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Improving quality and the Memory Services National Accreditation Programme

• 95 members– 46 accredited

• 31 as excellent

– 47 review stage

• 10 affiliate members• A heterogeneous mix

• With general hospital care, one of two national audits developed after Healthcare Commission scoping exercise

• Pilot in NW England

• First national accreditation programme quality improvement system for memory services

• Literature review• Modified Delphi exercise• Wide consultation• Revisions made – draft edition• North West England pilot• Consultation – pilot sites• Feedback event• Revisions made – 1st edition

• ‘As a minimum they (Department of Health) should find a way to ensure that PCTs commission sufficient memory services which are based on best practice and accredited by MSNAP’ (NAO, 2010)

• ‘Tips the balance about whether to commission or not to commission’ (a commissioner)

• 87% of GPs say they can access a memory service compared to 69% in 2007 (NAO, 2010)

• Better access for most dementia especially late onset• Need to ensure complex/rare dementias adequately served

Prime Minister's Challenge on Dementia• Called for more services to join MSNAP and

for action to increase participation in high quality research:

• two new MSNAP standards • (1) inform patients and carers about

opportunities to participate in research• (2) establish a register of people interested in

hearing more about research opportunities.

• Involved from the start as members of the steering group

• Carer questionnaires piloted with members of Uniting Carers for Dementia

• Participated in delivering training for peer review teams

• Consultation on standards• Peer review team members• Represented on AAC

• Not just a prescription & off you go!• Friendly environment & people• Diagnosis must be followed with information

& support• Information to take away with contact details• Opportunity to meet others• Support to make choices at the right time

• Type 1: failure to meet these standards would result in a significant threat to patient safety, rights or dignity and/or would breach the law

• Type 2: standards that an accredited service would be expected to meet

• Type 3: standards that an excellent service should meet or standards that are not the direct responsibility of the service

Type 1:Staff are courteous and treat people and their

carers with dignity and respect at all timesType 2:The memory service provides timely access to

assessment and diagnosis – assessment within 4 to 6 weeks of referral

Type 3:The person is asked if they would like to receive an

informal, non-medical and personalised letter containing information about their diagnosis and carer needs for the person and their carer

There are four main stages to the accreditation process:•Self review – 3 months•Peer review – 1 day visit•MSNAP Accreditation Advisory Committee (AAC) – RCPsych, BPS, RCN, Alz Soc, COT•Royal College of Psychiatrists’ Education, Training and Standards Committee (ETSC)

• Case Note Audit – documenting and recording• Patient Questionnaire – experiences of the service• Carer Questionnaire – experiences of the service• Staff Questionnaire – supervision and supports,

learning and development opportunities, signposting• Referrer Questionnaire – relationship with the

service• Organisational Checklist – policies, procedures,

access to signposting and follow up

Some standards around assessmentdiagnosis is made only after a comprehensive and holistic assessment. This includes: •Basic dementia screen and blood tests ( 1)•A physical examination and other appropriate examinations (1)•An assessment of vision, hearing and mobility (1)

Information sharing• People are made aware that their personal information may be

shared with other services involved in their care (1)• There is a policy in place regarding the sharing of information

between identified personnel and agencies in accordance with the Data Protection Act (1)

Consent issues• People who are assessed for the possibility of dementia are

asked if they wish to know the diagnosis (1)• People who are assessed for the possibility of dementia are

asked with whom the outcome should be shared (1)

However, these standards were quickly addressed in time for the peer review visit / AAC

Services asked to re-audit/evidence recent changes

• Increased staff morale, easier to recruit• Help with funding –to protect the service from

future funding cuts, to help acquire contracts • Benchmarking• Being seen as a leading service – raising your

profile within and outside the Trust• Networking with peers – sharing good

practice, email discussion groups, part of a community

• Reassurance for commissioners

Improvement in standards between 1st and 2nd reviews (2 year gap)

