Publish or perish – the
outcomes game
Andrew Vallance-Owen, Group Medical Director
BUPA
Founded 1947
“To prevent, relieve and cure sickness
and ill health of every kind and promote
health in any way”
BUPA - Overview
• A broadly-based international health and care group
– Private medical insurance
– Occupational health
– Care homes
– Hospitals
– Clinics
– Health assessment/wellbeing centres
• No shareholders – profits re-invested in business
• 8.1m customers in 190 countries
• Aspiration: to help our customers live longer,
healthier, happier lives
Outcomes – what are they?
• A means of seeing how well we’re doing
• A means of comparing ourselves against others
• A means of making sure we’re safe
• A means of patients telling us if we’re doing the right
thing
• A means of informing patients and facilitating
informed choice
Performance Indicators
• Deaths/survival rates
• Unexpected re-admissions
• Unexpected re-operations
• Infection rates
• Adverse incidents
• Clinical complaints
BHL in-patient mortality (QIP indicator 3.1); deaths as % of in-patient discharges, 2005
1.4
1.2
UK Ind. Mean +2 SD
1 UK Ind. Mean
BHL Mean
Rate (%)
0.8
0.6
0.4
0.2
0
AL BR BU CB CD CL ED GP HP HT HW LA LC LD MN NC NW PK PT RD RG SB TW WA WL WR
Hospital
BUPA Hospitals rates for clinical indicators
(Most indicators <0.5% of discharges)
1.0
% Surgical Deaths
0.9
% Transfers
0.8
% Re-ops
0.7
% of total discharges
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Hospital
BUPA Hospitals rates for clinical indicators
(What about the other 99.5% of patients?)
100
% Surgical Deaths
90
% Transfers
80
% Re-ops
70
% of total discharges
60
50
40
30
20
10
0
Hospital
Individuals’ capacity to exercise choice will
depend on 3 factors: understanding choice, and
having confidence and opportunity to choose
People need to be able to
Understanding understand choice in
order to exercise it
effectively
Understanding alone is
insufficient, however.
Confidence People also need
confidence to exercise
choice
…And people need the
Opportunity opportunity to exercise
choice
Without each of these elements, the consumer cannot successfully exercise choice
Raised The right The
awareness information involvement
of choice delivered of Healthcare
through the professionals
right channels,
in the right
format
Understanding
Confidence
Opportunity
Will increase Will increase an Will support
understanding individual’s individual’s
understanding of understanding and
and confidence confidence and will
to exercise ensure (s)he has the
choice chance to exercise
meaningful choice
Patient-Reported Outcome
• An additional insight, independent of data collection
on the ward, or by the consultant
• Shifts emphasis from ‘failure’ to health gain
• SF-36: the nearest thing to ‘gold standard’
– Rigorous development
– Validated worldwide
– Huge research literature
• Generic tools vs condition-specific eg VF-14
Outcome tools : SF-36, VF-14, Oxford
• We have used SF-36 since 1998 to monitor, for example:
– Inguinal hernia
– Laparoscopic cholecystectomy
– Hysterectomy
– Septoplasty
– TURP
– Augmentation mammoplasty
• VF-14 used to monitor cataract surgery since 2002
• Oxford scores now used to measure hip & knee replacemtents
Process
• Patients are identified when admission is booked
• SF-36 or VF-14 form sent with ‘to come in’ letter
• Baseline forms collected by hospital, sent to bureau*
• Bureau sends postal questionnaire 12 weeks later
