Policy responses and statements
- Name of organisation:
- Northern Ireland Department of Health, Social Services and Public Safety
- Name of policy document:
- Indicators of Safe and Effective Care - A Proposed Approach for Health and Social Care in Northern Ireland
- Deadline for response:
- 22 June 2007
Background: "Safety First: A Framework for Sustainable Improvement in HPSS", March 2006, described the DHSSPS policy to improve the quality of health and social care in Northern Ireland. It set out the key components of the safety policy and included an action plan for sustainable improvement based on 5 themes:
- Implementing evidence-based practice and learning from adverse events
- Agreeing common systems for collection, analysis and management of adverse events
- Sharing the learning
- Building public confidence
- Promoting education, training and support for health and social care staff
Under the theme of Building Public Confidence, DHSSPS was tasked with developing, in collaboration with the Health and Personal Social Services (HPSS), "A composite set of safety/quality performance indicators encompassing clinical and non-clinical care, and social care".
In response, DHSSPS led a Project Team that included representatives from primary, community, secondary care, and commissioning. The aim of the project team was, by 31 July 2007, "To develop and define indicators of safe and effective care that would be implemented by all of Health and Social Care Northern Ireland (HSCNI) from April 2008".
This document outlines the Project Team's recommendations for its 4 key products:
- A list of indicators for use by all of HSCNI from 1 April 2008.
- The technical definition of the proposed indicators, or a clear process to develop the definitions.
- A process that allows other indicators to be proposed, evaluated and, if appropriate, included beyond April 2008.
- Recommendations on using information technology, including web-based approaches to facilitate data collection and reporting.
COMMENTS ON
NORTHERN IRELAND DEPARTMENT OF HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
INDICATORS OF SAFE AND EFFECTIVE CARE: A PROPOSED APPROACH FOR HEALTH AND SOCIAL CARE IN NORTHERN IRELAND
The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health, Social Services and Public Safety on its consultation on Indicators of Safe and Effective Care: A Proposed Approach for Health and Social Care in Northern Ireland.
General Points
The idea of performance indicators for safe and effective care is not new. There is no ideological incompatibility for doctors. Much of the philosophy in the DHSSPS paper is praiseworthy.
At the outset it would be wise to state one overriding concern. Notwithstanding its worthy aims, inherent in the proposal there is the potential for adverse impact on clinical care. The proposal will, if implemented, generate at added expense an enormous amount of new information, some of which may prove to be of questionable value despite the proposed vetting process. There will be a further increase in the size of the NHS information industry, absorbing into IT and management roles nurses and other health professionals already doing valuable jobs in more direct patient care.
The DHSSPS proposal does not reflect awareness or recognition of the work carried out in recent years in many areas of specialty practice to develop and publish nationally agreed treatment standards/targets for audit, together with registries allowing national benchmarking of locally provided care. These professional initiatives are important achievements which contribute to building public confidence that safe and effective care is being provided; failure to mention them is a major omission. A proposal to collect and analyze another layer of information would have more credibility if it began with recognition of what has already been achieved and is being delivered.
It is unclear how the DHSSPS proposal relates to measures of patient safety contained in National Service Framework documents.
The scale of the project is ambitious and the information technology task to underpin it daunting. The DHSSPS proposal recognizes that direct care information is primarily available through manual review of patients’ case records and concludes correctly that “The task of data collection is therefore not insignificant”. The solutions to this proposed in the document are to:
- “use existing information sources”
- “Use existing resources for audit and governance”
- “Provide some central resource to support Trusts”
- “Explore formal links with national/international organizations with appropriate expertise”
- “Electronic patient records”
Roughly translated, this sounds like more work with the same resources. No estimates of the direct or indirect costs of the proposals are given.
At present, in most Trusts, personnel involved in Clinical Audit, Risk Management, Information Retrieval and analysis, etc, are autonomous groupings and not integral members of Clinical Directorates. Achieving the added information dimension required by the DHSSPS proposal would be helped by change in the internal shape of trust organisations whereby Directorates gain these personnel as team members (based in, and physically present in, the relevant unit) whose remit would be the information retrieval, collation and analysis required to deliver the new performance indicators.
An indicator driven pattern of practice best suits those specialties dealing with a large number of similar types of admission (e.g. coronary care units, diabetic ketoacidosis in a diabetic/endocrine unit). It is much harder to cope with this approach within generalist units, especially the acute and general medicine units in all the smaller hospitals up and down the country. The result will be pressure towards more subdivision and specialisation. Smaller hospital units will find it increasingly difficult to function.
Specific Points
The proposal to collect information on a monthly basis is surely, for many indicators, absurd. The danger is that the volume of information will flood any capacity to analyse it and respond to change.
It is disappointing to read on the “Sample Measure Information Form” the use of the term “federal hospital” and “vendor”. One can conclude that this section has been lifted from an American document and one wonders how much else has been copied from a similar source. One might have thought that governmental organisations would have learnt of the dangers of plagiarism in the last few years.
The difficulty of defining when an indicator is truly satisfied will need some consideration. For example, what does smoking cessation advice really mean? A brief clinical note by a junior doctor “smoking advice given” is useful, but may not indicate much about quality. In the heart failure section, the evaluation of left ventricular function is important, but it might not be necessary if it has been done during a previous admission. Slavish following of the rulebook, especially when clinical information systems are so poor, may lead to reduplication of work.
Looking at performance indicators derived by exception reporting of the use of a drug (e.g. the percentage of patients who received ACEI or ARB for left ventricular systolic dysfunction), it is obvious that unless the reason for deviation from the accepted standard (administration of the drug) is clearly and legibly recorded in the case notes at the time (unlikely), then retrospective case note study will be needed to inform interpretation of the overall “compliance” figure. In addition, one unintended consequence of improving compliance with evidence-based drug treatment could be an increase in adverse drug side effects. This could undermine the validity of using drug compliance percentages as performance indicators of “safe and effective patient care”.
Conclusion
In conclusion, there is much in this draft proposal worthy of support but more detail is needed on the practical aspects of implementation. No estimate of cost is included in the draft paper.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[19 June 2007] |
