Raising the Standards – NHS Kirklees Quality Performance Report 1.0 Introduction The Government set out its commitment to delivering services in England that met the highest quality standards . They set out this vision in High quality care for all – NHS Next Stage Review Final Report (DH 2008), NHS Kirklees is committed to achieving this vision and aspires to delivery health care that is of a consistent high standard and quality . To assure the Board of NHS Kirklees that we are leading the way in the delivery of this vision we have put in place systems and processes to set and monitor quality standards across the health economy, and as leaders of the local NHS we are delivering continuous quality improvement through world class commissioning.
2.0 Background NHS Kirklees is committed to implementing the standards, set out by the Government, in High quality care for all – NHS Next Stage Review Final Report (DH 2008), putting quality at the heart of health service delivery. Government targets have delivered vast improvements in health care over the last ten years and investment in services within NHS Kirklees has been unprecedented. In developing services closer to home we have focused on evidence based practice and clinical effectiveness . We have worked with all our providers to improve quality through pathway development and contractual quality performance indicators and incentives. This gives us the platform to focus on quality and improve services for the population of Kirklees , reducing variation in the quality of care, providing more information and choice for the public . To deliver world class high quality services, it is necessary to focus on the central tenants of Lord Darzi’s report which are , patient experience , patient safety and clinical effectiveness. To reduce the variation in care , and improve the quality of care we need to monitor quality metrics and benchmark services locally, regionally and nationally. Over the last two year NHS Kirklees has been working both regionally and locally to develop metrics , working in partnership with providers and partners , to drive up standards and to review and improve the quality of care through formal quality boards. In the turbulent times ahead we must have synergy between performance, finance, innovation and quality which will underpin the QUIP agenda .
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3 Quality Narrative 3.1 Model The model ( FIG 1) is the framework for the delivery of quality improvement that underpins the ethos of the board and is based on The Next Stage Review (DH2008) and the Yorkshire and Humber Strategy High Quality Care for All.(2008) Fig 1 Model for Quality Improvement
Involving people in service design
Improving patient experience
Focus on clinical effectiveness and evidence based practice
Setting standards for patient safety
Leading change and innovation through Quality Improvement
Partnership working
Clinical leadership and
World Class Commissioning
engagement
3.2 Early achievements. NHS Kirklees has made significant process over the last 12 month to improve the quality of our commissioned services . As leaders of the local NHS we have worked with providers of services to build a culture that supports continuous quality improvement. Through the clinical quality boards we have held organisations to account for the quality standards in their organisations. We have seen significant reductions in health care acquired infections and worked in partnership to deliver single sex accommodation . We have used incentives to improve the time spent on face to face contact with patient ,through the releasing time to care initiative, and have played a leading role in the delivery of the regional CQUINs programme . Created by S Dilks on 20/01/2010 15:20:00 VERSION 3
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All contracts and service specifications now include quality indicators which are monitored through the contract boards, with any variations in quality performance reported through to the clinical quality board . 3.2Challenges We do ,however, recognise that there are challenges ahead . Our stroke services do not meet the nationally set standards , we have high readmission rates , and our hospital standardised mortality rates, though declining are above the national average in some specialities . End of life care is variable and there is still a significant differential in the number of people who wish to die at home who die in hospital . 4 Mechanisms 4.1Quality Boards . Quality boards have been formed with all our main providers . The boards are clinically led with representation that includes medical and nursing directors from each organisation and clinical representatives from primary care . The aims of the boards are o
To identify quality priorities for the health economy which will form the framework for a local quality incentive scheme
o
To performance manage the delivery of regional quality indicators and review standards against regional benchmark
o
To identify and monitor core quality standards within the existing contract s, therefore to drive continuous quality improvement through the contracting process.
o
To lead the Contract Management Board on clinical standards to be incorporated into the core contract and areas where clinical incentives need to be prioritised.
o
To take action through the Contract Management Board where quality standards are not met.
o
To inform CMB on the inclusion of new quality standards into the core contract.
o
To set priorities for continuous quality improvement .
o
To monitor the delivery of National quality standards .
o
To agree action plans and monitor outcomes .
5 Quality Metrics. The Trust Board regularly reviews the quality of our services ,with key areas reported monthly through the performance report .
