www.hqip.org.uk

Monitoring and improving quality through national clinical audit

Kirsten Windfuhr Associate Director, Quality and Development HQIP

Saffron Homayoun ST5 CAMHS South London and Maudsley RCPsych CCQI Clinical Fellow National Medical Director’s Clinical Fellow 2016-17

February 9th 2018

Overview

• Who are HQIP and what do we do?

• National Clinical Audit driving local quality improvement

• Parity of esteem in national clinical audits

• Future directions

Who are HQIP?

About HQIP

Why do we need clinical audit?

What is clinical audit?

‘Clinical audit: a quality improvement cycle measuring effectiveness of healthcare against standards, & taking action to bring practice in line with these standards.’ Best Practice in Clinical Audit (HQIP, January 2016)

Key audiences

People who:

• receive care

• deliver care

• commission care

• assure/ regulate care

Our work

National Clinical Audit Programme 34 national audits covering: • Acute conditions • Cancer • Children and maternity • Cardiovascular • Long-term conditions • Mental health

Clinical Outcome Review Programmes 4 ongoing national programmes: • Maternal, Newborn

and Infant • Medical and Surgical • Mental Health • Child Health Programme

National Joint Registry Collects joint replacement information, monitoring implant, hospital and surgeon performance: • Holds 2m+ records • Includes hips, knees, ankles, elbows and shoulders • Covers England, Wales, Northern Ireland and Isle of Man • Mandatory for NHS since 2011 Quality Improvement and Development Supports QI at local level via: • Guidance, tools, case studies • Patient and public involvement • eLearning and webinars • Support for audit networks

National Mortality Reviews Four programmes covering: • Perinatal Review Tool • Learning Disability • National Care Record Review • Child Death Reviews

Clinical audit for QI : COP

Clinical audit for QI: data.gov.uk

Wythenshawe Hospital Hip Fracture Audit

Metric CQC Key

Question

2014¹

Report

2015²

Report

National

Aggregate (England)

National

Aspirational

Standard

Comparison to other

hospitals

339

cases Case ascertainment

All eligible patients Well Led n/a

110.0

% 93.5% none Higher than national aggregate

Crude proportion of patients

having surgery on the day or

day after admission

Effective 80.3% 77.6% 72.1% 85%*

Crude perioperative medical

assessment rate Effective 90.1% 95.9% 85.3% 100%*

Crude proportion of patients

documented as not

developing a pressure ulcer

Safe n/a 97.4% 97.2% none

Crude overall hospital length

of stay Responsive

24.9

days

28.4

days 20.3 days none

Risk-adjusted 30-day

mortality rate Effective 8.0% 6.2% 7.5%** none

29 69 81 95

0 85 96 100

9 16 22 34

84 96 99 100

*Audit recommendation based on NICE guideline **England & Wales

1 Jan 13- Dec 13 2 Jan 14- Dec 14

Anticipated date of next update is 09/2016

Within expected range

National Clinical Audit Benchmarks

Clinical Audit for QI

Reports

Rea time data/run

charts

Infographics

Workshops Videos

Case studies

Toolkits

National clinical audits and mental health: what next?

• 3 mental health audits

• NAP (psychosis)

• NAAD (anxiety and depression)

• NAD (dementia)

• Treating the whole person: how do we integrate

• mental health metrics into physical health audits

• physical health metrics into mental health audits

www.hqip.org.uk

Addressing parity of esteem in national clinical audit

NCAPOP

National Clinical Audits

Cardiac: Heart Failure

Cardiac: Myocardial Ischaemia National Audit Project (MINAP)

Cardiac: Percutaneous Cardiac Interventions (PCI)

Cardiac: Congenital Heart Disease

Cardiac: Adult Cardiac Surgery

Cardiac: Cardiac/Heart Rhythm Management

Diabetes: Paediatric

Diabetes: Adult

Epilepsy 12

Chronic Kidney Disease

National Vascular Registry

Sentinel Stroke (SSNAP)

Chronic Obstructive Pulmonary Disease (COPD)

Oesophageo-Gastric Cancer

Prostate Cancer

Lung Cancer

Bowel Cancer

Breast Cancer

Specialist Rehabilitation for Patients with Complex Needs

Rheumatoid & Early Inflammatory Arthritis

Falls & Fragility Fracture Audit (FFFAP)

Emergency Laparotomy (NELA)

