Programmes of analysis and service improvement - AQuA

The Advancing Quality Alliance (AQuA) was established in 2010 under the auspices of the North West Strategic Health Authority in order to improve health and care quality in the North West. AQuA is a not for profit NHS body which is hosted by Salford Royal Foundation Trust (SRFT), who provide overarching governance and service infrastructure. SRFT provide the statutory accountability for AQuA to operate as an NHS organisation; AQuA therefore does not have a separate independent legal status and is not a commercial arm of SRFT.

AQuA operates predominantly on a membership model and currently works with over 70 member organisations that include: Foundation Trusts, Mental Health Trusts and Clinical Commissioning Groups. AQuA’s core membership is based in North West England (covering a population of c. 7.5 million) with some cross-border members from the North Midlands and West Midlands. Associate members from other health or social care organisations in different areas are also considered. Members pay an annual fee to draw upon a range of services as appropriate to their local improvement needs. All of the membership income is used to invest in member organisation quality improvement. Only AQuA, under SRFT, has access to the data and is involved in the data processing, storage and analysis. Only individuals substantively employed by SRFT will have access to the data.

AQuA supports long-term quality improvement programmes, many of which require years of sustained and targeted work to demonstrate sustainable change and benefit to patient and population outcomes. In order to provide longitudinal analysis of the position before intervention and to establish whether planned improvements have transpired, continued access to HES data is required. Work is instigated by AQuA or by one or more of AQuA’s members. The reason is to support quality improvement work the ultimate aims of which are to reduce mortality rates and to improve patient, carers and staff safety and experience.

AQuA provides services in a number of ways:

- Through a membership arrangement with individual NHS and Social Care organisations (who pay a fee for access to AQuA’s service and regionally based expertise).

- on an ad-hoc basis (per service offered) to NHS and Social Care organisations

- In respect of income received from grant bodies (bid to be awarded via charity, non-profit making, covering costs only).

All of the above carry charges which are charged on a cost recovery basis.

“NHS and Social Care” is used as shorthand to include NHS or Social Care providers, commissioners, Local Authorities (in relation to delivering their public health duties only), CSUs, GP Practices and national NHS and Social Care organisations. It also includes private sector providers of health, in relation to the services provided by those private sector healthcare providers under NHS or Social Care contract.

Academic Health Science Networks may also commission work to support their health objectives. If tendered, AQuA may bid for aspects of this work which align to AQuA's organisation business objectives. AQuA would be bidding on a not-for-profit basis.

AQuA requires the HES data to be held for multiple years to provide longitudinal analysis to identify trends and year-on-year comparison. The nature of the data analysis will change over the life of the data extract based on the specific area being reviewed i.e. the latest healthcare issue e.g. re-admissions, mortality, Sepsis etc.

The services broadly fall in to two categories – a programme of work for a particular year which is established as part of AQuA’s strategic plan which is agreed with its members; and a grant or development programme which may generate the following year’s programme of work. Quality improvement programmes may be developed based on AQuA research to establish ‘what the data says’.

AQuA use publically available Summary Hospital-level Mortality Indicator (SHMI) data published by NHS Digital to support mortality analysis and use HES data to support mortality reduction programme, particularly regarding the level of the use of coding, crude mortality rates at a granular level.

AQuA works with provider trusts (and their partners) to provide a ‘whole-system’ review of their Governance, Systems, Processes and Information Management. As part of this review, AQuA undertakes detailed analysis of HES data to ascertain if the trust is an outlier in any of the scores of ‘indicators’ that AQuA examines. AQuA also undertake themed analysis (e.g. “Patient Flow”) to see if there is any pattern in potential challenges of a similar nature across several aspects of care (e.g. times of admission, episodes per spell, bed occupancy rates, delayed discharge). The mortality reviews assess a multitude of data fields from publically held data as well as local data sources. This is triangulated and explored further with organisational/economy-wide interviews and focus groups.

The service may be accessed by member organisations, but also by non-member NHS and Social Care organisations.

The Advancing Quality (AQ) programme is AQuA’s flagship offering having a significant impact in terms of improving the quality of care and reduce unwarranted variation. Key outcomes include: a reduction in avoidable mortality, reduced length of stay, financial savings etc. The AQ programme is funded by north-west CCGs and north-west acute trusts and specialist mental health providers that participate in the programme. It is operated in ten hospital conditions and one in mental health. These include metrics along whole pathways in areas such as diabetes and COPD.

