Commission for Health Improvement

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Commission forHealth Improvement

• Clinical governance in ambulance services
• Alex Kafetz Lead Analyst
• 13 November 2003

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Commission for Health Improvement

• To bring about demonstrable improvement in the
  quality of NHS patient care throughout England
  and Wales

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Clinical governance reviews of ambulance trusts

• began in February 2002
• to date 28 published
• reviews of the four others in progress
• similar process to reviews of other sectors
  although some adaptations
• sector report published September 2002

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A CHI clinical governance review

• aims to test whether clinical governance
  arrangements are effective
• identifies best practice and areas for
  improvement
• interested in systems and processes needed to
  monitor and improve services and whether they are
  working and making a difference to patient care

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The CGR process
Phase 1 Phase 2 Phase 3
Phase 4
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CGRs - Content

• CHI assesses the 7 components of clinical
  governance
• patient, carer, service user and public
  involvement
• risk management
• clinical audit
• clinical effectiveness
• staffing and staff management
• education, training and CPPD
• use of information
• CHI describes the patient experience and
  strategic capacity of the organisation

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CGRs - scoring

• scoring based on a i iv scale
• three different scores of ii
• looks at clinical governance at strategic and
  operational level and the links between the two
• in the main ambulance trusts scored lower than in
  other sectors

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CGRs staff involvement

• approximately two thirds of review week
  interviews are with front line staff
• informal conversation during observations
• invitation to stakeholder meetings
• staff survey - up to 500 sent out, stratified by
  staff group

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Star ratings

• published by CHI July 2003
• 10 three star trusts
• 7 two star trusts
• 9 one star trusts
• 5 no star trusts

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Star ratings - criteria

• key targets
• category A calls meeting 14/19 minute target
• category A calls meeting 8 minute target
• financial management
• Improving Working Lives
• indicators
• clinical focus
• patient focus
• capacity and capability focus
• CGR scores did not feed into this years
  assessment

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What CHI has found in ambulance trusts

• examples of good practice
• patients are overwhelmingly positive about the
  service
• many ambulance services are trailing the rest of
  the NHS in their procedures to promote high
  quality care
• areas for improvement
• issues affecting quality and a study of response
  time data

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Sector report good practice

• patients were overwhelmingly positive about the
  care they receive
• patients with special needs
• community presence
• innovative use of resources
• capturing patient view in PTS
• support systems for staff

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Sector report - improvements

• clinical leadership
• stretched management
• staff feel free to report concerns or incidents
• improved information systems
• further development of a clinical focus

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Sector report - improvements (contd)

• more public and patient involvement in the
  planning of services
• shorter handover times at A E
• shorter waits for PTS

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Sector report How are ambulances services
managed?

• significant differences in management styles and
  cultures
• management is stretched
• lack of clinical leadership
• partnership working
• clinical governance arrangements in their infancy

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Sector report modernising approaches to
staffing needs

• importance of education and training
• logistics around education and training
• consistent appraisal schemes
• communicating with staff
• managing shifts
• acting up opportunities

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Sector report - response times

• manual entry of arrival times led to exaggeration
  of performance in third of trusts
• small effect of exaggeration (2-6) but real
  improvement has occurred
• no concerted conspiracy but an obsession with
  eight minute target
• target distracts from the implementation of other
  service improvements
• target can be a focus for bullying

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Example of the 8 minute discontinuity
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Example of the 8 minute discontinuity
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Causes

• imprecise definitions
• weak systems
• inaccurate recording of arrival time
• pressure to meet simplistic target
• inappropriate investigation of slow responses
• pride and loyalty to organisation
• not enough critical judgement applied

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Limited investigation

• to look only at calls just outside eight minute
  target constrains improvement
• 750 for a call that should have taken 500
  potentially lots to learn, but not being looked
  at
• 805 for a call that should have taken 755
  random variation and little to learn, but
  considered in detail

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Conclusions

• conclusions for the ambulance service
• working with partner organisations to improve
  patient care
• MA
• DoH
• IPAS
• CHAI Commission for healthcare audit and
  inspection

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• COMMISSION FOR HEALTH IMPROVEMNET
• FINSBURY TOWER
• 103-105 BUNHILL ROW
• LONDON
• EC1Y 8TG
• www.chi.nhs.uk