Guidance on the Quality Improvement Criteria

The Daffodil Standards are not meant to be 'perfectionistic', instead they allow all staff to start and improve at their own individual pace and for a practice to understand and build on their strategy to reliably support all patients with advanced serious illness and end of life care needs, as a journey. The aim is to support a practice to always be ready to ask questions, find new solutions and continue to make small steps – testing change, removing problems/ inefficiencies and refining practice. Details of some of these tools that you could use can be found in the QI guidance below.

Q1 Yearly SWOT (Strengths/ Weaknesses/ Opportunities/ Threats) analysis of the practice's ability to provide high quality, safe and compassionate care for people affected by Advanced Serious Illness and End of Life Care

Yearly SWOT (strengths, weaknesses, opportunities and threats) analysis of the practice's ability to provide high quality, safe and compassionate care for people affected by Advanced Serious Illness and End of Life Care.

Guidance

This involves considering your practice team in terms of its 'Strengths', 'Weaknesses', 'Opportunities' and 'Threats'. This exercise is very useful in bringing together individuals with different viewpoints, so that they can air their opinions and concerns and at the same time hear why others are excited by care for people affected by Advanced Serious Illness and End of Life Care. With a focus on safe and compassionate care for people affected by Advanced Serious Illness and End of Life Care, ask the group to answer the following question and write their response down, one per post-it note.

In this aspect of care …

  • What are our strengths?
  • What are our weaknesses?
  • What opportunities can we see?
  • What threats can we see?

Then collate the post-it notes on a flip chart divided into 4 quadrants, asking for clarification about what is written if necessary, so all views are heard.

RCGP Daffodil Standards QI SWOT table

The team can then build on the strengths and opportunities, address the weakness and avoid the threats.

Q2 Monthly recording of percentage of practice list that is on Advanced Serious Illness + EOLC register

Monthly recording of percentage of patients on the practice list that is on Supporting Care Register with Advanced Serious Illness and EOLC. Displayed on a line graph, considering a number (or %) that is aligned with their population. Defined practice population (or %) = number of deaths in the last 12 months / total practice population.

Guidance

The national average of people dying each year is approximately 1%, but this can vary between individual practices due to differences in the demographics of the practice population. Practices can use the number of deaths reported in the previous year to calculate their own figure and use this to assess how well they are identifying patients who would benefit from end of life care. Estimates suggest that between 75-90% of deaths may be anticipated but this can be challenging to achieve in practice. A very good practice would be anticipating approximately 60% of deaths. 

Record the percentage of the people who died AND who had been identified on the supportive care register on the last day of each month. Plot the percentages on a line graph with the goal  e.g. 60% drawn as a line across the graph. There may be reasons related to your practice demographics where a lower goal can be justified. Display the graph in a prominent position in the practice where all involved in creating the list can see the effect of their work.

percentage on supportive care register

Q3 Interview a different carer every 6 months

Collect feedback (for example, sensitively discuss/ interview, survey) patients and carers to assess whether they think the practice is meeting their needs, and show how any information provided is used to help improve care and support.

Guidance

Sensitive patient and carer involvement is an important element of quality improvement.

Using a semi-structured question format for people may be helpful.

This discussion/ interview should occur separately  to  any  contact related to  their needs assessment.

Notes should be taken and suggestions for change for that individual or for the practice as a whole taken to the practice meeting +/- MDT to consider how these changes can be implemented. Feedback on what is planned should be delivered to the carer interviewed.

Q4 Retrospective Death Audit

Incorporate the use of Supportive Care Register Template to support better and consistent decision making and discussions at practice meetings and MDTs for patients and carers/those important to them. 

Use the same template to consider all deaths and any learning (for people identified on the Supportive Care Register and people who died but were not identified). 

If reflected on regularly at each MDT (for example, monthly), this naturally helps the practice a) plan care and support for those identified and b) learn from deaths. In addition, the template forms the basis of a regular (for example, annually) practice Retrospective Death Audit (to cover an agreed time) and action taken where outcomes achieved do not meet the practice accepted standards. 

Consider continuous monitoring of template criteria e.g. preferred place of death achieved, which are plotted on a line graph monthly. Consider National Information Standard for minimum EOLC dataset.

Guidance

1. Annual retrospective death audit.

This annual retrospective death audit may include less criteria than the first audit included in the evidence for the standards. You could omit criteria where there was no room for improvement.
The following are standard headings for a clinical audit report, with tips on how to define and fulfill each section. This process satisfies the requirements of General Medical Council revalidation. 

