A clinical decisions unit improves emergency general surgery care delivery

Purpose – Early access to senior decision makers and investigations has improved outcomes for many conditions. A surgical clinical decisions unit (CDU) was created to allow rapid assessment and investigation by on-call senior surgical team members to facilitate decision making and, if appropriate, discharge within a set time frame (less than four hours). The purpose of this paper is to compare outcomes for unscheduled general surgery admissions to the hospital before and after commissioning this unit. Design/methodology/approach – Prospectively collected hospital episode statistics data were compared for all general surgical admissions for one year prior to (July 2010-June 2011) and two years after (July 2011-June 2013) the introduction of the CDU. Statistical analysis using the Mann Whitney U-test was performed. Findings – More patients were discharged within 24 hours (12 per cent vs 20 per cent, p < 0.001) and total hospital stay decreased (4.6 days vs 3.2 days, p < 0.001) following introduction of CDU. Admission via A & E (273 vs 212, p < 0.01) was also decreased. Overall there was a 25.3 per cent reduction in emergency surgical admissions. No difference was noted in 30-day readmission rates (47 vs 49, p=0.29). Originality/value – The introduction of a CDU in has increased early discharge rates and facilitated safe early discharge, reducing overall hospital stay for unscheduled general surgical admissions. This has decreased fixed bed costs and improved patient flow by decreasing surgical care episodes routed through the emergency department (ED). In all, 30-day readmission rates have not been influenced by shorter hospital stay. Service redesign involving early senior decision making and patient investigation increases efficiency and patient satisfaction within unscheduled general surgical care. Not original but significant in that the model has not been widely implemented and this is a useful addition to the literature.

Inadvertent returns to theatre within 30 days (IRT30) of surgery

Purpose – When a patient unexpectedly has to go back to the operating theatre, there is often a perceived problem with the primary operation. An IRT30 is defined as any patient returning to the operating theatre within 30 days of the index procedure. IRT30 has been suggested to be a useful quality indicator of surgical standards and surgeon performance. The purpose of this paper is to evaluate the usefulness of this validated tool, by assessing all IRT30 over a 12-month period. Learning points for individual surgeons, surgical subspecialty units and the clinical governance leads were reviewed. Design/methodology/approach – Consecutive series of general and vascular surgical patients undergoing elective and emergency procedures between July 2012 and 2013. Prospective data collection of all IRT30s classified as Types 1-5 by a single-rater and in-depth discussion of Types 3-5 cases at the clinical governance meetings. The individual case learning points were recorded and the collective data monitored monthly. Findings – There were 134 IRT30s. In total 84 cases were discussed: Type 3 (n=80), Type 4 (n=4) and Type 5 (n=0). In total 50 cases were not discussed: Type 1 (n=27), Type 2 (n=23). Originality/value – It is crucial that surgeons continue to learn throughout their surgical career by reflecting on their own and their colleague’s results, complications and surgical performance. Analysing Types 3 and 4 IRT30s within the governance meetings has identified learning points related to both surgical technique and surgical decision making. By embracing these learning points, surgical technique and individual as well as group surgeon performance can be modified and opportunities for training and focused supervision created.

Clinical dashboards and their use in an adult mental health inpatient setting, a pilot study

Purpose – The purpose of this paper is to explore the experiences and opinions of mental health professionals working in two rehabilitation wards to a clinical dashboard system. Design/methodology/approach – Following the creation of the clinical dashboards, a questionnaire was developed and sent to staff and patients across two clinical wards involved in the clinical dashboard mental health pilot. Findings – The clinical dashboards were viewed as being useful tools for clinicians, supporting engagement. They can offer rapid access to large volumes of clinically useful information, in a palatable format. The pilot suggested that they could be presented in different ways to make them easier to engage with however they could also result in more paperwork for clinicians. Research limitations/implications – The main limitations included the sample size, responder bias and the limited sampling period. It would have been helpful to have obtained further responses to understand why individuals came to their conclusions. Practical implications – The development and use of clinical dashboards in a psychiatric rehabilitation setting offered the opportunity to improve quality, collect and respond to relevant clinical data trends: which is regarded positively by staff and patients. Originality/value – This study represents the first study to examine the use of clinical dashboards within a UK long stay adult mental health ward setting. The results suggest a positive response from both staff and patients and illustrates the potential benefits relating to clinical quality.

Clinical Governance Review 20:4

Purpose – The purpose of this paper is to provide a quick overview of the current journal content. Design/methodology/approach – A review of five papers. Findings – The review section brings together the differing aspects of clinical governance discussed in the current journal. Originality/value – The review section enables readers to prioritise articles with the most relevance for their needs or particular fields of healthcare.

