Module: Financial Management Methods

Assignment: Audit Report:What it reveals about the performance in the organization?
How appropriate the analysis recommendations and presentation are?

The analysis is based on this Audit Report by The NAO
Improving Emergency Care in England

This performance audit report has been prepared by The Computer and Auditor General of United Kingdom. The report evaluates A&E (Accident and Emergency) services in UK. The performance audit is based on two documents. The first, ‘The NHS Plan’ (DOH 2000) which envisaged the emergency care access target of four-hour time spend in A&E by December 2004.The second, ‘The Reforming Emergency Care’ (DOH 2001) which set the targets for modernisation, increasing capacity and introducing professionalism in the A&E services.

Performance in the organisation
A report of CAG (1992) had brought out that ‘of among patients actually using A&E, waiting time was the aspect they considered most important.’ The present report (CAG 2004) also highlights that ‘For many people, visiting A&E is their only contact with the NHS hospital sector.’ and any delays in A&E creates an adverse opinion of the organisation. The NHS (DOH 2001) is acutely aware of the fact that waiting times have a human cost, in having an impact on the patients. Long waiting times create anxiety for the patients, reduce their quality of life and can cause actual deterioration of their condition. Based on these the NHS had undertaken to reduce the waiting times in A&E and to improve the overall working of the A&E areas and the support systems.

Capability to deliver and perform
The CAG report (2004) states that there were 12.7 million visits to major A&E services in 2003-04. This covered a range of activities including Hospitals, Trusts, GPs, Ambulance services and Walk-in clinics. Since the implementation of four-hour performance criteria, trusts had reduced, the time patients spend in A&E. In 2002, 23 per cent of patients spent over four hours in A&E departments, but in the three months April to June 2004, this percentage has been reduced to 5.3 per cent. A significant number of trusts reported that 96-98% of their patients are treated under the specified deadline. Some trusts treated nearly all their patients within four hours and the variation among different trusts has reduced significantly. However the the worst performing trusts still have some way to go to reach the level of the best. It is seen that, there were patients who had to wait a long time for a simple procedure. The staff at times focussed more on patients who are in danger of breaching the four hour target rather than with those in greater clinical need; and also if the deadline is breached the incentive to expedite their admission or transfer was reduced leading to further delays. Although there is overall improvement in reduction in waiting times but some patients with complex needs as the older patients and patients with mental health problems were spending longer than four-hours in A&E.


Ability to innovate
The performance has improved not only in A&E but also in modernisation of related services and this has been because of changes in traditional working practices. In the A&E areas, significant improvements were achieved by separating patients into parallel streams with dedicated staff and improving access to diagnostic services. The trusts developed concept of ‘Clinical decision areas’ to attend to patients under observation.The report notes that improvements in these were made possible despite shortages of staff in the area of radiology, radiography and pathology.

The department and the trust have also responded to patient need by looking for solutions outside the A&E areas and orienting them around the patient needs. The trusts created new open-access minor injury and illness providers, which include 81 Walk-in Centers. These have been set up to complement GP and A&E services for patients with minor injury or illness. It also notes to get to patients that are more serious and to avoid getting bogged down by minor calls the A&E Ambulance services have devised a methodology to re-route ambulance callers or A&E patients to a more suitable provider. Certain trusts have developed an Emergency Care Practitioner who has autonomy to treat and make decisions about patients. The organization thus exhibited ability to break new grounds and develop new paradigms to deliver the targets. During this implementation process the patient needs were always kept in focus.

Ability to devolve targets & create internal productivity measurements
The A&E services run over a diverse geographical area and they involve close interaction of hospitals, trusts, GPs, Ambulance trusts and other clinical areas. The targets of improving the A&E services were, communicated to the entire organization and operational flexibility given to all hospitals and trusts. There was sufficient coordination and competition among various trusts. There was a vision and goal sharing. The Doctors and staff all made efforts to achieve the targets. There has been no compromise in patient care or neglect, in meeting the targets. There was increased response from senior members in devising new methods as increased hospital rounds, delegating decision making to junior and middle level doctors in less critical cases. Couple with this the trusts and the A&E areas of bigger hospital arranged to measure their own performance either by use of information technology or by engaging special personnel. The Department also regularly monitored the performance. Thus, the organization exhibited an inherent desire to improve and deliver results.

