Using Quality Standards to support improvement

To develop an electronic assessment system to identify how many cases of hospital-acquired blood clots have been prevented following the roll out of hospital associated venous thrombo-embolism (HAT) risk assessments as recommended in the VTE quality standard.

The Commissioning for Quality and Innovation (CQUIN) target is directed at ensuring over 90 per cent of patients admitted to hospital are risk assessed for HAT. The Trust wanted to go above and beyond this target and combine the CQUIN and the NICE quality standard on VTE prevention to improve outcomes, and to identify whether care was improving through a reduction in blood clots. The Trust set an aim to reduce the number of cases of hospital-acquired clots by 60 per cent. However it proved challenging to identify which clots were associated with a hospital stay and which were not.

HAT is an important cause of death in hospitalised patients, and treatment of non-fatal symptomatic VTE and related long-term morbidities is associated with a considerable cost to the health service. In 2005, VTE was registered as the underlying cause of death in more than 6,500 patients, although this figure is likely to be an underestimate of the true incidence.

NICE published its quality standard on VTE prevention in June 2010 to encourage trusts to check all patients admitted to hospital for their risk of developing HAT using clinical risk assessment criteria. The NICE quality standard ties into the national CQUIN for VTE prevention, which calls for hospitals to risk assess over 90 per cent of adult inpatients on admission to hospital. Salford Royal were certainly well on towards achieving this target, but it was not possible to identify if implementing the quality standard was making a difference to patient care by reducing the number of hospital acquired clots.

An electronic assessment system for HAT was designed which linked risk assessment & prescription of pharmacological and mechanical prophylaxis. This was built by the Trust electronic patient record (EPR) development team at no additional financial cost.

The assessment system was integrated into the prescribing process and included other key admission tasks so that using the admission bundle saved clinician time. This was introduced to staff during their induction and shadowing, and the risk assessment was checked as part of the reliable ward round checklist already in place. Other techniques to support implementation included:
- Weekly feedback of how each area was doing against aim
- Daily check by ward clerks, with reminder magnets on ward board
- Patients cannot leave theatre recovery to go to a ward until a HAT assessment has been completed.
- Posters, screensavers, education sessions in structured teaching Monthly electronic data was collected to inform the national returns, and this was quality assured by a team of doctors and pharmacists.
To identify HAT a system was developed where pathology & radiology flag any positive scan or clot found during a post mortem examination. A monthly 'VTE positive' report is generated, which is checked to see whether clots meet the definition for HAT. The named consultant is then asked to complete a root cause analysis (RCA) which assesses care against the NICE quality standard and reports in to Trust Clinical Governance.

This process was enabled with a local CQIN after discussion with the commissioners - the Trust would receive £40k to set the process up, which was offset against clinical time. Multiple previous attempts to create a system had failed; it was only the collaboration with the CCG that enabled this to happen.

Uptake among staff of the electronic assessment system was high. This was in part a measure of the convenience of an admission bundle, and also as a result of direct rapid feedback. Each clinical area was given information about their achievement on a weekly basis, and the work was rolled out through the emergency assessment unit as most patients were admitted through the unit, and most doctors worked on the unit at some point.

In 2010/11, 93 per cent of patients admitted to hospital were risk assessed for VTE. The national CQUIN target remained the same for 2011/12 but the Trust created a local CQUIN target and achieved 95 per cent and now reliably achieves 96-97 per cent risk assessment without any additional measures.

A total of 52 cases of hospital associated VTE were found in the first 6 months. The Trust now has a rolling programme of root cause analysis where a clot is perceived as 'preventable' if there is any failure in delivering the thromboprophylaxis items of the NICE quality standard (including extended prophylaxis). The system allows for the measuring of real time trust-wide data that can help drive improvements in areas the trust is struggling with. In the first 6 months of the 2013/14 financial year 41 new cases were found - with only 6 where current prophylaxis recommendations not followed reliably - suggesting that implementing the quality standard has already reduced the rate of preventable clots substantially from the figures quoted nationally.

The system is future proof ensuring that the trust can meet the targets of the 2013/14 CQUIN for root cause analysis and identify where assessment failure occur in patients with HAT. The root cause analysis system is now being used to inform process changes to prevent omissions in future cases.

This project highlights how trusts should aspire to achieving high-quality care and not focus solely on box-ticking i.e. exceeds the CQUIN. The aim of NICE quality standards is to provide a measurement strategy for high quality care. However solely implementing the process of risk assessment does not allow organisations to ensure that the changes made actually lead to an improvement. Working with commissioners to set up a system to identify HAT has allowed us to focus attention on reducing harm from VTE and to address the use of NICE quality standards in the care of the individual patient. Clearly our electronic patient record has been a key factor in our success, but the principles of combining the NICE quality standard with a clear approach to identifying hospital-acquired venous thromboembolism can be used anywhere. The example also demonstrates how collaboration with our local commissioners enabled us to address an issue which had previously been difficult to overcome.