SSNAP data: What are the benefits?

Tony Rudd

Without the audit data services would not have improved

2001 2005 2007 2010 2013

What does SSNAP measure?

Organisation of care (measures structure)

Clinical processes (measures process)

• Staffing • Quality of Stroke Unit (SU) • Stroke unit coverage, access to

SU, Acute care organisation • TIA/neurovascular service • Multidisciplinary working • Strategic groups • Policies • Research • Leadership

• Acute care processes • Door to needle time • Time to scan • Time to stroke unit • Medical, nursing & therapy

assessments & screening • Therapy intensity • Use of Intermittent Pneumatic

Compression • Thrombectomy processes

Outcomes

• Complications • 30 day Mortality • Modified Rankin score at 6 months

Bray BD, Ayis S, Campbell J et al (2013) Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study BMJ 346:f2827

Why bother?

‘Its tedious’

‘Its time wasting and time better spent looking after patients’

‘It doesn’t tell me anything I don’t know’

‘The data don’t reflect my service’

‘The results are wrong’

‘It doesn’t tell me what I need to know’

‘Why measure performance when I know it isn’t good. I’ll start when I have made some changes’

‘They will only use these data to beat me with’

Why bother?

Benefits for individual clinicians and their teams

Benefits for patients

Benefits for the public

Benefits for people paying for the care and the politicians

Benefits for understanding how stroke care should be provided – do the trials translate into real life?

How does it help the individual clinician and team?

Until you measure performance objectively you will not really know how you are performing and where to target improvement e.g. door to needle times, time to stroke unit

Introducing a healthy element of competition between clinicians, teams, hospitals and maybe even countries

Useful data for persuading managers/politicians that resources are needed

Brain Scanning January to March 2015

Physiotherapy

A (85+)

B (75-84)

C (70-74)

D (60-69)

E (<60)

Insufficient records

Source: SSNAP July-Sep 2013 (Patient Centred)

Physiotherapy: Domain 6

July – September 2013 January – March 2015

Team-centred performance table

Source: SSNAP October-December 2015 Team-centred performance table for Yorkshire and The Humber SCN

Routinely Admitting Teams Number of patients Overall Performance Team Centred Data

Team Name Admit Disch SSNAP Level CA AC Combined KI Level

D1 D2 D3 D4 D5 D6 D7 D8 D9 D10

TC KI Level Scan SU Throm Spec Asst OT PT SALT MDT Std Disch Disch Proc

Pinderfields Hospital 230 234 D A A D C↑ C D D C↓ C E D B B D

Hull Royal Infirmary 212 225 C↑ A↑ B B↑ A↑ C↓ C B A↑↑↑ B C↑↑ D B↑ B↓ B↑

Scunthorpe General Hospital 139 158 A A A A A B D↓ A A A B C A A↑ A

York Hospital 212 214 C↑ A B C D C C B A B E C A C↑ C

Chesterfield Royal 123 130 C A A↑ C C C D↓ D↑ B B E↓ C A↑ A C

Leeds General Infirmary 243 238 D A B D↓ C D↓ C↓ D↓ C D B D B↓ D D↓

Calderdale Royal Hospital 126 150 D A C C↑ D↓ C↑ C↓ C↑ C D↓ C B↑↑ C↑ B↑↑ C↑

Rotherham Hospital 106 97 C A B C A↑ C D C A B D D A C C

Royal Hallamshire Hospital 245 248 D A B D↓ B B E↓ D↓↓ C C E↓ D B D↓↓ D↓

Doncaster Royal Infirmary 140 145 B A A B B C C C A A A B A C B

Harrogate District Hospital 87 81 C↑ A A↑ C↑ D B↑↑ D C B↑ B↑↑ D↑ B↑↑ B C C↑

Bradford Royal Infirmary 136 160 D↓ A B D↓ C D↓ D E↓ C↓↓ B↓ D↓ D↓ A B↑ D↓

Barnsley Hospital 130 130 C↓ A A C↓ B↑ C D C A A D↓ C↓ A D↓ C↓

Case studies on action resulting from audit

“The PowerPoint slides are shown to therapists, nurses and doctors we then create action plans”

“All new stroke now go directly to the scanner. We used SSNAP data to identify where we have not met a target, and are now delivering care in a much more timely way”

“We have used SSNAP data to drive improvements in thrombolysis rates”

National SSNAP score over time

Jul - Sep 2013 Oct - Dec 2013 Jan - Mar 2014 Apr - Jun 2014 Jul - Sep 2014 Oct – Dec 2014 Jan – Mar 2015

A - no teams A - no teams A - no teams A - 6 teams (3%) A - 13 teams (6%) A - 16 teams (8%) A - 11 teams (5%)

B - 8 teams (4%) B - 5 teams (3%) B - 14 teams (7%) B - 17 teams (8%) B - 24 teams (12%) B - 27 teams (13%) B - 36 teams (18%)

C - 19 teams (11%) C - 26 teams (13%) C - 20 teams (10%) C - 38 teams (19%) C - 32 teams (16%) C - 43 teams (21%) C - 39 teams (19%)

D - 74 teams (42%) D - 93 teams (47%) D - 104 teams (53%) D - 97 teams (48%) D - 100 teams (50%) D - 89 teams (44%) D - 92 teams (46%)

E - 77 teams (43%) E - 74 teams (37%) E - 60 teams (30%) E - 46 teams (23%)

E - 32 teams (16%) E - 29 teams (14%) E - 24 teams (12%)

National SSNAP scores over time

0%

20%

40%

60%

80%

100%

Jul-Sep 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-Jun 2014 Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015

