NHSScotland is constantly striving to increase efficiency and productivity whilst improving quality and effectiveness. In this session, delegates heard directly from colleagues who have changed their systems to deliver more effective care and how they value difference and variation within the NHS, using evidence to affect change. Delegates also had the opportunity to see some real examples from various settings across NHSScotland where evidence-based practice has been used to change systems and processes and how this has made a difference to patient outcomes, experience and value. See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources

1. Reducing cardiac arrests in the Acute
Admissions Unit :
A Quality Improvement Journey
Dan Beckett
Consultant in Acute Medicine
Forth Valley Royal Hospital
SPSP Fellow

2. Situation
• Combined surgical and medical admissions unit
• 46 beds (but elastic walls...)
• Admits 1500 patients per calendar month
• In July 2011 moved from Stirling Royal Infirmary to Forth Valley Royal
Hospital

3. Background
Stirling Royal Infirmary, 2010

4. Assessment
• AAU morbidity and mortality meetings established in 2010
• Failure to rescue
• Recognition
• Response
• Resuscitation attempts undertaken on patients with terminal illness
• Limited learning from adverse outcome

5. Recommendation
• Aim statement developed
• FMEA (Failure Modes Effects Analysis) undertaken
• Driver diagram developed
• Structured response to the deteriorating patient
• Improved end of life care
• Improved learning from adverse events
• Measurement plan agreed
• Process, Outcome and Balancing measures
• Use of data for improvement vs data for scrutiny
• Sharing of data with board, staff, patients and relatives

6. Cardiac arrests in AAU per 1000 admissions
UCL
LCL0
1
2
3
4
5
6
7
8
9
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
Rate
Safety meetings start
Structured response
tested
Move to FVRH
Poor patient flow from
AAU starts
2.8/1000 to 0.8/1000 admissions = 72% reduction

7. 2222 calls in AAU per 1000 admissions
UCL
LCL0
2
4
6
8
10
12
14
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
Rate
Safety meetings start
Structured response
tested
Move to FVRH
Poor patient flow from
AAU starts

8. Use of data to soothe the naysayers
• ‘The reduction in rate of cardiac arrests in AAU has purely been
achieved by moving patients out of AAU earlier so they have their
cardiac arrests elsewhere...’
• ‘The reduction in rate of cardiac arrests in AAU is due solely to
patients having DNACPR decisions made earlier in their admission’

9. Dealing with the non-believers...
2222 call rate outwith AAU per 1000 admissions
UCL
LCL
0
1
2
3
4
5
6
7
8
9
10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Rate

10. 30 day mortality - all patients CAU/AAU
UCL
LCL
0%
1%
2%
3%
4%
5%
6%
7%
8%
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Percent
17% DROP IN 30 DAY MORTALITY
SINCE MOVING TO FVRH
=
16 LIVES SAVED PER MONTH
Safety
initiatives
started Move to
ward based
team at
FVRH
SIGNIFICANT SHIFT IN
MORTALITY

11. HSMR
0.0
0.5
1.0
1.5
2.0
Oct-
Dec
2006
Jan-
Mar
2007
Apr-
Jun
2007
Jul-
Sep
2007
Oct-
Dec
2007
Jan-
Mar
2008
Apr-
Jun
2008
Jul-
Sep
2008
Oct-
Dec
2008
Jan-
Mar
2009
Apr-
Jun
2009
Jul-
Sep
2009
Oct-
Dec
2009
Jan-
Mar
2010
Apr-
Jun
2010
Jul-
Sep
2010
Oct-
Dec
2010
Jan-
Mar
2011
Apr-
Jun
2011
Jul-
Sep
2011
Oct-
Dec
2011
Jan-
Mar
2012
Apr-
Jun
2012
Jul-
Sep
2012p
StandardisedMortalityRatio
Standardised Mortality Ratio (SMR) Regression line
HSMR October 2006 – September 2012 (19.5% reduction)

12. Total number of admissions to critical care per month
0
20
40
60
80
100
120
140
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
MedianMeasure
Move to
ward based
team at
FVRH
Safety
initiatives
started

13. Proportion of patients admitted to critical care on Day 0
UCL
LCL
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Percent
Safety
initiatives
started
Move to
ward based
team at
FVRH

14. Importance of data and measurement
• Use of data for improvement
• Sepsis 6
• Compliance with structured response checklists
• Use of data for scrutiny
• Cardiac arrests
• Mortality
• Sharing of data
Patients with NEWS4 sepsis getting the sepsis6 bundle within 60 minutes
UCL
LCL0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Percent
Number of patients referred to palliative care
0
10
20
30
40
50
60
70
80
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Median
Measure

16. Acknowledgements
• Sharon Oswald
• Monica Inglis
• Iain Wallace
• SPSP
• The whole AAU multidisciplinary team!
• daniel.beckett@nhs.net
• @djbeckett

