Scottish Clinical Indicators Strategy

1
Scottish Clinical Indicators Strategy

• Bruce Guthrie
• Community Health Sciences
• University of Dundee

2
The challenges posed

• Producing robust, interpretable indicators
• Embedding indicators in systems that lead to this
  information being used to improve patient care
• What am I going to talk about
• A personal narrative
• Scottish and English approaches

3
An explosion of data and quality assurance across
healthcare

• My practice in 1996
• Childhood immunisation and cervical smears
• Training practice standards
• Scottish Prescribing Analysis
• A range of contexts in which the data was used

4
An explosion of data and quality assurance across
healthcare

• My practice in 2006
• 135 (previously 147) indicators in nGMS Quality
  and Outcomes Framework
• Enhanced service indicators
• Childhood immunisation
• Training practice standards
• Patient survey data
• Lothian prescribing indicators
• Lothian Joint Formulary compliance indicators
• Referral indicators
• Scottish Prescribing Analysis

5
A range of contexts in which indicators are used

• Payment and accountability for payment
• Cost control
• Quality improvement
• Quality assurance and clinical governance
• Publication
• Peer comparison
• Cheers and jeers in the press
• Pride

6
Do we respond to them? Yes, but

• Real engagement with some
• Focusing our CPD
• Changes to individual practice
• Changes to how we organise care
• Defensiveness or comfort (almost always)
• Tokenism (ticking the box not uncommon)
• Being in the middle of the pack (but not for QOF)
• Crowding out tunnel vision (more than we know)
• Audit
• Non-incentivised work
• Unmeasured concepts effectiveness gtgt equity

7
Do we respond to them? Yes, but

• The importance of alignment to our beliefs about
  what good care is (but these beliefs arent
  fixed)
• The importance of publication (but potentially
  damaging for some)
• The importance of external accountability and
  facilitation
• Prescribing as a model in primary care
• Resource intensive
• Context, context, context

8
The context of indicator use

• Data for judgement, data for learning
• Accountability vs improvement orientated
  approaches
• Deterrence vs compliance orientated regulation
• Change through performance management and markets
  vs change through professionalism
• Different emphases in NHS England and NHS Scotland

9
The Scottish approach

• Supporting quality indicator development
• Measuring what matters
• Technically excellent metrics
• Designed with a range of users in mind
• Increased attention paid to how data is presented
  to maximise intended, and minimise dysfunctional
  consequences

10
The Scottish approach

• Compliance orientated regulation promoting shared
  learning and quality improvement
• Data for improvement, not data for judgement
• Require evidence of reflective use
• Dissemination of indicators and examples of
  successful use in quality improvement
• Education and training in the use of indicators
• Intended consequence local quality improvement
• Likely to minimise unintended and dysfunctional
  consequences (but still need to evaluate)

11
Cross national comparisons
12
Scottish Clinical Indicators strategy

• Needed to help set the context of (inevitable)
  increase in indicator use
• Appropriate focus on two linked tasks
• Good measures (but what to measure?)
• Applied well (but who will do it?)
• Data for learning, but swimming against the tide
  of the audit society?

13
(No Transcript)