Step 1: Title
A retrospective death audit

Step 2: Reason for the audit

To assess the standard of care the practice is providing for patients with advanced serious illness and at the end of their life.

Step 3: Criteria or criterion to be measured
Keep your audit simple and effective by choosing just a small number of criteria. Each criterion should pose easy ‘yes’ or ‘no’ questions so you will know if it has been met. The following criteria are examples of what can be included in the audit

• Patient reference

• Patient name

• Usual GP

• Care-giver or NOK identified?

• On QOF supporting care register?

• Time on supporting care register

• On shared electronic record?

• Date of death

• Age - at death

• Gender

• Cause of death OR major diagnosis

• Planable/expected OR sudden/unplanable death

• Known to specialist palliative care team?

• PCSP discussions sensitively offered a) treatment escalation b) advance care plan including DNACPR c) carer support map

• PPC recorded

• Reason for variance if different to PPD 

• Usual place of residence

• Place of death

• 5 priorities of care met - in community?

• Contact with bereaved documented

• Patient/family or care-giver feedback received?

• Inequality group?

• Communication and information needs?

• Number of admissions in last 3 months of life

Step 4: Standards set

In audit the RCGP defines a ‘standard’ as the level of performance achieved and expressed as a percentage. It can be derived from external sources, such as audits that have been done elsewhere, or determined internally from discussion with clinicians in the practice. The standard should be realistic rather than idealistic so try and avoid a standard of 100%.

Step 5: Preparation and planning
All patients with ASI or EOLC who died and were on the register should be included in the audit. Decide how you will record your results, whether by using a software package or a simple paper checklist that records Yes/ No/ Not applicable.

Step 6: Results and date of collection 1
Presenting the results in a table makes them easier to understand.
RCGP Daffodil Standards criterion table 1

Figure 1: Template for clinical audit results (collection one)

Step 7: Description of change(s) implemented

From your results it will be easy to see whether or not your criterion or criteria have been met. Based on this, a decision can be taken on the changes to be made. This may be done once results have been presented to others to gain their opinion, especially if the change(s) will affect other team members. Sharing your audit results with the whole practice team will increase the likelihood of improvements being sustained.

Step 8: Results and date of data collection 2

This can be presented in an extension of the previous table, with an additional column for the second data collection
RCGP Daffodil Standards criterion table 2

Figure 2: Template for clinical audit results (collection two)

Step 9: Reflections
Present the conclusions of your audit project including any lessons learned, any further steps of change required and when the audit will be repeated. Even when your target standard has been reached the audit should be repeated to ensure the change is sustained.

2. Regular monitoring

Some of the criteria monitoring (practice choice) should be plotted monthly on a line graph. This is best done as a percentage of all the sampled patients. Once data for a whole year has been collected then a cumulative line graph should be used. The standard percentage should be drawn as a line on the graph. In this the percentage for 12 months is used. Each month then the month at the start of the collection period is excluded and the new month is added to the rest of the 11
month figures. So if you collection of figures commenced in April 18 then when you have the figures for April 19 you omit those for April 18. By doing this it help copes with small numbers of patients dying every month in a practice

Every quarter the percentage of emergency admissions for those on the register should be recorded and plotted. As in the previous monitoring one a year’s figures have been collected then a cumulative line graph could be plotted. Trends can be identified on the graph, discussed and any further action planned.

Q5 The practice has identified areas for improvement from their process map

The practice has identified areas for improvement from their process map (see 5.1b). They then use the 3 questions from the Model for Improvement, which are:

  1. What are we trying to accomplish?
  2. How will we know if a change has made an improvement?
  3. What changes can we make that will result in an improvement? One of these changes at a time are taken into a Plan-Do-Study-Act cycle. Guidance on Model for Improvement and PDSA cycles can be found on the Quality Improvement page. 

Guidance

Often it is not easy to find an effective solution straight from the process map. Hence you can stop the process map tool after you have identified the areas for improvement. You then take one of these areas into the Model for Improvement.

  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What changes can we make that will result in improvement?

RCGP Daffodil Standard Act plan do study cycle image

Question 1: What are we trying to accomplish?

This needs to be specific and include 'by how much?' and 'by when?'

Question 2: How will we know if a change has been an improvement?

Decide what you are going to measure so that you know whether your ideas for change are working.

Question 3: What changes can we make that will result in improvement?

To answer this question, consider all of the ideas for change. This is best done by asking for all team members to suggest a change in a meeting.

Then one of these changes are taken into a PDSA cycle.

