Kupu Taurangi Hauora o Aotearoa

Quality Safety Markers for FallsRichard Hamblin, Director of Health Quality Evaluation, HQSC

Presentation 4 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC

Quality and Safety Markers

• QSMs are the way of keeping track on progress on the four priority areas– Falls– Infection Prevention and Control

• Hospital acquired infections • Central line associated bacteraemia

– Surgical Safety– Medication errors (on hold)

Quality and Safety Markers – the context

• Measurement and publication of measures of health service performance has a 20 + years history

• Ministerial enthusiasm for this• Large literature which largely suggests that done well it can help

incentivise change, but get it wrong and there are large pitfalls• Big debate in this is between process enthusiasts and outcome evangelists• Our aim to stimulate change in priority areas (process) but also

demonstrate the benefit in reduced harm and saved $ (outcome)• So our idea was to combine process and outcome into QSM sets

The QSM set

• Process measures – – practices that are shown to improve care– should (except for specific exclusions) always be undertaken– therefore set a national threshold to be achieved with differential trajectories agreed

between NHB and DHBs– Under the control of the provider– Suitable for targets and league tables

• Outcome measures –– outcomes that should be related to changed practice– harm avoided, cost reduced– not directly under the control of the provide so no targets or league tables used for

these– contextualise process measures– quantify effects at a national level

How outcome contextualises processP

roce

ss • But did it make any difference?

• “Hitting the target and missing the point”

• Failure to recognise improvement

• Gaming and other nasty things

+

-

Elation

Despair

How outcome contextualises process

+ -

+

-

Pro

cess

Outcome

Looks to be working (but keep thinking!)

?Hitting the target and missing the point

?Is there a new problem

?What else is happening

?Regression to the Mean

Get on with it!

Presentation in line with the principles

New Zealand Quality and Safety Markers

Select a DHB by clicking on the map Waikato DHB This year On track? Last year

Using the right processes 94% 80%

Infection Rate per 1,000 days 1.5 (New Zealand – 1.4)

How many fewer deaths? 2 (New Zealand – 31)

How many $’000 saved? 100 (New Zealand – $2.8m)

Click here for more detail about the markers and expected performance Range of performance

Why does this matter?

Bacterial infections around central lines in Intensive Care Units greatly increase the risk of already seriously ill patients dying, and increase the amount of time they stay in the unit 1. It is estimated that each case costs $20,000 to treat2. Following some simple rules at the time of inserting a line and regular checks thereafter are shown to minimise the risk of infection. This marker set looks at how regularly this good practice is followed and what the effects of this are.

2012 2013 2014

60%

70%

80%

90%

100%

Actual

Target

Performance v. target

Plus…

• Use existing data where possible• Ensure support and understanding of sector• Ensure fit with the 4 priority programmes• Delivery baselines by December 2012

Progress• Approach agreed with Minister late May• Feedback sought from DHBs, National Health Board, the

colleges and professional bodies June 15 deadline• Finalising analysis of feedback and response now• Feasibility testing and some detailed consultation on specifics

with view to initial baselining in September

FeedbackResponse • 16 DHBs • 13 professional bodies or colleges and an international

advisor to Surgical Checklist Advisory Group • Surgical Checklist Advisory Group minutes• Some feedback very brief and general • Other in-depth relating to definitions, data collection, validity• A few suggestions of new markers • Offers to assist Commission in refining indicators and/or

provision of references.

Falls QSM setProcess markers• Percentage of patients aged 75 and over that are given a falls risk assessment and

implementation of appropriate falls prevention. - proposed national threshold 95%• Percentage assessments that result in a positive intervention to manage the risk of

fall. (a subset used to contextualise the primary marker – no national threshold)

Outcome measures• In hospital Fractured Neck of Femur (FNOF) per 1,000 admissions (age/sex

standardised). • Mortality following in-hospital FNOF (actual lives lost and rate per 1,000

admissions).• Additional occupied bed days (OBDs) and associated cost following in hospital

FNOF (actual OBDs and $s).

Specific feedback (1)Percentage of patients aged 75 and over that are given a falls risk assessment and implementation of appropriate falls prevention - proposed national threshold 95%

Feedback• Why 75+? – believe best balance between amount of activity and affect on falls• Specify tool; specify timescale for use – we have sought not be prescriptive but

advice sought on this• Use bed days as a denominator – distorts result (OBDs per patient increase as

FNOF does)• Who should be excluded from the measure – clearly will be some instances where

this might be inappropriate but what are they? advice sought on this• Comparatively little disagreement with 95% of non excluded patients• Strong view that data can only be collected through retrospective audit – we

believe that this is both inaccurate and misses the point – your advice sought

Specific feedback (2)Percentage assessments that result in a positive intervention to manage the risk of fall. (a subset used to contextualise the primary marker – no national threshold)

Purpose of this widely misunderstood so will give a clearer explanation and definition

Specific feedback (3)In hospital Fractured Neck of Femur (FNOF) per 1,000 admissions (age/sex standardised).

Feedback• Why just FNOF – this excludes a lot of other harms? This is a definite and routinely

recorded measure which represents 50% of recorded falls with serious harm• Risk standardisation essential for fair comparison. We are not comparing between

DHBs we are looking for change over time. Some risk adjustment likely to be needed but we will look at options in feasibility testing

• Can this be captured from NMDS – feasibilty testing now but early analysis gives similar figures to SSE report – Can we use ACC data as a check?

• Use Northern region First do no harm or falls incidence measures. Not doing this to avoid corrupting powerful local improvement measures

Specific feedback (4)Mortality following in-hospital FNOF (actual lives lost and rate per 1,000 admissions).

Feedback• Cannot show causality between FNOF and death. Causality versus actuarial risk –

a key concept to understand• Need to risk adjust to show comparisons - We are not comparing between DHBs

we are looking for change over time. Some risk adjustment likely to be needed but we will look at options in feasibility testing

• Are you looking only at in hospital deaths? Initially considered doing this but we do have out of hospital death data which can be linked to NMDS – could show all deaths within 30 days of admission – To be tested in feasibility testing

Specific feedback (5)Additional occupied bed days (OBDs) and associated cost following in hospital FNOF (actual OBDs and $s).

Feedback• There is already a preworked estimate of additional cost of $26k per FNOF – why

not just use this. If its reliable that’s not a bad idea Your advice sought• Complicated to calculate additional OBDS. Yes but not impossible – this to be

tested in feasibility testing• Are these two related indicators? Yes – however, we could consider going to one if

the $26k figure works Your advice sought