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CRAB is C-CI’s surgical quality assessment tool. It received the endorsement of Lord Darzi in his report Healthcare for London, and is now acquiring a growing reputation in healthcare as a reliable and clinically fair system of measurement.

CRAB is a web-based software package that provides a wide range of reports based on extensive data captured before or at the time of operation documenting the patient’s condition. For each case, the risk of mortality or morbidity is calculated using POSSUM algorithms (see below) and the raw data may be reviewed by drilling down to individual cases in the risk report. CRAB may also be set up with alerts to notify potential problems as early as possible.

CRAB is unique in calculating the risk for every patient as an individual rather than making assumptions about patients from national statistics. With CRAB assessments of clinical quality and performance can be reached with a reliable evidence base.

In Lord Darzi’s NHS Next Stage Review, quality is one of the key objectives. But to deliver quality successfully, it must be possible to measure it accurately.

Statistical tools and general proxy measures, such as death and readmission rates have been the long-standing quality metrics in the absence of anything more sophisticated. These may work at a national or regional level for general planning, but neither necessarily gives a true picture of local clinical quality, as insufficient account is taken of the types of patients clinicians have to treat.

For example, it may actually be the case that hospital units with higher death rates are getting the best possible results, but appear much worse using bald mortality data because they are treating the most seriously ill patients that no one else can deal with. Without CRAB, it is hard to recognize these centres of excellence.

It is imperative – for patients and surgeons alike – that measures of quality are properly adjusted for the individual conditions of the patients receiving treatment and the complexity of the care involved.

Consider two hospitals of similar size and geographic coverage which are routinely compared for performance. One has worse mortality statistics, but it has been historically overlooked that this hospital takes all high-risk patients in vascular surgery from its neighbour. With CRAB, the true quality of treatment can be assessed.

Likewise consider the surgeon suspended on suspicion of bad practice as a result of their mortality rates, when closer investigation reveals he is routinely treating high-risk patients; his colleagues may be cherry-picking low-risk patients for surgery to improve their mortality statistics, but rejecting higher-risk patients for life-saving surgery.

Conversely, CRAB can alert that a surgeon is under-performing on a particular procedure from a very small number of data points. The drill down facility allows the underlying cause to be researched and identified quickly without the usual time consuming investigations. As a result, the problem can be addressed well before it has become apparent in any other way.

CRAB has been designed to be installed onto existing hospital IT platforms and interfaced to the systems and so that data may be collected automatically. It also has a manual data capture module as well as a PDA / tablet PC data entry system for use in theatre.

CRAB has been developed in partnership with Mr. Graham Copeland. Mr. Copeland is the architect of the POSSUM surgical audit system, published in the early 1990’s and now a world-renowned methodology for risk adjustment and assessing clinical performance against case-mix.

POSSUM is the clinical audit system of choice recommended by the Royal College of Surgeons of both England and Scotland, NCEPOD, the Vascular Society of Great Britain and Ireland, the Association of Coloproctology of Great Britain and Ireland, and the Association of Upper Gastrointestinal Surgeons.

Mr. Copeland is an international authority in clinical audit, and his systems are in use in over 35 countries around the world.

CRAB builds on nearly 30 years of Mr. Copeland’s research and practice to deliver a state-of-the-art package for predicting and monitoring clinical outcomes.

CRAB prevents surgeon from being wrongly suspended

A surgeon who was identified as having a high comparative mortality rate was vindicated within 48 hours using the CRAB software from C-CI.  

The report produced by CRAB showed that the higher than usual mortality rate was entirely due to the fact that the surgeon regularly operated on patients with a poor prognosis, often when there were no other options left to save the patient’s life.   The report also showed that the surgeon was actually performing somewhat better than the norm.

Surgical statistics from all NHS hospitals are analysed by the Department of Health, by Strategic Health Authorities and externally the company Dr Foster on a routine basis. Surgeons and organisations whose mortality rates are significantly higher than the norm are often identified, and this can precipitate a Healthcare Commission investigation.  A full investigation can last a number of months and involves resource-intensive scrutiny of paper records by their peers.   

During the investigation, the surgeon involved will be at best supervised in theatre and at worst suspended from work.  False alarms are not uncommon and can be massively destructive to the morale and reputation of the individual concerned – possibly even the whole organisation -, despite being unfounded.  Moreover, they burden the NHS with unnecessary costs such as manually investigating records for the source of problems and providing locum cover.

One surgeon, identified at a point as a mortality outlier in the North West, benefits from C-CI’s CRAB software for surgical audit.  CRAB assesses a clinician’s true performance, calculating for each case the risk of mortality or morbidity following surgery by applying a sophisticated mathematical model to physiological and operative factors.  It then compares the actual result of surgery with the predicted outcome.   CRAB enables the details of each case with complications to be easily reviewed and can thus provide a true and detailed picture of the surgeon’s work.  