Plan

Planning will include identifying who will be responsible for the change; when it will be carried out; over what timescale; and how the measurement will be conducted. Involve all stakeholders in the process and do persuade any reluctant team members to participate. Consider how you might look out for the unexpected.

Do

First collect your baseline data to monitor the existing state of play. You might do this as part of 'planning' or 'doing'. Ensure that all individuals who are conducting the measurements understand what data is being collected and how to collect it. After sufficient time, continue to collect the data but introduce the agreed change. If you are considering implementing several changes, you would usually introduce one change at a time so that the effect of each can be measured. By introducing only a small change you are likely to encounter less resistance, and, if unsuccessful, adaptions can be made more quickly. The scale at which you test your change should also be kept small at first. Any problems encountered, and any unexpected consequences, can be recorded as implementation progresses.

Study

The success or failure of the change is assessed at this stage, both quantitatively (by looking at the data collected) and qualitatively (by discussing how everyone experienced the change). You should compare the results with the predictions you made and document any learning, including a record of the reasons for success or failure. Not all changes result in improvement, but learning can always be gleaned.

Act

In this stage, decide whether you just need to adapt what you have tried or whether you might try something completely new instead.

The online Rubiks Cube solver program will help you find the solution for your unsolved puzzle.

Q6 Audit implementation of 5 priorities of care

Implementation of 5 priorities of care across all deaths and action taken where outcomes achieved do not meet the practice accepted standards. Continuous monitoring of these criteria e.g. pain and symptoms assessed regularly in last days of life.

For example, consider if the practice has a reliable system in place to assess with the patient and those important to them the 5 priorities of care AND document that the 5 priorities of care have been met, where possible. 

Guidance

Guidance on audit can be found in the guidance for QI 4. The 5 priorities of care are:

  1. RECOGNISE: The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly.
  2. COMMUMICATE: Sensitive communication takes place between staff and the person who is dying and those important to them. Conversations are appropriately documented.
  3. INVOLVE: The dying person, and those identified as important to them, are involved in decisions about treatment and care.
  4. SUPPORT: The people important to the dying person are listened to and their needs are respected.
  5. PLAN & DO: Care is tailored to the individual and delivered with compassion – with an individual care plan in place.

Not all these priorities are well recorded in the records but you should encourage future recording. Choose a priority that is recorded and where you think the practice has room for improvement. All deaths on the register should be included. You may wish to do the audit quarterly collecting the data retrospectively or prospectively. You should monitor this data over several quarters.

Q7 Regular audit of support offered to the bereaved

Regular audit of support offered to the bereaved for example, documented contact with the bereaved, support information given. 

Guidance

Guidance on audit can be found in the guidance for QI 4.

You should use criteria that are derived from your practice policy on support of the bereaved. Examples are:

  • An information leaflet is provided to the bereaved
  • A call either by phone or visit is made to the bereaved
  • A quarterly audit done over several quarters would be appropriate.

Q8 Regular SEA meetings in order that lessons can be learned from EOLC

Regular SEA and debrief meetings in order that lessons can be learned from EOLC and deaths. The lessons are shared with the relevant people. 
Annual evaluation of compassionate organisational culture. 

Guidance

SEA meetings have been shown to be a valuable tool in learning. They can form part of a doctor's evidence for appraisal.

SEA process enables the following questions to be answered:

  • What happened and why?
  • What was the impact on those involved (patient, carer, family, GP, practice)?
  • How could things have been different?
  • What can we learn from what happened?
  • What needs to change?

Enhanced significant event analysis is a further improvement to the existing SEA structure. A 'human factors' approach was taken in a NHS Education for Scotland (NES) pilot funded by the Health Foundation Shine programme. It considers contributory factors to an event and their interactions under headings of People factors, Activity factors and Environment factors. Human factors addresses problems by modifying the design of the system to better aid people: to understand and limit conditions in the system that predispose an individual to make an error and to reduce the risk of errors leading to harm. Further details on this study can be found on the NHS Education for Scotland website

The evaluation of compassionate organisational culture can be done through discussion at a practice meeting. In this discussion you are concentrating on how the practice team are supported. Tools such as SWOT analysis (see guidance for QI 1) or a celebrations/frustrations charts can be used. In the latter, two flipchart sheets are used. One is headed celebrations and the other frustrations. Ask the team what they think is good about the practice's compassionate culture and list all comments under "celebrations". They can write the item on a post-it and stick it onto the sheet. Then move onto frustrations, reminding participants that this should not be criticism of a person but rather of systems and processes. Remember to steer the group to completing the celebrations before moving to frustrations. Actions can be considered to overcome the frustrations.

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