NHS 111 SERVICE
How internal systems and processes drive
continual quality improvement within our
NHS 111 service
© Harmoni 2013
BACKGROUND
• The NHS 111 service is a singular point of access for the public to use
when needing health care and advice
• It is designed to facilitate calls which are less urgent than 999
(however still incorporates 999 process when required)
• It is a national program designed to meet the local requirements of an
area
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UNDERSTANDING THE HARMONI NHS 111 PROCESS
• The patient calls 1-1-1 and is routed to the local call centre. The first
point of contact is with the NHS 111 Health Advisor
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UNDERSTANDING THE HARMONI NHS 111 PROCESS
I take down the contact details and
demographics of the patient . With
the help of my NHS SMART card I
have quick access to existing
patient contact / demographic
information, which speeds up the
initial exchange and gets me
straight into patient triage.
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THE CALL PROCESS
• The caller dials 1-1-1
• The Health Advisor takes down demographic information using the
Adastra system and pulls patient details off the NHS SPINE using their
smart card
• If the patient is symptomatic the Health Advisor will triage the call using
NHS Pathways
• If the patient is asymptomatic such as a request for health information, the
Health Advisor has various services via Adastra and using the DOS
(Directory of Services) to refer or advise the patient
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THE CALL PROCESS
• Pathways uses a “ruling out” technique, which is risk averse and will arrive
at a disposition to manage the assessed risk
• A disposition is determined based on appropriate time frame and identified
health needs:
• “Consult your GP practice within 6 hours” or
• “Attend / go to an A&E within 1 hour”
• After the disposition is reached the DOS is launched which lists in ranking
order all the services which match the required skill set and are
geographically appropriate for the patient
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EXAMPLE OF THE DOS
Lists appropriate services
available and ranks them (top
being most appropriate)
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UNDERSTANDING THE HARMONI NHS 111 PROCESS
From the information you have given me
you need to contact your GP practice with
the view of getting a possible
appointment within the next 6 hours. As it
is currently out of practice hours, I can
arrange for a base visit for you to see a
practitioner from your local out of hours
service.
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THE CALL PROCESS
• Each NHS Pathways disposition is given a code which is linked to all
the relevant services on the DOS
• This allows for several appropriate services to be displayed on screen
which the Health Advisor can use to direct the patient to
• If the call is complex, beyond the scope of the Health Advisor or the
patient refuses the NHS Pathways disposition instruction, the Health
Advisor can warm transfer this call to an in-house clinician (Paramedic
or Nurse)
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DEPENDANT ON PATIENT RESPONSE REVERTS
TO MODULE 0, 1 OR 2
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PATHWAYS MODULES
Module 0
- Used by Health Advisors
- Immediate life-threats
identified via smaller
database of age and gender
Pathways
- Basic, but vital information
collected e.g. illness or injury
GP urgent/hospital transfers
handled here
- Some care advice available
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Module 2
Module 1
- Used by Health Advisors
- Large database of age &
gender specific Pathways
- Extensive care advice
available
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- Used by NHS Pathways
trained clinicians
- Smaller database of
Pathways
- Pick up where the
corresponding Module 1
Pathways ended
- Extensive care advice
available
RULES OUT LIFE THREATENING CONDITIONSFIRST
• Example: Dx010
• Dispatch for potential Cardiac Arrest (Displayed as:Emergency
ambulance is needed)
• Auto and Manual – Ambulance Dispatch
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CQI AND CALL AUDITING
• Health Advisor (HA) and Clinical Advisor (CA) Call Audits:
• HA and CA are audited at least 4 times every three months throughout
their NHS 111 service
• The audit is a standardised audit tool which looks at 8 key competencies
which are required for both a Health Advisor and a Clinical Advisor
• These competencies include various technical, interpersonal and
operational skills, including a heavily weighted scoring for Clinical Safety
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Partial
Full or NA
The Pathways Call Audit Tool Call Handler
Date:
Call ID:
Staff member name:
Auditor:
Not achieved
Example of the Call Audit Tool for a NHS 111 Health Advisor
Compete Indicators
ncy
Effective
call
control
1
Makes efforts to speak directly
to patient
2
1
0
2
Greets caller appropriately
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
3
4
5
6
1
Skilled
questioni
ng
2
Recognises when to probe
2
1
0
3
Phrases questions in a way that
callers can understand
2
1
0
4
Avoids overly leading questions
2
1
0
2
1
0
2
1
0
5
1
Active
listening
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Explains process to caller
effectively
Controls flow of information
from caller
Paces call according to clinical
urgency, caller's needs &
service demands
Maintains call flow by effective
multi-tasking
Accurately conveys the clinical
meaning of questions
Ensures every question is
answered adequately
Picks up accurately on verbal
cues/non-verbal cues/relevant
background noise
2
Recalls information given
2
1
0
3
Demonstrates active listening to
caller
2
1
0
Any other relevant information:
Comments- give specific examples to aid constructive & specific feedback
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CONTINUOUS QUALITY IMPROVEMENT
• Every month a formalised CQI report is generated by Connecting for
Health and given to each NHS 111 service provider
• This report can be used to highlight individual outliers who are either
under or over performing. This allows for focused call audits to verify
performance and manage clinical safety
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CQI AND CALL AUDITING
• CQI reports show the following:
•
•
•
•
•
Individual average call handling times
% of calls an individual Health Advisor transfers to ambulance
% of calls an individual Health Advisor transfers to an in-house clinician
% of calls an individual Health Advisor transfers to various services
Where in NHS Pathways the Health Advisor transfers
There are a number of other fields which can be used to analyse Health
Advisor performance.
