Quality Improvement Strategy
For
Commissioning High Quality
Health and Healthcare
June 2012
CONTENT
Page
INTRODUCTION
3
AIM OF THE STRATEGY
3
PRIORITIES
3
DEFINITIONS
3
QUALITY FRAMEWORK
5
HOW THE QUALITY FRAMEWORK WILL BE IMPLEMENTED
6
MEASURING QUALITY
8
EXTERNAL REGULATORS
10
GOVERNANCE
10
CLINICAL ENGAGEMENT
11
CLINICAL CAPABILITY
11
IMPLEMENTATION OF THE STRATEGY
11
SUMMARY
13
REFERENCES
13
2
1.0
INTRODUCTION
Blackpool Clinical Commissioning Group (CCG) commissions a wide range of services for Blackpool
people in partnership with Blackpool Council and aims to secure the highest quality and value within
finite resources. Delivering the highest quality of care for all is a fundamental goal of the NHS and is
priority for Blackpool CCG.
This strategy provides positive assurances around quality and safety needed to demonstrate to the
Board that high standards of care are commissioned for the people of Blackpool. This Strategy will
also provide assurances for external inspectors, regulators, service users and the wider public.
2.0
AIM OF THE STRATEGY
To set out the strategic approach Blackpool CCG will ensure that services commissioned on behalf of
the population of Blackpool are of the highest quality. The strategy is to ensure that quality is at the
heart of Blackpool’s commissioning process and there is commitment in place to continually improve
the quality of services for the people of Blackpool
3.0
PRIORITIES
Our priorities are to:
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3.1
Improve the patient experience and to listen and act on patient feedback
Ensure health care is clinically and financially effective
Receive assurances that quality standards are implemented and targets are achieved
in Blackpool
Support continual improvement in safety and quality outcomes year on year
Identify clinical risks and manage underperformance
Develop a culture of transparency and consistency to quality improvement
Ensure that patients are kept safe during contact with health care
Scope
All services commissioned by NHS Blackpool will have a contract containing quality schedules based
on this strategy. These will include quality indicators, and in some contracts Commissioning for
Quality and Innovation incentives (CQUIN).
4.0
DEFINITIONS
4.1
What is quality?
Quality is defined in “High Quality Care for All” (DoH, 2008) as encompassing patient safety; patient
experience and clinical effectiveness. In addition to quality encompassing patient safety, experience
and clinical effectiveness NHS Blackpool have expanded the definition to include timelines, efficiency
and equity. ‘Interface’ quality was also seen to be important particularly in relation to
communication across provider services.
The framework (Figure 1) to support the strategy sets out the approach that NHS Blackpool will take
to ensure that the services commissioned on behalf of the people of Blackpool are of the highest
quality. The framework will apply to all commissioned and contracted services. All contracts and
Service Level Agreements will include quality schedules based on the framework, including service
specific quality performance indicators. All newly commissioned pathways will be evidence based
and outcome measures will be agreed as part of the development work.
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Blackpool CCG has made progress in developing itself as the local leader of the NHS; and as an
outward facing and proactive commissioning organisation. This commitment has been demonstrated
across the whole commissioning cycle, from the development of quality schedules within the
contracting framework through to the development of newly procured and commissioned services.
5.0 QUALITY FRAMEWORK OPERATING PRINCIPLES
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The patient comes first – not the needs of any organisation
Quality is everybody’s business – from the ward to the board; from the supervisory
bodies to the Regulators, from the commissioners to primary care clinicians and
managers
If we have concerns, we speak out and raise questions without hesitation
We listen in a systematic way to what our patients and our staff tell us about the
quality of care
If concerns are raised we listen and ‘go and look’
We share our hard and soft intelligence on quality with others and actively look at the
hard and soft intelligence on quality of others
If we are not sure what to decide or do, then we seek advice from others
The Quality framework will be shaped around the three pillars or goals of High Quality Care for All:
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Safety
Effectiveness
Patient Experience
Figure 1
5.1
Quality Goal - Safety
We will ensure systems are in place to track and manage performance including taking action when
required standards are not met. To ensure patient and staff safety, it is important that we
encourage learning from mistakes and make changes in practice to ensure that incidents do not
repeatedly occur. Where serious incidents occur, Blackpool CCG will be informed within an agreed
timeframe and will monitor the investigation and learning from the incident.
