SNAPScottish National Audit Project

CE BucknallChair, Bicollegiate Physicians Quality

of Care Committee, on behalf of project team

SNAP

• Health Foundation funded (EwQ initiative)

• Community acquired pneumonia

• Epilepsy

• Long term aim – a model for quality improvement for medical topics

Epi-SNAPImproving the quality of annual review for epilepsy patients in primary care

Quality of Outcomes Framework awards points for annual reviews which:

Record seizure frequency Undertake medication review

Epi-SNAP: Protocol which targets poorly controlled Guidance for exemption coding Patient information leaflets with Epilepsy

Scotland

Collaborated to adapt SPICE* software epilepsy screens,used by approx 1/3rd of Scottish GP practices

*Scottish Programme for Improving Clinical Effectiveness

Epi-SNAPFirst Seizure Clinics

Problems:poor quality of referrals

poor documentation of driving advice (medicolegal obligation)

Electronic First Seizure Service referral template – forces

referrer to document driving advice

Fast track appointments for professional drivers

Re-audit started 1st October

SNAP-CAP: Care bundle

• key aspects of care, linked to evidence

• delivered by a single team over a short period of time

• Influenced by parallel policy of SPSA & possibility of benefiting from developing experience of hospitals using these

SNAP-CAP

Care bundle of key items1. severity scoring using CURB652. Management guided by severity 3. first antibiotic dose within 4 hrs4. Oxygen saturations ≥ 92% during first 4

hours

Monthly monitoring & feedback Small changes in practice in response

to data, using PDSA technique

Antibiotics within 4 hours

0

20

40

60

80

100

120

minimum

maximum

average

Bundle Compliance

0

20

40

60

80

100

120 D

ec-

06

Fe

b-0

7

Ap

r-0

7

Jun

-07

Au

g-0

7

Oct

-07

De

c-0

7

Fe

b-0

8

Ap

r-0

8

Jun

-08

minimum

maximum

average

Examples of Practice Changes

Having appropriate antibiotics (& formulations) in A&E

Writing up first dose as “once only”

Fast tracking patients for X-ray

System for enabling home Rx of mild CAP cases

Telephone follow-up of discharged patients

Electronic referrals Structured/targetted

annual review

Hyperlinks to Patient information leaflets

SNAP-CAP:practical Epi-SNAP:structural

Challenges

Persuading clinicians that monitoring the process of care is important

Rapid turnover of junior & middle grade staff (4 monthly) Collecting bundle data in real time (Unavoidable) delays involved in consulting with national

bodies (eg electronic referrals, changes to GP data monitoring screens)

Engaging managers in non priority topics In hospital: building useful prompts into systems which

are still largely paper based

SNAP: secondary objectives

• Sharing experience in a network with other HF projects

• Developing professional leaders• Ensuring sustainability – start-up packs,

organisational prompts, long term “home” within quality organisation in NHS in Scotland,

• Identifying problem areas early using a mapping process

Version 6 March 2008

Project: My NAME: DATE OF COMPLETION:

HEALTH FOUNDATION Engaging With Quality Programme Scottish National Audit Project Š

Community Acquired Pneumonia (SNAP-CAP)

Produced by John.Bullivant@bradford.nhs.uk

07775524390

The Matrix identifies ten ke y areas for individual and collective attention in delivering the pr ogramme. In relation to each element try and assess your own perspect ive on the level to which you believe the progr amme or you ha ve progressed. If you feel you have not yet reached basic leve l, mark the NO column. Revisit at regular intervals. Please mark the form with O for current pos ition and draw arrow-- to place you expect to be achieved in next 6 months. Id the project, your name a nd date at top and return to address given in letter or John Bullivant. All return wil l be anonymised for analysis and presentation

Example

planned position in six months FUTURE Progress

Key Elements No

Basic level Š agreement of commitment and direction

Firm progress in development Maturity Š impact achieved and reviewed

1. I believe the overall purpose to improve patient experience in appropriate care setting is being achieved

_

Purpose and best care setting debated and agreed; Priorities expressed

Targets and priorities agreed with stakeholders and plans in place, confidence in delivery

Evidence that targets and priorities are being met and review in place

2. I think our interventions are achieving specific intended outcomes

_

Project has specific outcomes agreed, described & measurable in terms of quality improvement

Plan in place to achieve specific objectives, record and share outcomes

Plan in place to spread experience and knowledge supporting others to improve

3. As a stakeholders to programme I am getting a return on my commitment (ROC) for my organisation / consituency

_ Clarity of who stakeholders are; I have thought about and expressed my expectations on behalf of my organisation or constituency

My expectations have been recognised and either accommodated within the plan, rejected or parked

Individual stakeholder members expectations have been met and shared with their constituency.

4. I think contributors believe the programme is having an impact on clinical practice in Scotland

_ Clear plan in place to influence clinical practice in Scotland. Drivers for change identified

Messages from programme is getting to those people or drivers with influence on clinical practice in Scotland

Clinical practice in Scotland has changed as a result of the programme. Impact on policy achieved

Maturity Matrices have been developed under license from the Benchmarking Institute

now

Royal College of Physicians and Surgeons of Glasgow

Getting started with small number of committed sites & evolvingSimple data entry systems / prompt feedback Collaborating with other agencies & health policy initiatives (Scottish Patient Safety Alliance)Feedback has some impact, but we need to incorporate quality reminders into system of care – not easy in Acute Medicine (paper based system;huge variety of caseload)Different approaches needed for different topics but adapting existing policies & practices to add value in terms of quality is the essence of the model which emerges.

Lessons Learnt