neurology quality indicators · » sam lane, programme manager, national mental health, dementia...

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December 2016

Neurology A new approach for London

Neurology quality indicators

For adult neurological services

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Community neurology serviceFor common neurological conditions

AcknowledgementsThe London Neuroscience Clinical Network is grateful to all who have contributed to this publication.

Authors

» Davina Richardson, Clinical Service Lead Therapist Neurosciences, Imperial College Healthcare NHS Trust » Michael Oates, Quality Improvement Manager, London Neuroscience Clinical Network

Development team » Davina Richardson, Clinical Service Lead Therapist Neurosciences, Imperial College Healthcare NHS Trust » Michael Oates, NHS England, London Neuroscience Clinical network » Dr Jozef Jarosz, Clinical Director / Consultant Neuroradiologist, King’s College Hospital NHS Foundation Trust » Sam Lane, Programme Manager, National Mental Health, Dementia and Neurology Intelligence Network, Public Health England » Alex Massey, Policy, Neurological Alliance » Dr Nick Losseff, Consultant Neurologist, UCLH & Clinical Director London Neuroscience Clinical Network » Leadership group, London Neuroscience Clinical Network

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The London Neuroscience Clinical Network established a working group to review available indicators and their usage and recommend a neurological set in support of neurological service improvement.

The following neurological quality indicators cover key areas of the neurological pathway and are divided into the following service areas: » Whole systems working indicators » Neuroscience specialist centres indicators » District general hospitals indicators » Rehabilitation services indicators » Long term monitoring and Surveillance indicators

The indicators are designed to use as a self-assessment.

The peer review system in operation in cancer services and major trauma services has been successful in driving forward service improvement across the country. To encourage use of the neurological indicators and stimulate discussion, the working group recommended that the indicators are used with a peer review approach. That is, hospitals / clinical groups working as a network would visit and discuss the self-assessment to support the local team to develop its improvement case for change for internal discussions. The peer review approach provides both clinical challenge and shared learning.

The indicators are not designed for patient decision making or commissioner performance management; they are a first iteration and can be expanded to cover additional areas and levels of detail.

Introduction

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Whole systems quality indicators | NSCN-WS-1Number Indicator Data sourceNSCN-WS-1 GP registers GP practice dataNSCN-WS-2 Whole systems approach Self-declarationNSCN-WS-3 Integrated commissioning for services that people with neurological impairment access Commissioners NSCN-WS-4 Involvement of third sector neurological charities Neurological Alliance / other charitiesNSCN-WS-5 Training and education for management of neurological conditions HENWL, self-declaration

Neurosciences regional centre indicators | NSCN-RC-1 Number Indicator Data sourceNSCN-RC-1 Early diagnosis Self-declaration NSCN-RC-2 Access to neurologists Self-declaration, BMCNSCN-RC-3 Access to investigations Self-declarationNSCN-RC-4 Access to specialist mutlidisciplinary team (MDT) allied health professional (AHP) Self-declaration NSCN-RC-5 Communications Self-declaration

District general hospital indicators | NSCN-DGH-1Number Indicator Data sourceNSCN-DGH-1 Effective access to specialist advice Waiting times to transfer of careNSCN-DGH-2 Access to neurologists Number per bedsNSCN-DGH-3 Access to online reporting of investigations Radiology and pathology service

reportsNSCN-DGH-4 Access to AHP assessments Self-declarationNSCN-DGH-5 Communications Self-declaration

Neurological quality indicators: In summary

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Rehabilitation quality indicators | NSCN-R-1Number Indicator Data sourceNSCN-RC-1 Access to specialist level 1 and 2 neuro rehab beds NHS EnglandNSCN-RC-2 Access to level 3 rehab beds CCG commissioners local reportNSCN-RC-3 Access to specialist community based non bedded MDT team assessment and

managementCCG commissioners

NSCN-RC-4 Use of PROMS and outcome measures Self-declarationNSCN-RC-5 Effective referral systems and feedback Self-declaration

