The 5 Dimensions of Quality in Healthcare

The “triple aim” is well known to many - that to be rated as high quality, healthcare must score well on patient experience, outcomes achieved and value for money. Or more pithily; care, health and cost. It was devised by the leading institute for quality improvement in healthcare, the Institute for Healthcare Improvement in 2008. More recently though, two important additions have been made to incorporate clinician well-being - an extremely topical subject at the moment in the UK - and reducing health inequalities. These make the new aim (or Quintuple Aim) very much stronger in my view.

The development of these additions is described well in the article at the link below where the authors argue that to provide quality care we must look after staff and that we have an obligation to do all we can to close the health inequalities gap in our work.

We have been using this Quintuple Aim across our work programme this year and I would commend it to others. To bring it to life, some examples of the types of benefit we are identifying through Supporting People at Home - the name of our programme seeking to accelerate the use of digital home care across the NHS in England - follow.

About the Quintuple aim –         

The full text of Kedar Mate's article is at the link and this quote summarises it -

“In 2008, Don Berwick, Tom Nolan, and John Whittington published a paper that first laid out what they called the Triple Aim — simultaneously improving population health, enhancing the care experience, and reducing costs. Subsequently, some thought leaders believed it was important to add a fourth aim to address either the growing challenge of burnout in the health care workforce — i.e., exhaustion, professional dissatisfaction, and cynicism — or the significant inequities present in health and health care. In a recent JAMA Viewpoint, my co-authors Shantanu Nundy, MD, MBA, and Lisa A. Cooper, MD, MPH, and I have proposed adding both a fourth aim of workforce well-being and safety and a fifth aim of advancing health equity — because we cannot achieve safety or high-quality care for all without these additional aims" Kedar Mate, Feb 2022.

On the Quintuple Aim: Why Expand beyond the triple aim?        

The 5 aspects are -         

Aim 1) Care – Improving the experience of care

Aim 2) Health - Improving population health

Aim 3) Cost – reducing per capital costs of health care

Aim 4) Staff - Workforce wellbeing

Aim 5) Equity - Advancing Health Equity

Across the digital home care programme, a number of projects have been sponsored by NHS England, with many having examples that cover all or most of the Quintuple Aim objectives. These follow in the case study section with some specific examples of each of the 5 below.

Aim 1) Care – Improving the experience of care

With digital home care the level of patient and carer satisfaction tends to be very high.

In Norfolk and Norwich the tech enabled virtual ward recorded a 96% satisfaction score from its first 1,000 patients by March 2022

Testimonials include from a relative of a patient cared for by East Kent hospitals “We were over the moon when we realised we could have treatment at home rather than going to hospital. The service the team provided was second to none and he was so much better when he was discharged”.

In Mersey Care Patient Reported Outcome Measures for people being supported at home with digital tools shows that 80% patients are reporting increased confidence in managing their long-term conditions.  

Each of the projects introduced a digital element to support and empower people to manage their conditions from the comfort of their home and to remove unnecessary face to face appointments. This removes the need of the patient to travel and means clinical teams can prioritise face to face appointments to those who need it most. The use of these innovations also creates a digital communication link between patient and clinician giving the patient the reassurance that they are still being monitored and looked after. This was described by a Heart Failure patient at Imperial as “Like a hand, always on my shoulder”.

Aim 2) Health - Improving population health

Examples include Dorset achieving greater blood pressure control via home blood pressure monitoring, assessed as reducing the risk of stroke in those patients by 14% and their risk of coronary heart disease by 9%. (Case study summarised below).

Leicestershire Partnership NHS Trust achieved a 50% reduction in readmissions for patients transferred from the acute hospital to the virtual ward, compared to those not discharged to a virtual ward.

Many of the digital innovations sought to improve one or more of the following: reduction of time to receive results, provide improved resources, or to increase communication between patient and clinician. All are linked to improved patient outcomes.

Aim 3) Cost – reducing per capital costs of health care

Many of the examples reduce pressure on the NHS and save clinical time, so I will list in this category but recognise they are equally important contributors to the next one. The projects intended to give providers more tools to help support patients, whilst removing unnecessary appointments and freeing up their time and to reduce the cost of care.  

The Dorset BP@Home work had a productivity value increase of £181,000 based on its first 100 patients, which was predominantly time saved by GPs and other clinical practice staff.

Snapshots have indicated marked bed day savings across Hertfordshire and West Essex and Cambridge and Peterborough, a non cash releasing saving of £500,000 per year at the time of the study.