Advancing Quality:

• Focuses on issues that matter locally, underpinned by robust provider and commissioner involvement

• Adopts and spreads best practice

• Creates high quality, benchmarked information to help local systems understand their current performance and health inequalities, and to inform the development of improvement strategies whilst tackling unwarranted variation

• Uses information to develop shared priorities based on outcomes that are in greatest need of improvement and comparing that information with peers to drive up further improvements

AQuA has an extensive Patient Safety programme which involves ad hoc information analysis to support improvement programmes. A recent example is the 28-day re-admission rate used in AQuA's Quarterly Safety Report.

The data is required in order to support AQuA’s and members’ objectives of reducing mortality rates and improving patient, carer and staff safety and experience. Data relating to Admitted Patient Care [APC] for the period 2008/09 to 2017/18 is initially required and newer data will be received on a quarterly basis until 2020/21. AQuA will only retain a maximum of 10 complete years of data and will destroy older years on a rolling basis as new complete years are received.

Funding organisations/members will place no restrictions or limitations on the dissemination of outputs.

When NHS Digital data is available via Secure File Transfer (SEFT) AQuA will download the HES data to a secure SQL server in SRFT Data Centre, Stott Lane, Salford which can be remotely accessed from AQuA premises at 3rd Floor, Crossgate House, Sale.

The data will be processed and validated by AQuA staff in accordance with internal procedures. It will then be available for analysis for the purposes described above with outputs suppressed in line with the HES analysis guide. Analysis predominately provides aggregated counts of data in line with the criteria set in the query. Some data analysis requires the extraction of a filtered set of record-level data but this is for internal purposes only and no record-level data leaves AQuA. Means, Medians, Quartiles and Deciles are calculated and presented on the charts / in the tables. Data processing and outputs will take place within England/Wales.

All AQuA staff are on substantive posts with Salford Royal NHS Foundation Trust. The data is only accessed by substantive employees of Salford Royal NHS Foundation Trust.

The data received will not be linked with any other data set in its patient level form.

A maximum of ten years data will be retained at any point, such that as each new data year is received, the oldest year will be deleted (i.e. at any point in time only ten historic years of data plus the current year may be held).

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract - i.e. employees, agents and contractors of the Data Recipient who may have access to that data).

No data will be shared with third parties.

The Data will only be used for the purposes described in this Agreement.

Outputs comprise charts, data tables and written reports. Charts draw data from aggregated counts, not record-level data. Outputs show a range of metrics for an individual organisation, over time and in comparison to peers and national rates.

All outputs will be aggregated with small numbers suppressed in line with the HES Analysis Guide.

Outputs are only available for members. This is controlled via a secure members’ area of AQuA’s website which is accessed via an individual log-on/password.

Record-level data is not shared with third parties.

AQuA do not use the data, or its outputs, to inform marketing activities and, therefore, do not use it to actively ‘target’ the marketing of AQuA’s products and services to any organisation e.g. GP Practice, CCG, Trust.

Research will not be used to establish a protocol for a clinical trial.

At least one Mortality Review report per annum is produced whilst Quarterly Mortality Report is published in January, April, July and October of each year.

The Quarterly Safety Report is published in March, June, September and December of each year.

Advancing Quality:

AQuA works with clinicians to agree a common set of quality standards which define and measure good clinical practice. Robust data collection and reporting supports clinical teams to benchmark themselves against peers and neighbours and identify opportunities for improvement. Collaborative learning events and other networking forums allow teams to come together and share best practice and experience. This is complimented by an incentives framework that includes public reporting and Commissioning of Quality and Innovation (CQUINs) monitoring.

Data from HES will be used to analyse, compare, and benchmark healthcare providers participating in the AQ programme with providers in the rest of England. Indicators such as length of stay, re-admissions, mortality, complication rates and other health-related outcomes will be studied with the aim of evaluating and understanding the impact of the AQ programme. This is an ongoing programme with no specific end-date.

Outputs achieved:

Reduced Mortality with Hospital Pay for Performance in England:

N Engl J Med 2012; 367:1821-1828 http://www.nejm.org/doi/full/10.1056/NEJMsa1114951

This study used HES data to analyse mortality for 134,435 patients admitted to hospitals participating in the Advancing Quality programme. The authors used difference-in-differences regression analysis to compare mortality 18 months before and 18 months after the introduction of the program with mortality in two comparators: 722,139 patients admitted for the same conditions to the 132 other hospitals in England and 241,009 patients admitted for six other conditions to both groups of hospitals.