17. Effective Haemophilia
Care in Scotland

18. • A severe inherited X-linked bleeding disorder
• Untreated males suffer spontaneous bleeding in joints, soft tissues
and brain
• Treatment strategies: ‘on demand’ or ‘prophylaxis’
• ‘On demand’ patients may suffer 2-6 bleeds per month
-> chronic joint damage
Background - Haemophilia


19. • Six Haemophilia Treatment Centres in Scotland [2 west + 4 east]
• Recombinant coagulation products are managed as part of the risk
share scheme: total cost for 2012/13 was £24.5million
• UK Annual Report 2009-10
Identified geographical variation in
mean annual coagulation product use
per patient with severe haemophilia
Background

20. • A review was commissioned by Board Chief Executives’ in 2011 to
assess clinical practice and product usage across the six centres
• Review highlighted:
- Subtle variation in clinical practice
- No standard way to measure clinical outcomes or quality of care
• Recommendations:
- Developmental of standardised protocols
- Development of key performance and clinical outcome indicators
Background

21. Centres worked together to
- produce standard policies and
protocols in relation to dosing, stock
holding and management
- develop key performance
and clinical outcome
indicators
- produce a clinical audit
form to capture dataset in
relation to the indicators

22. Largely confined to treatment of severe haemophilia
• Performance indicators
• % attending for 6-month review
• Uptake of home treatment & home delivery of product
• % severe patients receiving ‘standard’ prophylactic coagulation factor
treatment
• % patients receiving an excess amount of coagulation product per Kg in 6m
• Outcome indicators
- Patients with spontaneous major bleeds
- Days missed from school/work because of bleeds
- Patients on standard prophylaxis remaining bleed free
- Patients having had joint replacement or arthrodesis
Performance & Clinical Outcome
Indicators

23. • Policies and Protocols have been
implemented in all centres
• Clinical Audit Forms are completed for
moderate and severe users of
recombinant products 6-monthly from
January 2012
• Data is recorded in clinics based on
information provided by patients
• The Data has been recorded on the
Clinical Audit System
• Allowing comparative clinical audit
across the Haemophilia Centres
Systems & processes adopted in
clinical practice

24. % severe patients on home therapy
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aberdeen Dundee Inverness Edinburgh Glasgow Edinburgh-
Paed
Yorkhill -
Paed

25. % severe patients receiving
standard prophylaxis
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aberdeen Dundee Inverness Edinburgh Glasgow Edin
burgh-
Paed
Yorkhill -
Paed
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aberdeen Dundee Inverness Edinburgh Glasgow Edin
burgh-
Paed
Yorkhill -
Paed
% patients with a
spontaneous major bleed

26. % severe patients losing
>5 school or work days
as result of bleeding
% severe patients free
of spontaneous bleeds
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aberdeen Dundee Inverness Edinburgh Glasgow Edinburgh-
Paed
Yorkhill -
Paed
Treatment Centre
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aberdeen Dundee Inverness Edinburgh Glasgow Edin
burgh-
Paed
Yorkhill -
Paed

27. Improving quality and effectiveness of care
Policies and Protocols have driven changes in practice
- formalised processes and ensures a standardised approach across all
centres
Clinical Audit reports:
- demonstrate patient outcomes
- allows centres to review and discuss the most clinically appropriate and
effective care for patients
- Scottish peer review meetings established to discuss ‘exception cases’
- highlight where targeted work is required to drive improvements in
clinical care

28. Disinvestment in NHS Lothian..........
“just say NO!”

30. Disinterested in NHS Lothian..........
“just say NO!”

31. Disinvestment in NHS Lothian..........
Attempting to use evidence to
change practice.....

32. Just say NO!
• ..............it’s not affordable
• ..............it’s not possible
• Difficult in a “free” healthcare system
• Politically damaging
• Withdrawal of what is already available is unpopular with
patients and doctors.
• Can’t just say NO!!!

33. Priority setting...... Which one?
• Patient- did we ask?? Most important?!??!
• Financial- don’t need to ask!!
• Quality- what questions to ask?
• Outcomes- Was the question biased?
• Many more.................... -Croydon list
-McKinsey

34. Lothian RILCV process.
• Identify area of interest
• Contact clinicians and seek “buy in”
• Assessment of health intelligence (HIU and ISD, BQBV dashboard)
• EVIDENCE REVIEW -efficacy
-cost effectiveness
-controversy in literature
-impact of change
• ENGAGE STAKEHOLDERS
• Develop plan
• Enact and review plan