(16 weeks for VF-14)
• Quarterly reporting to hospitals, annually to
consultants
• Patient ID not revealed to consultant or hospital
*Bureau: Outcome Technologies Ltd (BUPA subsidiary)
A typical hospital report (hysterectomy)
Internal monitoring of performance
Clinical Scorecard Q4 Net
2006 Definition Target AL BR BU CD CL ED GP HP HT HW LA LC LD MN NC NW PK PT RD RG SB SH TW WA WL WR work
AVLOS Episodes meeting target LOS hip
Q4 ≥ 70 % 50 50 71 61 68 33 74 88 48 59 61 71 48 62 63 69 52 58 94 68 88 77 67 40 83 38 65
Clinical reliability
variance arthroplasty (5d)
AVLOS Episodes meeting target LOS
Q4 ≥ 70 % 71 74 73 22 77 40 70 56 77 67 79 78 67 70 38 62 65 70 83 51 56 85 70 80 69 67 68
variance knee arthroplasty (5d)
A ≥ 40% 62 47 57 61 77 48 54 23 52 55 52 59 29 37 50 33 55 32 38 39 30 43 48 39 37 36 41
Blood usage Blood cross matched -transfused
Prosthesis % Contracted referral
Q4 ≥ 95 % 100 91 100 0 100 88 100 50 68
compliance arthroplasties with standardised
Cases of MRSA bacteraemia per
MRSA rate Q4 < 0% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.00
1000 bed days
Surgical site Hip arthroplasty site infections as
Q4 ≤ 1% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.56 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.94 0.00 0.00 0.00 0.21
infection % total procedures
Surgical site Knee arthroplasty site infections
Q4 ≤ 0.8 % 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
infection as % total procedures
QIP definition - as % inpatient
Patient safety
DVT/PE rate Q4 ≤ Mean 0.00 0.00 0.13 0.00 0.00 0.09 0.00 0.12 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.28 0.00 0.00 0.30 0.00 0.00 0.00 0.04
surgical admissions
Sentinel
Perioperative QIP definition - within 48 hours
Q4 0 0.00 0.00 0.00 0.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.26 0.00 0.00 0.13 0.00 0.00 0.00 0.00 0.02
mortality anaesthetic
Unplanned
return to Q4 ≤ 0.5 0.61 0.29 0.53 0.22 0.67 0.78 0.34 0.35 1.08 0.69 1.20 1.36 0.81 1.06 0.83 1.41 0.19 0.48 0.51 0.84 0.38 1.32 1.78 0.70 1.18 0.52 0.73
QIP definition
theatre
Critical Care
procedure
Q4 ≤ 0.2 0.00 0.00 0.24 0.64 0.15 0.00 0.28 0.23 0.41 0.60 0.43 0.76 0.20 0.87 0.19 0.30 0.00 0.00 0.76 0.00 0.00 0.60 0.50 0.00 0.00 0.23 0.28
Transfers QIP definition (level 2 and 3)
Falls Q4 ≤ 0.2 0.00 0.05 0.08 0.00 0.14 0.11 0.25 0.11 0.16 0.08 0.00 0.13 0.04 0.07 0.08 0.04 0.21 0.22 0.00 0.00 0.27 0.04 0.08 0.24 0.43 0.20 0.10
QIP definition
Readmission Q4 QIP definition - within 31 days ≤ 0.9 1.17 0.48 1.08 0.43 0.77 1.03 1.70 0.12 0.84 0.60 2.14 0.61 0.79 1.74 1.71 0.60 0.16 0.31 0.54 0.72 1.44 2.02 0.47 0.86 1.15 0.89
outcomes,
Hand washing
A Hand washing audit score ≥ 85 % 87 80 88 90 85 80 84 96 95 84 94 93 87 81 95 81 92 84 96 88 88 80 83 81 99 87 88
audit
Record keeping audit score EWS
EWS Q4 ≥ 75% 51 52 28 100 16 16 86 32 51 48 62 48 63 46 97 65 56 86 62 66 90 74 20 12 59
full compliance
against
% fully signed /dated consultant
Patient record Q4 ≥ 70% 11 35 3 3 21 23 10 17 7 18 28 18 1 17 70 61 31 45 58 28 29 1 11 31 27
Governance
entries
NJR Complying with NJR submission
Q4 ≥ 90% 91 84 92 45 84 98 80 96 10 50 73 60 21 54 68 91 0 95 97 80 97 85 62 0 81 63
compliance as % total
TSSU Hospitals using CE accredited
internal
Q4 Y P Y N Y N Y Y N Y P P P N Y P P Y P Y N P P P P P P
compliance service
Outcomes % of available Sentinel pre-