Blackpool CCG will expect the providers to demonstrate a reduction in HealthCare Associated
Infections (HCAI) in line with agreed trajectories. Additionally, there must be robust infection
prevention and control plans, policies and capacity in place to demonstrate full compliance with the
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Health Act 2006 Hygiene Code. We will require infection control reports, root cause analysis (RCA)
investigations of infection occurrences and will review data captured from patient/service user
experiences reports.
Blackpool CCG will ensure that systems and processes are in place to fulfil specific duties of cooperation and best practice in relation to safeguarding is embedded. All contracts and SLAs will
require providers to adhere to Blackpool’s Safeguarding policies, which promote the welfare of
adults and children. Blackpool CCG will be informed of all incidents involving children and adults,
including death or harm, whilst in the care of the provider. We will have senior clinical leadership in
the oversight of safeguarding arrangements at Board level for both Adults and Children. Providers
will also be required to ensure the safety indicators are in place:
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5.2
Ensure National Patient Safety Agency (NPSA) guidance is implemented
Identify safeguarding issues relevant to their areas of provision
Ensure that policies and procedures related to safety are implemented and monitored
Ensure that safe recruitment procedures are in place including vetting and barring requirements
of the Independent Safeguarding Authority
Staff will be able to identify and report safeguarding concerns
Robust incident reporting and monitoring systems that include escalation procedures for serious
untoward incidents will be in place
Care Quality Commission (CQC) regulations to be met
Quality Goal - Effectiveness
In order to provide cost and clinically effective care and treatment, providers will be required to
comply with national and local standards/guidance such as National Service Frameworks and NICE
technology appraisals and guidance. Blackpool CCG will expect to see evidence of compliance with
guidance from other professional bodies. We will continue to support the Advancing Quality
programme which is based on international best practice to reduce deaths, lengths of stay and
readmissions to hospital.
Clinical and practice audit is one of the key mechanisms that monitors the performance and quality
of services and demonstrates continuous quality improvement at service level. NHS Blackpool will
expect all providers to have in place, or continue to have, jointly agreed prioritised clinical and
practice audit programmes and demonstrate active participation in audit, including national audits.
Providers will be required to share outcomes of clinical and practice audits. Additionally, Blackpool
CCG will undertake independent audits where necessary. Through balanced score card and quality
framework monitoring, NHS Blackpool will ensure that providers can evidence benchmarking.
5.3
Quality Goal - Patient Experience
We will strive to promote compassion, dignity and respect and demonstrating positive patient
experiences. Quality will be measured by public perception of the NHS in Blackpool such as
outcomes of the annual national patient satisfaction survey and the governmental IPSOS MORI
survey. We will shorten feedback cycles of these surveys by monitoring feedback locally using local
mechanisms and acting on that feedback. We will inform people of how their involvement in these
surveys has improved services. We will facilitate this locally developed engagement mechanism as
identified in the Communication and Engagement Strategy.
Blackpool CCG will lead on the engagement of public and patients in the planning of services. We
have developed ways that will assist all people in Blackpool to have the opportunity to get involved
in service development. Providers will be expected to use feedback to improve services. Providers
are also expected to work with Blackpool CCG to regularly inform, consult and involve patients, their
families and carers and the public in the planning and review of services. The aim of this
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engagement and improved patient experience is to ensure compassion, by engaging staff and
promoting an environment of empathy and listening to service users. We will promote dignity and
respect and aim to achieve this by monitoring dignity and single sex accommodation requirements.
5.4
Patient Experience
The measures and metrics linked to patient experience that capture real time views and experiences
of patients will require extra energy and focus. Existing measures will continue to mature and inform
us as commissioners. We will work in partnership to respond to issues of quality raised through
patient experience feedback, building on the national programme Patient Reported Outcome
Measures (PROMS) and strengthening this through local projects that will build on among others,
the implementation of the new complaints system Making Experiences Count.
5.5
How will we respond to poor performance?
