Benchmark for out of hours How to make sure that the benchmark figures align with yours…. Henry...

Benchmark for out of hours

How to make sure that the benchmark figures align with yours….

Henry Clay 07775 696360

[email protected]

© Primary Care Foundation

Agenda – and thank you!

Some very detailed and specific points …and perhaps a more general discussion about how

we try to ensure comparability

Time to definitive assessment Coding Inconsistent use of the system


I know that there are difficulties…

Wide range of staff, some working irregularly By definition staff work awkward hours so may be seen

infrequently Difficult to get staff together for training Not everyone reads the messages or notes issued Many Adastra systems have legacy coding structures

from when the system was less capable than now There is often little headroom in the contract price to

allow these things to be fixed

..but the aim is to highlight some of the issues and point you towards solutions

Time to definitive assessment

Some specific points


Time to definitive clinical assessment – the standard

Definitive Clinical Assessment Providers that can demonstrate that they have a clinically safe and effective system for prioritising calls, must meet the following standards:

Start definitive clinical assessment for urgent calls within 20 minutes of the call being answered by a person

Start definitive clinical assessment for all other calls within 60 minutes of the call being answered by a person

Providers that do not have such a system, must start definitive clinical assessment for all calls within 20 minutes of the call being answered by a person.

Outcome

At the end of the assessment, the patient must be clear of the outcome, including (where appropriate) the timescale within which further action will be taken and the location of any face-to-face consultation.

Definitive clinical assessment is an assessment carried out by an appropriately trained and experienced clinician (not a call-handler) on the telephone or face-to-face. The adjective ‘definitive’ has its normal English usage, i.e. ‘having the function of finally deciding or settling; decisive, determinative or conclusive, final’. In practice, it is the assessment which will result either in reassurance and advice, or in a face-to-face consultation (either in a centre or in the patient’s own home).


This slide shows the differences in measuring time to definitive assessment

Standard process for a base visit

Walk in patient or Call streaming to a base visit – clinical assessment is part of face to face consultation

Standard process for a base visit with two assessments (say by a nurse then a doctor)

Standard process for a home visit with one assessment but a call by doctor on the way or locked case

Key

Initial call or contact Telephone assessment Face to face consultation

Green is the time to definitive assessment by the standard,

red as measured by most services. Yellow shows the

time to face to face consultation.

Green is the time to clinical assessment, but the standard does

not recognise call streaming. Because of the possible long wait before the patient talks with a clinician it is vital

that processes for making and reviewing call-handler decisions are robust. In our analysis these cases

are excluded from the main measure of time to assessment

Green is the correct way to calculate time to definitive

assessment if there are two assessments. Red is as

measured by most providers


How to set up to report in line with the standard (1)

Set these to Y


How to set up to report in line with the standard (2)

Set these to Y


Locking telephone advice callsThis puts them back in the advice queue – so they still count as awaiting assessment

Lock cases if the assessment is not complete or you are checking something – for example

● The mobile phone signal dropped and you haven’t immediately re-connected

● You need to check if there is a bed available● You need to check with the poisons specialists● You need to check with the district nurse before ringing again

Do NOT lock the cases if you spot two or three duplicate cases for the same patient

Do NOT lock the case if you have finished the assessment, even if● You plan to ring again later (comfort call)● You are interrupted and know that you have yet to complete the notes


Suggested solutions…

Speak to the Adastra consulting team but look at… A standard process for dealing with multiple cases to look through

them, close all except the earliest without entering any consultation details and record the phone assessment on the first case

Setting up a separate case type and queue for comfort calls Looking at other case flow methods with your Adastra consulting

team such as….. Using delayed messaging capability as a reminder about a comfort

call that is needed Adopting a standard practice of completing notes promptly in every

case (but when this is impossible, closing the case and completing the notes using by editing them)

