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Developing an urgent care dashboard – findings from a rapid literature review 1
Developing an urgent care dashboard – findings from a
rapid literature reviewundertaken by
Dr Jackie Gray MBBS MSc FFPH MRCGP
for the North East Quality Observatory Service
on behalf of Yorkshire & Humber
Academic Health Science Network
JANUARY 2016
NEQOS is jointly operated by Northumberland, Tyne and Wear
and South Tees Hospitals NHS Foundation Trusts
North East Quality Observatory Service
Ridley House
Henry Street
Newcastle upon Tyne
NE3 1DQ
Tel: 0191 245 6708www.neqos.nhs.uk [email protected]
Copyright © 2016 Northumberland Tyne and Wear NHS Foundation Trust & South Tees Hospitals NHS Foundation Trusts (On behalf of the North
East Quality Observatory Service, NEQOS)
Developing an urgent care dashboard – findings from a rapid literature review 2
Contents
List of Tables 3
List of Boxes 3
List of Figures 3
Executive Summary 4
Section 1: Introduction 5
Section 2: Methods used 5
Section 3: Definitions and language 6
Section 4: Layout 6
Section 5: The context for an Urgent Care Dashboard 7
5.1 Urgent care needs transforming 7
5.2 Developing community services 8
5.3 A whole systems approach 8
5.4 Priority groups in an urgent care system 11
Section 6: Urgent Care Dashboards in Practice 13 6.1 Support for urgent care dashboards 13
6.2 The challenges to developing whole system urgent care 14 dashboards
6.3 The QIPP Urgent Care Dashboard 14
6.4 Local examples of whole system urgent care dashboards 16
6.4.1 The Bolton dashboard – the prototype for the QIPP 16 Urgent Care Dashboard
6.4.2 Central Midlands Commissioning Support Unit (CSU) 16
6.4.3 NHS Eastern Cheshire CCG – Snow White 17
6.4.4 NHS Dorset CCG 17
6.4.5 Unscheduled care services in Wales 17
6.4.6 NHS Cambridge and Peterborough CCG 18
Section 7: Selecting Urgent Care Metrics 19 7.1 Proposed changes to national urgent care indicators 19
7.2 Evidence-based urgent care indicators 19
7.3 Expert suggestions for urgent care indicators 19
7.3.1 Indicators for older people 19
7.3.2 Indicators for children 20
Section 8: Adopting Urgent Care Frameworks 21
8.1 Frameworks used to organise Urgent Care Indicators 21
Section 9: Conclusions 22
Section 10: References 33
Developing an urgent care dashboard – findings from a rapid literature review 3
List of TablesTable 1: Draft KPIs under development by NHS England 25
List of BoxesBox 1: Providers in the urgent care system 9
Box 2: RCGP proposals of benefits of a whole system approach 10
Box 3: Priority groups in the urgent care system 11
Box 4: The various opportunities of urgent care data 13
Box 5: Information included in the Bolton Urgent Care Clinical Dashboard 15
Box 6: Sheffield MCRU recommendations for six routine indicators of urgent 19 care
Box 7: Silver Book recommendations on metrics to describe the urgent care 20
system performance in older people’s care
List of FiguresFigure 1: NHS England vision for integrated urgent care services 7
Figure 2: RCGP summary of the urgent care landscape 9
Figure 3: Performance indicators for the urgent care system developed by 26 Sheffield MCRU
Figure 4: Indicators achieving consensus as ‘good indicators’ of the quality of 27 care in emergency departments (S=Structure P=Process O=Outcome)
Figure 5: Conceptual overview of the QIPP Urgent Care Dashboard architecture 28
Figure 6: Example screen shot from the QIPP dashboard 29
Figure 7: NHS Eastern Cheshire CCG – Snow White Dashboard summary view 30
Figure 8: NHS Dorset CCG Urgent & Emergency Care Dashboard summary view 31
Figure 9: NHS Cambridgeshire and Peterborough CCG Urgent Care Dashboard 32
Developing an urgent care dashboard – findings from a rapid literature review 4
Executive Summary
This report summarises the findings of a rapid literature review seeking to identify information that can guide the future development of a ‘whole system’ urgent care dashboard. It has been developed alongside a separate report that describes the existing metrics relating to urgent care.
The review examines:
the context for an urgent care dashboard
urgent care dashboards in practice
selection of urgent care metrics
urgent care frameworks
This review has identified a pressing need to develop more information about urgent care services, and found few examples of existing urgent care dashboards beyond the QIPP (Quality, Innovation, Productivity and Prevention) Clinical Dashboard, which was developed as a clinical decision management tool.
The review identifies patient groups and services that could feature in an urgent care system dashboard.
Developing a whole system dashboard is likely to be an important yet costly undertaking. Any plans to develop an urgent care system dashboard will need to address:
the ultimate purpose of the dashboard
the available resource for developing and maintaining the dashboard on an ongoing basis
the engagement and leadership challenges for creating and rolling out a dashboard
Developing an urgent care dashboard – findings from a rapid literature review 5
Section 1: Introduction
The purpose of this report is to summarise the findings of a rapid literature review seeking to determine:
The development of urgent and emergency care dashboards and associated resources to support implementation
Any quality frameworks or domains used to develop frameworks – for example, patient experience, safety, financial etc.