Ability to link financial incentives
The Health department built an incentive mechanism to enhance performance and created a 500,000-pound sterling grant. This grant was for the trusts exceeding 96% target and sustaining it. The trusts responded to this incentive and 107 claimed this grant indicating inherent competitive and improvement seeking strength of the organisation. This grant was then utilised by the recipient trusts to make fresh investment s in infrastructure, improvement of buildings and redesigning old building and equipment for better patient safety and comfort. This helped to take care of the second goal of modernisation and infrastructure improvement. The trusts who received the incentive payments re-oriented their staff to cover up for shortages of staff and trained personnel. However these incentives have not worked for all trusts and there are certain trusts who despite the incentives have not improved. These trusts need to be focussed upon

Ability to enhance public value
This reduced time patients spend in A&E has led to increased patient satisfaction. There have also been physical improvements to the environment in A&E to help reduce stress for both patients and staff. The Department is a huge organisation consisting of several trusts catering in diverse areas in different conditions and circumstances. The service provided is critical and essential and 24x7 hence, there is no scope for any laxity or relaxation. The demand and expectation levels are often high as people approach the A&E services in crisis. It is indeed a creditable performance to have such an all around improvement.

Problems remain
A per the report a vast majority of the trusts have made improvement sto their A&E services and were confirming to the four hour deadline as also having a ‘Modern Matron’ …who had responsibility for the quality of patients' experience…maintaining and improving the fundamentals of care.’ CAG 2004 , but there were some trusts which were lagging behind these targets and special efforts were needed to bring them at par with others. There are also bottlenecks outside the A&E systems, which affect its performance. These include, ‘avoidable peaks and troughs in the availability of beds on wards caused by mismatches between admissions and discharges; barriers to obtaining a specialist opinion, caused by conflicts with specialists non-emergency work; and difficulties in obtaining authority to admit patients to wards’.CAG2004. The trusts have shotage of trained emergency care medical staff and clinical suport staff for diagnostic facilities.The design some of the A&E buildings is not suitable for modern working practices. Thus the A&E are not able to provide efficient, patient-orientated environment.


How appropriate the analysis recommendations and presentation are

Analysis
The NAO formed a consultative panel with representatives from NHS, Department of Health, Ambulance services, Nursing bodies and patient associations. The diverse group A&E professionals have ensured entire gamut of A&E services is examined and critically evaluated. The performance analysis is therefore reliable, as both the auditors and professionals from the A&E services have carried it out.

The NAO team has used a wide variety of tools for diverse data collection. The reporting team from NAO carried out four censuses in different spheres of A&E. It collected feedback and data from most hospital trusts through emailed questionnaires. It also carried out field visits to five major health economies. It has did case studies and conducted a patient surveys. The performance analysis is thus fairly accurate.

The NAO team has referred to the previous CAG report (1992) on this subject. They updated the problems and issues raised in that report. The analysis is thus ensures continuity as it assesses performance over a period.

The present report (CAG 2004) thus is fairly accurate in its analysis and assessment of the performance of the A&E services. The report has covered not only the actual working of A&E areas but has also examined the associated areas as diagnostics, ambulance availability, and 24-hour accessibility to services. Besides analysing percentage of patients treated in the four hour targeted deadline but it also studies the effect of lack of bed availability in compromising with the waiting time for elective operations in accommodating A&E patients. It also analyses effect on the clinical priorities in meeting the deadline. This has been examined by analysing premature patient discharges and unnecessary admissions. It also analysed that if the size of department gave flexibility or proved to be a hindrance in achieving reductions in delays. NAO has used objectives and performance targets as management tools to help the trusts develop policy, manage resources effectively and accurately report their performance to Parliament and the public. (NAO 2000)

After discussing the four hour target the report then focuses on the second aspect of the performance indicator which is the modernisation of the hospital and services.
The report has not merely focussed on the A&E services but has gone deeper into other areas, which affect the A&E services. ‘Avoidable peaks and troughs in inpatient numbers, widening traditional staff roles and greater use of information technology and remote access, make use of local benchmarking; to rationalize patient time spends for those areas being rebuilt or being built afresh, incorporate good design practice developed by NHS Estates.’