The quality framework will be embedded into the commissioning arrangements for existing and
potential providers using a consistent and robust approach to the commissioning cycle. Figure 3
outlines the approach to poor performance. Figure 3
6. 0
MEASURING QUALITY
6.1
Nationally Agreed Quality Toolkits
There are a number of new methodologies to support measuring and analysis of quality. We
will utilise these tools to support commissioning performance management and monitoring of
contracts. These include:
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Commissioning for Quality and Innovation (CQUIN)
Patient Reported Outcome Measures (PROMs)
Quality Accounts
Quality Observatories (Advancing Quality Alliance - AQuA)
Nationally Agreed Quality Metrics
National Quality Board
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6.2
CQUIN Incentives
Part of the quality incentive payment to providers we will continue to encourage
achievement of local, regional and nationally agreed quality outcomes. CQUIN is an
incentivised money rewarding scheme that has been developed to allocate payments to
providers if they meet quality outcomes on domains such as safety, effectiveness and patient
experience. CQUIN schemes will focus on an innovative approach to improving the
patient/service user experience. This approach can offer incentives up to 2.5% of contract
value – robust data capture and milestone monitoring will be agreed with providers.
6.3
PROMs
Patient Reported Outcome Measures (PROMs) are questions asked of patients before and
after a specific treatment, to measure improvements to quality of life from the patient’s point
of view. PROMs are included in provider CQUIN payments.
6.4
Quality Metrics and Quality Markers
The vision is that all NHS staff will measure what they do as a basis for improving quality. In
partnership with professionals across the NHS, the Department of Health and the NHS
Information Centre have identified an initial, but evolving, set of indicators to describe the
quality of a broad range of services – the Indicators for Quality Improvement. The long-term
vision is to build an extensive menu of indicators that will help every tier of the NHS
understand and improve the quality of services it provides to patients/service users. The
indicators can be found on the Measuring for Quality Improvement website:
http://www.ic.nhs.uk/services/measuring-for-quality-improvement
Quality is systemic: it depends upon many different individuals, inputs, process and
organisations. It is also, to a degree, subjective. The data required to assess quality,
therefore, needs to be drawn from many different sources, to ensure that we are capturing
relevant information on the three domains of quality: effectiveness, safety and patient
experience. The metrics used to populate the national quality dashboard should be used as a
starting point although other data sources should be included.
In this context the following is a list of additional sources/areas which should be used. Please
note that this is not a comprehensive list; all relevant and appropriate sources should be
drawn upon:
Performance data on the priorities set out in the Operating Framework relevant to
quality (i.e. waiting times, infection rates etc.)
• Never Events and serious incident data
• CAS alerts closure rates and outstanding issues
• Hospital Mortality
• Patient survey results, PROMS and other patient data such as Net Promoter scores if
available and website material such as NHS Choices)
• Staff survey results
• Complaints and litigation data
• Monitor ratings
• CQC inspections - registration details, warning notices and related CQC notifications
• Quality Risk Profile data
• Quality Accounts
• Adult and Child safeguarding
• Homicides/unlawful killings – historic and ongoing including action plans
• Serious case reviews
• Maternity Services, Local Supervisory Midwifery Authority reports and audits
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6.5
Data from the Quality Observatory
Safety Thermometer and Energising for Excellence
Quality impact assessment of Provider Cost Improvement Programmes
Peer reviews, recommendations and action plans
Clinical Audits/ Confidential enquiries
FT Quality assessments
National Quality Board
The National Quality Board recommend (May 2012) that whilst there have been improvements
in recent years in capturing hard data about quality, we must not lose sight of the importance
of ‘soft’ intelligence. We have national staff patient surveys included in the dashboard, but in
addition we should also be looking at and listening to:
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Media – traditional and social – negative and positive
Patient websites such as Patient Opinion, NHS Choices, local user groups
OSCs, local MPs, LinKs, etc.
Social Partnership Forum, staff side
Professional Regulators and Royal Colleges Trainee feedback / Deanery reports
Whistleblowing and similar reports from staff
One of the lessons from the National Quality Board assurance visits was that much of the data
tended to focus on acute settings. It is crucial that we acknowledge the importance of
ensuring that quality data and knowledge is captured for non-acute settings, including primary
care, independent sector, ambulances, mental health services, screening programmes under
health. The above list is not exhaustive; we will use our judgement and common sense to
proactively capture the intelligence that exists within our systems.
7.0
EXTERNAL REGULATORS
All service providers are subject to assessment and audit by a range of external regulators and
assessors including the Care Quality Commission, Monitor, and Royal Colleges, Peer Reviews,
the Health and Safety Executive, the National Audit office and LINKs. It is important that as
commissioners we are aware of the findings of all external regulator reports in order to inform
commissioning decisions and monitor any required development.
