PROMs 2.0

Bibhas Roy, Consultant Orthopaedic Surgeon Trafford General Hospital, CMFT

Clinical IT Lead for Secondary Care, NHS North West

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Experience & Outcome

Definitions

Measuring Healthcare

Validity

PROMs – National approach

PREMs

Example - PROMs 2.0

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Quality in Healthcare “Even though quality cannot be defined, you know

what quality is.” Robert M. Pirsig 1928 American philosopher

“Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Institute of Medicine 1990

“Quality is a process of meeting the needs and expectations of patients and health service staff.”

WHO 2000

We are guests in our patients' lives; and we are their hosts when they come to us. Why should they, or we, expect anything less than the graciousness expected by guests and from hosts at their very best. Service is quality – Don Berwick "The Permanente Journal, Volume 3 No. 1". Kaiser Permanente.

Winter 1999.

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Donald M. BerwickChief Executive Officer of the Institute for Healthcare Improvement

My right knee will probably need to be replaced soon. This has given me the opportunity to define, in very personal terms, 5 specific dimensions of “total quality” that I will require from the medical institution that does my surgery and that every patient has the right to require of their encounters with the health care system.- Don’t kill me (no needless deaths).- Do help me, and don’t hurt me (no needless pain).- Don’t make me feel helpless.- Don’t keep me waiting.- And don’t waste resources, mine or anyone else’s.

Given my requirements, it is not clear that any health care institution in the United States will want to take me on as a patient…”

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Measuring Healthcare

This has become a multi-million pound industry fuelled partly by increasing anxiety by society (especially its political representatives) about the variation in quality and safety of care—an anxiety heightened as the results of more measurements reveal even more problems. Whenever such an industry develops rapidly, it is useful to pause and reflect on the degree to which it is acting optimally and in the interests of society and health.

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The healthcare quality measurement industry: time to slow the juggernaut? Professor T A Sheldon Department of Health Sciences, University of York Qual Saf Health Care 2005

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Prof. Iain Buchan, University of Manchester

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Measures

Outcome Measures – What is the result

• For access: Number of days to appointment

• For critical care: ICU mortality

Process Measures - parts/steps in the

system

• For access: Average daily clinician hours available For critical care: Use of adverse drug event chart review

Balancing Measures - Are changes designed to improve a part of the

system causing new problems in other areas• For reducing patients' length of stay in the hospital: Make sure readmission rates are not increasing

Institute for Healthcare Improvement (IHI)

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Hawthorne effect

Hawthorne Works

• 1924 -1932• commissioned a

study to see if its workers would become more productive in higher or lower levels of light.

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Outcome Measures

• Mortality / Number of treatments performed

Blunt figures

• Evolution from broad subjective categories to validated sensitive quantified tools

• Eg - Constant-Murley Shoulder Score

Clinician / Physician reported

Patient Reported Measures

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Stratification/Adjusting for risk

Variation in outcome may be due to differences in

healthcare quality - BUT

Type of patient - age, gender, co-morbidity,

disease severity, socio-economic status

etc…Data collection /

reporting - numerator /

denominator / case mix adjustment

definitions

Chance

Conclusions that outcome differences

are caused by differences in quality

will always be tentative.

Factor not measured or inadequately

measured?

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PROMs & PREMs

Unidimensional /

Multidimensional

Condition Targeted / Generic

Desirable Attributes

• Important• Sound

theoretical basis

• Validated• Reliable• Sensitive• Acceptable

The Point of Care Measures of patients’ experience in hospital: purpose, methods and uses - Angela Coulter, Ray Fitzpatrick, Jocelyn Cornwell, July 2009 – The King’s Fund

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Experience & satisfaction

•what actually occurred, rather than the patient’s evaluation of what occurred.

Experience

• the personal preferences of the patient• the patient’s expectations• response tendencies due to personal

characteristics• the quality of the care received

Satisfaction

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• standardised validated instruments (question sets)

• measure patients’ perceptions of their health status (impairment),

• their functional status (disability)

• their health-related quality of life (well-being).

PROMs

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Spreading the project

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People are not passive recipients of innovations. Rather (and to a greater or lesser extent in different individuals), they seek innovations out, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, ‘work round’ them, talk to others about them, develop know-how about them, modify them to fit particular tasks, and attempt to improve or redesign them (often through dialogue with other users).