The report has accurately identified areas which are being neglected as a result of increased focus on four hour dead line and it also is able to identify the areas which are affecting the process of modernization and reorienting priorities around patient needs.

The report also looks at the fact that that A&E is not a standalone process but a ‘multidisciplinary, cross organisational’ operation. It also focuses on the bottlenecks outside the A&E, which are holding back the performance.
However, the report even after having collected so much data and details fails to analyse the performance of individual trusts and hospitals. The report only gives a holistic view of the entire NHS. It has glossed over the performance of Individual trusts. It has highlighted a few outstanding trusts in bold blocks to serve as beacons for other trusts but does not give a comparative analysis of all the hospitals. These, benchmark performances and average performances could have been available for each unit. This data could have also provided information on trusts meeting the benchmark, average percentage achieved by all hospitals and the number of hospitals above and below the benchmark. Thus, the department and each trust would know their relative position.

Recommendations
The recommendations cover here different areas one is the A&E services themselves second is the collaboration effort with other clinical and Para-clinical departments thirdly covering the emergency care networks. “The Department and the NHS have made significant and sustained improvements in A&E waiting times, though more needs to be done. Achieving the Department's vision for whole-system modernization of emergency care will require greater integration and more effective joint working.”
It also suggests that the emergency care as a system as a whole should be developed. The Department should seek to establish emergency care networks that will be ‘cross-organizational’ and ‘multi-disciplinary groups’. These would take the lead in developing local delivery. The report points out that A&E departments are not the only source of emergency care, nor the only option for all patients, though patients continue to expect their emergency care needs to be met by A&E departments. The report recomends that an integrated system be formulated in which all servicesa re integrated.It stresses the need that the A&E services cannot function alone for that they have collaborate with other clinical areas. The department and the trusts should work on the ‘department workforce planning model’. This will involve all departments involved with the process. The strategic bodies who are designing and planning the services should also agree plans to address the shortfalls in skilled staff through workforce planning. Improving joint working in emergency care as A&E is not stand-alone but dependent so many others areas to deliver.
The report also looks at the limitations of the reporting systems, which were in existence before the new four hour deadlines came into operations.

Presentation
The report is presented in an easy to read and understand format. It is available in print and electronic form on the internet. Easy accessibility helps in transparency and establishes faith in the organisation. The report is prepared to assist the parliament to analyse the performance of the organisation. The report provides a brief overview the organisational performance. This summary covers target achievement, areas of improvements and recommendations. It also provides a glossary of medical terms to enable better understanding of the report.

The report in fact also targets the NHS Trusts, Ambulance Trusts, the Health Department, the Health Commission and the various health administrators. To help them assess their performance and ascertain their standings the report has four detailed sections. These elaborate on the summary topics and include performance, modernisations and areas requiring further improvement. The most meaningful part of the report is the section on recommendations. These are clear and concise and have opinions of the experts in their respective fields.

The executive summary, graphs and the appendices are very useful media for its reports. Media can follow up on the practices of the top performing hospitals highlighted in the boxes.

Conclusion
The report is quite comprehensive and largely commendatory of the efforts of the NHS medical and paramedical staff. In a way coming from an independent body, this would be a morale booster for the entire system. Significant improvements have taken place without compromising on patient quality and mortality. Target setting by the organization it self has lead to better patient focus as also a large number of innovations to remove bottlenecks. The patients and the victims who are already experiencing the improvements would feel reassured about the ongoing process. The report is not all adulatory but it sends in a word of caution by highlighting the areas which need improvement as also pointing out the fact that at times in a bid to meet the target there may be some bypassing of the processes. It also stresses the need that the gains are not uniform and although they are linked to incentives, there are places, which need to do the catching up. It further highlights the work force, resource and architectural difficulties, which still need to be resolved in fulfilling the complete expectations of patients.

References
DOH, 2000) The NHS Plan: a plan for investment, a plan for reform, Department of Health, July 2000

DOH, 2001)Reforming Emergency Care, Department of Health, October 2001
Department of Health research, 2004

CAG, (1992) Accident and Emergency Services in England, Comptroller and Auditor General (London: NAO)

CAG, (2004) Accident and Emergency Services in England, Comptroller and Auditor General (London: NAO)