This surgeon’s practice data for the previous five years were immediately accessed using CRAB and a detailed and conclusive report on his work was produced within 48 hours.  The report demonstrated that the surgeon was performing to a good standard despite the comparatively high mortality rate and that he was achieving favourable outcomes given the case-mix of his patients.  The Healthcare Commission quickly reviewed and accepted the report, the case was dropped, and the surgeon was able to continue to work as normal. 

CRAB (Copeland’s Risk Adjusted Barometer) is based on the algorithms and techniques developed by Mr Graham Copeland, formerly National Director for Clinical Audit and Chairman of the National Clinical Audit Group, and widely recommended by Royal Colleges and professional associations. C-CI provide a range of products for assessing and improving clinical quality and cost effectiveness and for managing clinical resource allocation.

Introduction

In December 07, the DH published World Class Commissioning. This document describes the core task for PCTs as being to invest locally in order to achieve the greatest health gains and reductions in health inequalities, at best value for current and future service users. In achieving this task, the document describes three key outcomes that improved commissioning will help to deliver. These are:

• a self-improving NHS,
• visionary leadership,
• provider innovation and efficiency.

CRAB can play a role is helping to deliver on all three of these outcomes.

A Self Improving NHS

World class commissioners are central to a self-improving NHS. They will operate as learning organisations, seeking and sharing knowledge and skills. The commissioning competencies needed to underpin this are described by a series of 11 headlines, which require that commissioners:

• Are recognised as the local leader of the NHS
• Work collaboratively with community partners to commission services that optimise health gains and reductions in health inequalities
• Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health
• Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource utilisation
• Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements
• Prioritise investment according to local needs, service requirements and the values of the NHS
• Effectively stimulate the market to meet demand and secure required clinical, and health and well-being outcomes
• Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration
• Secure procurement skills that ensure robust and viable contracts
• Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvements in quality and outcomes
• Make sound financial investments to ensure sustainable development and value for money

CRAB can assist PCTs across the range of these competencies, but in particular CRAB can support PCTs more directly in:

• Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health CRAB provide patients with an opportunity to exercise meaningful choice in their care. A commissioner that requires all it main providers to use CRAB (or supply with it the relevant data) can give patients the ability to make positive, informed choices about care. For example, by choosing a particular provider because it has the best record for a particular procedure or it has the lowest for particular complications, such as post operative infection.
• Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource utilisation CRAB gives clinicians information not just about amount of work they’ve done, but shows them their mortality and morbidity statistics benchmarked against a sophisticated risk adjustment, reflecting the true mix of patients treated.
• Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration Commissioners who can compare mortality and morbidity across their providers in this sophisticated way can use this to either influence providers directly through contracts or indirectly, through specifying requirements as part of a procurement process which then requires providers to compete against other providers who can meet this this requirement.
• Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvements in quality and outcomes For the first time,CRAB gives commissioners the ability to monitor quality and outcomes on a regular basis. Analysis by specialty gives commissioners the ability to identify trends in quality and outcomes that would otherwise be lost in information that is too infrequent or provider wide.

Visionary Leadership

Increasingly commissioners will be locally perceived as investors; that is, they will commission to achieve the greatest health gains, return on investment and reduction in inequalities at best value. The process is often referred to as “commissioning for improved outcomes”, and in this context PCTs may have to consider their investment role in three different outcomes. These are improvements in:

• health outcomes – health gains for specific or general communities through service improvement or redesign (this includes promoting people’s independence, reducing inequalities and promoting social inclusion),
• community outcomes (these may not relate directly to PCT activity but could result in another part of the system improving, for instance through a regeneration programme, in ways that enable clinical or health gains),
• clinical and care outcomes (the results of medical and social interventions), for example clinically effective care pathways.

CRAB can play a central role in helping commissioners achieve the third of these improvements. CRAB can already measure the outcomes for surgery based on an assessment of risk, an analysis of complications and the ratio of Expected against Observed Outcomes. In aliition it can also monitor and support the performance of individual clinicians. Over time, CRAB will apply it’s approach to the whole of the care pathways thereby assisting commissioners in this care element of their role.

Providing Innovation and Efficiency

PCTs need to ensure that commissioning is not characterised by cost and volume, but increasingly through specifications that support quality and outcomes. By commissioning and specifying for outcomes, commissioners will stimulate provider innovation and efficiency, thereby transforming, rather than merely transacting for, local health and well-being outcomes.

CRAB will support this by assist commissioners to specify outcomes in a much more detailed and sophisticated way. For example, by the using the OE ratio and perhaps by setting a tolerance against the benchmarked figures.

Summary & Conclusion

CRAB has been designed by clinicians, but with management objectives in mind. Consequently, CRAB finally bridges the divide between what clinicians want, what patients need and what managers have to deliver - including the the development of world class commissioning.

C-CI’s technology uniquely enables the quality of healthcare to be measured through direct assessment of outcome. Its power lies in empowering NHS managers and policy setters to define quality targets in terms of outcome, not process and then measure performance against these targets using powerful reporting tools.