The impact of any urgent care dashboards, including any learning such as implementation challenges, performance improvement, staff training needs, data warehousing and any inputting and reporting complexities.
Section 2: Methods used
The review and reporting was conducted over five days during January 2016.
The reviews examined the published peer-reviewed literature and the grey literature.
The organisations considered in the grey literature review included:
Specific reference was made to:
Connecting for Health clinical dashboard programme
Ambulance clinical quality indicators
National QIPP urgent & emergency care work stream – urgent care clinical dashboard
Royal College of General Practice (RCGP) Guidance for commissioning integrated urgent & emergency care – a whole system approach
Search terms included – in combination
“Urgent Care” “emergency care” “unscheduled care” “unplanned care”
“metrics” “indicators” “dashboard” “measures”
“CCG” “CSU” “urgent care board”
“urgent care system”
British government
Department of Health
Health Watch
Scottish government
Welsh government
Primary Care Foundation
NHS Confederation
Health & Social Care Information Centre
The King’s Fund
Health Foundation
Nuffield Trust
Royal College of General Practice
British Geriatric Society
Royal College of Physicians
Association of Ambulance Directors
Developing an urgent care dashboard – findings from a rapid literature review 6
Section 3: Definitions and language
Urgent and emergency care, unscheduled care and unplanned care are all terms used interchangeably to indicate similar activities. This report adopts the widely accepted Department of Health definition of urgent and emergency care, i.e.:
“Urgent and emergency care is the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly.” (1)
Throughout the report the term ‘urgent care’ is used as shorthand to reflect this definition of urgent and emergency care.
Section 4: LayoutThis report organises the findings from the literature into the following headings:
5: The context for an urgent care dashboardThis information can be used to identify relevant themes that might be priorities for a dashboard
6: Urgent care dashboards in practiceThis information draws on practical experience elsewhere to guide future development of a dashboard
7: Selecting urgent care metricsThis information helps to guide the content of a dashboard
8: Urgent care frameworksThis information helps in the selection of an approach to organising the metrics in a dashboard
9: Conclusions This information summarises the main considerations for future dashboard development
10. BibliographyThe sources of information used in this review
Developing an urgent care dashboard – findings from a rapid literature review 7
Section 5: The context for an Urgent Care Dashboard 5.1 Urgent care needs transforming There is wide agreement that urgent care services in England need transforming.(2,3,4)
The challenges that are consistently cited include:
Urgent care services are currently highly fragmented and generate confusion in patients about how and where to access care
Poor sharing of information between different providers is a cause of poor health outcomes
The quality of out-of-hours (OOH) care is variable, especially in terms of continuity, leading to variable patient experiences
The growth in urgent care provision has failed to reduce A&E attendances, which continue to rise
Walk-in centres do not appear to have either reduced waiting times in general practice or lowered admission rates
Emergency admission rates continue to rise
Poor leadership across a highly complex system
National plans entail fundamental reform(2) to integrate existing urgent care services and develop community services so that more care can be delivered closer to home.
The proposed integrated system, summarised in Figure 1, will be supported by an Integrated Clinical Advice Service, which will assess the needs of people and provide advice for access to the most appropriate course of action.
Figure 1: NHS England vision for integrated urgent care services
Developing an urgent care dashboard – findings from a rapid literature review 8
5.2 Developing community services Regional pilot schemes have demonstrated that developing community services can reduce demand for urgent care.(4) Three community services have been highlighted:
Community pharmacy – with specific reference to the West Yorkshire scheme, was shown to be very effective at reducing demand on other parts of the urgent care system
Mental health – needs to be afforded the same strategic focus as cancer and diabetes
Dental health – dental pain without injury is one of the commonest reasons for calling NHS 111.
5.3 A whole systems approach There is widespread support to develop and manage urgent care as a whole system supported by whole system metrics.(3, 4, 1)
There is growing recognition that improving the performance of the urgent care services requires a whole system approach to patient flow, matching capacity and demand and removing some of the visible and hidden backlogs along the patient system.(2)
In 2011, the RCGP led a collaborative project examining a whole systems approach to urgent care.(1) With broad stakeholder representation, the project concluded that the historical focus on accident and emergency departments, out-of-hours (OOH) services and ambulance services as isolated units is unhelpful because it fails to capitalise on the interdependencies between health, social care, self-care and the third sector. The group recommended that a whole systems approach to urgent care would enable services to be more joined up and seamless for patients, and lead to better patient outcomes and experiences whilst increasing cost efficiencies.
This systems approach seeks to integrate all elements of the urgent care landscape, as summarised in Figure 2 and listed in Box 1.