7.1 Care Quality Commission Regulation
Essential levels of quality and safety will be externally assessed through the new system of
registration with the Care Quality Commission (CQC). Statutory guidance about compliance
with registration requirements has been issued by the CQC with more detail on the
requirements under each area. Contractors will need to assure the commissioner that they
have met the criteria and submitted robust compliance evidence. As commissioners we will
work with Providers and monitor compliance as part of the contract monitoring process.
8.0 GOVERNANCE
NHS Blackpool reports compliance and exception reports in relation to quality standards
through an internal committee structure to the Board. The framework in Figure 5 outlines the
reporting arrangements. The quality components of the contracts will be monitored through
ongoing Quality Review meetings with providers and by a range of announced and
unannounced visits to provider settings. The sub Committee will oversee the provider
performance to ensure consistency of achievement. The PPI Forum will be a crucial part of the
governance framework relating to patient experience, engagement and involvement in service
redesign and delivery.
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8.1 The Quality Reporting framework
Figure 5
Clinical Commissioning Group Board and Committee Structure
1 April 2013
CCG Chairs
Network
Clinical Commissioning Group
Governing Body
Commissioning
Advisory
Board
Broken line - Advisory
Health and
Wellbeing Board
Blackpool
Safeguarding
Adults Board
Solid line - Delegated
responsibility/authority
Quality and Engagement
Committee
Blackpool
Safeguarding
Childrens Board
Audit
Committee
Remuneration
Committee
Patient and Public
Involvement
Forum
Finance and Performance
Committee
Clinical Commissioning Group
Member Practices
CCG Board and Committee Structure as at 13 June 2012
NHS Blackpool’s Assurance Framework captures all the organisation’s key risks including
commissioning poor quality services. The Assurance Framework is also monitored internally through
the Quality and Engagement Sub Committee under delegation authorised by the Clinical
Commissioning Group.
9.0
CLINICAL ENGAGEMENT
Clinicians who are fully engaged with NHS Blackpool will share its aims for patient safety and care
quality and will be committed to helping achieve them. We will establish a structure for clinical
engagement that will enable clinicians to be engaged in the purpose, objectives and strategy of NHS
Blackpool with a depth of understanding of how we work to achieve high quality, safe, personalised
and effective care for all.
The importance of clinical engagement is reflected in the partnership working between the Clinical
Commissioners across the Fylde Coast; integrated commissioning with Blackpool Council and
ongoing collaboration at a Fylde Coast Commissioning Advisory Board. Regular GP link meetings will
continue to be held and we are developing a CCG newsletter and website to ensure information is
up to date and accessible to clinicians. Implementation of NHS Blackpool’s Communication and
Engagement Strategy will support further development and involvement of clinicians in the quality
agenda.
10.0
CLINICAL CAPABILITY
We need to promote capability building for quality improvement at all levels in the organisation. The
appropriate use of staff clinical knowledge to inform the delivery of this strategy is imperative. We
will want to encourage quality champions throughout the organisation and develop an open culture
for reporting quality errors with providers. Throughout each element of the commissioning cycle,
different ‘bundles’ of knowledge will be an essential component to promote quality performance
discussions.
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A key enabler for this strategy is the clinical knowledge necessary to determine and assure quality,
safety and clinical effectiveness. The aim will be to develop a clinical knowledge information
structure that supports and enables lead commissioners to achieve sustainable improvement in
patient safety and quality. The key components essential to achieving this are listed below:
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NICE Guidance Implementation
National Health Services Litigation Authority (NHSLA) Standards Achievement
Robust safeguarding arrangements
National & Local review recommendations (CQC or SHA)
National & Local Clinical Audit findings
Local and national research and innovation developments
Local and national incident trend analysis
Infection control benchmarking analysis
Complaints and compliments
Serious incident lessons learned evaluations
Patient and staff satisfaction surveys
Quality Outcomes Framework and Quality Assessment Framework reviews of independent
contractors
11.0
IMPLEMENTATION OF THE STRATEGY
Through clear approaches to commissioning, contract development and management we will aim to
support contractors to deliver improvements in service. In addition local, regional national and
international benchmarks will be shared to provide the impetus for quality improvement. The
development of a quality dashboard demonstrating progress and areas of concern will be a key way
in which commissioners can identify and review performance in relation to quality.