Long term monitoring / Surveillance indicators | NSCN-LTC-1Number Indicator Data SourceNSCN-LTC-1 GP monitoring and review including medicine management GP practicesNSCN-LTC-2 Carer support services Local governmentNSCN-LTC-3 Systems for admission avoidance and prevention of secondary complications Commissioners / Self-declarationNSCN-LTC-4 Access and understanding of advance care planning and end of life care GP registers

Neurological quality indicators: In summary

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Number NSCN-WS-1 Registers of patients Data source | GP practiceDescriptor Notes Evidence requiredGP registers of patients with neurological conditions /access to information on practice level impact of neurological conditions on services

» Where there are national registers/ guidelines it is expected these are included in the guidelines

» Could include research registers » To have understanding of the impact on

resources. » Risk stratification

» GP practice codes for common neurological conditions

» Research registers

Number NSCN-WS-2 Whole systems sommunication Data source | Self-declarationDescriptor Notes Evidence required » Regional service providers and commissioners

to have regular meetings to explore and support the needs of the neurological patient within the service deliver plans.

» Data on neurological conditions to be discussed at partnership meetings.

» Commissioners, acute, specialist, community care, social care and third sector providers should be encouraged to participate

» Patient involvement to support co design of services

» The use of right care data (bench marking data for CCGs available on web site)

» Minutes of meetings » Partnership working for management of long

term conditions » Joint commissioning » Commissioning and provider meetings » Evidence of patient involvement and use of

patient feedbackNumber NSCN-WS-3 Commissioning Data source | CommissionersDescriptor Notes Evidence requiredHealth sectors to integrate commissioning of services to support neurological condition management (for example, NWL sector, SEL sector)

This should enable two way feedback and learning between CCGs in a health sector. Informed commissioning across larger populations for efficiencies

Business planning for commissioners

Whole systems quality indicators descriptors | NSCN-WS

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Number NSCN-WS-4 Involvement of third sector neurological charities and patient feedback

Data source | Neurological Alliance

Descriptor Notes Evidence requiredThird sector neurological charities and patient feedback used to shape services

Perception of how well services are doing » More patients being allocated a single point of contact who can be

relied upon to provide key information » Measurable improvements in the number of patients who feel they

have been treated with dignity and respect » Patients reporting an improved quality of life » Patients, carers and families reporting the provision of good

quality, accurate and timely information regarding the condition and the pathway as a whole

» A perception that services are easily accessible and straightforward to navigate

» Improved provision of psychological and emotional support » More patients feeling they have been effectively and meaningfully

included in the rehabilitation programme and goal setting » More patients given the opportunity to die in their preferred place

of care (linkage to end of life care)

» Minutes of meetings » Partnership working for management of

long term conditions » Evidence of patient involvement and use

of patient feedback

Number NSCN-WS-5 Training and education for the management of neurological conditions

Data source | Self-declaration

Descriptor Notes Evidence requiredStaff involved in the management of neurological conditions will have access to training and education on the assessment, interventions and management of these conditions

This should involve shared learning from specialist centres to the general acute, and primary care settings, voluntary sector and social services.

» Teaching programs » Time tables » Job plans » Access portals » Training needs surveys » Evidence of CPD for staff working with

neurological conditions

Whole systems quality indicators descriptors | NSCN-WS

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Number NSCN-RC-1 Early diagnosis Data source | Self-declarationDescriptor Notes Evidence required » Timely and accurate diagnosis of a

neurological condition » Timely access to neurological specialist

within A&E settings » Timely access to neurological advice within

primary care settings

» Patients informed in a timely manner post investigation of the outcome of the investigation

» Access to planned investigation units 5/7 » Access to specialist neurology beds

» Waiting times » GpwSI in neurology » CNS numbers » Number of beds » Activity of PIU’s