Ophthalmology

National Neonatal Audit Programme (NNAP)

National Maternal & Perinatal Audit

The Paediatric Intensive Care Audit Network (PICANET)

National Joint Registry

Psychosis

Dementia

Anxiety & Depression

Clinical Review Programmes

Mental Health Clinical Outcome Review Programme

Child Health Clinical Outcome Review Programme

Maternal and Newborn Infant Clinical Outcome Review Programme

Medical & Surgical Clinical Outcome Review Programme

Learning Disability Mortality Review Programme

HQIP Mental health programmes webpage http://www.hqip.org.uk/national-programmes/mental-health-programmes/

What is Parity of Esteem?

• ‘Valuing mental health equally with physical health’.

• More fully, parity of esteem means that, when compared with physical healthcare, mental healthcare is characterised by: – equal access to the most effective and safest care and treatment

– equal efforts to improve the quality of care

– the allocation of time, effort and resources on a basis commensurate with need

– equal status within healthcare education and practice

– equally high aspirations for service users

– equal status in the measurement of health outcomes.

http://www.rcpsych.ac.uk/policyandparliamentary/whatsnew/parityofesteem.aspx

Key facts

• Mental health problems are the greatest single cause of UK disability

• One in four UK adults has a diagnosable mental health problem in a year but this is left untreated in three quarters

• People with serious mental illnesses die approximately 20 years younger, mainly because of physical health problems

• Total health costs for a person with a chronic physical condition are increased by at least 45% if they have a co-morbid mental health condition

• There is a large overlap between physical and mental health conditions as 30% of people with a long term condition have a mental illness and 46% of people with a mental health problem have a long term condition

Addressing parity of esteem in national clinical audit, a guide from HQIP

www.hqip.org.uk/resources/parity-of-esteem-clinical-audit-guide/

Parity of esteem broken down

• Audit design

• Audit components – Clinical and organisational

• Stages of the patient journey – Prevention

• Risk factors

– Acute assessment

• Past medical/psychiatric history

• Screening

– Follow up

Recommendations

Appendices

I National alignment of parity of esteem

II National commissioning incentives for parity of esteem

III Examples of scientific research in relation to parity of esteem

IV Parity of esteem in NICE Clinical Guidelines and Quality Standards

V Parity of esteem examples in national clinical audits managed by HQIP

VI Best practice examples of integrated physical and mental healthcare in the NHS

I- National alignment of parity of esteem

• Parliament

– Parity in Progress 2015

• Government

– No Health without Mental Health 2011

– Future in Mind 2015

– Closing the gap: priorities for essential change in mental health 2014

• NHS Digital

– Adult Psychiatric Morbidity Survey, last in 2014

• Medical Royal Colleges

– Improving the Physical Health of Adults with Severe Mental Illness: Essential Actions AoMRC, 2016

– Whole Person Care- from Rhetoric to Reality RCPsych, 2013

– Who Cares Wins RCPsych, 2005

• BMA

– Recognising the importance of physical health in mental health and intellectual disability- achieving parity of outcomes, 2016

• Charities

– 20 Years Too Soon Rethink Mental Illness, 2012

– A Place for Parity Centre for Mental Health, 2013

– Bringing Together Physical and Mental Health: A New Frontier for Integrated Care King’s Fund, 2016

– Long-term conditions and mental health- The cost of co-morbidities Centre for Mental Health, the King’s Fund, 2012

II- National commissioning incentives for parity of esteem

Commissioning for Quality and Innovation (CQUINS) 2017-19 • Indicator 3- Improving physical healthcare to reduce premature mortality in

people with serious mental illness (PSMI)

– 3a) Cardio metabolic assessment and treatment for patients with psychoses

– 3b) Collaborating with primary care clinicians

• Indicator 4- Improving services for people with mental health needs who present to A&E

• Indicator 9- Preventing ill health by risky behaviours – alcohol and tobacco

– Adult patients admitted to acute and mental health hospitals

• 9a Tobacco screening

• 9b Tobacco brief advice

• 9c Tobacco referral and medication offer

• 9d Alcohol screening

• 9e Alcohol brief advice or referral

III-Examples of scientific research in relation to parity of esteem

• Chronic illness

– Katon et al. (2007) conducted a literature review of 31 studies involving 16,922 patients with diabetes, pulmonary disease, heart disease or arthritis and concluded that after controlling for severity of illness, those with co-morbid anxiety or depressive disorders had a significantly higher number of medical symptoms.

