Developing and implementing

clinical standards for seven day

services

Celia Ingham Clark

National Director:

Reducing Premature

Mortality

11/12 June 2014

National seven day services Forum

• The national Seven Day Services Forum led by Bruce Keogh is

leading the approach to deliver seven day health care services

• It initially focussed on the acute inpatient pathway, although there

is recognition of the need for whole-system change.

• As such, there is alignment with other national work including the

Urgent and Emergency Care review, primary care transformation

and the integrated care programme.

• A clinical reference group reviewed the evidence base and

developed clinical standards for acute inpatients, based on

recommendations from professional bodies.

• The NHS England Board has agreed to the inclusion of these

clinical standards in the standard contract over the next three

years

2

Seven day services: Why?

• Illness happens seven days a week

• Currently outcomes differ at weekends

• Trainee feedback suggests variable consultant involvement in acute care out of hours

• Hypothesis that patients admitted at weekends are sicker due to limited access to primary care

• Importance of “failure to rescue” in defining the difference between hospitals with high and low mortality rates

• Acute illness can occur at any time and patient expectations are rising as other sectors (e.g. banking and retail) have moved to offer seven day services

3

Key themes

• There is often inadequate involvement of senior medical personnel in the assessment and subsequent management of many acutely ill patients, particularly at the weekend

• Limited access to diagnostic services and allied health professionals at weekends to establish multi-disciplinary management plans and facilitate transfer out of hospital

• Poor weekend emergency service provision is associated with an increased variation in outcomes such as:

• Mortality rates

• Patient experience

• Length of stay

4

Cause of the weekend effect - multifactorial

• Variable staffing levels in hospitals at the weekend

• Fewer senior decision makers of consultant level skill and experience on site at the weekend

• A lack of consistent support services, such as diagnostic and scientific services at weekends

• A lack of community, primary and social care services which could prevent some unnecessary admissions and support timely discharge

5

In London data shows higher mortality rates for

weekend emergency admissions than weekdays

Total

emergency

admissions

In hospital mortality

following emergency

admission

In hospital mortality

following emergency

admission (%)

Weekday 521,868 16,377 3.14 +0.32

Weekend 159,676 5,531 3.46

The 0.32% difference between weekday and weekend

mortality equates to 520 potentially avoidable deaths

London’s heart attack centres already operate a consultant

delivered service seven days per week and no observed

difference is found in mortality rates in the week and at the

weekend, suggesting where systems are in place to respond

seven days a week, there is a direct effect on mortality rates

6

Similarly elective surgical mortality is higher

for weekend admissions

Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

BMJ 2013;346:f2424 (Published 28 May 2013)

7

Seven Day Services – What?

• What we mean by Seven Day Services

• Emergency care Must Do

• Urgent care Should Do

• Elective care Could Do

• ? All of the above

8

Seven day services: What?

9

True emergencies –

where minutes delay

can affect risk of death

• Cardiac arrest

• Ruptured aortic aneurysm

• Acute MI

• Extra-dural haematoma

Services provided

promptly

• Emergency laparotomy

• Fractured NOF (DH 2011 BPT to improve care)

• “hot” cholecystectomy

Routine services • Endoscopy

• MRI scans

Services not

commonly provided

at weekends now

• Routine elective surgery

• Routine GP consultations

• Contact with specialist nurses

• Routine outpatient appointments

Similar spectrum applies to diagnostics and their reports: FBC, U&E, ECG,

CXR, CT, USS and cardiac echo, spirometry, histopathology

Sp

ectru

m o

f care

Seven day services:

Not ‘should we’ but ‘how far should we go’?

10

• Care and services need to shift towards seven day services to abolish differentials in:

• Patient safety

• Patient experience

• Clinical effectiveness

• Discussions underway: should this also address patient convenience?

11

Review of literature

and College reports

Develop case for

change

Develop

standards

Commission

standards

Audit acute hospitals

against standards

Follow up with acute

hospitals

Engagem

ent

with k

ey s

takehold

ers

Development of the London acute care quality

standards

London quality standards – overview

• Addressing the variations in service arrangements and patient outcomes

between weekdays and weekends was identified by the NHS in London

as a key priority in 2012/13 and has remained as such.

