177 hospitals admitted 65958 patients with hip fracture last year. Ensuring safe, effective and equitable care remains a major public health issue. Overall one year mortality is high at 30%. The pathway of care is complex. Survivors often face a life with decreased function, with 15% to 20% of people needing to change residence. The cost of care provision is high and set to rise sharply as our population ages.
High quality, safe care requires the coordinated effort of a multidisciplinary team who are committed to evidence-based and person-centred care. Our hip fracture improvement programme (HIP QIP) had been running for 4 years and had been extremely successful
Our programme sought to make further improvements in Northumbria following major organisational change and radical pathway redesign on the opening of a new emergency care hospital in 2015. Our ambition was also to see these improvements adopted in 4 partner NHS organisations. Project setting: 5 NHS acute orthopaedic units in England. 3 of the sites joining Northumbria in this safety collaborative were deliberately selected based on poor outcomes in the National Hip Fracture Data base (NHFD) annual report.
By 2036, there could be as many as 140,000 people admitted with hip fracture each year. The number of attributed hospital bed days is set to double by 2036 and the annual cost of care predicted to top £6billion by this time.
Through high quality, safe, and evidence based care, our primary goal was to save 100 additional lives by the end of a 2 year collaborative. In seeking to replicate HIP QIP in other organisations we knew our aims were highly ambitious: most NHS scaling efforts do not succeed.
Don Berwick in ‘Organising for Quality’ (2008) hints at how tough spread and adoption can be. Dixon Woods (2014) explores this issue and offers reasons why interventions, that were previously successful, might then fail when implemented in a new and different context.
Either the approach to improving quality in the new environment is not the same even if it appears to be i.e. ‘there is heterogeneity in implementing the intervention’ or the new context is so fundamentally different from the old context that the intervention cannot work i.e.
‘There is heterogeneity in the context.’ Or the challenge of successfully replicating improvements might be a combination of both of these things.
HIP QIP launched in September 2016 supported by The Health Foundation’s Scaling up Improvement programme. We deliberately partnered with organisations who were outliers for mortality based on NHFD data. Across the 4 English HIP QIP hospitals 30 day mortality fell from 9.2% in the year to August 2016, to just 5.8% for people presenting in the year to August 2018.
Results for the Scottish site were not included in the external review of mortality in the absence of NHFD data. Mortality also fell in 16 matched control hospitals who were recording the same 30 day mortality figure at baseline. Improvement in these controls was more limited; only falling to 7.7% for people presenting in the year to August 2018. Analysing the HIP QIP hospitals’ results, 119 fewer deaths were recorded than would have been expected if mortality had remained at the baseline figure of 9.2%.
The true impact of the HIP QIP intervention is highlighted by the fact the four HIP QIP hospitals prevented an additional 77 deaths – above and beyond any QI changes in the 16 control hospitals made in the same time period. Mortality graphs and infographic illustrating further patient safety outcomes are included as an attachment.
During the set up phase, all of the participating sites received a peer review coordinated by the British Orthopaedic Association. This provided a more detailed understanding of organisational context and challenges. We then brought teams together for 5 learning events to review the evidence supporting best care, exchange ideas and discover the potential for improvement that existed.
These sessions were supported by programme leads, orthopaedic experts, improvement fellows and patient leaders. We established Quality Accounts to outline deliberately ambitious but focused improvement standards. We knew that projects that are underpinned by a strong evidence base are more likely to succeed. Patient stories highlighted the consequences of poor or fragmented care and added further weight to the case for change.
Our intention was to take time to build trust and foster a strong sense of community, a shared ownership of change and an improvement climate in which we all felt able to help each other to be better. Between learning sessions (during “action periods”), teams tested and implemented changes in their local settings and collected data to measure the impact of these changes. Participants felt encouraged to report their changes and results, sharing all experiences – including the unintended consequences of improvement
In addition to lives saved by reducing mortality from 9.9% to 5.9%, for Northumbria Healthcare, there was an additional opportunity to demonstrate added value of safer care with reduced costs through radical pathway redesign and the opening of a new emergency care hospital.
Overall, Northumbria has reduced LOS from nearly 30 days to around 20 since 2008 (see rolling average graph). In the last 12 months alone however, with mortality performance at its best, length of stay has fallen by 4 days. Yasin and Saqib (2015) placed the average daily cost of an inpatient rehabilitation stay at £287.39. This estimate would suggest a benefit for the 4 day reduction observed in the last 12 months of approximately £1,150 per patient. For the 695 Northumbria patients cared for in 2017, this would lead to annual savings of 800k in organisational costs alone.
Placing a value on lives saved is complex. The standard unit for Quality of Life analysis is a QALY (Quality Adjusted Life Years). External evaluators, as part of our acute care collaboration Vanguard, have independently assessed HIP QIP data and concluded a total social value of £1m based on 39.7 QALYs saved by the Collaborative’s intervention in 2017
Experience from Safety Campaigns show that QI communities should combine grass roots momentum with vertical integrating structures that co-ordinate and manage potentially competing interests. Success has been achieved through significant and on-going investment in a number of important relationships. Support from the Health Foundation enabled us to invest time and resources where it mattered.
Funding for nutritional assistants was critical to mortality reduction. It is particularly rewarding to know that this initial pump priming has been replaced with substantive funding in each of the adopting sites. The involvement of the British Orthopaedic Association for peer reviews, and the Royal College of Physicians for outcome evaluation added further weight and credibility to the work we wanted to do.
Our commitment to person centred care lay at the heart of all of this. Well trained and supported patient leaders, together with real time patient experience feedback from over a thousand patients, has brought a unique and valuable perspective to inform, influence and contribute to our improvement work. Finally, highly engaged and committed collaborative site teams have enabled front line staff closest to the issue to play the lead role in developing changes and testing whether these change result in the improvements predicted.