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CQI AND CALL AUDITING
• Data collected from both the CQI report and individual call audits, drives
performance management of Health Advisors and Clinical Advisors within
the NHS 111 service
• A coaching ratio of 1 coach for every 12 Health Advisors , and 1 coach for
every 6 Clinical Advisors allows for constant in-service support
• Managers and supervisors use call audit results and CQI reports to plan
what interventions can be put in place to improve individual performance
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KEEPING THE TOOLS SHARP!
• Both Health Advisors and Clinical Advisors need to maintain an
average of 200 calls per month over a year period in order to maintain
their NHS Pathways call handler license
• The service also looks at identifying other areas of development and
up skilling, such as the case in equipping advisors with vital
requirements such as safeguarding skills
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EXTERNAL REPORTING AND REVIEW
• Patient feedback groups, and regular formalised feedback channels for
GPs and other health service providers are also used as input into our
NHS 111 service review
• This has specific focus on the patient journey and elicits response from
all stakeholders - (the patient, health care practitioners, service
providers, commissioning officials, and patient review / focus groups)
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REPORTING AND REVIEW OF NHS PATHWAYS ISSUES
• Issues with various individual Pathways, the DOS and NHS Pathways
systems have formalised feedback and reporting channels
• This means constant improvement to the NHS Pathways tool, and
improvement to the NHS 111 service
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DATA COLLECTED AND USED
• CQI, Call Audits, and Patient, Stakeholder feedback allow for focused
review of our overall operational delivery of the service, both on an
individual level and on the service as a whole
• This allows for improved training, coaching, processes and
procedures, and the development of improved IT and Telephony
systems and reporting / service management tools
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Sitrep – 111 Site Reporting to Commissioners and Key
Stakeholders
NHS 111 Sitrep Reporting
Data Collection Template DHV0.4
Please choose date:
111 Area : SW (All Contracts)
Provider :
Daily Reporting
Daily Sitrep (Period should run from 00:00.00 to 23:59.59)
1.0 telephony system total number of calls Offered to the NHS111 provider ACD (OOH &
111) over the 24hour period
1.1 Total number of abandoned calls 30 seconds after the message (NQR8 <5%)
MDS Abandoned calls as a percentage of total calls offered (target <5%)
abandoned calls as a % of offered - calls abandoned before 30 seconds
1.2 Total number of calls answered over the 24hour period
This is taken from the telephony system and counts all the calls that were answered
from the OOH and 111 Calls offered
number of calls answered as a percentage of Offered
1.3 Of the calls answered how many calls were answered within 60 seconds (NQR8,
target 95%)
Percentage answered calls within 60 seconds
of all the calls answered in section 1.2, these calls were answered within 60 seconds
of the message finishing
Based on calls answered
1.4 Total number of phantom calls received over a 24 hour period
This is the number of calls where, when answered, there is nothing or no one at the
end of the phone and would be classed as non triaged
Based on calls answered
1.5 Total number of calls answered not requiring 111
This is the number of calls where the caller did not require 111 and would be classed
as non triaged. Call logs should be completed by staff member on host system as per
operational process
1.6 Total number of remaining calls answered not requiring triage
This is the number of calls where the caller did not require 111 and would be classed
as non triaged.
1.7 Total number of calls triaged over a 24 hour period
This is the number of cases that has launched NHS Pathways assessment (final DX
code count)
1.8 Average episode length of call (mins) (hh:mm:ss)
The episode length is taken from the moment that the host system case is created to
when the case is closed following completion of the call. This includes any wait time
or transfer time, the non clinical and clinical time plus any onward referral time
through dos. The top 2.5% and bottom 2.5% should be removed.
Based on calls answered
Based on calls answered
Based on calls answered
Case entry to finish case
1.9 Average length of call (mins) with the non clinical Call handler (hh:mm:ss)
This is taken from the telephony and is the talktime, patient related not ready time and
wrap time
2 Average length of call (mins) with the clinical 111 advisor (hh:mm:ss)
This is taken from the telephony and is the talktime, patient related not ready time and
wrap time
2.1 Total number of calls directed for ambulance dispatch
Ambulance dispatch as a percentage of total
This is the number of calls with an ambulance disposition code as defined by DH MDS
definitions list
Based on calls answered
based on calls triaged
2.2 Total number of Non conveyed 999 dispatches
Of the incidents in 2.1, these calls were not conveyed to hospital
No data available
as a % of 999 dispositions
Based on SWAST data
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DATA COLLECTED AND USED
• The data collected by the singular point of access (NHS 111 service)
allows for valuable information on service utilisation and specific skill
set demands at the local level
• This is a valuable tool which can be used when commissioning
services in the NHS
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OUR OVERALL COMMITMENT
• Our focus is treating our patients as family
• We want our patients to have not just the expected high levels of good
service but to also have a truly positive and impactful experience
during their patient journey while phoning 1-1-1
• Our focus is not only on improving service delivery and maintaining
patient safety but also on developing a culture of empathy and
compassion for all who call in on our NHS 111 service
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Questions
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Contact Details
Lesley Boler - Director of Nursing and Education
M: +44 (0) 7540902419
E: [email protected]
Craig Atkinson- National Training Manager – 111
M: +44 (0) 7795159770
E: [email protected]
© Harmoni 2013
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