35. 2008/09 2009/10 2010/11
NHS Board of residence 75+ 85+ All ages 75+ 85+ All ages 75+ 85+ All ages
Scotland 44.8 44.0 6.2 46.2 45.0 6.4 44.2 42.8 6.3
Ayrshire & Arran 60.0 58.3 9.1 57.8 54.9 8.9 46.0 44.9 7.5
Borders 58.7 61.4 8.7 72.3 73.2 10.6 65.8 66.8 9.7
Dumfries & Galloway 68.3 59.7 11.4 65.5 56.9 11.6 59.3 52.5 10.4
Fife 37.2 35.7 5.4 38.9 37.9 5.8 38.7 40.6 5.8
Forth Valley 54.4 53.6 6.9 50.4 49.9 6.9 56.7 55.5 7.4
Grampian 35.0 35.5 4.6 39.3 40.6 5.0 32.1 31.6 4.4
Greater Glasgow & Clyde 42.5 40.9 5.8 40.9 39.7 5.7 42.8 41.4 6.0
Highland 50.6 54.2 7.5 52.5 51.9 7.8 50.6 43.3 7.9
Lanarkshire 36.2 36.2 5.2 38.0 32.7 5.2 33.0 32.0 4.8
Lothian 42.8 41.3 5.2 43.4 42.5 5.4 42.3 40.3 5.3
Orkney 35.9 45.9 5.6 29.9 37.8 4.4 22.5 26.6 3.6
Shetland 42.1 42.3 5.4 20.0 27.8 3.4 19.3 18.4 2.9
Tayside 42.8 42.8 6.8 54.2 53.9 8.2 57.1 56.7 9.1
Western Isles 57.6 54.3 8.7 67.1 71.8 10.8 50.7 45.4 9.3
First quartile 38.5 41.0 5.4 39.0 38.4 5.2 34.4 34.1 5.0
Crude Rate of Cataract Interventions by NHS Board of
residence (all) per 1,000 population, 2008/09 - 2010/11

36. Cataract RILCV process.
• Identify area of interest- Cataract
• Contact clinicians and seek “buy in” – Oph & optoms
• Assessment of health intelligence – 4500 operations, half coded, 35%
second eye
• EVIDENCE REVIEW - impact of threshold
- value of 2nd eye surgery

39. Cataract RILCV process.
• Identify area of interest- Cataract
• Contact clinicians and seek “buy in” – Oph & optoms
• Assessment of health intelligence – 4500 operations, half coded
• EVIDENCE REVIEW - impact of threshold
- value of 2nd eye surgery
• ENGAGE STAKEHOLDERS – oph, other boards, RNIB, E&D unit,
• Develop plan – Set threshold at driving test level plus other “soft”
measures run as a shadow audit
• Enact and review plan – 5% reduction in referrals, 0.4% reduction
surgeries

40. Classes of interventions to target for decreased utilisation – Lancet Oncology Commission 2011

41. Over-utilisation
• Quicker to discuss TP than discussion of no treatment
• Quicker to order a scan than history and exam
• In breast cancer no benefit to follow up with tumour markers (Rosselli
JAMA, GIVIO study JAMA)
• Many examples of futile care in last weeks and days of life (studies
suggest up to one third of cancer care costs)
• In 2010 the US Patient Protection and Affordable Care Act established
a Patient Centred Outcomes Research Institute

42. Improving efficiency and value in cancer
care
• Physician education!!!
• Identifying interventions of marginal or no clear benefit with high cost- SR’s,
meta-A’s, comparative effectiveness research & RCT’s
• Physician education focussed on tech skills- primary and continuing education
needs to incorporate understanding of cost-effectiveness!!!
• Personalised medicine
• More rapid adoption of innovation (sentinel & others)
• Translational and clinically focussed research
• Comparative effectiveness research and health-services research- how to deliver?
• Development of outcome data (SCAN report), rapid learning healthcare system
• Focus on end of life care: account for wishes of patients and families

43. Limitations of evidence
• RCT’s do not imply clinical significance ONLY statistical significance
• NCI Canada reported median overall survival benefit of 0.33 months
for Erlotinib plus gemcitabine in advanced pancreatic cancer
• Massive toxicity, FDA, EMA and SMC approved at cost of $500,000
per life year gained (Threshold?? NICE 10%)
• EUROCAN project- ethical, political and administrative barriers to
acquiring and sharing data on outcomes

44. Cancer surgery
• Hunter “an armed savage trying to render by force that which a
civilised man would render by strategem”- Main method of cure for
solid tumours globally
• In common cancers surgery alone 50% of direct costs (Warren JNCI
2008)
• Curative in absence of metastatic disease- little emphasis on defining
staging
• ASCO 2010- ACOSOG Z0011 study showed no benefit of ALND in
women with 1-3 positive SNB- Surgical bias!!!
• Challenge the surgical dogma (XS, trade-off)

45. Where are we with prioritisation?
• RILCV
• Quality based commissioning
• Guideline driven care (rationing)
• We do not have or own the data!
• Data not geographically/culturally sensitive
• Data not appropriate to our healthcare system
• Where are the outcomes for our organisations?? (31/62 vs survival)

46. Some solutions.....
• Consult widely on the questions and priorities
• Commission and own the data
• Share and collaborate on the data
• Analytical methods that compare and that emphasise clinical benefit
• Educate physicians with the data (challenge)
• Use and implement changes
• Rapidly adopt technological advances

47. We need to be able to do more
than “just say no”
Thank you!
Dr Victor Lopes PhD FRCS
Assoc Medical Director NHS Lothian