Coding

The sorts of problems we see…


Coding

Coding – typical issues Codes where completion is not mandatory so obvious

gaps in the record Drop-down lists with

● insufficient options to cover all possibilities● so many that users have difficulty

Codes that are confusing and interpreted inconsistently by users

Fields that are used for more than one thing, making use and analysis problematic


Informational outcomes – 106 of them…and they mix condition and outcome

Diabetic Related CallDiarrhoeaDiarrhoea & VomitingDizzinessEarache/InfectionEmergency Ambulance CalledEmergency Contraception RequestEpilepsy/SeizuresEye ProblemsFallFeverFlu Related IllnessFungal InfectionGP To Contact PatientGastroenteritisGeneral Advice CallGroin/Genital ProblemsHaemorhoidsHeadache Related CallHigh TemperatureHome Visit - Base CancelledHome Visit - Patient CancelledHypertension/High BPInjuriesInsect BiteLife threatening emergency detectedMastitisMedication AdviceMigraineMumpsMuscle PainNo Follow Up

Nose BleedOther (Please Add Comments)Outside LSLPV/PR BleedingParkinson's DiseasePatient Gone To Hospital.Patient To Register At EACPeriod PainPost-Natal Symptoms/IllnessPregnancy Related CallPsychiatric PatientPt Advised To Attend A & EPt Advised To Call 999Pt Referred To A&E By Dr.Pt To Contact Own GpRash Related CallReferred / Admitted To HospitalReferred Back To Own GpReferred To DNRelated Joint/Limb ProblemsRepeat PrescriptionRoutine - Case CompletedRun Out Of MedicationSWINE FLU RELATED CALLSee Own DentistSickle Cell CrisisTeethingTonsillitis/Throat ProblemsTreatment Centre - Base CancelledTreatment Centre - Patient CancelledURTIUlcer

Urine Infection/UTIVertigoViral InfectionVisit - Patient Confrimed DeceasedVomitingWheezingWounds

Condition

Outcome


Informational outcomes – some shorter lists

A&E AdmissionAdmitted To HospitalAmbulance CallCall Again If NeededDistrict NurseENTEmergency Department AdmissionMIU Redressing NeededMaternityMental HealthNo Follow Up - Call Again If NeededNo Follow-UpOrthopaedics AdmissionOtherPaediatric AdmissionPatient Advised Must See Own G.PPatient DeceasedPatient Did Not AttendPatient Left Before Consultation CompletePatient Stayed At HomePrincess Royal HospitalSurgical Assessment Unit

Advise Own GPCall Back If No BetterCompaint OrganisationalContact Own GPFor Follow UpGP To Ring PatientLife threatening emergency detectedPassed To District NursePatient Deceased (Expected)Patient Deceased (Unexpected)Patient To Ring GPRefer To HospitalRefer To Social WorkerRepeat PrescriptionSwine Flu

Admission or referral?

Different to A&E?

By service or GP?

What does this tell us?

999 Ambulance Called A&E Referral Or Amb Called Active Followup By Own GP Admission DGH Asthma Problems Breathing Diffs Collapse Death - Expected Death - Unexpected Diabetic Issues Discharged To Own GP DVT Followup Fall Fitting No Further Anticipated Action Not Applicable Other Illness Patient Deceased (Expected)Patient Deceased (Unexpected) Psychiatric Problems Refer To Own GP Refer To Social Services Other Refer To Social Services Vulnerable Adult Referred To GU Clinic Repeat Scan Satisfied With Treatment

Condition

Outcome

Difference?


A suggested approach for coding informational outcomes

Completion of the code is made mandatory

Use field for one thing only - to report next contact with NHS

Staff trained to respond consistently

List is comprehensive (to cover each situation) but..

…short enough to be easy to choose

Structured in a logical order

Example: Ambulance/999 GP follow-up recommended Hospital - A&E Hospital - for admission Hospital – for assessment Hospital – patient choice No further contact expected Primary Care – see own GP Primary Care – WIC/MIU Primary Care – Other service


Coding – further examples where services confuse themselves (and me!)