In North West London the tech supported pathway has reduced non-elective admissions by 36% in the COPD pathway.

In Hampshire 453 ambulance callouts to care homes were averted through a virtual consultation (23% of consultations).

Among residents aged over 65 in care homes in Mid and South Essex using technology-enabled remote monitoring, comparing June 20 to June 21 to the previous 13-month period and adjusted to consider the impact of Covid, the team recorded: 

·        A 24 per cent reduction in non-elective hospital admissions (compared to 13 per cent reduction in homes not using technology-enabled remote monitoring), equating to approximately 307 admissions avoided - or 24 fewer admissions per month. 

Aim 4) Staff - Workforce wellbeing

In Croydon, the team was able to manage a 51% increase in referrals to the virtual ward without needing more staff.

In North Tees a community psychiatric nurse found the new pathway supported by tech so transformational to her working life she feedback “If you take this device away from me I will cry!”

In Northampton the nurse ratios could be reduced in the virtual wards, thanks to the monitoring technology, releasing nursing capacity to provide other care.

The feedback from clinicians is that they found the new systems easy to use, which improves provider experience. Additionally, the ease of use helps create 'efficiencies in bookings and clinical prioritisation', which can help to further support improving patient outcomes. Clinicians find that the technology provides consistent information throughout and that cutting out duplication and 'having to negotiate different platforms' greatly enhances user experience. Clinicians find that the technology helps improve patient compliance with advice as well as their trust in the pathway and PIFU, which 'improves the effectiveness of appointments and can help to decide whether a remote contact' appointment [consultation] can do the trick. 

Aim 5) Equity Advancing Health Equity

Part of the reason we focused on hypertension is that it is a disease where the burden sits most heavily on those living with health inequalities. During the pandemic there was real concern that people would struggle to access regular health checks including blood pressure, and that this could serve to widen the health equality gap. So we purchased 200,000 home BP monitors and they were distributed locally by GP practices to those that needed them most. This was part of the BP@Home scheme designed to increase the rate of home monitoring. We have recently seen the data showing a marked increase in this rate with an increase of 170% (based on coding within GP systems) of the number of people home monitoring their blood pressure in 2022 compared to 2019.

 A series of summary case studies that describe some quintuple aim benefits follows -

Case study: North-East and Yorkshire region 

Confidence around the clock: how technology-enabled remote monitoring is empowering patients and transforming lives in Yorkshire and beyond. 

Thousands of people living with Chronic Obstructive Pulmonary Disease (COPD) across Bradford District and Craven are managing their condition from the comfort of their own home, with life-changing assurance and support from a nurse-led digital service. Based at Airedale NHS Foundation Trust, within the Digital Care Hub, the MyCare24 COPD service is supporting an increasing number of people through technology-enabled remote monitoring, with patients, families, clinicians and health and care staff reporting positive and in some cases life-changing results. 

Benefits and impact 

Early data suggests a positive impact in reducing acute hospital-based activity for those referred to the service.  

Looking at six months pre and post referral for the 232 patients referred to the service in December 2021: 

·        A&E attendances reduced by 10.7 per cent, from 121 to 108. 

·        Emergency admissions reduced by 28.8 per cent, from 80 to 57. 

·        COPD related hospital days reduced by 63.4 per cent, from 142 to 52.  

Testimonials 

Patient: “I feel listened to and very reassured that the service is there when I need it as I have difficulty breathing and can panic when I can’t contact my doctor. I have been calling the ambulance but don’t feel I need to with this new service.” 

Family member: “This app gives us peace of mind if anything is of concern. I feel reassured that my dad will get the attention he needs quickly.”   

Case study: South West region 

Culture, capability, and co-design: how technology-enabled remote monitoring is helping move the dial towards empowered personal care in Dorset. 

Hundreds of people in Dorset are being supported to take control of their long-term conditions from the comfort of home thanks to a step-change digital programme expanding across the region. 

NHS Dorset’s Digital Access to Services at Home (D@SH) programme is shaped by a multidisciplinary team of clinical and non-clinical specialists, thinking differently about how to best care for and empower communities. 

The team aims to embed equitable digital access for all through innovations like technology-enabled remote monitoring, without creating additional dependencies on patients, people or those who care for them. This work is catalysing a behavioural shift among the population, encouraging better self-management of long-term conditions through digital support and tools. 

Benefits and impact 

More than 31,000 blood pressure readings have been recorded by more than 450 patients since the project fully launched in March 2022. 

Patient testimonials 

“Using the app has made me take more notice and have a better understanding of my blood pressure.” 