Mental Health Services
Voluntary/third sector
Integrated Approach
Community Care
Primary Care
Social Care
Hospital Services
Figure 2: RCGP summary of the urgent care landscape
Developing an urgent care dashboard – findings from a rapid literature review 9
Ambulance services
A&E departments
Hospital acute assessment and treatment services
NHS 111
Walk-in centres
GP surgeries
OOH GP services
Community services – nursing and pharmacy
Adult social care
Mental health
Carers
Box 1: Providers in the urgent care system
System gearing is a key concept behind the enthusiasm for a whole systems approach. This concept recognises that the various providers are interdependent and a small change in one ‘cog’ can have a dramatic impact elsewhere in the system. For example, general practice, which provides the majority of urgent care (95% of urgent care is accessed in primary care, with 5% in secondary care) is a key cog. The evidence indicates that small changes in overall access and response to urgent care requests in general practice are likely to have a significant impact on subsequent A&E attendance rates, as well as hospital admission rates. The RCGP has quantified this effect as a 1% increase in primary care leading to a 20% decrease in secondary care.(1) Despite the vital importance of primary care, both access to GPs for urgent same day appointments and the responsiveness and quality of OOH services remains variable.(1)
Further support for a whole systems approach comes from evidence showing that some emergency admissions can be avoided if acute exacerbations of health problems are managed by a range of health services providing emergency and urgent care.(1)
The cited opportunities of a systems approach are summarised in Box 2.(1)
Developing an urgent care dashboard – findings from a rapid literature review 10
Harnessing the opportunities afforded by existing services: Often overlooked, community pharmacies play a key role in the system. Many pharmacies provide extended hours access often when other healthcare services are closed. They are mostly easily accessible – 99% of the population can get to a pharmacy within 20 minutes by car and 96% by using public transport or walking.
Harnessing the role of carers and communities: Recognition and support for carers and communities could harness their ability to manage problems at home rather than seeking urgent care.
More ambulatory care services could reduce unnecessary hospital admissions: Ambulatory care services enable a significant proportion of adult in-patients to be managed safely and appropriately without admission but provision of such services varies considerably across areas. Ambulatory care is especially effective for cellulitis; chest pain; headaches; abdominal pain; renal colic; pulmonary embolism; DVT (deep vein thrombosis); asthma; falls and syncope; gastroenteritis; and gastrointestinal bleeding.
Care planning and risk management: Anticipatory care planning and risk management programmes for patients with long-term conditions are proven to reduce hospital admissions but are not routinely implemented.
Promoting reablement: Enhanced recovery and reablement schemes remain in their infancy but are fundamental to enabling hospital discharge and preventing readmissions.
Overcoming fragmentation: A whole systems approach would enable patients and staff to access and provide urgent care more easily and quickly instead of – as is the current experience – trying to navigate and coordinate a confusing and complex array of services.
Promoting health and wellbeing: A raft of health improvement measures could reduce urgent and emergency presentations. Key themes include improved self-care, falls prevention, outreach support and health promotion for people with mental health problems, reducing alcohol and substance misuse, and better services for people at the end of life.
Shaping health seeking behaviours: A wide range of third sector agencies can powerfully influence help-seeking behaviours and thus demand for urgent care; however, such groups are not routinely involved in service developments.
Enabling better workforce planning or development: The urgent care workforce is hugely diverse, with variable levels of training and experience across different settings. A whole systems approach could enable better deployment and development of skills and knowledge.
Box 2: RCGP proposals of benefits of a whole system approach
Developing an urgent care dashboard – findings from a rapid literature review 11
5.4 Priority groups in an urgent care systemThe various reviews emphasise that some groups of users need specific recognition. These groups, listed in Box 3, are highlighted either because they have specific needs that urgent care services must be resourced to meet, or because they are more likely to generate significant or growing demands on the urgent care system.
Older people
Vulnerable groups such as those with learning difficulties, sensory impairment or language difficulties
Children
People with mental health problems
People who misuse alcohol
Health ‘tourists’
People at the end of life
People with long-term conditions
Box 3: Priority groups in the urgent care system
The special needs and demands of these groups are summarised as follows:
Older people have greater levels of morbidity and are increasingly frequent users of A&E departments. They often have complex medical and social needs over and above the clinical cause of attendance. Attendance rates increase with social isolation and long-term conditions. Reduced functional reserve in older people may result in significant impairment following relatively trivial illness or injury, with a subsequent increased need for hospital admissions. Rehabilitation and reablement is vital to enable such people to return home.(10)
People at the end of life are more likely to die in hospital, although many would prefer to die at home. When a death is expected, advanced care planning can help to avoid unnecessary deaths in hospital as well as minimising urgent care presentations and promote a better quality of life.(3)
Vulnerable groups experience greater challenges in accessing urgent care. Also, urgent care settings are important areas for identifying safeguarding issues.
Children and young people comprise around 25% of A&E attendances at emergency departments, and concerns relating to children under 10 years of age comprise 13% of calls to OOH services.(1)
Mental health problems account for 5% of A&E attendances, 30% of acute in-patient bed occupancy and 30% of acute readmissions.(1) Patients with a depressive disorder are twice as likely to use A&E services than those with other long-term conditions. The number of patients who self-harm is rising. Early intervention is key to improving mental health outcomes, with significant implications for service provision given that first presentations of mental illness and substance misuse are often in A&E.
