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Care Bundles & COPD – UK Experience. Dr James Calvert FRCP MPH PhD BTS Professional & Organisational Standards Committee. Introduction. Need for change Why care bundles UK experience of care bundles General and COPD BTS Elements for success Avoiding pitfalls. Drivers for change.
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Care Bundles & COPD – UK Experience Dr James Calvert FRCP MPH PhD BTS Professional & Organisational Standards Committee
Introduction • Need for change • Why care bundles • UK experience of care bundles • General and COPD • BTS • Elements for success • Avoiding pitfalls
www.rightcare.nhs.uk www.inhale.nhs.uk
The Bottom Line3 fold variation in COPD Mortality • Significance of unwarranted variation: • After adjusting for population differences - If all the areas in England were to achieve the COPD mortality rates of the best-performing 7,800 lives would be saved each year • 15% of patients dead within 90 days • IQR for mortality 9-21% – 25% of difference due to case-mix • Price et al. ; Thorax: 61 (10): 837. (2006)
NHS Funding v Fully Engaged INDEX 2006/7 = 100 €2.5 bn * NHS real spend based on IFS projections IFS 2009
Unwarranted variation matters Unwarranted variation produces: • Worse outcomes for many patients • Lower value in healthcare spend If unwarranted variation is reduced it will save money and improve outcomes
Where next “Insanity; doing the same thing over and over and expecting different results” Albert Einstein
What are care bundles • Care bundles • Developed in USA • Efficacy in NHS demonstrated (Rob & Jarman, BMJ 2010) • Not a checklist • 3-5 items • Evidence based • Simple • Permits variance monitoring Bundles should be necessary & sufficient
Why do care bundles work • They work by; • Ensuring standard work • Facilitating ownership & communication • Responsibility for delivering each element of care is clear
Quality Improvement • Development of better care pathways is insufficient to improve quality of care. • Pathways must be implemented effectively and be sustainable. • Education on management and quality improvement methodology is not part of medical education
1200 bundles • SMR’s fell for 11 of 13 diagnoses targeted • HSMR fell from 89 to 71
Analysed 30 day mortality amongst 134,000 patients admitted to 24 hospitals in the N.W. • Pneumonia, heart failure, acute myocardial infarction • Risk-adjusted mortality decreased significantly • Absolute reduction of 1.3 % (95% CI: 0.4 to 2.1; P = 0.006) • Equivalent to 890 fewer deaths (95% CI, 260 to 1500) over 18 months • Largest reduction was for pneumonia: 1.9% (95% CI, 0.9 to 3.0; P<0.001)
10 Acute Trusts, 6 Community Providers, 3 Mental Health Trusts • Clinically-led • Reduces variation • Spreads innovation in adoption of NICE Quality Standards and Guidance using: • Collection and consistent use of clinical process data triangulated with outcomes • Every patient, every time • Fall in pneumonia mortality from 27% to 24% in year one
BTS National Audit Programme • Number of institutions increasing but results show little overall change; • Data submitted to Part 2 of the audit, there is evidence that institutions are taking action as a result of audit participation • The effects of audit are variable, but generally small to moderate (Jamtvedt G et al, Audit & feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Syst Rev 2006, Issue 2)
Transforming Acute Care • What are we doing • Joint project with British Thoracic Society and NHS Improvement • What's happened so far • Bundle development day organised at BTS • 3 care bundles designed and agreed with BTS Committees • Education, measurement & spread strategy agreed with NHS Improvement • 25 hospitals recruited via BTS • Outcome Measures • A reduction in in-hospital mortality • Reduction in length of stay • Reduction in total bed days • Reduction in COPD readmissions at 28 days
Driver Diagram for Improving Care at Admission for AECOPD
Driver Diagram for Quality of Discharge Care following AECOPD “I want to manage my condition and not let the condition manage me, information changes lives”
Key Elements for Success • Pre-requisite for success is an alignment between clinicians and managers – with a focus on improving outcomes for patients • Components of bundles should be accepted as evidence based to ensure clinician engagement with implementation • Data collection must be feasible, affordable and based on existing data where possible • Measures chosen must be broadly applicable, sensitive to change, agreed to be important by all participants
Levers for change • National discussion and review of existing data – engage clinicians, patients, policy makers, managers • Central government • ERS • National Respiratory Societies • Financial incentives • Local • Best practice tariffs (Why would a purchaser pay for second best when the very best is next door?)
Minimum needed to succeed in an individual hospital • Criteria for participation: • Project led by a senior healthcare professional (consultant or senior specialist nurse) • Written agreement for participation from hospital’s chief executive, medical director or director of nursing • Participants should commit to attending study days and posting data on their progress – sharing learning • Resource • Small amount of money • Learning sessions to educate participants in QI methodology • Webex/telephone conferences • Data • Clearly measureable baseline; Has change led to an improvement • Assistance with project management plus collection and display of data e.g. online data templates and production of run time charts
Pitfalls • Not understanding whole patient pathway • Process mapping • Forgetting the aim is better patient care – not better data • Forgetting that data is needed to ensure that any change had made a difference – stops wasted effort • Not ensuring leadership buy-in
Change isn’t easy… For every complex human problem there is always one easy answer that is neat, plausible… …and wrong HL Mencken Find a faster way to fail, recover, and try again. If the problem you are trying to solve involves creating a magnum opus, you are solving the wrong problem AzaRaskin