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5.1 Setting Priorities The quality board uses performance information , patient experience data , national and regional benchmarking data to set the priorities for the year . In setting these priorities we have identified both national and local challenges , these have required a whole health community .approach to deliver the desired outcomes . The quality board is the vehicle for facilitating the partnership approach . Table 1 sets out the 2009/2010 priority areas by domain , the group responsible for performance monitoring , where the data can be found and the outcome . Table 1 Priority Areas 2009/2010 Domain
Patient Safety
Patient experience
Issues
Performance Monitoring
Outcome
•
HCAI
Monthly HCAI Strategy Group
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Discharge letters and summaries
Clinical quality board
Monthly progress review
New system being piloted. Roll out of discharge letters going out electronically by July 2010
•
Reducing Hospital standardised mortality rates
Clinical quality board
Regular update of Trusts action plans .
Improved outcomes for patients
•
Delivering Same sex accommodation
Clinical Quality Board work programme
National reporting. Review of Trust action plans
Achieved government target
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Patient satisfaction
National patient survey
All providers to be in top quartile for patient satisfaction.
•
Patient experience
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Performance data and benchmarking evidence NHS Kirklees performance report .
Report from 4
Year on year reduction in HAI rates
•
•
Clinical effectiveness
PROMS
Trust Patient experience surveys DH monitoring awaiting Data
Releasing time to care
KPI in contract quarterly monitoring of progress
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Stoke Care
Quality board priority Redesign of stroke pathway
•
Pressure area management
Quality board priority Trust task group
Improved Patient experience
CQUINS data Q2 (appendix 1) NHS Performance report
Improved patent experience and safety Reduction in Mortality rate. Increase to above target the number of people admitted with Stroke who re treated on a stroke unit
CQUINS data Q3
Improved outcomes , reduction in Grade 4 ulcers
Governance
5 NHS Kirklees Commissioning for Quality in Primary Care As a commissioner of services, we are responsible for the quality of services provided to the people of Kirklees, and as leaders of the local NHS we are committed to continuous quality improvement.
5.1 Quality Matrix As well as the clinical quality boards we have also developed a quality matrix for primary care which will enable commissioners to monitor that the services commissioned are being provided to the relevant standards/ service specification. Equally, this information will be Created by S Dilks on 20/01/2010 15:20:00 VERSION 3
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beneficial for independent contractors to evidence their level of service provision and outcomes achieved. For the Quality Improvement Team, the profile will provide shared organisational intelligence that could be used to inform quality improvement. This will include the ability to reinforce the positive and highlight actions required to address areas of further development or concern.
Initially, this tool is being piloted with GP practices. The outcome of this pilot will inform the further extension of this matrix to other providers.
5.2 Progress to date A Quality Matrix Steering Group has been set up to take this work forward and, following a scoping exercise to identify best practice already in place; discussions are taking place with all relevant leads to identify indicators that will be used. The indicators currently cover QOF outcomes, Safeguarding, Medicines Management, Infection Control, Primary Care Contracting and PALs/Complaints. Consideration is also being given to Quality Accounts, CQUINS, PROMS & PREMS and CQC standards. 5.3 Indicators The indicators identified have been grouped into the three key areas: patient experience, patient safety and effectiveness.
5.3.1 Patient Experience Indicators in this section include o o o
QOF Patient Experience Domain score PALs/Complaints indicators (to be determined) PROMS & PREMS (to be determined)
5.3.2 Patient Safety Indicators in this section include o o
o
QOF Organisational Domain score Infection Control Infection Control Audits are undertaken at GP practices once every three years. The audit tool has been developed to include a RAG status for each of the sections, which are weighted to give an overall status. Four priority areas have been identified – vaccine management and cold chain; decontamination; environmental cleaning; minor surgery. Medicines Management Three high level indicators have been agreed - Benzodiazepine prescribing; Antibiotic prescribing rates; receipt of statutory declaration regarding controlled drugs
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o
Safeguarding Two areas have been agreed, namely record of CRB checks for independent contractors and their staff and record of attendance at mandatory safeguarding training for independent contractors and their staff.
5.3.3 Effectiveness Indicators in this section include o o
o o
QOF Clinical Domain score and Additional Services Score Medicines Management Better Care Better Value indicators - Increasing low cost prescribing for lipid modification; Increasing low cost proton pump inhibitor prescribing; Increasing low cost prescribing for drugs affecting the renin angiotensin system NICE guidance Research activity
The Quality Matrix Steering Group is linked into the Primary Care Quality Information Group, and is working with Peter Flynn, Director of Performance & Information, and his team to systematise the Quality Matrix.
6 Internal Quality Assurance As well as monitoring the performance of the providers we need to assure ourselves that the services we are commissioning are based on evidence and are clinically effective. To do this we have set out the following principals. 1 2
3 4
All pathways and audit standards explicitly utilise the best available evidence of effectiveness We ensure the evidence base is derived from a wide range of the best available evidence including patient views, research, NICE guidance, clinical consensus, performance data, PHO/JSNA Pathways and NICE guidance feature prominently on the audit and effectiveness programme PROMS and PREMS will also provide an invaluable source of effectiveness from the patient perspective.