Developing an urgent care dashboard – findings from a rapid literature review 12
Alcohol is increasingly placing additional pressures on A&E departments. Up to 70% of night time attendances and 40% of daytime attendances are caused by alcohol. The number of under-18s admitted to hospital due to drinking increased by 32% between 2002 and 2007. Across England, on average 36 children per day are admitted for alcohol-related conditions.
Health tourism is sensitive but costly and growing – an estimated £35 million of NHS spend relates to patients from countries without reciprocal arrangements. Maternity-related tourism is a growth area, placing maternity units under additional pressures.
People with long-term conditions are prone to disease complications and exacerbations that require urgent care. Common examples include diabetic coma or hypoglycaemia, epileptic seizures, breathlessness from asthma or COPD (chronic obstructive pulmonary disease), and chest pain or transient ischaemic attacks with cardiovascular disease. Consistent high-quality disease management combined with self-care and primary or secondary prevention can reduce the demands that long-term conditions place on urgent care services.
Developing an urgent care dashboard – findings from a rapid literature review 13
Section 6: Urgent Care Dashboards in Practice6.1 Support for urgent care dashboardsThere is growing recognition of the importance of accountable health care, especially in the NHS. It is impossible to achieve accountability without some means of determining the value, quantity and quality of services provided.(2)
Moreover, there is governmental pressure to develop clearer information about urgent care services. A health committee review described the current approach to urgent care provision as ‘flying blind’, and recommended that more information is required to better understand the demands on the services and hence organise them accordingly.(1) The review highlighted a pressing need to ensure data is collected in a consistent basis across the country in order to understand:
Where urgent care patients present across the system and the case mix of urgent patient presentations
Waiting times for urgent care services to evaluate how accessible they are to patients in urgent need
Trends in the level and nature of demand for urgent care
The role of delayed discharges as a key threat to patient flows.
A King’s Fund review in 2013 recognised the value of having system-wide ‘dashboards’ that would allow oversight of the emergency care system and enable the identification of problem areas and system blocks; however, their work was limited to emphasising the drawbacks of the current data and did not extend to defining appropriate measures for such dashboards.(3)
An NHS Confederation review called for measures beyond key performance indicators (KPIs), measures that would enable an understanding of levels of demand and the characteristics of the service users in order to align system responses and underlying need. It called for whole-system, outcome-based performance metrics.
Overall, there are different views on how data should be used to describe and monitor urgent care services. The various views are summarised in Box 4:
Enable monitoring of trends in the level and nature of demand for urgent care
Identify where urgent care patients present across the system
Describe the case mix of urgent patient presentations
Explore waiting times for urgent care services to evaluate how accessible they are to patients in urgent need
Explore the role of delayed discharges as a key threat to patient flows
Allow oversight of the emergency care system to identify problem areas and system blocks
Align system responses and underlying need
Enable whole-system, outcome-based performance metrics
Box 4: The various opportunities of urgent care data
Developing an urgent care dashboard – findings from a rapid literature review 14
6.2 The challenges to developing whole system urgent care dashboards It is widely recognised that there are few examples of whole system dashboards.(8,2,6)
Sheffield University MCRU (Medical Care Research Unit) suggests that whole system dashboards are difficult to develop because:
There are significant technical challenges to linking and updating all of the various data sources
It is difficult to construct meaningful outcome measures because differences in case mix cannot be accounted for
6.3 The QIPP Urgent Care DashboardDespite the challenges, the NHS QIPP work stream successfully piloted and developed an urgent care dashboard. The work stream entailed pioneer sites including Bolton, Devon and Gateshead.
The QIPP dashboard is a clinical decision and management tool. Its aim is to enable general practices to more pro-actively manage and coordinate patients’ healthcare.
It does not include any more information than GP practices already receive (i.e. it does not include performance information about ambulance services, NHS 111, A&E or OOH services etc.). Its advantage is that it provides the usual information in real time, in a more user-friendly way and in a collated manner so that the GP can see the whole picture, as illustrated in Figure 6.
By providing information in this way, it enables practices to be more pro-active about managing and coordinating healthcare, especially for the most vulnerable patients.
A list of the metrics is provided in Box 5:
The QIPP Dashboard includes real time information on:
A&E attendances
Trusts admissions and discharges
Use of other urgent care systems e.g. walk-in centres
The information can also be linked with practice disease registers and predictive risk assessment tools.
Developing an urgent care dashboard – findings from a rapid literature review 15
Metrics vary between localities according to local goals and priorities.