• Cardiovascular disease

– Daskalopoulou et al. (2016) performed a cohort study of nearly 2 million adults who were free from cardiovascular disease at baseline and found that the risk of 12 cardiovascular diseases including myocardial infarction, heart failure, angina, stroke and peripheral artery disease were all increased in those with depression (Hazard Ratio 1.13-1.70).

• Cancer

– Chang et al. (2014) found that people with cancer and mental illness have a worse survival prognosis even when diagnosed at the same stage of disease, suggesting that the differences arose during care. They found that people with serious mental illness had a 74% increased mortality risk over the 4-5 year follow up period and this was 66% higher in people with co-morbid dementia and 30% higher in people who also had diagnosis of depression, compared to those who did not.

IV-Parity of esteem in NICE Clinical Guidelines and Quality Standards

• Depression in adults with a chronic physical health problem: recognition and management (NICE CG91)

– Depression is approximately 2-3 times more common in patients with a chronic physical health problem than in people who have good physical health and occurs in about 20% of people with a chronic physical health problem.

– Any patient who may have depression (especially those with a past history of depression or who suffer from a chronic physical illness associated with functional impairment) should be asked the following two questions:

• During the last month have you been feeling down, depressed or hopeless?

• During the last month have you often been bothered by having little interest or pleasure in doing things?

– If they answer yes to either then to refer to someone who can perform a ‘mental health assessment’

• Cancer, cardiac, stroke, diabetes, maternity, older adults, epilepsy, COPD, Rheumatoid arthritis

• Depression, psychosis, LD, GAD, dementia

V- Parity of esteem examples in national clinical audits managed by HQIP

• Audits focused on mental health

– Physical health examinations, nutrition, smoking, exercise

• Audits focused on physical health

– Access to psychological advice and counselling, cognition and mood screens, mandatory training in mental health

• Clinical Outcome Review Programmes

– Maternal, New-born and Infant Severe maternal psychosis

– Child Health Adolescent mental health (self-harm and eating disorders)

– Medical and Surgical ‘Treat as One’ 2017 looked at the quality of mental health and physical health care provided to patients with significant mental health conditions who were admitted to a general hospital with physical illness

‘Treat as One’

• Physical co-morbidities present at admission of patients with a serious mental illness

VI-Best practice examples of integrated physical and mental healthcare in the NHS

• Integrating Mental & Physical healthcare: Research, Training &

Services (IMPARTS) King’s Health Partners initiative to integrate mental and physical healthcare in research, training and clinical services at GSTT, KCH, SLaM.

• Mind and Body King’s Health Partners initiative which incorporates IMPARTS as well as learning modules and other projects such as the ‘3 Dimensions for Long-term Conditions (3DLC),’ which will provide improved mental and physical healthcare for patients with COPD, heart failure and hypertension.

• Heart 2 Heart is an integrated cardiac rehabilitation and psychological therapy service at Oxford Universities Hospital Trust

• Breaking Down the Barriers UCLPartners have designed and developed a suite mental and physical health training modules

• NHS England has showcased a number of Trust case studies

www.hqip.org.uk

What’s next for NCAPOP and HQIP?

HQIP resources

• 47 resources

• Covering: – Quality improvement

– Patient involvement

– Statistics

– Best practice in clinical audit

– Statutory requirements relating

to clinical audit

– Information governance

– Governance

– Outliers

Clinical Service Accreditation

• HQIP

• The Royal College of Nursing

• The Royal College of physicians

• The Royal College of Surgeons

• The Royal Pharmaceutical Society

• The Allied Health Care Professionals and

• The Academy for Healthcare Science

• Support professional bodies who wish to develop professionally-led and patient-centred clinical accreditation schemes

Developing programmes and new directions

• Patient and Public Involvement (PPI) in commissioning

• Parity of esteem

• Seven Day Services with NHS England

• Methodology Development

• Closer working with NICE

New contract for NCAPOP

www.hqip.org.uk

Thank you! Questions?

Saffron Homayoun @saffronhomayoun @hqip Facebook (HQIP) Saffron.homayounmirza@slam.nhs.uk

Kirsten.Windfuhr@hqip.org.uk Twitter: @HqipKirsten www.hqip.org.uk