To complete the assurance process high quality clinical audits are essential. The following examples show current and completed audits and the links to the principals. 6.1 Current Audits
Chronic Fatigue Service Evaluation - focus group activity to seek the views of patients. All participants were very positive in their feedback of the pilot and were keen for the service to continue in Huddersfield Created by S Dilks on 20/01/2010 15:20:00 VERSION 3
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Baseline Audit of Care Homes Medical Support - carried out to establish if Care Homes in Kirklees feel that they receive enough medical support (to support possible introduction of LES). Most Care Homes felt that they did but a third could recall having to ring 999 for support as the GP was unavailable. Most homes felt that GP, Primary Care and Pharmaceutical advice and support were adequate to meet the needs of their residents. Training needs identified in relation to dementia awareness, palliative care and diabetes
Kirklees Obesity Audit – collaborative project with GPs and Public Health colleagues. Final report and action plan to be agreed.
Evaluation of the Basic health Task Pilots - focus groups carried out firstly with District Nurses and then Home Care staff to gain an understanding of the problems, concerns and positive aspects of the pilot. Improved joint working, communication, training and support were seen as the main outcomes for both groups of staff.
Baseline Audit of TIA Assessment and Referrals in General Practice - carried out to ascertain the training and educational needs of GPs before introducing a new TIA Pathway (based on NICE Guidance). Questionnaire produced and circulated, awaiting the final report from the Stroke Programme Lead
Asthma and COPD Audit - collaboration with Respiratory Programme and HIT lead on this PBC audit of how GPs support and follow up patients in General Practice. Includes annual reviews, medication, of all patients with COPD/Asthma in the Practice assessed against NICE Guidance).
Evaluation of the Telehealth Project - focus groups with Community Matrons to ascertain their views of the project, problems and advantages.
6.2 Examples of planned audits directly linked to Pathways, NICE guidance, PbC in 2010:
1 ADHD Pathway Audit 2 Audit of Colorectal Cancer Emergency Admissions (National Audit) 3 DiabetesE Audit 4 Falls Audit 5 Evaluation of Community Matrons pre and post Predictive Risk Implementation 8 Created by S Dilks on 20/01/2010 15:20:00 VERSION 3
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Delayed Discharges (older people) Breastfeeding Audit using the UNICEF Audit Tool Phlebotomy Service Audit - PBC audit of current experience of phlebotomy services in General Practice before new services are introduced.
7 Patient Experience The quality of care should be reflected in the patient experience . The delivery of same sex accommodation programme across Kirklees has had a direct impact on patient experience NHS Yorkshire and the Humber received £10.5 million funding from the DH to significantly improve the provision of same-sex accommodation. Local PCTs have been monitoring progress with over 90 schemes in NHS organisations across Yorkshire and the Humber to improve patient experience in terms of privacy and dignity. The Delivering Same-Sex Accommodation Privacy and Dignity Challenge Fund Report (SHA December 2009) indicates tremendous progress has been made with this agenda. Example views expressed by patients are given below:
‘Its come so far compared to what it used to be like – same sex accommodation is a marvellous step forward.” Male patient at Calderdale and Huddersfield NHS Foundation Trust.
“When not well and in night attire, especially in hospital night dresses which are open down the back, and struggling to get to the bathroom or toilet you feel very vulnerable. It is so more comfortable being able to do so without worrying about passing through areas where members of the opposite sex are being nursed.” Female patient at Mid Yorkshire NHS Trust.
Patient experience is the final arbiter of success. At national level patient experience will be assessed annually by CQC in the Patient Survey. To supplement this SHAs and trusts will carry out local patient experience surveys to give a clearer picture of the progress made. 8 Summary This report demonstrates NHS Kirklees commitment to improving the quality of services across Kirklees . Working in partnership with providers we are challenging the system to demonstrate continuous quality improvement . Created by S Dilks on 20/01/2010 15:20:00 VERSION 3
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We have metrics in place to monitor the quality of provision and are developing ours systems to improve the collection of local PROMS and PREMS . Where the system is failing the public or we are not delivering to National and Regional standards we are monitoring providers through their action plans , and any concerns are fed into the contract management board. A clear accountability framework that links quality to contract monitoring has changed the culture of commissioning, making quality everybody’s business.. Recommendations The Board receives this report. The Board supports the process for monitoring and commissioning for quality The Board to advise on future information it would like to see in this report . The Board agrees to quarterly reporting of the quality report
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