Improving service delivery with benchmarked data

benchmarked data

The Southern Health and Social Care Trust provides health and social care services in Northern Ireland across the three council areas of Armagh City, Banbridge and Craigavon Borough Council, Mid Ulster District Council (Dungannon and South Tyrone) and Newry, Mourne and Down District.

It runs Craigavon Area Hospital, Daisy Hill Hospital, Lurgan Hospital, South Tyrone Hospital, Armagh Community Hospital and St Luke’s Hospital. The Trust won the 2022 CHKS Top Hospitals award for benchmarking and is now producing detailed mortality reports which are being used as the basis for quality improvement and assurance.

Benchmarking data provided the foundation for improving care and outcomes

Southern Health and Social Care Trust has worked closely with healthcare intelligence company CHKS to provide an in-depth and comprehensive mortality review that enables benchmarking against other organisations while also providing a comprehensive picture of performance, that can help reshape service delivery, improve care and outcomes.

Using the CHKS quarterly mortality rates, the Southern Trust Quarterly Mortality Report uses the data as a foundation to build a detailed picture of performance and quality for every speciality service within the Trust. Triangulating the quantitative information with qualitative information (sourced through consultant review of highlighted cases, morbidity and mortality meetings, serious adverse incidents and complaints) which can reveal where processes are working well, but also highlight where learning is needed to improve service delivery.

CHKS data comprises a significant part of the report which is presented to the trust board and governance committee, to convey how the trust is performing as a whole and as individual sites, before drilling down further into specialities. The report generates an extra level of assurance with each Divisional Medical Director reviewing the deaths to quality assure the actions taken by their consultants.

As a result, there have been improvements to access to stroke services, development of a Diabetes Education Programme for medical staff and a review of hypoglycaemia management guidelines.

Using data to reflect on performance and improve service delivery

Suzanne Barr, the Trust’s Senior Systems Assurance and Improvement Manager manages the report which helps to provide the maximum assurance for board members that the Trust’s processes are leading to the best possible outcomes.

“The data was telling us what the outcome was, but we needed to link this with our activity to ensure this was good as it could have been. For example, with non-elective surgery, we knew we were doing well in comparison to our peers, but as an organisation we need to ask if we can do better,” she said. “I wanted to give as much assurance to senior managers and the board as possible but sometimes the data doesn’t mean that much on its own. I wanted to make the data the main character in the story and build the narrative around it.”

The regular data review from CHKS allowed for routine benchmarking within the organisation, as well as regionally and with UK peers. Using this as a starting point enabled the trust to review clinical processes, looking inward to see whether the data was truly reflective of the way that they were working and where/if change could be made to improve services and delivery of care.

“The report has evolved over time. The data was giving us assurance but now it has more meaning and value. It helps us to scrutinise what we are doing and ask ourselves, did we follow the processes and did we learn from it?”

Suzanne Barr, Senior Systems Assurance and Improvement Manager

Suzanne believes staff are buying into the new report. The clinical teams knows it is more than just a box ticking exercise and are taking greater ownership because they know there is clear value, purpose and meaning in the processes.

The focus on processes in the report has highlighted the importance of good data and how it can reveal the bigger picture within healthcare systems.

“Data is paramount to the report, you can’t do one without the other. Staff and senior managers are starting to see the point of having data as a narrative and how the process must be right in order for the data to be right.”

Suzanne Barr, Senior Systems Assurance and Improvement Manager

Support from CHKS in creating the report was also crucial. Suzanne built up a good relationship with the team, enabling her to able to work closely with CHKS to ensure she was receiving the information she needed for the report.

“It was good to know I could email them to ask for help or clarification and they would always reply really quickly,” Suzanne commented. “The CHKS team was very helpful and wanted me to have a good understanding of the information that was being sent to me. CHKS support was vital in ensuring I had insight into the data presentation, without this collaborative working, utilising the data would have been much more challenging.”

The report has been well received across the Trust and by the senior management team.

Southern Health and Social Care Trust Chairperson, Eileen Mullan, said: “the CHKS data presented in the Trust report provides the opportunity to benchmark our care against others, not only in the region but also across the UK. The data has become an integral part of assurance that the Trust is delivering safe and effective care, actively identifying areas for improvement and developing services as best we can, for our patients, their families/ carers and our staff.”

The Trust’s Chief Executive, Dr Maria O’Kane, added: “the Southern Trust uses the CHKS mortality data as a key part of our patient safety assurance processes. The data is scrutinised and cross referenced with Trust information and processes including adverse incident information, allowing triangulation of data to inform quality improvement activities and provide assurance on the safety of our services to our Trust Board members.”

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