Number NSCN-RC-2 Access to neurologists Data source | Self-declarationDescriptor Notes Evidence requiredWithin the system 24 hour access to neurology services

» Evidence of training positions and recruitment » Provision of triage/assessment, advice, support » Use of telemedicine » Response time for a neurological opinion (A&E - 4 hours;

primary care - 24 hrs) » Availability of a navigation service » Number of neurologists per head of local population » Evidence of robust referral pathways to neurology

» Vacancy rates in neurology » Training posts in neurology » Number of neurologists » Hyper acute neurology beds

Number NSCN-RC-3 Access to investigation Data source | Pathology, radiologyDescriptor Notes Evidence requiredAll necessary diagnostics available with evidence of good management and use of scanning resources, pathology and neuro physiology

» Comprehensive specialist diagnostics with co-existing support from level 3 beds (neuro ITU), neurosurgery, neurophysiology, neuro psychiatry and neuro ophthalmology

» Level 3 beds (ITU) per 100,000 population » Adequate radiology staffing levels to support scanning and

reporting. » 24/7 access for intubated patients for CT scans » 24/7 access for intubated patients for MRI scans » 24/7 access for fitting patient for EEG and report within 1 hour

» Diagnostics available » Use of centralised pathology services. » Time to deliver results

Neuroscience regional centre indicators descriptors | NSCN-RC

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Number NSCN-RC-4 Access to specialist MDT AHP assessment Data source | Therapy staffing levels / teamsDescriptor Notes Evidence required » Within the acute specialist centres

physiotherapy, occupational therapy, speech and language therapy and dietetics should be available within a 72 hour period from admission to a specialist centre

» CNS posts/roles for common neurological condition

AHP staff with a specialist in neurology and neurosciences is required

Staffing levels, response times to assess, training records

Number NSCN-RC-5 Communication Data source | Self-declarationDescriptor Notes Evidence requiredRobust record keeping demonstrated within the specialist services with treatment summaries and care plans

» Where possible use of electronic transfer of information to GP

» Patient held treatment summary. » Use of 111 for sharing (eg neuro response

model at NHNN, includes patient care plan on NHS 111)

» Examples of templates for treatment summaries » Examples of treatment summaries » Feedback from GPs

Neuroscience regional centre indicators descriptors | NSCN-RC

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Number NSCN-DGH-1 Effective access to specialist advice Data source | Self-declarationDescriptor Notes Evidence requiredAccess to inpatient neurology review 5 days a week

Evidence of systems being implemented to enable specialist neurological advice to be accessed quickly

Number of patients in DGH not transferred to specialist centres

Number NSCN-DGH-2 Access to neurologists Data source | Self-declarationDescriptor Notes Evidence requiredTime taken for neurological opinion Evidence that a neurologist is contactable for face

to face assessment of the patient within working hours

» Number of requests » Response times to requests

Number NSCN-DGH-3 Access to online reporting of investigation Data source | Pathology, radiologyDescriptor Notes Evidence required.Access to MRI and neurophysiology 5 days a week Ability to access results from specialist centres

quicklyEvidence of systems set up to enable care record exchange

Number NSCN-DGH-4 Access to MDT AHP assessment Data source therapy staffing levels / teamsDescriptor Notes Evidence requiredWithin the DGH access to physiotherapy, occupational therapy, speech and language therapy and dietetics should be available within a 72-hour period from admission

AHP staff who can have access to a specialist in neurology and neurosciences are required

Staffing levels, response times to assess, training records

District general hospital indicators descriptors | NSCN-DGH

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Number NSCN-RC-1 Access to specialist level 1 and 2 neuro rehab beds. Data source | NHS England / CCGDescriptor Notes Evidence requiredPatients requiring specialist rehabilitation at any point in the pathway should be able to access appropriate level beds

» Evidence of self-management approaches and support structures within these services

» Evidence of timely assessment and access to services » Access to assessment by rehabilitation specialist