Q3 ≥ 60% 55 53 37 83 61 50 22 34 7 82 45 56 49 54 13 69 56 90 35 27 68 65 79 57 54 10 50
first pass operative questionnaire
Nunber of Core and Acute
Regulation <6 2 1 0 0 5 0 1 2 7 3 0 6 0 1 0 16 0 0 9 5 6 19 0 0 4 2 3
quarterly
Standards not met
Patient % replying excellent/very good to
Q3 ≥ 80% 89 89 92 89 84 93 83 88 91 87 95 94 91 88 89 90 90 90 81 88 87 92 92 92 90 77 89
Patient empowerment
satisfaction prepared for stay
Patient % replying excellent/very good to
Q3 ≥ 90% 95 90 90 93 92 91 91 89 99 86 92 96 93 87 90 90 91 98 86 97 86 96 95 88 95 91 92
satisfaction cleanliness index
target
Patient % replying definately to advise
Q3 ≥ 70% 63 58 63 62 68 68 61 69 69 60 71 71 62 60 61 66 65 68 60 72 58 63 74 63 67 60 60
satisfaction friend to use
Patient % replying excellent/very good to
Q3 ≥ 90% 91 87 87 88 92 95 85 90 94 87 87 96 87 86 86 92 87 94 88 88 84 96 89 90 90 86 89
satisfaction overall satisfaction index
Complaints per 1000 patient
Complaints Q4 < /=1 2.0 0.7 0.8 2.3 1.3 1.0 1.5 1.3 1.0 1.0 3.2 1.9 1.2 2.7 0.8 1.3 1.3 1.0 0.1 0.6 2.0 1.0 2.5 1.9 1.1 2.7 2
episodes
Clinical % increase in SF36 score for hip
Q4 ≥ mean 1.8 6.1 12.3 6.1 12.0 7.0 13.4 -2.4 14.2 6.3 9.5 12.3 2.7 12.5 17.5 6.5 12.5 5.7 9.2 9.1
Outcome arthroplasty
Clinical % increase in oxford score for
Q4 ≥ mean
Outcome knee arthroplasty
Clinical % increase in SF36 score for lap
Q4 ≥ mean 8.7 2.4 0.5 5.6 -2.9 7.9 6.0 6.6 3.0 5.4 5.7 6.6 0.8 9.1 8.1 -3.2 4.7
Clinical effectiveness
Outcome cholecystectomy
Clinical % increase in VF14 score for
Q4 ≥ mean 5.1 7.1 8.4 10.7 14.6 11.3 11.1 9.5 11.3 9.4 16.9 9.4 5.3 5.6 7.9 7.7 8.7 31.8 11.2
Outcome phako
Clinical % increase in SF36 score for
Q4 ≥ mean 3.0 -2.3 3.5 0.5 1.2 5.5 -1.9 1.3
Outcome septoplasty
Clinical % increase in SF36 score for
Q4 ≥ mean 5.2 1.1 6.4 -4.6 7.3 0.6 0.7 5.5 0.4 6.0 -1.9 -1.3 3.6 5.1 2.6 4.6 10.5 -1.8 4.0 0.6 9.7 7.1 3.5
Outcome inguinal hernia
Clinical % increase in SF36 score for aug
Q4 ≥ mean 1.1 -3.9 0.5 -1.1 -0.4 7.2 -0.3 -0.5 -3.1 -1.3 -1.0 -2.9 -0.3
Outcome mammoplasty
Clinical % increase in SF36 score for
Q4 ≥ mean 0.5 -3.1 4.2 -0.3 2.8 4.9 3.0 2.9 -0.1 6.5 -0.3 -5.0 -0.5 -0.5 2.7 10.9 7.1 2.4
Outcome hysterectomy
Clinical % increase in SF36 score for
Q4 ≥ mean 4.8 -0.6 -2.6 7.0 1.2 1.1 1.7
Outcome TURP
Consultant Consultant satisfaction score
Staff empwnt
A ≥ 58% 56 64 77 57 71 75 34 62 83 62 50 26 72 60 69 29 62 73 41 53 32 84 50 46 34 57
satisfaction (%excellent/very good)
RGN's as % of ward total nursing
Skill mix Q3 ≤ 65 % 79 60 71 62 69 79 70 67 83 70 75 68 76 79 72 73 83 69 64 81 77 60 68 73 69 84 73
complement
Employee Employee overall satisfaction
A ≥ 80% 86 83 84 81 76 81 82 86 72 79 81 80 80 78 83 78 84 80 78 74 75 80 82 73 81 75 79
satisfaction score from SOP
Changed on 15/2/06 v4
The challenge of
how to explain
complex
statistics in very
simple terms
Listen to
our
consumers
Help to Give
develop consumers
new tools real
appropriate information
to specialty for choice
Involve
health
professional
s in
outcomes
Outcome Technologies Ltd
• Wide range of tools such as SF36, VF14, Oxford Hip and
Knee Scores etc.
• Consultancy service to identify appropriate outcome tools
• Largest SF-36 database in Europe
• Scaleable and cost effective capture of outcomes
• Ability to use wide selection of media – Paper, Email, Phone,
Text, Fax, PC etc.
• Contact: c.minnett@outcometechnologies.com
+44 (0)207 656 2460
Any
Questions?