In Bolton the urgent care metrics that were adopted were:
1. Urgent contacts – Activity figures: the number of patient events at each of the various local, unscheduled care services yesterday and for the last seven days
2. Urgent contacts – Activity time series: the number of patient events at various local, unscheduled care services over time
3. Urgent contacts – Disease registers and frequent attenders: the number of patient events at various local, unscheduled care services who are on a disease register, and those with more than one contact in the last 30 days (both covering yesterday and the last seven days)
4. Urgent contacts – Patient list: a list of patient details for those patients who have attended various local, unscheduled care services, who are on a disease register, and those with more than one contact in last 30 days
5. Urgent contacts – 13 days patient list: a list of patient details for those patients who have attended various local, unscheduled care services in the last 14 days
6. Urgent contacts – Patient contact list: a list of a single patient’s details who has attended various local, unscheduled care services
7. Urgent contacts – Contact type list: a list of patient details with the selected type of unscheduled care service contact, occurring in the last 30 days
8. Urgent contacts – Contact date list: a list of patient details for all patients attending unscheduled care on a chosen date
Box 5: Information included in the Bolton Urgent Care Clinical Dashboard
The QIPP work stream recommended the following guidance regarding developing an urgent care dashboard:
Strong clinical leadership is a critical success factor
Effective clinical engagement is essential if the dashboard is to be welcomed and used across practices
Clinical metrics should be selected by local clinical teams with reference to understanding where the gaps are, and what actions clinical teams will be able to take by having access to the information.
A conceptual overview of the QIPP urgent care dashboard is provided in Figure 5, and further guidance to developing this type of dashboard is available in an implementation guide and toolkit.(14,4) One of the underpinning tools is CLEARWATER, which is a set of open source software that enables organisations to import urgent care dashboard data into a Microsoft SQL Server Database.(1)
The QIPP programme was suspended in 2012; however NHS Networks continues to play a key role in developing metrics.(8)
Personal experience of rolling out this dashboard in Gateshead suggests that the context for roll out is key to success and impact. Roll out in Bolton was successful in the context of an established primary care development strategy supported by strong clinical leadership and engagement. By contrast, although Gateshead Primary Care Trust was able to create a technically effective urgent care dashboard, this was not routinely embraced by GP practices.
Developing an urgent care dashboard – findings from a rapid literature review 16
6.4 Local examples of whole system urgent care dashboards This review has identified some whole system dashboards, which are described below. They vary in the extent to which they cover the whole system. Aside from the Bolton dashboard, it was not possible to identify clear details of the purpose, target audience, value or impact of any of the other dashboards.
The Bolton dashboard has been widely emulated and many Clinical Commissioning Groups (CCGs) and Commissioning Support Units (CSUs) have developed versions.
6.4.1 The Bolton dashboard – the prototype for the QIPP Urgent Care DashboardThe Bolton dashboard was the prototype for the national QIPP urgent care work stream, and the approach was rolled out to other sites. It was developed as part of a comprehensive ‘triple aim’ primary care development programme in Bolton. This programme entailed a whole population to tackle deprivation and long-term conditions.
The Bolton Urgent Care Dashboard project started in 2008 and provided data feeds at patient, practice and PCT level.(8) Over a 12-month period, it achieved a reduction in A&E attendances of 3.14% and a reduction in non-elective admissions of 4.19%: this impact equated to an efficiency saving of more than £600,000.
6.4.2 Central Midlands Commissioning Support Unit (CSU) Central Midlands CSU has developed plans for a dashboard that would provide real-time A&E, in-patient admissions and discharge data triangulated with the other disparate datasets to enable CCGs to case manage patients and inform plans to mobilise resources.(12)
The plans for the dashboard entail:
Real-time information on local health economy unscheduled care activity, including A&E attendances, emergency admissions, Minor Injuries Unit (MIU), walk-in centre and GP OOH attendances
Patient-level data relating to GP practice disease registers
A graphical web-based browser application, enabling practices to more pro- actively manage and co-ordinate the healthcare of their patients.
It will utilise daily feeds on:
A&E attendances
In-patient open episodes
MIU attendances
Walk-in centre activity
OOH activity
West Midlands Ambulance Service data
GP practice disease registers
Escalation Management System (EMS)
Bed capacity data
Four-hour wait data
12-hour trolley wait data, and
Developing an urgent care dashboard – findings from a rapid literature review 17
Planned and delayed discharge data Further work would be needed to explore the practicalities of creating and delivering this dashboard.
6.4.3 NHS Eastern Cheshire CCG – Snow White The Snow White dashboard is an urgent care dashboard that provides a real-time view of the local health system using data from several sources, including:
SUS (Secondary Uses Service) – hospital admissions and length of stay
Somerset Cancer Register
NHS Safety Thermometer
Health Protection Agency
NHS England Friends and Family data
Cheshire & Wirral Partnership Mental Health Dashboard
The resulting dashboard is a complex ‘patchwork quilt’, which can be accessed here.
A snapshot of the front page is presented in Figure 7.
6.4.4 NHS Dorset CCGThis CCG has collated a range of urgent care data into a paper-based dashboard accessible here. This collection includes a front page that summarises the data on subsequent pages relating to:
A&E attendances
Emergency admissions
Admission information regarding length of stay, bed occupancy and delayed transfers
NHS 111 data
Ambulance service data.
A snapshot of the front page is presented in Figure 8.
6.4.5 Unscheduled care services in WalesIn 2011, the Welsh government published a one-off publication which brought together information on all aspects of unscheduled care in Wales.(13)
The report included charts and tables on the:
attendances at all A&E departments, and performance within the four-hour target
numbers of ambulance calls, and performance of emergency responses to the scene within eight minutes
numbers of calls made to the main 0845 NHS Direct Wales service
numbers of emergency admissions to hospital and emergency admissions as a percentage of all admissions.
