103, QS15) and the National Best Practice Tariff (BPT) 2016/17 benchmarked process measures, through monthly reporting of the National Heart Failure Audit (NHFA) dataset.
A Patient Reported Outcome Measure set (PROMs) has been established in 2016 /17 as a pilot project in four community heart failure teams across the region.
* This example demonstrated implementation of NICE guideline CG108 when originally submitted. It has been reviewed and the practice described remains in alignment with the updated NICE guidance (NG106). The updated NICE guideline should be referred to if replicating this initiative.
Aims and objectives
Across KSS there are 50,000+ patients with Heart Failure with evidence showing significant variation in admission and readmission rates, in-hospital crude mortality and other outcomes. People with heart failure need optimal diagnosis, treatment and surveillance.
The EQ Pathway is built around coordinated integrated systems for improvement and the focus is always on the person - not the system. The monthly data dashboard reports are delivered at Trust and site level and benchmarked for the 16 hospitals and 13 community services across the region.
The reports enable commissioners and providers to examine and understand how they can deliver better care and outcomes for people with heart failure and their families, as well as address the considerable variation that currently exists in the management of heart failure and their associated outcomes.
Reasons for implementing your project
The EQ programme was established across KSS in 2010 bringing together heart failure specialist teams from acute and community settings to benchmark the quality of care being provided, measure improvement of that care and provide regional and international comparisons.
- In 2015 the EQ programme aligned with the NHFA data collection to support greater compliance with NICE heart failure guidelines and Quality Standards for Chronic Heart Failure (CHF) , the Acute Heart Failure (AHF), the Quality Standard for improving patient experience in adult NHS services and the Best Practice Tariff 2016/17.
Two separate dashboard reports for acute and community providers are produced and delivered monthly.
- The acute dashboard reports on six key measures as a care bundle and four fields are reported on for information only.
- The community dashboard reports on two key measures and also report on information only fields to demonstrate the symptoms and complexity of the patient group.
- The monthly dashboard reports are delivered at Trust and site level and benchmarked for all participating sites: 16 hospitals and 13 community heart failure services across the region. Patient experience measurement commenced in May 2012 focusing at service interfaces and the patient’s perception of their information, their understanding and involvement. In 2015 we supported local patient groups to feedback their experience of heart failure services.
In 2016 /17 we are supporting an ICHOM pilot project to integrate PROMS into our existing community measure datasets in four community heart failure teams who see ‘all cause’ heart failure patients.
How did you implement the project
Pathways were not joined up between care providers, snap shot audit in primary care and acute settings showed sub optimised treatment and a lack of supported self-care. Detailed metrics covered early and appropriate diagnosis, optimised management, discharge and personalised care planning and end of life care across primary, community and acute settings.
Referring to NICE guidelines (CG108 - now updated and replaced by NG106, CG187) and Quality Standards (QS9, QS103, QS15) we examined the variations demonstrated in the NHFA reports running since 2007. Regional clinical leadership and expertise was crucial, designing appropriate metrics using the evidence, gaining clinical consensus and then having providers of the different parts of the pathway come together to review their respective performance against the metrics and how they can work together better in the interests of the patient. EQ is a large scale change programme which uses various quality improvement tools including driver diagrams and process mapping to create a culture of sharing best practice across the region.
The set-up process:
- Data sharing agreement established.
- 3 x training sessions delivered at hospital or community site.
- Guidance and data tools package provided.
- EQ acute reports run four months later, so hospitals can validate against their HES data.
- Hospital inputs data to NHFA database monthly.
- Hospital extracts data from NHFA and submits monthly to EQ.
- Community teams input data to a spread sheet and submit monthly to EQ
- Dashboard reports delivered monthly.
- AHSN Informatics team support.
- AHSN EQ HF Programme Lead support.
In addition to delivering dashboard reports, EQ brings together clinicians and patients enabling a transparent discussion around areas of variation, sharing best practice, to make a marked improvement in outcomes and care for patients.
The EQ programme was incentivised through CQUIN initially for collaborative event attendance and data submission and then for increased performance against clinical quality scores. The Best Practice Tariff now acts as incentive for participation as EQ facilitates optimal data submission.
In April 2015 – EQ was refreshed to ensure the latest best practice was being adopted as part of the care bundle and to support greater compliance to NICE guidelines (CG108 - now updated and replaced by NG106, CG187) and Quality Standards (QS9, QS15).
The uptake has included 9 KSS provider Trusts who achieved an Appropriate Care Score (ACS) of 63% in Q1 up to 76% in Q4, (averaging 71% over the first year). The ACS gives an indication of the amount of bundle interventions a patient could have received with 100% being all.
Early positive results measuring outcomes where the care bundle has been adopted, has shown the top 3 trusts to apply the EQ care bundle within the KSS region managed to reduce admissions by a combined 190 patients few than baseline forecasts. This would account to a non-cash releasing saving in the region of just over half a million pounds based on the average cost of heart failure admissions in those specific hospitals.
The top performing Trusts, LOS reduced by just over half a day equating to potential spare capacity of 452 bed days. The three Trusts that saw the biggest improvements in mortality saved proportionally 35 more lives combined against baseline.
Key learning points
If we started again we would have merged with the NHFA from the beginning to avoid duplication of data collection and resource requirements.
Patients receiving clear information about their condition and on-going care are key to continuity of care, patient understanding and involvement. The ability to benchmark results at individual clinician, ward or team level assists with peer review, the improvement cycle and identifying beacons of excellence or areas of concern were paramount to ensuring clinical engagement was maintained and the facilitated bi-annual collaborative events supported the drive to keep the programmes and vision focussed.
A clear data dictionary ensuring comparability and transparency of the data is key. In light of the considerable impact that heart failure has on patients, carers and the NHS at large, and given the significant variation in the quality of heart failure care across the country, we believe the EQ Programme should be adopted at a national level by all acute and community heart failure services to improve patient care and outcomes. Adoption of the EQ programme has been supported out of region in some areas of Surrey and London so far and we are seeking other Trusts to work with to continue to scale this innovative programme across the UK.