Patients versus healthcare providers’ perceptions of quality of care

Purpose – The purpose of this paper is to find out whether there are any significant gaps in perceptions of quality of care between patients and healthcare providers in Ghana’s hospitals. Design/methodology/approach – A cross-sectional survey of patients seeking outpatient consultations in 17 general hospitals in Ghana was conducted. A total of 818 patients and 152 hospital managers were interviewed. A 22-item quality of care scale was used in data collection. Data were analysed with the aid SPSS version 20. Summary statistics and t-test were used to analyse the data. Findings – There was a significant difference in the overall perception of quality of care between patients and healthcare providers (Patients: M=89.11, SD=11.457; Providers: M=94.60, SD=10.922; t (845) −4.956, p < 001, two-tailed). Also, 18 items out of the 22-item quality of care scale showed significant difference between patients and providers. However, levels of quality of care is generally rated fairly favourably by both category of respondents. Research limitations/implications – Further study is required to explore the reasons for the perceived quality gaps between patients and healthcare providers. Practical implications – Management of hospitals need to evaluate patients’ perceptions of quality of care to inform measures aimed at improving quality of care, since what they may consider as good quality service may be rated less favourably by patients. Originality/value – Comparing perceptions of quality between patients and healthcare providers is important in order adopt measures to address any differences in perceptions of quality between the two stakeholders. To the best of the author’s knowledge no study has been conducted in Ghana to that effect.

Building analytic skills to drive improvements in patient care and organisational decision making

Purpose – This paper briefly outlines a development programme designed to improve the skills of NHS Information Analysts and assesses the extent these skills have been developed. There are significant opportunities for the NHS to utilise information more effectively, and Analysts have a key role. However, training opportunities prior to the development of this programme have been limited for this professional group. The purpose of this paper is to explore the potential benefits to the organisations, patients and the NHS as a whole, that improvements in the quality of analysis can deliver. Design/methodology/approach – The authors compared pre-course and post-course self-assessment of skill levels of Analysts who attended the programme. The authors also considered general feedback and comments from participants. Findings – All of the 40 skills areas assessed demonstrated an increase in mean competency score. In cohorts 1 and 2, 38 of these were statistically significant (p < 0.001-0.041, mean increase in score 1.0). For cohorts 3-5, 37 were statistically significant (p < 0.001-0.012; mean increase 1.2). These findings were supported by the positive feedback from participants. Practical implications – The programme develops skills for NHS Information Analysts which can improve the quality of analysis in the NHS, offering significant potential to improve the effectiveness and efficiency of healthcare. Originality/value – The Information Analysts’ Development Programme provides the only training programme available for NHS Information Analysts, contributing to the development of data driven service improvement within the NHS. This may harness the power contained within data to drive improvement and ensure patients receive the highest quality of care.

The economics of health service transformation

Purpose – This is a report on a recent development of an innovative coordinated care solution named the Care Coordination Centre (CCC), which targets coordinated care arrangements for a populations expected to benefit the most. The purpose of this paper is to identify the patients who might comprise this group, and to assess the best ways to meet their health, community, and social care needs before and after introducing the coordinated care solution across care settings. Design/methodology/approach – This is a summary of the author’s experience in the design and development of a care coordination business model for US providers and UK Clinical Commissioning Groups (CCGs) using coordinated care not only as a cost-cutting tool, but as a mechanism for creating a flexible and responsive patient-centered care. The author makes an assessment of the economic benefits of coordinated care resulting from: the shift to less costly interventions; reduction in readmissions; reduced unplanned admissions; increased time allocation efficiency of healthcare staff; and the overall reduction in per-patient costs. Findings – The health and social care systems in the USA and the UK are facing the biggest challenges in their history. Payers, providers, governments, and communities need to work to build better coordination and integration mechanisms to manage the increasing demand on health and social care in a period of stagnant health and social care budgets. New innovative models of coordinated care have been developed in both countries, at the local economy level, as the health service systems are undergoing crucial transformation from a supply to a demand-based model. In the UK, the Trafford CCG has commissioned a new CCC, responsible for the delivery of high-quality coordinated care. The CCC is designed to function at clinical, service, and community levels across multiple providers to cover, among other tasks, chronic condition patient case management, risk stratification of preventative, elective, and unscheduled care for the whole region. Originality/value – Insights from the work with Trafford CCG would be of considerable methodological and practical interest to researchers, policy makers, commissioners, healthcare professionals, and innovators.

“Teleswallowing”: a case study of remote swallowing assessment

Purpose – Telemedicine has enabled speech and language therapists (SLTs) to remotely assess swallowing difficulties (dysphagia) experienced by nursing home residents. The new technique, “teleswallowing”, was designed by the Speech and Language Therapy Service at Blackpool Teaching Hospitals NHS Foundation Trust. It allows prompt assessment, avoiding potential risks of aspiration pneumonia, malnutrition, poor rehabilitation, increased hospital stays and reduced quality of life (Hinchey et al., 2005; Langmore et al., 1998). The purpose of this paper is to report on a second pilot of teleswallowing and the concomitant adoption study. Design/methodology/approach – The adoption study employed qualitative methods, including consultations with senior managers, semi-structured interviews with nursing home matrons/managers and nurses, two focus groups and semi-structured interviews with SLTs. The project clinical lead kept an activity log, which was used to estimate resource savings. Findings – Over a three-month period, six SLTs and 17 patients in five nursing homes participated in teleswallowing assessments. Teleswallowing benefited both patients and participating nursing homes. Better use of therapist time and cost savings were demonstrated and evidence showed that the service could be successfully scaled up. Despite this, a number of barriers to service transformation were identified. Originality/value – This is the first implementation of teleswallowing in the UK, but it has been used in Australia (Ward et al., 2012). The approach to engaging stakeholders to understand and address barriers to adoption is novel. The value lies in the lessons learned for future innovations.