Long-Term Effect of Hospital Pay for Performance on Mortality in England:

N Engl J Med 2014; 371:540-548 http://www.nejm.org/doi/full/10.1056/NEJMoa1400962

This study used HES data to analyse the long-term effects of Advancing Quality. The authors studied the 24 hospitals in the northwest region that AQuA are participating in the programme and 137 elsewhere in England that AQuA are not participating. Using difference-in-differences regression analysis to compare risk-adjusted mortality for an 18-month period before the program was introduced with subsequent mortality in the short term (the first 18 months of the program) and the longer term (the next 24 months).

Mortality:

The aim is to reduce the levels of mortality for acute trust members for whom AQuA conduct an in-depth review. This will be measured by improved SHMI banding and crude in-hospital mortality rates. Mortality rates for trusts across the North West of England are expected to reduce as a result of actions taken from reviewing AQuA’s Quarterly Mortality Report and AQuA’s wider reducing mortality programme.

The Mortality Review report identifies positives, challenges and opportunities as well as a series of recommendations. These are themed around the five key drivers of clinical care, reliable care, documentation & information, leadership and end of life care. It is recognised that a higher than expected Mortality rate may well be a warning flag for other underlying quality and safety concerns.

AQuA's Quarterly Mortality Report provides information on a wide range of mortality-related indicators. Time-series charts for each member organisation (acute trusts only) are shown, together with comparative information relating to the latest time-period; this comparative information benchmarks trusts to others in the region and to national rates.

Safety:

The key areas for improvement relate to the "Sign up to Safety" ‘safety wall’ i.e. Venous Thromboembolisms (VTEs), Healthcare Acquired Infections (HCAIs),Pressure Ulcers (PUs), Acute Kidney Injury (AKI), Maternity, Medication Errors, Deterioration in Children, Falls, Handover and discharge, Nutrition and hydration.

The Quarterly Safety Report pulls together metrics from a broad range of data sources that are indicators of safety. Data from HES is used and includes such metrics as re-admission rates. The publication of a broad range of bench-marked data will improve patient safety by driving organisations to look for improvements in areas where they are performing less well.

All 6 of the Trusts that AQuA have carried out an in-depth mortality review for in the past have a lower SHMI value than when AQuA started working with them and 5 of the 6 trusts are currently in the "As expected" range.

Crude in-hospital mortality for the North West of England shows a long-term downward trend.

2009/10 - 2.7%

2010/11 - 2.5%

2011/12 - 2.4%

2012/13 - 2.5%

2013/14 - 2.3%

2014/15 - 2.4%

2015/16 - 2.3%

2016/17 - 2.4%

The North West SHMI has reduced from 1.06 [Jul 12 – Jun 13], to 1.05 [Jul 13 – Jun 14], 1.03 [Jul 14 – Jun 15] although has increased to 1.05 in the latest release [Jul 15 – Jun 16]. It is anticipated that the work will continue to support this downward trend over the next four releases of SHMI.

Greater Manchester Stroke Pathway:

In 2017, AQuA analysed stroke activity In Greater Manchester and compared it to the rest of England. Greater Manchester had implemented a regional stroke pathway to improve treatment and outcomes and the analysis was a retrospective review of the activity from 11/12 – 16/17. The purpose of the review was to evaluate the effects of the reorganisation. This review compared the Greater Manchester region with London (which had a similar stroke pathway) and the rest of England. The initial proposal for the stroke reorganisation estimated that it could save 50 lives a year. While stroke mortality declined across all regions over that period, it declined slightly faster in Greater Manchester, resulting in an estimated reduction of between 14-30 deaths annually in Greater Manchester compared to the expected number of deaths if the mortality declined at the average rate for England over that period. Annually, this total of 75 is broken down thus:

2012/13 19

2013/14 14

2014/15 (3)

2015/16 30

2016/17 15

Safety:

It is too early to define tangible benefits of this programme. The work supports the national patient safety initiative "Sign up to Safety" data and benefits will be targeted at areas within the ‘Safety Wall’. Further information on this initiative is available on the NHS England website at https://www.england.nhs.uk/signuptosafety/.