11.1
Quality Ambitions
To deliver best practice the following Quality performance indicators will be monitored:No
1.0
QUALITY
DOMAIN
Safety
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
2.0
2.1
2.2
2.3
Experience
OUTCOME
No methicillin resistant staphylococcus aureus (MRSA) bacteraemia in
hospital more than 48 hours after admission
Reduction in clostridium difficile in hospital
Achieve and maintain performance for cleanliness in all Blackpool facilities
in the top 10% nationally
A year-on-year reduction in harm arising from medical and clinical error
demonstrated through the National Reporting and Learning System statistics
Full implementation of National Patient Safety Agency safe practice guidance
To demonstrate learning from complaints, incidents, Serious Untoward Incidents
% reduction in falls year on year
To demonstrate learning from safeguarding incidents and compliance with national
standards
Safeguarding concerns are identified, reported and investigated
Safeguarding procedures are embedded
Elimination of mixed sex accommodation
Improvement in national and local Patient Survey results
Improved discharge planning and management e.g. 95% discharge letters being
transmitted electronically within 24 hours of discharge
Promotion of dignity and respect
Transparent and accessible complaints procedures in place
Engagement with patients and the public embedded
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3.0
3.1
3.2
Effectiveness
3.3
4.0
Efficiency/
Productivity
4.1
4.2
4.3
4.4
11.2
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Learning lessons from complaints and untoward incidents
Providers will meet the requirements of CQC registration and regulations
Implementation of Technology Appraisal guidance published by the
National Institute of Health and Clinical Excellence
Progress against an agreed range of clinical metrics e.g. Advancing Quality
and Quality Outcomes Framework
Partnership working across agencies evident
Improvement in National Staff Survey
% staff sickness absence reduced
% staff turnover compares well with national benchmarks
% improvement in staff appraisal through Personal Development Review
Implementation of LEAN methodology
How will we deliver on these ambitions?
We will develop a learning and innovation culture, building effective collaborative partnerships
for continuous quality improvement to drive system reform
Strong clinical leadership will be recognised as being key to promoting quality
All commissioned and contracted services will be expected to participate in the National Patient
Safety Campaign facilitated by the National Patient Safety Agency
We will learn from best practice nationally and internationally and use the learning to drive
forward innovation
We will further develop safe and effective prescribing advice
The views and experiences of patients will be sought to ensure that they are at the centre of
decision making and service development
The involvement of patients and the public at all stages of the commissioning cycle (health
needs analysis, pathway redesign procurement and evaluation).
Through the involvement and empowering of clinicians and teams in developing quality
improvement techniques and in service redesign with the aim of Improving clinical value and
productivity
Through use of the contracting mechanisms with our providers we will incentivise improvements
in patient safety, experience and effectiveness
We will develop quality dashboards for all the commissioning work stream activities that are
consistently reviewed
We will utilise the contracting process to penalise unacceptable practice and withhold payments
when quality thresholds have not been achieved
We will maintain a standardised and consistent approach to quality monitoring and reporting
12.0
SUMMARY
The Strategy has set out the context of how NHS Blackpool will commission quality services. It has
also set out a draft Quality Framework and a range of quality monitoring approaches. The strategy
highlights that there needs to be robust performance management regimes in place to measure
quality and to tackle areas of concerns. The quality ambitions and associated work plans will be
regularly monitored.
The achievement of this strategy cannot be assessed by a single measure – qualitative as well as
quantitative data will be reviewed and assessed. In order to achieve continuous quality improvement
in the services commissioned by Blackpool CCG the strategy will need to be reviewed annually in
order to be responsive to the needs of Blackpool’s resident’s new quality standards emerging
external regulators.
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13.0
REFERENCES
Manifesto for the Care Quality Commission. Care Quality Commission (2008).
High quality care for all: NHS Next Stage Review final report, Department of Health (DH) Darzi (2008).
Using the Commissioning for Quality and Innovation (CQUIN) payment framework DoH (2008).
Measuring for Quality Improvement: the approach. Nicholson, D. (2008).
From Good to Great vision. 2010/2011 Operating Framework for the NHS. Department Of Health (DH) (2009)
Communication and Engagement strategy NHS Blackpool. 2010-2015
Clinical Governance Strategy 2009 - 12 NHS Blackpool. (2009)
The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009
Putting Quality First in the Boardroom. The Kings Fund (2010)
Review of early warning systems in the NHS (February 2010):Maintaining and improving quality during the transition: safety, effectiveness, experience (March 2011)
How to maintain quality during the Transition. National Quality Board (2012)
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