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In 2008, Lord Darzi’s report, High Quality Care for All, was published as the final part of the NHS Next Stage Review.

A major aim of the report was to change the focus of the NHS, away from building capacity, towards providing high quality care. “High quality care” in this case, is defined as safe and effective care of which the patient’s whole experience is positive.

“We can only be sure to improve what we can actually measure,” said Lord Darzi in his 2008 report and to this end, a constantly evolving set of “measures of quality improvement” (MQI) or metrics, is being devised.

At the heart of the MQIs are the three themes: safety, effectiveness and patient experience.

Following an online survey, and consultation with specialist organisations and Royal Colleges in April 2009, a set of more than 200 independent quality indicators (IQI) were released onto the NHS information website. They are defined as being:

• A resource for local clinical teams, providing a set of robust indicators from which they can select as the basis for local quality improvement
• A source of indicators for local benchmarking

The theory is that they will assist local health economies to measure the quality of their services; this information can then be used to improve customer care.

Metrics in Geriatric Medicine
A menu of 240 existing indicators were gathered., only some of which can be adapted for the specialty of geriatric medicine. “Death” being too blunt a measure, there are MQI markers such as length of stay; discharge destination; patient feedback, time to CT; time to hip surgery.

Rehabilitation is recognised as a tricky measure and the only MQI established so far, is: “How soon after stroke is patient seen by a therapist?”

In mid July 2009, data values for over two thirds of these indicators was released onto the MQI website.

Of the three criteria mentioned above, most fall into the ‘effectiveness’ category.

The Department of Health treats the development of indicators as an evolving project, with further metrics to be established over 3-5 years following ongoing consultation with professional bodies and specialist societies.

Clinical Dashboards
‘Clinical Dashboards’ are part of the NHS Connecting for Health programme, and are likely to be a way of applying metrics in daily work. They are defined as a “toolset developed to provide clinicians with the information they need to inform daily decisions that improve quality of patient care”.

They remain in the pilot phase, and are being trialled in a variety of medical and surgical specialities throughout England, as well as in primary care. The Geriatric Medicine pilot has been taking place in Salford and commenced in May 2009. If clinical dashboards are deemed to be successful, it is planned to implement them nationally throughout all specialities.

The theory behind dashboards is that they will integrate relevant data into a single display; each department or team will be able to modify their own dashboards to their needs and workload. Their own data will be displayed alongside national metrics and best practice guidelines.

The NHS Connecting for Health website the benefits of the dashboards as:

• Providing better information for clinical teams presented in an easy to understand format
• Utilising multiple sources of pre-existing data, providing clinical information relevant across a multi-disciplinary team
• Real time information, facilitating immediate decisions to improve care and avoid delay
• Improved data quality through immediate visualisation of data
• Capacity to be configured to local requirements while providing comparison against national data sets.

Setting up clinical dashboards
I have discussed the current methods for configuring a Clinical Dashboard with Dr Sally Getgood, Clinical Speciality Lead for the dashboards programme. Initially a meeting is held with the relevant clinical teams to identify the areas of key interest, or any problem areas that could be helped by the use of the software. Relevant metrics relating to these areas are identified, and discussion is held with the Trust’s IT team to establish the areas where data is readily available. A further meeting with lead clinicians is then held to confirm the data to be included. The dashboard is then built specifically for that team.

Potential Pitfalls
Clearly the Clinical Dashboards are in a very early stage, and it is impossible to assess how effective they will be until they are in use in a greater number of centres and cover a number of clinical areas within a speciality.

There are, however, some areas of potential concern from the information available already:

• How well are the current IT systems available on the hospital wards going to cope with a further, complex demand on them – it is already common for ward-rounds to take longer as a result of electronic prescribing and PACS systems?
• Who is going to input the data to keep the dashboards up to date and working in real-time?
• Will they pick up issues relevant to us as practicing geriatricians, in patients not currently under our care? If so, will there be appropriate remuneration for the additional input to the care of these people?
• Are they further expanding the ‘tick-box’ culture which seems to beset modern hospital medicine?

The Future
Metrics, or IQI, are here to stay, and are likely to become increasingly relevant. They will give us a way to measure the care we provide, which in turn will help to show the relevance of services that geriatricians can provide to the healthcare commissioners. We currently have the opportunity to influence the creation of Metrics relevant to our speciality and it is vital we grasp this with both hands.

Zoe Wyrko
SpR Geriatric Medicine
BGS lead on Metrics and Clinical Dashboards

Useful websites:

www.dh.gov.uk/en/Healthcare/Highqualitycareforall/MeasuringforQualityImprovement/DH_099998

www.ic.nhs.uk/services/measuring-for-quality-improvement

www.connectingforhealth.nhs.uk/systemsandservices/clindash

BGS Newsletter, September 2009
Issue 23 ISSN 1748-634000 23