Developing an urgent care dashboard – findings from a rapid literature review 18
6.4.6 NHS Cambridge and Peterborough CCGThe CCG has developed an urgent care dashboard which consists of a series of screens that enable the user to view unscheduled care attendances, in-patients or discharge events at walk-in centres, medical investigation units, OOH GP services, emergency departments or hospitals.
A snapshot of one of the dashboard screens is presented in Figure 9 and further information can be accessed here.
The dashboard target user is a GP practice and it has been used for a variety of purposes:
Pro-active management of patients following urgent care service attendance
Winter planning and admission avoidance
Pro-active management for current in-patients/recent discharges
Case finding
Learning
The dashboard was extended to link with an end of life care dashboard.
Developing an urgent care dashboard – findings from a rapid literature review 19
Section 7: Selecting Urgent Care Metrics7.1 Proposed changes to national urgent care indicators Following publication of the NHS England Commissioning Standards report,(21) work has been underway to develop new KPIs for an integrated urgent care system. The current draft presents 14 KPIs (listed in Table 1) concerning four aspects of care – access, assessment, advice and treatment across the three domains of patient safety, effective care and patent experience.
7.2 Evidence-based urgent care indicators Between 2006 - 2010, the Department of Health funded Sheffield University MCRU to identify a set of indicators to measure the performance of urgent care. Based on a long list of 70 potential indicators, the project entailed a Delphi consultation with experts to agree, by consensus, a final list of 16 indicators, which are presented in Figure 3. (15,16)
The Sheffield University MCRU also identified six performance indicators that could be calculated using national routine data (see Box 6) and developed a questionnaire that could be used to elicit patient experience. Finally, they developed a toolkit for commissioners and examined possible indicators for the ambulance service.
1. The standardised population mortality rate 2. The standardised case fatality rate3. The standardised urgent admission rate4. The emergency readmission rate 5. The rate of unnecessary referrals by emergency and urgent care
services to emergency departments6. The rate of unnecessary referrals by ambulance services to EDs
Box 6: Sheffield MCRU recommendations for six routine indicators of urgent care
Another study also used a Delphi approach to whittle down an initial long list of 224 performance indicators to a shortened list of 36 preferred indicators.(17) The final preferred list of indicators is listed in Figure 4.
7.3 Expert suggestions for urgent care indicators Various professional or expert groups have highlighted the need to measure urgent care for specific groups of people.
7.3.1 Indicators for older people The Silver Book was developed as a multi-agency collaborative project to develop standards for the urgent care of older people.(18) The metrics listed in the Silver Book to describe the system’s performance with regard to older people’s care are listed in Box 7.
Developing an urgent care dashboard – findings from a rapid literature review 20
Proportion of urgent care encounters in primary care leading to a hospital attendance, and separately hospital admission in people aged 65+/75+/85+
ED attendance and re-attendance rate per 1,000 population of 65+/75+/85+
ED conversion rate for people aged 65+/75+/85+ per 1,000
Hospital readmission rates for people aged 65+/75+/85+ and ED re-attendance rate for same group
Rates of long-term care use at 90 days post-discharge following ED attendance and discharge from hospital for people aged 65+/75+/85+
Mortality rate per 1,000 in the 65+/75+/85+
Patient and/or carer satisfaction survey
Box 7: Silver Book recommendations on metrics to describe the urgent care system performance in older people’s care
7.3.2 Indicators for children In 2012, expert guidance for the care of children in A&E departments was updated to reflect changes in the organisation of urgent care systems.(19)
The document recommends separate monitoring of adult and paediatric re-attendance rates and also suggests that children under five years should be monitored as a subgroup of 0-16 year olds. The report also recommends use of the Royal College of Paediatric and Child Health (RCPCH) patient-reported experience measure.(20) The RCPCH has worked with the Picker Institute to develop an evidence-based, patient-reported experience measure for 0-16 year olds in all urgent and emergency care settings. There are two versions of the tool for each urgent care setting, one for 0-7 year olds and the other for 8-16 year olds.
Developing an urgent care dashboard – findings from a rapid literature review 21
Section 8: Adopting Urgent Care Frameworks8.1 Frameworks used to organise urgent care indicators The national commissioning guidance for urgent care and related KPIs are organised according to four areas of service delivery and three domains.(21)
The academic studies largely organise indicators into the three quality domains:(21, 22)
Structure
Process
Outcome
Additionally, the Sheffield study also considered ‘equity’ indicators and specified urgent and serious conditions.
The dashboards that have been identified do not appear to have any clear framework.
Some of the reports reviewed discuss urgent care in terms of pre-hospital and hospital services.
Areas of service delivery
Access
Assessment
Treatment and clinical advice
Advice and referral
Domains
Patient experience
Effective
Safe
Developing an urgent care dashboard – findings from a rapid literature review 22
Section 9: Conclusions The growing pressures on urgent care services in England have generated widespread interest in a ‘whole systems’ approach that could better manage supply and demand.
