2023 Awards - Safety and Quality

IC24 carried out a Quality Improvement Project to improve the process of providing care within our NHS 111 service.

This specifically focused on our palliative care patients who, following an NHS Pathways assessment, were deemed to need to speak to a clinician immediately.

By reducing waste activity in this way, it fulfils our purpose of providing responsive, safe, high-quality urgent health care at the right time, in the right place, supporting our patients to ensure they live their lives to the full.

A quantitative data review showed there were delays within our care pathway for palliative patients due to duplicate clinical assessments.

• Anecdotal feedback highlighted mapping created additional waits and delays and was not achieving the intended aims.
• The process increased responsibility on the Health Advisor (HA) as there was an expectation that when they reached a palliative care disposition, they performed extra steps to highlight the call as urgent.

Data identified that 77% of patients were assessed by a 111 Clinical Advisor where then transferred to a Clinical Advisory Service (CAS) Clinician for further assessment.

We gained feedback from our clinicians who expressed that they did not always feel confident in dealing with palliative care needs due to their complexity.

Patients at one of our urgent treatment centres are using eTriage on arrival - to ensure the most unwell patients are seen even faster and ensuring their clinical safety.

It was the first in the region to introduce the digital electronic triage system and has five eTriage kiosks which use algorithm-based questions about symptoms and medical history, enabling multiple patients to be booked in and assessed at once, and quickly identifying those most in need of treatment to prioritise their care.

Patients are asked to input details in response to specific questions about their condition. These questions have been written and designed specifically by urgent and emergency care doctors and nurses to help provide clinicians with the information needed to prioritise and improve the flow of patients, ensuring the more serious cases are seen first. there are certain responses that alert clinicians to anyone that requires immediate intervention and escalation.

The system has sped up time to assessment, reduced queues for the reception team and freed up a clinician to treat patients (they would have normally triaged individuals). It flags up the more serious cases much earlier to improve the patient experience.

Adopting the technology has both improved and streamlined the booking-in and triage process for patients. The impact is visible – the way the main entrance is structured means that at peak times there would have been patients queueing out of the door. But this new way of working has prevented that, reducing risk and delivering a safer arrival into the centre.

Triage takes no more than two or three minutes and once complete, the patient is asked to take a seat and wait in the reception area for treatment or, in some cases, be referred to a more appropriate place – including an acute hospital.

The system has positively impacted patient care at the UTC, particularly during busy periods and is supporting the team in quickly identifying seriously ill patients. Patient representatives were involved in the adoption of the system and their feedback influenced the way it was introduced and installed.

The e-triage kiosks are ensuring patients get the right treatment more quickly. With a high number of walk-in patients each day the system is relieving pressure on the unit through more efficient streamlining of patients and prioritisation of the more serious cases – ensuring efficiency but more importantly a high-standard of safe clinical services.

As an OOH provider we our contractually obliged to perform a 1% audits on all our clinicians. In the past this has been quite a manual process and did not result in any obvious improvement to quality or safety. Though we tried several different approaches to managing audit results we did not find an effective approach.

At the end of last year we engaged with an organisation who could provide us with auditing software.

We have now been utilising this for the last 10 months.

In addition to auditing clinical consultations we also audit prescribing of antibiotics and other high risk medications.

We have a team of auditors working across our services.

On a monthly basis we have an audit review meeting. This is attended by the clinical leadership team and the governance team.

We are able to review any cases of concern relating to documentation, prescribing and clinical management. We also highlight examples of best practice too.

From this review we then take an individual approach to each case tailoring the actions to the individual and the specific issue. We are able to offer specific support to clinicians to help them improve their practice resulting in improved quality and safety.

Trends can be identified which lead to organising education events that address those identified learning needs. All staff are invited to these creating a great learning environment.

We are able to set higher level audits for new staff so we can pick up any issues early and also have higher level audits set on groups of clinicians that we feel need it. These would include those who work solely at night,for example.

The individual feedback to clinicians has been received well and their has been a notable improvement across all services in audit results.

The number of cases required to be reviewed at the monthly meeting has decreased demonstrating the general improvement.

The introduction of this approach has not only improved audit results but has been really beneficial for the clinical leaderships team. Having the ability to discuss issues as a whole team has also created a great learning environment for them. Being able to learn from our peers and those working in the service has been an unexpected consequence of this process.

Auditing has changed from being a chore to a worthwhile and effective process with all involved gaining something from it but most importantly improved quality and safety and gives the clinical leadership greater confidence that , as a service, we are providing a high quality service.

Feedback from our clinicians has all been positive and it feels like our approach has felt very supportive and has improved relationships across the services.

NEMS Community Benefit Services provides around 1.1 million people in Nottinghamshire with urgent primary care based out of four locations. Over the past two years, through a focussed and integrated workforce development and diversification drive, it has seen a doubling in permanent clinical staff, substantially reducing its dependence on agency workforce, thus reducing risk and improving quality.

Coming out of the pandemic in 2021, the new Clinical Management Team (CMT) at NEMS set out to turn around the composition of its workforce mix that had been deteriorating over a number of years. The declared vision was to promote NEMS as a leading organisation, that is supportive and dynamic, and that can nurture and grow our own clinicians into independent practitioners. The CMT believed this would increase staff retention, staff morale and diversity of clinicians entering the NEMS organisation. The workforce pressures across the NHS had increased to levels that risked seriously undermining the stability of NEMS’ care for patients. They team knew that in order to be an organisation that attracts and retains clinical staff in that climate they would need to implement several initiatives in a joined-up and determined manner.