Patients and Carers’ views

• 298 carers and 280 people with dementia from 21 memory services

• Very satisfied with diagnostic process and courtesy from staff

• Lack of written information • Carers appear better informed about symptoms

(p= 0.013) and prognosis (p = 0.009) • Carers more likely to feel stressed about

treatment decisions

Memory Services National Accreditation Programme

‘Accredited’ services (n=14)

‘Accredited as excellent’ services (n=27)

Total (n=41)

Patient questionnaire

183 400 583

Carer questionnaire

209 454 663

CARER QUESTIONNAIRE - Have you received written information on the following:

Accredited as excellent

Accredited

χ2

p-value

signs and symptoms of dementia 85% 81% 1.23 0.133

course and prognosis of the condition 83% 76% 3.93 0.023*

Options for care and treatment, including coping strategies

83% 76% 3.90 0.024*

Local care and support services/ groups 91% 86% 2.90 0.044*

Sources of financial and legal advice, and advocacy

79% 70% 4.61 0.015*

Medico-legal issues, including driving 80% 71% 4.26 0.019*

Local and national information sources 80% 76% 0.79 0.186

Improving general health, living positively and maximising quality of life after diagnosis

83% 77% 3.44 0.031*

Any medication prescribed 82% 75% 3.23 0.036*Any non-drug interventions offered 64% 48% 8.65 0.001**

PATIENT QUESTIONNAIRE - Have you received written information on

Accredited as excellent

Accredited χ2

p-value

signs and symptoms of dementia (85% 76% 5.23 0.011*

course and prognosis of the condition 79% 73% 2.23 0.067

Options for care and treatment, including coping strategies

81% 76% 1.05 0.151

Local care and support services/groups 87% 81% 2.83 0.046

Sources of financial/legal advice, and advocacy

76% 63% 7.23 0.003**

Medico-legal issues, including driving 82% 70% 5.29 0.010*

Local and national information sources 77% 74% 0.61 0.215

Improving general health, living positively and maximising quality of life after diagnosis

82% 80% 0.23 0.315

Any medication prescribed 83% 78% 1.16 0.140Any non-drug interventions offered 65% 52% 4.59 0.016*

Tangible improvements

• Funding to open a physical examination unit on site

• Assigned a medical lead for the service• New information leaflets/packs for people

with dementia and carers• Checklist for assessments• Speeding up shared care agreements

Improvements against standards

• Increase in % of new referrals seen within 4-6 weeks

• Increased % of patients reported being asked who their diagnosis could be shared with

• Reduction in % staff reporting a lack of funding for training

• Increased % referrers reported being given referral protocols + info about the service

Possible quality indicators

• % people diagnosed in early stages of dementia• % people with dementia registered their interest

in participating in research • % new referrals whose initial assessment

process began within six weeks of referral• % people with dementia accessed psychosocial

interventions in the past year• % dementia in service’s catchment area who

received a diagnosis• Use of outcomes measures in audit

– MMSE, QOL-AD/DEMQOL

Possible reasons for improvement

The programme does not end after accreditation

“All of the improvements made have been received well, and some have led to changes being made across the Trust—not just to our memory service. This can only benefit service users and carers...”

“We have developed leaflets and information sheets for service users and carers as a result of the accreditation procedure; reviewed the support provided to service users and carers; we have looked at staff training issues; GP training issues; documentation in case notes and even the availability of Trust policies amongst other things...”

[The person I care for] has benefitted greatly by visiting the clinic - the atmosphere is friendly and

inviting - and she is happy to attend. The consultant is extremely caring and friendly, and

explains the treatment which has been extremely beneficial.

All staff were very kind and welcoming.

All staff were very kind and welcoming.

Always treated with dignity and respect.Always treated with dignity and respect.

The doctors/staff we saw were always ready with advice etc., and more importantly gave us

plenty of time to discuss this.

The doctors/staff we saw were always ready with advice etc., and more importantly gave us

plenty of time to discuss this.

We have been given enough

information for the present time

and patient's condition, and I

know that if I need more I only have to ask and I will

get it.

Patient and carer feedback

Sophie Hodge

[email protected] 7977 4971

www.rcpsych.ac.uk/memory-network