How to Spread Good Ideas, A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisationTrisha Greenhalgh et.al 2004

Product & Process Know your products Map processes

Break it into components and timeframes

Discover what works well

Discover what does not work well

Clinical Engagement? Clinician

a doctor having direct contact with patients rather than being involved with theoretical or laboratory studies. - oxforddictionaries.com

HICAT version (for informatics) 'Figurehead' Clinicians (Doctors, Nurses, AHPs etc.)

These Clinicians no longer have clinical responsibility and are not on the front-line

Clinicians who work part-time in the Programme. These Clinicians work for 40-60% of the time in the

Programme and 40-60% of the time in clinical care Fulltime clinicians

Clinicians who are fully committed to improving patient care through the use of IT

Establishing the Culture and Beliefs to Deliver Clinical Engagement

1. engagement follows debate at a local level2. place the patient at the centre of development3. evidence - “observability & trialability” is required Rogers & Plsek

4. local clinical leaders are essential – real full time clinicians5. concept applied successfully in a local context, this “strength of

evidence” is very compelling6. align objectives between clinician and manager7. a request to change their working process will produce

dissonance – change management

New Double HelixApproach

PatientsPathwayDriver

ValueBelief

EngagementProgramme

implementationDriver

Clinical Champions to bring aboutClinical Engagement and Service Improvement becoming business as usual

Awareness-raising

Clinical volunteers

Early implementers

Dissemination

Acceptance and implementation

Business as Usual

Clinical Engagement Escalator

Evidence on quality& benefit realisation

Evidence on quality& benefit realisation

Aligned with Managerial Colleagues Project Plan

NewVision

Framing as described in Large Scale Change

Clinical LeadersNetworkAn Ethos of

Implementation At LHC

Medical Directors

Cancer network

LMC

Stroke network Royal

Colleges

Mental Health

TraumaNetwork

Respiratorynetwork

AHP network

Children’s network

Upscaling the change

NursingDirectors

PECChairs

CHILEnabling

Health Informatics

Pathology

BMA

GP ConsortiaNetwork

Clinical ExpertiseQuality, Design

Governance

Sixty Three NHS Organisations

“Realise the cultural change”

PROMs 2.0 National PROMs

PROMs are measures of a patient's health status or health-related quality of life. They are typically short, self-completed questionnaires, which measure the patients' health status or health related quality of life at a single point in time. – NHS Information Centre

Must be Validated tools Shared decision making with patients QIPP principles

Quality Innovation Productivity

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E-mail to patient

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Validate the patients into the system

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No passwords

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Patient Generated data – their responsibilities

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List of scores that require completion

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Confirmation of Completion

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Logic based feedback to guide patients about their care

Birth of PROMs 2.0

Innovations funding (2010)

• rejected

Business case for

£250,000

Dragon’s Lair

£20,000 award

Software £15,000

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Phase II

Adoption bursaries for 10 more organisations (2011) - £150,000• 9 Acute Trusts• 2 CCG

Clinical Leaders Network funding (2012)• Further 2/3 organisations

Many different PROMs now in system• Minimal Data set• EQ5D

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Experience & satisfaction

•what actually occurred, rather than the patient’s evaluation of what occurred.

Experience (PREMs)

• the personal preferences of the patient• the patient’s expectations• response tendencies due to personal

characteristics• the quality of the care received

Satisfaction

Trust Speciality

Salford Royal NHS Foundation Trust Orthopaedics

Norfolk & Norwich University Hospital Orthopaedics

University Hospital of South Manchester Orthopaedics

East Lancashire Hospitals NHS Trust Orthopaedics

East Cheshire Clinical Commissioning Group Pulmonary rehabilitation

Stockport NHS Foundation Trust Orthopaedics

Central Manchester University Hospitals NHS Foundation Trust Anaesthetic, Urology

Wrightington, Wigan and Leigh NHS Foundation Trust Orthopaedics

United League Clinical Commissioning Group ENT

Countess of Chester Hospital Trauma Network

Royal Liverpool and Broadgeen University Hospitals Orthopaedics

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PROMs 2.0 Team All organisations represented PROMs & PREMs Mapping Governance Consent

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PROMs 2.0 a success? Funding process

The software development and pilot cheap due to the direct relationship between the

stakeholders and the designer No elaborate reports necessary to justify funding

Implementation of product required

Business requirements analysis to convince early adoptors adoptors were actively chosen

Future? PROMs Summit (6th December Manchester)

Why do we fail?

Lack of user involvement clinical engagement

Poor requirements Long or unrealistic timeframes Scope creep- the scope increases

insidiously as the project progresses No change control system - especially in

consideration of changing requirements Poor testing- testing is not done by those

on the front-line, but by contract workers