• Investment in clinical education, learning programmes and promoting the culture of developing and ‘growing our own’. Through the appointment of a dedicated clinical educator, and by reprioritising the focus of its clinical management team, NEMS has been able to create an active development pipeline programme that attracts and supports clinicians to autonomous and up to advanced clinical practice.
• A professional approach to people management and staff wellbeing. In a new way of working for NEMS, we invested in a small team of HR professionals, including a dedicated recruitment specialist to work alongside the clinical team to get real focus on what was required.
• Adept use of social media and new recruitment platforms. The team embraced contemporary channels of communication and resourcing to get NEMS out there among the clinical workforce. We are now also benefiting from the word-of-mouth recommendation pipeline.
• Following recommendations arising from a newly-established Workforce Forum, NEMS established an Employee Assistance Programme providing fit for purpose support to its workforce, including counselling support, advice on health & wellbeing, legal, money & debt and other matters. We also implemented another suggestion to align our maternity cover with NHS staff to retain key clinicians. All of this supported NEMS’ aims to be an ‘employer of choice’ in the local health economy.

The turnaround in workforce balance has been stark. Contracted hours using employed clinicians has increased by 110% and, when the current wave of training & supervision is complete, NEMS will be able to meet 97% of its core staffing needs through employed and its own bank clinicians.

The benefits to NEMS have been to provide more assurance to its clinicians that they have support from clinical colleagues that see NEMS as their long-term home, who are invested in quality and improvements. A substantive workforce also reduces the known risks generated by agency and sessional workforces. A more stable and developing clinical leadership team also allows NEMS to maintain and continuously improve its approach to patient safety through mitigating trainee skill mixes, joint working and promoting a learning and just culture.

Hypertension is the 3rd biggest risk factor for premature death and disability in England and affects 1 in every 4 adults whilst the most deprived areas are 30% more likely than the least deprived to have the condition. It is responsible for half of all heart attacks and strokes.

During the Covid pandemic there were 2 million fewer blood pressure checks undertaken in Primary Care and it is estimated that for every 10 people diagnosed with hypertension, a further 7 remain undiagnosed and untreated. In Cumbria it is estimated that a quarter of our population should be treated for hypertension but the actual figure is one sixth. Population wise this will equate to 50,000 undiagnosed.

In order to combat this, CHoC set up 2 services: BP@Home Service and Digital Health Checks.

The BP@Home service is a patient facing digital service provided to patients with suspected high blood pressure. Using a BP monitor and a mobile phone, the patient will submit BP readings in morning and evenings for 7 consecutive days with the final results, including averages being submitted to the practice for action by the appropriate clinician.

The service has been subject to a number of spotlights at various conferences throughout the year including the national remote monitoring at scale event hosted by NHSE, the Innovation Collaborative in Birmingham and the recent AHSN NENC regional event for CVD Prevention held in Durham and attended by the National Clinical Director for CVD prevention.

Over the last year, the service has seen a significant number of patients benefit with one practice – Alston, seeing their hypertension list size increase by 7% of their total population.

Digital Health Checks is modelled on the NHS Health check and aims to reach hard to reach group patients, either due to the remoteness of where they live; lack of service provision in deprived areas or an unwillingness to attend appointments such as farming communities. The Digital health check is performed using point of care testing devices, remote diagnostic equipment and a clear referral route onto digital remote monitoring schemes and enrolment on NHS Apps. The checks are carried out in non-clinic sites and on a fully equipped double decker bus.

A recent analysis has shown that 67% of attendances at a farmers market resulted in BP@Home referrals, half of whom are now being treated for hypertension and therefore, at reduced risk of heart attack or stroke.

We proudly nominate the ‘Shift Lead Clinician Demand Management Initiative’ for the category of Best Quality and Safety Initiative.

Outline

The Cornwall 111 IUCS has introduced an innovative initiative combining a new Shift Lead Clinician (SLC) role, an intelligent auto-populating demand management matrix and a set of streamlining protocols which come together to form the ‘Shift Lead Clinician Demand Management Initiative’.

Innovation and Ambition

Having successfully launched the SLC role last year, this continuously ambitious initiative was driven further by the development of an auto-populating dashboard, with an algorithm that informs the clinician and shift managers in a live fashion what level of escalation the service is currently within and the associated actions (taken from our Demand Management Plan) to initiate. Alongside this, innovative auto-dispatching protocols are embedded within the dashboard, delegating authority to the clinicians to undertake streamlined functions such as ‘straight to home visit/ treatment centre’ ‘patient deferral protocols’ and linking to auto-populated GoodSAM templates to send to patients.

Quality and Care

Having designated SLC empowers clinical colleagues, provides peer-to-peer education and enables prompt, clinically led management of a service in escalation. With the addition of our auto-populating demand management matrix and streamlining protocols, clinicians know exactly where the service is from an escalation perspective, patients have demonstrably received more streamlined journeys and have been seen in clinics and home visits in a more rapid fashion or alternatively have had their presentations managed remotely with senior oversight.

Effectiveness and Impact

The combination of a SLC alongside the dashboard and protocols has led to a 62% downgrade rate on patients provisionally booked into a home visit of clinic appointment, a 93% downgrade rate on clinical validation calls and a 20% increase in the efficient handling of high-priority cases such as End-of-Life patients and Health Care Professionals on Scene, thereby enhancing patient safety and improving operational effectiveness. The service has been able to continually de-escalate from challenged positions and recover in a much more rapid fashion from large surges in activity and, most importantly, frontline workers hugely value the initiative.

The future of this model hopes to incorporate artificial intelligence, linking the demand management plan to messaging systems and pre-recorded actions and templates. Thus, demand will be monitored by AI (alongside the auto-populating demand management matrix) and clinicians will automatically receive delegated actions to manage demand whilst patients will receive pre-scripted messages via text.