» Number of beds per population » Average waiting times » Outcome measures. UK Rehabilitation

Outcomes Collaborative (ROC) » Access to rehabilitation medicine

Number NSCN-RC-2 Access to Level 3 Rehab beds Data source | CCGDescriptor Notes Evidence required Patients requiring specialist rehabilitation at any point in the pathway should be able to access appropriate level beds

» Evidence of self-management approaches and support structures within these services

» Access to assessment by rehabilitation specialist

» Number of beds per population » Average waiting times » Outcome measures. UK Roc

Number NSCN-RC-3 Access to specialist community based non bedded MDT team assessment and management

Data source | CCG

Descriptor Notes Evidence requiredCommunity based rehabilitation services should be able to support a self-management approach to neurological conditions in a timely manner

» Access to supported discharge » Evidence of self-management approaches and support

structures within these services. » For many neurological conditions quality of life can be

improved with self-help (programmed support, motivation, ownership)

» Waiting times to access community based services

» Presence of supported discharge teams

Rehabilitation quality indicators descriptors | NSCN-RC

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Number NSCN-RC-4 Use of PROMS and outcome measures Data source | Self-declarationDescriptor Notes Evidence requiredServices should use recognised outcome measures

EQ5D score by conditions and by number of conditions in order to see how/whether a person’s quality of life is affected by the conditions or number of co-morbidities that the person has » Patients with long-term neurological problems

report both some of the worst states of pain and some of the highest levels of anxiety or depression.

» Condition specific information provide – medium, languages

» Data on outcome of service » Use of outcome measures including PROMS » Patient information examples

Number NSCN-RC-5 Effective referral systems and feedback Data source | Self-declarationDescriptor Notes Evidence required » Robust referral systems to the rehabilitation

services with quick response times » Rehabilitation prescriptions and or treatment

summaries for all patients having rehabilitation to be shared with appropriate care providers and GP

» Navigator roles » Single point of access schemes » Case management » Follow up schemes

» Number of referrals made » Number accepted » Number declined » UK roc Badgernet other local reporting systems

Rehabilitation quality indicators descriptors | NSCN-RC

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Number NSCN-LTC-1 GP monitoring and review including medicine management Data source | GP Descriptor Notes Evidence required » Regular reviews to support

admission avoidance and optimal management

» Monitoring of progression /improvement

» Potential use of pharmacists for regular medicine management » Telephone follow-up » Patient with cognitive impairment unlikely to initiate timely review

and self-management

» GP registers » Patient stories » Medical records

Number NSCN-LTC2 Carer support services Data source | Local government / CCG / health

Descriptor Notes Evidence required Schemes or initiatives to support formal and/or informal carers of people with a neurological condition

» To support patients and carers to understand their condition and its consequences.

» For many neurological conditions quality of life can be improved with self-help (programmed support, motivation, ownership)

» Description of schemes » Number of people trained » Carer information

Number NSCN-LTC-3 Systems for admission avoidance and prevention of secondary complications

Data source | CCG, GP, local government

Descriptor Notes Evidence required » Access to community based rapid

response teams and risk stratification for patient with neurological conditions

» Surveillance and monitoring systems

» Rapid response teams in the community » Access to equipment/ online ordering systems (eg TCES /

Mediquip) » Disability caused by a neurological condition prevent individuals

from working » Surveillance and monitoring systems should include depression

and employment status

» Access to vocational rehab » Access to IAPT (improving access to

psychological therapies) » Robust equipment provision

Number NSCN-LTC-4 Access to understanding of advance care planning and end of life care

Data source | GP registers

Descriptor Notes Evidence requiredIdentification of patients whose presentations may be best managed with support from palliative care services

Where there are national registers / guidelines it is expected these are included in the guidelines

Engagement with palliative care systems such as Coordinate My Care or other local schemes

Long term monitoring / surveillance primary care indicators descriptors | NSCN-LTC

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