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Quality and Safety inPrivate Healthcare

Andrew Vallance-OwenGroup Medical Director

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Quality – The Target

Appropriate, cost-effective care and treatment

whose outcomes will benefit the patient

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Quality – The Target

• The right treatment

• At the right time

• Managed by the right person

• In the right place

Where ‘appropriate’ means:

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The Cochrane Principle

“Best clinical practice often represents best financial value in healthcare”

Cochrane AL (1999) Effectiveness and Efficiency.

Random Reflections on Health Services. March. 3rd Edition. Royal Society of Medicine Press, London. ISBN 1-85315-394-X

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Professor Jack Wennberg and Professor Elliott Fisher Dartmouth Medical School

• Compared with the lowest use areas, people in the highest use areas get ten times as many prostate operations, six times as many back operations, seven times as many coronary angioplasties and ten times as many hospital days if they have heart failure

• What predicts the rate is the number of specialists per capita. The more doctors, the more consultations

• High use did not mean better quality of care and outcomes. In fact, for many measures, quality and outcomes were best in the low-use areas

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National Institute for Health and Clinical Excellence(NICE)

• An independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of good health

• Guidance is developed using the expertise of the NHS and the wider healthcare community, including NHS staff, healthcare professionals, patients and carers, industry and the academic world.

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NICE Produces Guidance in Three Areas

• Health technologies - including new and existing medicines, treatments and procedures

• Clinical practice - appropriate treatment and care of people with specific diseases and conditions

• Public health - guidance on the promotion of health and the prevention of ill health

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Implementation of NICE Guidance

“Once NICE publishes clinical guidance, health professionals and the organisations that employ them are expected to take it fully into account when deciding what treatments to give to people.”

“To develop NICE interventional procedures guidance, NICE reviews evidence and collects and analyses information. By providing guidance on how safe procedures are and how well they work, NICE makes it possible for new treatments and tests to be introduced into the NHS in a responsible way.”

A Guide to NICE 2006

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Speciality networks

Driving the Quality agenda forward

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BUPA’s Role

• BUPA seeks to be at the forefront of developments in quality based contracting

• We have a responsibility to set and monitor standards. This is in the members’ interests

• We have built the credibility to challenge

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Approved Cancer Hospitals

• BUPA spends $35m AUD per year on the diagnosis and treatment of breast and bowel cancer

• BUPA was the first UK insurer to develop a national network of quality assured hospitals for breast and bowel cancer

• Currently over 130 BUPA Approved Breast and 120 BUPA Approved Bowel Cancer Hospitals

10/05

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Why is BUPA’s accreditation process for cancer units important?

A study in the British Journal of Cancer states that “Local recurrence rates were 57% lower and the risk of death from breast cancer was 20% lower for women treated in specialist units…the surgical management in specialised breast units is more often adequate, local and regional recurrence rates are lower, and survival is correspondingly better.”

Of those who applied to be an approved cancer hospital just 64% have been able to meet the standards we seek

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Case Management

• Nurses micro manage treatment & work with providers to ensure delivery of appropriate, cost effective care

• 32 experienced nurses and 29 expert advisors

• Manage complex care – diseases and cases– critical care– cancer care– rehabilitation– back pain– medical cases & psychiatry

• BUPA Initiatives do change clinical practice– Wisdom Teeth Extraction– Hysterectomy

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Supported Decisions - BUPA Healthline

24 hour health Information Service made up of :

• A team of specialist nurses, available 24/7

• Supported by research based health information

• Confidential service• Triage via a comprehensive symptom assessment• Information on specific health topics & Travel advice• Self help groups & Fact sheets• Home Treatments• Advice on medications

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Patient Satisfaction Survey

• Monthly survey to approx 5,000 randomly selected members who have had an inpatient or day case episode of care asking them for feedback about their hospital stay.

• Key themes below:– 85% of members rated the overall service provided

by the hospital as excellent or very good;– 94% of members said that the overall service met

or exceeded their expectations;– 74% of members rated the overall level of comfort

as excellent or very good;– 84% of members rated the hospital as very clean;– 80% of members rated the nursing staff as excellent

or very good for each of the five questions relating to them (e.g. attitude/efficiency)

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Compare Practice with

standards

Compare Practice with

standards

Clinical improvement cycle

Set Standards

Set Standards

Measure OutcomesMeasure

Outcomes

Improve StandardsImprove

Standards

Peer Review

Peer Review

Improve PracticeImprove Practice

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BHL in-patient mortality (QIP indicator 3.1); deaths as % of in-patient discharges, 2005

0

0.2

0.4

0.6

0.8

1

1.2

1.4

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

Rat

e (%

)

UK Ind. Mean +2 SD

UK Ind. Mean

BHL Mean

Rate %

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BUPA Hospitals rates for clinical indicators(Most indicators <0.5% of discharges)

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Hospital

% o

f to

tal d

isc

ha

rge

s

% Surgical Deaths

% Transfers

% Re-ops

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BUPA Hospitals rates for clinical indicators(What about the other 99.5% of patients?)

0

10

20

30

40

50

60

70

80

90

100

Hospital

% o

f to

tal d

isch

arg

es

% Surgical Deaths

% Transfers

% Re-ops

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Functional Outcome Measurement

• Thoroughly validated and reviewed

• Suitable for most surgical, medical and psychiatric treatment

• Measures physical and psychological health status

• Risk-adjusts

• Reliable process for collecting data

• Does not impose extra work on clinicians

Why SF-36?

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The SF-36 Survey Process

• The baseline questionnaire is completed by the patient at admission

• A follow-up questionnaire is sent to the patient at twelve weeks after the treatment

• The participation of the patient is entirely voluntary

• Patients cannot be identified by their doctors

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Change in SF-36 Physical Summary Score after 12 weeksBUPA Hospitals top-20 therapeutic procedures

-4

-2

0

2

4

6

8

10

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Phako

emuls

ificati

on of le

ns

TURP

Excisi

on o

f lesio

n of sk

in or s

ubcu

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us tis

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Septo

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ose

Surgica

l rem

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th

Ligatio

n/strip

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ng/sh

ort v

ein

Thera

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c OGD

Hyste

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Carpal/

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lease

Sub-a

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Cathete

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Total

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an

ch

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um

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Change in SF-36 Mental Summary Score after 12 weeksBUPA Hospitals top-20 therapeutic procedures

-3

-2

-1

0

1

2

3

4

5

6

Thera

end

o ops

cavit

y of k

nee

Total

pros

thet

ic re

place

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t of k

nee jo

int

Carpal/

cubit

al tunn

el re

lease

Thera

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Primar

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Phako

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Surgica

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d tee

th

Excisi

on o

f lesio

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Ligatio

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Sub-a

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ecompre

ssion

Septo

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ose

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Epidur

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(lum

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Cathete

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t

Total

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ic re

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ip jo

int

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c OGD

Lapa

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Tonsil

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Autog

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Hyste

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Me

an

ch

an

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in M

en

tal S

um

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ry S

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(an

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e in

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al)

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Professor Sir Cyril ChantlerChairman, Great Ormond Street Hospital

“Medicine used to be simple, ineffective and safenow it’s complex, effective, and potentially dangerous”

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BUPA

Vision

“Caring for the lives in our hands”

Mission

“To help our customers liver longer, healthier and more productive lives”