Supporting NHS Wales to Deliver World Class Healthcare All Wales Stroke Services Improvement Collaborative Learning Session One 21 st October 2009.

Supporting NHS Wales to Deliver World Class Healthcare

All Wales Stroke Services All Wales Stroke Services Improvement CollaborativeImprovement Collaborative

Learning Session One Learning Session One 2121stst October 2009 October 2009

Slide 2

Why are we here?

Alan WillsonDirector of Research and Development

NLIAH

Slide 3

• Improve the reliability of care in Wales

• Raise the standards of care in Wales

What are we actually trying to do?What are we actually trying to do?

Slide 4

An example from another settingAn example from another settingAcute MI Care in US• Aspirin at discharge • ACEI for LVSD • Beta-blocker at arrival • Beta-blocker at discharge • Door to lytic • Door to PCI • Smoking cessation advice • Composite and all-or-none scores • Survival rate/index• Aspirin at arrival

Slide 5

Slide 6

Slide 7

Model for ImprovementModel for Improvement

Slide 8

Acute Phase Acute Phase Driver Driver

DiagramDiagram

Slide 9

All Wales DataAll Wales Data

Uptake of Data Collection

02468

1012

Novem

ber

Decem

ber

Janu

ary

Febru

ary

Mar

chApr

ilM

ayJu

ne July

Month

Nu

mb

er o

f S

ites

Series1

Slide 10

Examples from One TrustExamples from One Trust% patients who have swallow assessment within 24 hours of

admissionOne Trust Stroke patientsfrom May 2009 to Jul 2009

0

10

20

30

40

50

60

70

80

90

100

Weeks

% p

ati

en

ts

Slide 11

% patients who have their physiotherapy assessment in first 72 hours

Glan Clwyd Hospital Stroke patientsfrom Jan 2009 to Aug 2009

0

10

20

30

40

50

60

70

80

90

100

Jan2009

Feb2009

Mar2009

Apr2009

May2009

Jun2009

Jul2009

Aug2009

Months

% o

f p

atie

nts

Slide 12

% patients who have swallow assessment within 24 hours of admission

Withybush Stroke patientsfrom Jan 2009 to Jun 2009

0

10

20

30

40

50

60

70

80

90

Jan 2009 Feb 2009 Mar 2009 Apr 2009 May 2009 Jun 2009

Months

Slide 13

% compliance with First 3 Days bundleABMU West Division Stroke patients

from Dec 2008 to Aug 2009

0

10

20

30

40

50

60

70

80

Dec2008

Jan2009

Feb2009

Mar2009

Apr2009

May2009

Jun2009

Jul2009

Aug2009

Months

Slide 14

All Wales - Compliance with First Hours All Wales - Compliance with First Hours BundleBundle

% compliance with First Hours bundleWales Stroke patients

from Dec 2008 to Jul 2009

0

1020

30

4050

60

70

8090

100

10

/12

/20

08

24

/12

/20

08

07

/01

/20

09

21

/01

/20

09

04

/02

/20

09

18

/02

/20

09

04

/03

/20

09

18

/03

/20

09

01

/04

/20

09

15

/04

/20

09

29

/04

/20

09

13

/05

/20

09

27

/05

/20

09

10

/06

/20

09

24

/06

/20

09

08

/07

/20

09

Weeks

% c

om

pli

ance

Within 3 hours• Screening tool• Confirmation of

diagnosis by experienced clinician

• Stat aspirin

Slide 15

All Wales - Compliance with First Day All Wales - Compliance with First Day BundleBundle

% compliance with First Days bundleWales Stroke patients

from Dec 2008 to Jul 2009

0

1020

30

4050

60

70

8090

100

10

/12

/20

08

24

/12

/20

08

07

/01

/20

09

21

/01

/20

09

04

/02

/20

09

18

/02

/20

09

04

/03

/20

09

18

/03

/20

09

01

/04

/20

09

15

/04

/20

09

29

/04

/20

09

13

/05

/20

09

27

/05

/20

09

10

/06

/20

09

24

/06

/20

09

08

/07

/20

09

Weeks

% c

om

pli

ance

Within 24 Hours

• CT Scan• Admission to

stroke bed• Swallow screen• Regular aspirin

Slide 16

All Wales – CT Scan within 24 hoursAll Wales – CT Scan within 24 hours

90

80

70

60

50

40

30

20

10

0

Week Date

Hours

_X=31.69

UCL=62.77

LCL=0.62

Time from admission to CT scan

Slide 17

All Wales – Swallow Screen in 24 All Wales – Swallow Screen in 24 hourshours

100

80

60

40

20

0

Week Date

Perc

enta

ge

_X=56.8

UCL=84.1

LCL=29.5

08/ 12/ 2008 06/ 04/ 2009

% patients who have swallow assessment within 24 hours of admission

Slide 18

All Wales – Mobilisation within 72 All Wales – Mobilisation within 72 hourshours

80

70

60

50

40

30

20

10

0

Week Date

Perc

enta

ge

_X=56.51

UCL=75.81

LCL=37.21

08/ 12/ 2008 06/ 04/ 2009

% patients who were sat out of bed or mobilised in first 72 hours

Slide 19

All Wales – Time to stroke ward All Wales – Time to stroke ward admissionadmission

300

250

200

150

100

50

0

Week Date

Hours

_X=43.2

UCL=83.8

LCL=2.7

08/ 12/ 2008 30/ 03/ 2009 22/ 06/ 2009

Time from admission to admission to a specialist stroke wardTime in hours

Slide 20

FindingsFindings

• Method makes sense

• Measurement and reliability are new concepts

• Team work is encouraged across pathway

• Connections with management need work

• We are seeing change and so are patients!

Slide 21

Why isn’t this audit?Why isn’t this audit?

IMPROVEMENT• Measure and use data now• Include all patients and

measure continuously• Rapid cycle change• Keep it simple• Don’t aim for

comparability• Use charts of change over

time• Think of Obs Charts

AUDIT• Retrospective, report

later• Use snapshot audit

giving one point in time• No link to change process• Often very detailed• Aim is comparison• No time run charts

because too little data• Think Post Mortems