• Scope of the standards:

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Adult emergency

services (AES)

Paediatric emergency

services (PES)

Maternity

services

Emergency departments

Acute medicine

Emergency general surgery

Critical care

Fractured neck of femur

Emergency departments

Emergency inpatient

medicine

Emergency general

surgery

Specific parts of the

pathway requiring

specialist acute care:

- Labour

- Birth

- Immediate postnatal

care

London quality standards: Key themes

• Admissions seen by consultant <12 hours

• Twice daily ward rounds for all acute patients

• MDT plan within 24 hours including EDD

• Timely access to diagnostics and reports

• Timely access to interventions including theatre

• Good information for patients and their carers

• Timely transfer to next place of care

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London quality standards:

consultant-delivered care

• All patients seen and assessed by a consultant within 12 hours of admission

• Emergency admissions to be managed in MAU, SAU or Critical Care Unit

• Rotas constructed to maximise continuity of patient care

• Access to all key diagnostic services in a timely manner 24 hours a day, seven days a week to support clinical decision making

• Access to Interventional Radiology 24 hours a day, seven days a week within 1 hour for critical patients

• Access to comprehensive endoscopy 24 hours a day, seven days a week

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London quality standards:

consultant-delivered care

• All health professionals use unitary document for medical record

• EDD set within 24 hours of admission

• All patients on MAU/SAU seen and reviewed by a consultant during twice daily ward rounds

• All referrals to intensive care should have consultant involvement

• Structured handovers should take place twice a day and at every handover between consultant teams

Patient experience

• Consultant-led communications and information to patients, including patient information leaflets

• Patient experience data recorded, analysed and acted on

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National approach

The National Seven Day Services Forum established by Professor Sir Bruce Keogh in 2013 found that:

• Variation in outcomes exists for patients admitted at the weekend, seen in mortality rates, patient experience, length of hospital stay and re-admission rates

• Our junior doctors often feel clinically exposed and unsupported at weekends

• Lack of many seven day services has an adverse effect on measurable outcomes in each of the five domains of the NHS Outcomes Framework:

• mortality amenable to healthcare

• quality of care for people with long term conditions

• outcomes from acute episodes of care

• patient experience

• patient safety

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Developing national clinical standards

A Clinical Reference Group (CRG) was convened with

representation from patients, primary care, secondary care, social

care and colleagues from Colleges and professional bodies to

develop clinical standards on behalf of the Forum.

The CRG was asked to:

• Establish the clinical evidence base for providing NHS

Services, 7 days a week

• Defining standards of care that will help commissioners and

providers to deliver a consistently high quality acute care

service at all times of the week.

17

18

Consultant review within 12/14 hrs

Availability of core MDT

Rapid access to diagnostics

Only 16% of hospitals

review all emergency

medical admissions

within 14 hours of

arrival

Nearly 80% have

5 or more MDT

members during

the week. This is

just 30% at the

weekend

X-ray and CT availability is

consistently high but other services

vary considerably making informed

decision making difficult

Seven Day Services Forum: survey findings

Seven Day Services Forum: clinical standards

The CRG developed 10 clinical standards based on the evidence and recommendations from Royal Colleges and expert bodies. These follow the patient pathway, apply seven days a week and aim to ensure:

• Prompt access to consultant review and multi-disciplinary assessment

• Availability of diagnostics to support decision-making

• Timely treatment and interventions

• Planned, safe and appropriate timing of transfers from hospitals

All standards are based on existing recommendations from Royal Colleges and expert bodies and will cover the seven days of the week

19

Alignment with Academy of Medical Royal

Colleges

The clinical standards are deliberately aligned with the Academy of

Medical Royal Colleges work on consultant-delivered care:

• Consultant involvement: All hospital inpatients should be reviewed by

an on-site consultant at least once every 24 hours, seven days a week,

unless it has been determined that this would not affect the patient's care

pathway

• Consultant supervision: Consultant-supervised interventions and

investigations, and their reports should be provided, seven days per

week, if the results will change the outcome or status of the patient’s

care pathway before the next ‘normal’ working day – this should include

interventions and investigations which will enable immediate discharge

or a shortened length of hospital stay

• Support services, seven days a week: Support services both in

hospital and in the community and primary care setting should be

available seven days per week to ensure that the next steps in the

patient’s care pathway, as determined by the daily consultant review, can

be taken

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Clinical standard 1:

Patient experience

• Patients, and where appropriate families and carers, must be actively involved in shared decision making and supported by clear information from health and social care professionals to make fully informed choices about investigations, treatment and on-going care that reflect what is important to them. This should happen consistently, seven days a week.