Call origin A&E referral Ambulance call

Case type A&E referral Ambulance call

Case type Admitted to hospital 999 Ambulance Asylum seeker

Agreed: These were referred FROM

A&E and Ambulance service

Confused: Were they from or to A&E

and Ambulance service?

But were these cases assessed by phone or seen face

to face?

Mis-use of the system

…often with the best of intentions!


Clinicians phone a patient when sent a home visit

Reasons for the phone call To confirm likely arrival time, check priority, reassure Because the doctor thinks that the case can be closed as

phone advice Because the organisation has built it in as part of the

process Appears to be more prevalent where two services are

involved or nurses send cases to home visits

But it means that you report incorrectly on QR9 and12…

…and you say you will visit a patient but then don’t.


Here is an extreme example – this is a random selection of case type home visit but 7/10 have two home visits recorded on the system

1stConsultationEndDateTime 1stConsultationType

Cons1Locked

1stConsultNotes

2ndConsultationStartDateTime

2ndConsultationType

Cons2Locked

3rdConsultationStartDateTime

3rdConsultationType

Cons3Locked

30/03/2009 23:17:06 Advice FALSE 37 TAPES STREET

PAIN IN R

30/03/2009 23:53:50 Home Visit FALSE 31/03/2009 00:58:00 Home Visit FALSE

30/03/2009 20:07:01 Advice FALSE MON 19-57 S/W/MUM -- CHILD 04/04/2009 13:23:05 Home Visit FALSE spoke to patient , unwell for 1 week,

04/04/2009 15:40:00 Home Visit FALSE

05/04/2009 10:53:22 Advice FALSE very deaf gentleman, unable to get much


04/04/2009 14:24:34 Advice FALSE PALALISED PT FROM NECK


03/04/2009 21:23:00 Advice FALSE Spoke to Son. Has been coughing


04/04/2009 12:17:12 Advice FALSE Spoke to pt's wife. Suffers with heart


01/04/2009 06:45:26 Home Visit FALSE

SPOKE TO NURSE 01/04/2009 20:43:13 Advice FALSE SPOKE TO NURSE;T 38.7,BP HIGH,P


04/04/2009 18:36:09 Advice FALSE 91yrs old,sharon , carer says she


Advice finishes at 14.24

First ‘home visit’ at 14.38

Second home visit at 16.36

Adastra reports measure QR12 from the end of the advice call to the start of the first hoe visit – which is right…...but only if it was a home visit!


Suggested solution….

Ban doctors from re-assessing cases once a decision has been made for a home visit

Focus your attention on making sure that the right decision is made first time

Enter details of any extra phone call not as if they were the home visit consultation, but as case notes HOW?

And, for the rare occasions where a home visit has to be changed to an advice call, speak to the Adastra consulting team about setting up an informational outcome as ‘given advice – no visit needed’ and set this up to change the case type


Converting a planned base visit to advice when closing a DNA

Reason for doing this Good safety precaution that a clinician should check the case if the

patient does not attend – may or may not phone the patient

Problems Clinician goes into case and makes a note – but the system records it as

a base visit Case is changed to advice – but it looks as if it is a second advice call –

so time to definitive assessment is wrong

Solution Speak to the Adastra consulting team about setting up an informational

outcome as ‘DNA - given advice’ and set this up to change the case type


Failure to count all the cases you have dealt with…

Call-handlers who refer a patient without capturing any details – ‘we don’t have X-ray so you would need to go to A&E’

Solution – training!

Providers who filter all their reports by doctors operating group (say) forgetting that there are some cases where this field is not completed

Solution – check your filters carefully and make sure that you populate the field correctly

Providers where the mapping of practices to PCTs does not reflect the CfH list

Solution – check mapping periodically against latest versions

Discussion and questions….

Benchmark for out of hours How to make sure that the benchmark figures align with yours…. Henry...

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