C-CI assesses clinical outcome at an unprecedented degree of granularity by using sophisticated, sensitive, risk adjusted measures that takes into account the problems presented by the individual case. It uniquely enables trends and variations to be quickly and easily identified and interrogated right down to the level of single patient procedures to identify excellence, problems and their causes.

Getting the basics right first time, every time	C-CI’s technology can flag every instance of infection and safety lapse and allow them to be quickly and easily interrogated. The causes of problems can be rapidly identified and rectified.
Independent quality standards and clinical priority setting	C-CI’s technology enables sophisticated outcome based quality standards to be set and performance measured against them. It avoids discrimination against high risk patients and treatment withdrawal that is rumoured to result when simplistic outcome targets, such as simply reducing deaths in surgery, are set.
Quality of care from the frontline up to be measured and published	C-Ci’s technology uniquely provides measures of individual patient procedures and treatment that are adjusted for the difficulty of the case so that quality may be accurately assessed.
Reflecting the quality of patient care in hospital funding	C-CI’s technology enables this priority as it allows quality to be accurately and fairly assessed with an unprecedented degree of detail.
Strengthened Clinical Excellence Awards Scheme to reinforce quality improvement	C-CI’s technology allows the performance of senior doctors and each member of their team to be accurately assessed. It can be used with historical data to evidence improvement in risk-adjusted clinical outcomes.
Continuous improvement in the quality of primary and community care	C-CI can provide tools for assessing quality in primary and community care to enable this objective.
New best practice tariffs	By measuring risk adjusted outcome, payment may be linked to quality of service in a way that is sophisticated and fair.
Driving innovation	C-CI’s technology will drive innovation through providing sensitive and detailed data that enable problems to be identified and solved innovatively.
Enabling NHS staff to lead and manage the organizations in which they work	C-CI’s technology provides the sophisticated quality assessments and medical detail that will empower expert leadership.
Enhancing professionalism	C-CI’s technology provides a tool for enhancing professionalism by enabling sophisticated and sensitive measures of clinical performance to be assessed each time a procedure is undertaken. The resolution of the data will uniquely empower individuals and managers to hone performance.
A clear focus on improving the quality of NHS education and training, and Strengthened arrangements to ensure staff have opportunities to update and develop their skills	For the reasons stated immediately above, C-CI’s technology empowers these objectives.

The current focus on quality in healthcare is unprecedented, and it has never before been as important that quality is measured and understood so that healthcare professionals may be treated fairly and patients properly informed.

For many years, much of clinical practice has been judged and managed using efficiency targets. There is now a serious move, in the wake of Lord Darzi’s report Healthcare for all and statements from the Medical Director for the NHS, Sir Bruce Keogh, to put quality on an equal footing with financial performance. Management structures are also changing to bring clinical leadership to the fore.

C-CI’s technology uniquely enables the new clinically-led world to be supported with sensitive, representative and clinically relevant information which enables the real picture to emerge. It moves away from historically crude management information sets which were at best blunt and at worst misleading and destructive.

C-CI assesses the quality of clinical outcomes at an unprecedented degree of granularity by using sophisticated, sensitive, risk adjusted measures that takes into account the problems presented by the individual case. It uniquely enables trends and variations to be quickly and easily identified and interrogated right down to the level of single patient procedures to identify excellence as well as problems and their causes.

C-CI’s CRAB surgical audit tool is used in a number of NHS Trusts to demonstrate staff competence against benchmarks, reveal excellence and provide early indication of problems. It can also be used to provide commissioners’ reports and to ensure that HES data are corrected prior to submission.

C-CI’s technology can drive improvements in care and reductions in cost through efficient allocation of resource.

C-CI’s tools can be used to profile individual patients before procedures to determine the risk of complications. This allows clinicians to highlight high risk cases and ensure patients are closely monitored during treatment. Likewise, they can be used to predict care requirements, such as length of stay, enabling resource to be allocated much more efficiently with reduced requirement for contingency. They also help to prevent unforeseen overload on the system.

Clinicians may use C-CI tools to discuss patients’ personal risk of complications with them when choosing between alternative procedures. If a procedure is determined to be high risk, the tools may also be used to demonstrate how the risk may be reduced (e.g. losing weight).

C-CI’s technology may be used to predict the costs of performing individual procedures. These may be compared against the actual costs to identify discrepancies. Doing this will provide invaluable management information. In particular the high level of available detail will allow inefficiencies to be identified and reduced, thus driving costs down.

Payment by commissioning authorities is increasingly being linked to quality. C-CI’s tools create information that may be published to evidence the excellence of an organization. This information may be published to create and improve brand awareness, demonstrating clinical excellence and / or cost effectiveness.

By improving the perception of excellence in the eyes of the commissioning authority and the public, higher rates may be charged for procedures and work secured.

C-CI’s software is written using Visual Studio to run on standard NHS clusters. It is designed to accept data automatically from other hospital systems. C-CI’s partner, Leading Light Software Services (L2S2) is able to provide engineering services to enable interfaces to be implemented to existing hospital datasets.