There is also a pressing need to develop more explicit information about the urgent care services and many authorities support the development of whole system metrics relating to urgent care.
There is no consensus on the purpose of whole system metrics, however. Information could be used in a variety of ways including:
Enabling monitoring of trends in the level and nature of demand for urgent care
Identifying where urgent care patients present across the system
Describing the case mix of urgent patient presentations
Exploring waiting times for urgent care services to evaluate how accessible they are to patients in urgent need
Exploring the role of delayed discharges as a key threat to patient flows
Allowing oversight of the emergency care system to identify problem areas and system blocks
Aligning system responses and underlying need
Enabling whole-system, outcome-based performance metrics
Enabling efficiency savings by supporting improved clinical decision management.
NHS England is progressing with plans to integrate urgent care services rather than develop an urgent care system. This approach excludes primary care, which is a key ‘cog’ in the urgent care system – a 1% change in primary care can lead to a 20% change in demand for A&E services.
Although there are many examples of trust or service specific dashboards there are few examples of system-wide dashboards other than the QIPP Urgent Care Clinical Dashboard.
Nationally, the QIPP Urgent Care Clinical Dashboard has been well evaluated and successfully rolled out in some localities, such as Bolton and Devon, where it has supported efficiency savings. It is a dashboard that enables clinical decision-making and does not include data regarding key elements of the urgent care system such as ambulance services or NHS 111. Also, its success appears to relate to the context for roll out and strongly relies on clinical leadership, engagement and alignment with local strategic plans.
There are numerous metrics that relate to urgent care – all described in the accompanying report. NHS England is currently developing new performance metrics to replace the current NHS 111 and ambulance metrics.
The following services play a key role in the urgent care system and could be included in a whole system dashboard:
Ambulance services
A&E departments
Hospital acute assessment and treatment services
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NHS 111
Walk-in centres
GP surgeries
Out-of-hours GP services
Community services – nursing and pharmacy
Adult social care
Mental health
Carers
Public health support for prevention and self-care
Ambulatory care services
The following patient groups place special needs or demands on the urgent care system, and an urgent care dashboard might include indicators relating to these groups:
Older people
Vulnerable groups such as those with learning difficulties, sensory impairment or language difficulties
Children
People with mental health problems
People who misuse alcohol
Health ‘tourists’
People at the end of life
People with long-term conditions
The following conditions appear most frequently in the literature relating to urgent care, and indicators relating to these conditions might be included in an urgent care dashboard
Major trauma
Acute ambulatory care sensitive conditions – cellulitis, DVT, urinary tract infections
Long-term conditions
Stroke and myocardial infarction
Falls and fractures
Mental health
Acute intoxication
Dental pain
Pyrexia in children
There are numerous metrics which relate to the urgent care system and that are summarised in the accompanying report. Integrating and updating the various datasets poses significant technical challenges and will be costly and challenging to maintain on a daily basis.
Most approaches to developing dashboards utilise a consensus setting approach
Developing an urgent care dashboard – findings from a rapid literature review 24
starting with a long list that is narrowed down by stakeholders and/or experts according to decisions and views regarding the purpose of the dashboard and the validity of the measures. Examples of existing preferred or recommended metrics are provided in Table 1, Boxes 5 to 8 and Figures 3 and 4.
The review identified three distinct approaches to conceptualising urgent care:
Pre-hospital or in-hospital urgent care
The Donabedian triad of structure, process and outcome, with or without equity being added
The NHS England framework of four areas of delivery [Access, Assessment, Treatment and Clinical Advice, Advice and Referral] and the three domains of performance [Patient experience, Effective and Safe]
The prerequisites to developing a successful urgent care dashboard include:
Strong clinical leadership
Clinical engagement
Stakeholder engagement
Clarity of purpose
Value to the end-user
Creating a whole system dashboard will be challenging because there will be multiple stakeholders with multiple views as to the purpose and value of the dashboard, and there will be multiple datasets to include, integrate and maintain.
Moving forward any plans to develop an urgent care system dashboard will need to address:
the ultimate purpose of the dashboard
the available resource for developing and maintaining the dashboard on an ongoing basis
the engagement and leadership challenges for creating and rolling out a dashboard.
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Table 1: Draft KPIs under development by NHS England
Proposed KPI Domain Area Source
Of calls offered, proportion abandoned after at least 30 seconds
Safe AccessExisting 111 minimum dataset (MDS)
Mean average time from call connect to call answer
PEx Access Existing 111 MDS
Proportion of survey respondents who partially or fully complied with advice
PEx/Effective
AdviceInitial measure can be set from existing data
Of calls with a disposition (Dx) code corresponding to a referral, the proportion with secure electronic transfer of information
Effective AdviceWait until data available from new service
Of calls triaged, proportion closed in Integrated Urgent Care (IUC) with self-care advice only (and not referred to an onwards service)
Effective AssessmentWait until data available from new service
Of calls closed in IUC with self care advice (the numerator for previous KPI), proportion with unplanned re-contact within 72 hours
Safe AssessmentWait until data available from new service
Of calls generating a Directory of Services (DoS) search, the proportion where A&E is returned as a ‘catch all’
Effective AssessmentWill need requesting from NHS Pathways
Mean average time to definitive clinical assessment (call closed with self-care and safety netting advice only, or treatment started, whether remote or face-to-face)
PEx/Safe TreatmentProviders of new service
How helpful was the advice given by the 111 service?