“It’s good seeing my blood pressure and being able to monitor it and watch the progress.” 

“Using the app has encouraged me to make improvements” 

“I’ve used the tips to improve my lifestyle. I’ve reduced red meat and salt.” 

Early data suggests this work has reduced the number of GP visits and improved management of a patient’s condition through access to diagnostic blood pressure readings. 

Crystal Djadali who leads digital home care across Dorset said: “One example of BP@Home impact is a patient who submitted five uncontrolled readings over their monitoring week.  

“Previously, each would have required a 15-minute clinical appointment to review and provide an updated medication plan, resulting in a total time of 1hr 15minutes. The new process meant the medication changes happened virtually with only one clinical appointment required.” 

At this stage it is difficult for the team to evidence the reduction of strokes and heart attacks, but early data from the existing cohort shows, in the first 100 patients: 

·        an approximate systolic reduction of 7mmHg and diastolic reduction of 3.65mmHg in the last six months, helping to reduce the risk of mortality, stroke (by 14 per cent) and coronary heart disease (by nine per cent). 

·        of those patients, 74 per cent are between the ages of 40-65yrs and 24 per cent are between the ages of 65-80yrs. 

Since the project launched to July 2022, the programme has also reported: 

·        a 55 per cent cost saving on patient appointments, by optimising GP and workforce activity and time per patient 

·        a 45 per cent reduction in hypertension patient appointments 

·        a productivity value increase of £181,000. 

Case study: North West region  

Hearts, minds, and original thinking: scaling a technology-enabled remote monitoring hub to support thousands of people at home across Cheshire and Merseyside.  

Engagement, insight, evidence and original thinking in Liverpool has paved the way for the rapid expansion of a remote monitoring hub that now supports thousands of people in nine localities across Cheshire and Merseyside. 

Borne out of a 2011 partnership between Mersey Care NHS Foundation Trust and Liverpool CCG involving 50 patients, the hub has supported up to 5,500 people daily to safely manage their health and care at home across clinical pathways including, COPD, heart failure, Type 2 diabetes and Covid. 

Following extensive strategy and engagement groundwork, the telehealth hub began to significantly increase capacity from 2014. It has subsequently been able to scale and adapt to meet challenges including the pandemic while, more generally, achieving its aim to maximise finite resources to best support people who are living longer and often with more comorbidities. 

Benefits and impact 

·         Since the service began, emergency admissions to hospital among remote-monitored long term condition patients have consistently reduced by 22.3% on average, compared to those who are not. 

·        Patient self-reporting suggests a reduction of up to 40% in use of health and care services including visits to GPs, community nurses and matrons.  

·        Nursing and clinical teams say the service supports them with effective time management.  

·        Teams in different localities have increased cross-boundary working across primary, acute and community settings.  

·         Patient Reported Outcome Measures show increased confidence and awareness in managing their conditions, with 80% patients reporting increased confidence in managing their long-term conditions.  

·        Families and friends report they have increased peace of mind, knowing that their loved one is being supported at home through technology-enabled remote-monitoring. 

Case study: East of England region 

Trust, tech, and teamwork: how Essex’s health and care professionals are using technology-enabled remote monitoring to protect health and prevent hospital admissions. 

Thousands of residents in Mid and South Essex (MSE) are being supported at home and protected against the development of serious health infections by staff using technology-enabled remote monitoring.  

This work is saving and improving the lives of people from the comfort of home, including 227 care homes in MSE, and reducing the incidence and potentially devastating impact of conditions like sepsis and urinary tract infections (UTIs) through early detection and prompt management. 

Benefits and impact 

Among residents aged over 65 in care homes using technology-enabled remote monitoring, comparing June 20 to June 21 to the previous 13-month period and adjusted to consider the impact of Covid, the MSE team recorded: 

·        A 24 per cent reduction in non-elective hospital admissions (compared to 13 per cent reduction in homes not using technology-enabled remote monitoring), equating to approximately 307 admissions avoided - or 24 fewer admissions per month. 

·        A reduction in length of stay from 6.8 to 5.6 days – a fall of 18 per cent compared to 12 per cent overall reduction. 

·        899 bed days saved – or around 69 per month - including a significant reduction in sepsis bed days. 

These are great achievements and show the power of digital home care to advance each of these important 5 aims for healthcare. Fuller versions of each of these casestudies are available on the Innovation Collaborative for Digital Health site – to become a member of this digital home care community simply email innovationcollaborative-manager@future.nhs.uk to join.