Pe

rce

nta

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f te

ams

Reporting Quarter

SSNAP overall score

A

B

C

D

E

Other examples of changes in SSNAP results over time

Acute Assessments

July – Sep 2013 Jan – Mar 2015

Domain 3: % Eligible patients Thrombolysed as per RCP criteria

75% 81.8%

Domain 4: Stroke Consultant Assessment within 24 hours

72.8% 76.4%

Swallow Screening Within 4 hours for applicable patients 64.6% 68%

Domain: 8 72 hour Bundle: If applicable, nurse within 24 hours, AND at least one therapist within 24h AND all relevant therapists within 72h AND rehab goals within 5 days

43.2% 52.4%

Appropriate place of care regardless of age

Source: Sentinel/SINAP/SSNAP

Admission to stroke unit

Thrombolysis provision over time

% of patients who were thrombolysed out of all strokes

Year of audit

Speech and Language Therapy

April – June 2013 April – June 2014 April – June 2015 49.6% 67.1% 69.5%

April – June 2013 April – June 2014 April – June 2015 53.4% 67.3% 75.3%

Physiotherapy

April – June 2013 April – June 2014 April – June 2015 22.3% 30.9% 37.8%

Occupational Therapy

Compliance (%) against the therapy target*

(based on target of 80% (OT), 85% (PT), or 50% (SALT) of patients being applicable to receive 45 minutes of OT/PT/SALT on 5 days per week)

Using SSNAP data: Atlas of Variation: Rates of AF Treated with Anticoagulation

Collecting and reporting data is only one part of quality improvement

• Regional Workshops – most regions using data to plan reconfiguration of stroke care

• Slide toolkits – bespoke for each hospital every 3 months

• Publicity and peer reviewed publications

• Provide transparent information to all

• Peer review team supporting change

• NHS Performance indicators and single quality marker

Information for patients and families

• Patients will get better care if they know what they should be receiving

• They can be powerful advocates for service improvements

Information for the Public

• The public are paying for the services and should know what they are getting

• Required in England as part of transparency agenda

• Getting the public arguing for change is a lot more powerful than professionals arguing for change

• Encourage the press to write about stroke

Information for those paying for the services and those responsible for managing the services

• Help decide overall organisation of care – used in every region in England to inform decisions about reconfiguration

• Ability to make decisions about resources – where do they need to invest or disinvest

Ensuring audit data are used in key academic publications: Association of care with good outcomes

“Stroke unit” item

Early stroke consultant assessment

CT scan within 24 hours

Early nurse & therapist assessment

Early swallow assessment & nutrition

management

Early iv fluids and aspirin

P value

0.009

0.49

0.028

<0.001

<0.001

0.5 0.75 1

Odds of death at 30 days

Bray et al BMJ (2013)

Size of unit and thrombolysis rate and efficiency

Door to needle times

Number of patients thrombolysed

Bray et al Stroke 2013

Time to SALT dysphagia assessment and risk of stroke-associated pneumonia

Modelled association adjusted for age, sex, stroke type (ischaemic, primary intracerebral haemorrhage, undetermined), pre-stroke functional level (modified Rankin Score), place of stroke (out of hospital or inpatient) and comorbidity, and NIHSS

Bray et al, In press with JNNP

Adjusted hazard ratio of 30-d mortality of patients admitted on weekends, by ratio of registered nurses per ten beds on the weekend.

Bray et al PLoS Med 2015

Higher mortality with fewer nurses

SSNAP in Northern Ireland: Participation Oct – Dec 2015

Stroke Unit Domain

No team in Northern Ireland received better than a ‘D’ score for the stroke unit domain. Averages across participating Northern Ireland teams (Oct – Dec 2015): • 26% of patients being directly admitted to a stroke unit within 4 hours of

clock start

• 67% of patients spend at least 90% of their stay on stroke unit

Median time to stroke unit (in hours)

0:00:00

5:00:00

10:00:00

15:00:00

20:00:00

25:00:00

30:00:00

35:00:00

AltnagelvinHospital

Antrim AreaHospital

CausewayHospital

Craigavon AreaHospital

Daisy Hill Hospital South WestAcute Hospital

Tim

e t

o s

tro

ke u

nit

in h

ou

rs

Team

25 hr 56 mins

28 hr 47 mins

14 hr 36 mins

6 hr 55 mins

4 hr 8 mins

3 hr 30 mins

South West Acute Hospital achieved an ‘A’ for the Thrombolysis domain. Nationally, only 7% of teams have achieved an ‘A’ for this domain (team-centred).

3 teams achieved a team-centred score of ‘B’ for the Physiotherapy domain. These are South West Acute Hospital, Craigavon Area Hospital and South Tyrone and Lurgan Hospitals.

Discharge processes

0

10

20

30

40

50

60

70

Antrim AreaHospital

CausewayHospital

AltnagelvinHospital

Craigavon AreaHospital

Daisy Hill HospitalSouth West AcuteHospital

% o

f p

atie

nts

tre

ate

d b

y a

stro

ke s

kille

d E

arly

Su

pp

ort

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Dis

char

ge t

eam

Team SSNAP Regional Summary Report (Oct – Dec 2015)

Conclusions

Data essential to persuade policy makers and clinicians that something needs to be done

Continuous data collection is a lot more powerful than snapshot data collections but more time consuming and requires much greater resource.

Comparing performance with rest of UK would be very valuable. Although systems different in Northern Ireland your patients are the same and the treatments they receive should be the same

Don’t be frightened of initially performing badly. It may actually help you get the resources you need

Data collection just one small part of the process of quality improvement

Please all start taking part in SSNAP!