PEx Treatment Existing 111 survey
Proportion of survey respondents satisfied or very satisfied
PEx All Existing 111 survey
Proportion of respondents who felt their experience was good or very good when they wanted a GP but their surgery was closed
PEx AllExisting GP Patient Survey (GPPS)
Of Serious Incidents (SI) at IUC providers, proportion with root cause analysis (RCA) completed within the Serious Incident Framework timescales
(latest March 2015, www.england.nhs.uk/patientsafety/serious-incident)
Safe AllOperations/commissioners to assess locally
Of cases reviewed, the proportion with an end-to-end clinical review reported of the patient journey through IUC
All AllClinical Governance Lead
Financial information:Cost per head and cost per episode
Effective AllOperations/commissioners to assess locally
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Figure 3: Performance indicators for the urgent care system developed by Sheffield MCRU
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Figure 4: Indicators achieving consensus as ‘good indicators’ of the quality of care in emergency departments (S=Structure P=Process O=Outcome)
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Figure 5: Conceptual overview of the QIPP Urgent Care Dashboard architecture
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Figure 6: Example screen shot from the QIPP dashboard
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Figure 7: NHS Eastern Cheshire CCG – Snow White Dashboard summary view
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Figure 8: NHS Dorset CCG Urgent & Emergency Care Dashboard summary view
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Figure 9: NHS Cambridgeshire and Peterborough CCG Urgent Care Dashboard
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Section 10: References 1 Fernandes A. Guidance for commissioning integrated urgent and emergency care. A ‘whole system’ approach. RCGP Centre for Commissioning: August 2011.
2 UEC Review Team and ECIST. Safer, Faster, Better: good practice in delivering urgent and emergency care. NHS England: August 2015 (accessed here Jan 2016)
3 Urgent and emergency care. A review for NHS South of England. The King’s Fund 2013. (accessed here Jan 2016)
4 O’Cathain et al. A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study. BMJ Quality & Safety online: July 3013 (accessed here Jan 2016)
5 BGS 2008; The Older person in the Accident & Emergency Department web resource
6 House of Commons Health Committee. Urgent and emergency services. London: Stationery Office Ltd. July 2013. (accessed here Jan 2016)
7 NHS Networks. The urgent care clinical dashboard toolkit (accessed here Jan 2016)
8 NHS Urgent care clinical dashboards ClearWater tool. (accessed here Jan 2016)
9 NHS Networks. The urgent care clinical dashboard implementation guide - supporting your team to develop and implement locally. (accessed here Jan 2016)
10 Liversedge S. et al. Effective primary care approaches for improving population health. Bolton CCG accessed here Jan 2016
11 Talbot A. Clinical lead for the Bolton Dashboard. Presentation to the King’s Fund (accessed here Jan 2016)
12 Management Intelligence Commissioning Support. Data exchange agreement. Central Midlands CSU: Feb 2013 (accessed here Jan 2016)
13 Statistics for Wales. Unscheduled Care Services in Wales – September 2011. (accessed here Jan 2016)
14 Draft KPIs for IUC v20151023 (accessed here Jan 2016)
15 Nicholl J, Coleman P. et al. MCRU Programme 2006-10. The emergency and urgent care system. Sheffield University: 2011. (accessed here Jan 2016)
16 University of Sheffield. Performance Indicators for Emergency and Urgent Care Systems. (accessed here Jan 2016)
17 Beattie E. A Delphi study to identify performance indicators for emergency medicine. Emerg Med J 2004; 21: 47-50 (accessed here Jan 2016)
18 The Silver Book (accessed here Jan 2016)
19 RCPCH Standards for children and young people in emergency care settings. RCPCH 2012 (accessed here Jan 2016)
20 RCPCH. The PREM tool for urgent and emergency care (accessed here Jan 2016) RCPCH: 201221 NHS England. Integrated Urgent Care Commissioning Standards. September 201522 Turner J. Building the evidence base in pre-hospital emergency and urgent care. University of Sheffield MCRU (accessed here Jan 2016)
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DOCUMENT GOVERNANCE
Document name UEC Dashboard Literature Review
Document type Report
Version Draft 1.0
Date 25/01/2015
Document Classification
Prepared on behalf ofYorkshire & Humber Academic Health Science Network
Created by Jackie Gray
Approved by Epidemiologist Jackie Gray/Liz Lingard
Approved by Project Director Helen Ridley
Peer Reviewed by (if appropriate)
Originating Organisation NEQOS
Website of originating organisation
www.neqos.nhs.uk - Please contact the NEQOS advisory service through this web link for further information or to enquire about NEQOS undertaking similar work.
Contact email address [email protected]
Public file location
Internal file location