21

2: Time to first consultant review

• All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours of arrival at hospital

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3: Multi-disciplinary team review

• All emergency inpatients must have prompt assessment by a multi-professional team to identify complex or on-going needs, unless deemed unnecessary by the responsible consultant. The multi-disciplinary assessment should be overseen by a competent decision-maker, be undertaken within 14 hours and an integrated management plan with estimated discharge date to be in place along with completed medicines reconciliation within 24 hours

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4: Shift handovers

• Handovers must be led by a competent senior decision maker and take place at a designated time and place, with multi-professional participation from the relevant in-coming and out-going shifts. Handover processes, including communication and documentation, must be reflected in hospital policy and standardised across seven days of the week

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5: Diagnostics

Hospital inpatients must have scheduled seven-day access to diagnostic services such as x-ray, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy, bronchoscopy and pathology. Consultant-directed diagnostic tests and their reporting will be available seven days a week:

• within 1 hour for critical patients

• within 12 hours for urgent patients

• within 24 hours for non-urgent patients 25

6: Interventions

Hospital inpatients must have timely 24 hour access, seven days a week, to consultant-directed interventions that meet the relevant specialty guidelines, either on-site or through formally agreed networked arrangements with clear protocols, such as:

• critical care

• interventional radiology

• interventional endoscopy

• emergency general surgery

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7: Mental health

Where a mental health need is identified following an acute admission the patient must be assessed by psychiatric liaison within the appropriate timescales 24 hours a day, seven days a week:

• Within 1 hour for emergency care needs

• Within 14 hours for urgent care needs

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8: Ongoing review

• All patients on the AMU, SAU, ICU and other high dependency areas must be seen and reviewed by a consultant twice daily, including all acutely ill patients directly transferred, or others who deteriorate. To maximise continuity of care consultants should be working multiple day blocks

• Once transferred from the acute area of the hospital to a general ward patients should be reviewed during a consultant-delivered ward round at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway

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9: Transfer to community, primary

and social care

• Support services, both in the hospital and in primary, community and mental health settings must be available seven days a week to ensure that the next steps in the patient’s care pathway, as determined by the daily consultant-led review, can be taken

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10: Quality Improvement

• All those involved in the delivery of acute care must participate in the review of patient outcomes to drive care quality improvement. The duties, working hours and supervision of trainees in all healthcare professions must be consistent with the delivery of high-quality, safe patient care, seven days a week

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Seven Day Services: Implementation

• Year 1 (2014/15) – local contracts should include an Action Plan to deliver the clinical standards within the Service Development and Improvement Plan Section

• Year 2 (2015/16) – those clinical standards which will have the greatest impact should move into the national requirements section of the NHS Standard Contract

• Year 3 (2016/17) – all clinical standards should be incorporated into the national requirements section of the NHS Standard Contract with appropriate contractual sanctions for non-compliance.

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Enablers for implementation

• NHS England Implementation Board and delivery sub-group

• Development of metrics to support the standards

• Clinical Senates support

• NHS IQ to introduce a large-scale transformational change programme to support the spread of seven day services

• CRG continues to provide expert advice

• In London – ongoing audit of implementation of Quality Standards, and lessons shared

• Inspection and assurance – CQC hospital inspections to include assessment of seven day services implementation

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The wider context

Recognising relationships with other work including:

• Primary Care Transformation

• Urgent and Emergency Care Review

• Integrated care programme

• Reconfiguration proposals and service change plans

• Productive elective care

33

Patient perspective

• “I was lucky. Shouldn’t every one of us have the best chance possible no matter what time of day or day of the week it is?”

• Rodney Partington, Patient representative

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