Quality Accounts 2010-11 Guide February 2011
Contents 1. Introduction 2. Quality at the Heart of the Organisation 3. Engagement 4. Continually learning 5. A listening organisation 6. Registration and External review 7. Transparent and Open 8. Clear and easy to follow 9. Robust external audit 10. Indicator list 11. References 12. Data Sources
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WMQI Quality Account Guide 2010-11
1. Introduction The West Midlands QI, the regional Quality Observatory, has produced this guide after reviewing best practice from the West Midlands 2009-10 Quality Accounts (QA), and reflecting the latest guidance from the Department of Health, and the evaluation undertaken by the King’s Fund. In drawing up the guide we have sought to align the proposed content to the requirements of other agencies such as Monitor. In reading this guide Trusts should note that the role of Quality Observatories in regard to quality accounts is: A helping hand providing o
Expertise on data and its analysis and presentation
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Advice from reviewing QAs
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Shared learning from across the country
Providing critical comment o
As the only regional body looking at QAs
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To both Trusts and their assurers (PCT, OSC, Links)
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Individual feedback to authors
Should haves NOT Must Haves
o A list of useful sources is provided at the end of the guide In addition to the comments of the WMQI, the SHA would like Trusts to consider the following areas: Patient experience - how does the Trust measure, assess and respond to patient feedback The High Impact Actions – how the Trust is delivering these and monitoring improvement, especially in regard to pressure ulcers How safe is the service? Details of how the Trust has applied and conformed to national patient safety guidance, Central alerts etc How the Trust has planned, executed and 'used' clinical audit. What do the staff say about the organisation? How the Trust is listening, responding and learning from complaints How the Trust is adopting the NICE Quality Standards in partnership with their commissioners How the Trust is addressing the challenges of QIPP
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How the Trust is responding to the challenges of quality assuring any community services transitioning to them (where relevant)
WMQI has structured this guide using the following themes; in each section we provide examples of how Trusts can evidence their performance:
Quality at the Heart of the Organisation Engagement Continually learning A listening organisation Registration and External review Transparent and Open
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Clear and easy to follow
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Robust external audit 24
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2. Quality at the Heart of the Organisation In part 1 of the Quality Account the Trust has the opportunity to explain how it assures itself as to the quality of the services it provides within the statement from the Chief Executive (or equivalent). A good model for demonstrating how a Trust does this is Monitor’s Quality Governance Framework (see table 1). The framework captures the combination of structures and processes at and below board level that lead on Trust-wide quality performance including: ensuring required standards are achieved investigating and taking action on sub-standard performance planning and driving continuous improvement identifying, sharing and ensuring delivery of best-practice identifying and managing risks to quality of care Trusts should be able to evidence how they address the challenges raised in each section by providing evidence of their governance arrangements.
Table 1: Monitor’s Quality Governance Framework 1. Strategy 1a: Does quality drive the Trust’s strategy?
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Example good practice Quality is embedded in the Trust’s overall strategy The Trust’s strategy comprises a small number of ambitious Trust-wide quality goals covering safety, clinical outcomes and patient experience which drive year on year improvement [as indentified in QA 2009-10] Quality goals reflect local as well as national priorities, reflecting what is relevant to patient and staff Quality goals are selected to have the highest possible impact across the overall Trust Wherever possible, quality goals are specific, measurable and time-bound Overall Trust-wide quality goals link directly to goals in divisions/services (which will be tailored to the specific service) There is a clear action plan for achieving the quality goals, with designated lead and timeframes Applicants are able to demonstrate that the quality goals are effectively communicated and well-understood across the Trust and the community it serves The Board regularly tracks performance relative to quality goals
WMQI Quality Account Guide 2010-11
2. Capabilities and culture 2a. Does the The Board is assured that quality governance is subject to rigorous challenge, Board have the including full NED engagement and review (either through participation in necessary Audit Committee or relevant quality-focused committees and subleadership and committees) skills and The capabilities required in relation to delivering good quality governance are knowledge to reflected in the make-up of the Board ensure delivery Board members are able to: of the quality o Describe the Trust’s top three quality-related priorities agenda? o Identify well- and poor-performing services in relation to quality, and actions the Trust is taking to address them, o Explain how it uses external benchmarks to assess quality in the organisation (e.g. adherence to NICE guidelines, recognised Royal College or Faculty measures) o Understand the purpose of each metric they review, be able to interpret them and draw conclusions from them o Be clear about basic processes and structures of quality governance o Feel they have the information and confidence to challenge data Be clear about when it is necessary to seek external assurances on quality e.g. how and when it will access independent advice on clinical matters Applicants are able to give specific examples of when the Board has had a significant impact on improving quality performance (e.g. must provide evidence of the Board’s role in leading on quality) The Board conducts regular self-assessments to test its skills and capabilities and has a succession plan to ensure they are maintained Board members have attended training sessions covering the core elements of quality governance and continuous improvement 3. Structures and Processes 3a. Are there Each and every board member understands their ultimate accountability for clear roles and quality accountabilities There is a clear organisation structure that cascades responsibility for in relation to delivering quality performance from „Board to ward to Board‟ (and there are quality specified owners in-post and actively fulfilling their responsibilities) governance? Quality is a core part of main Board meetings, both as a standing agenda item and as an integrated element of all major discussions and decisions Quality performance is discussed in more detail each month by a qualityfocused board sub-committee with a stable, regularly attending membership 4. Measurement 4a: Is The Board reviews a monthly ‘dashboard’ of the most important metrics. appropriate Good practice dashboards include: quality o Key relevant national priority indicators and regulatory requirements information o Selection of other metrics covering safety, clinical effectiveness and being analysed patient experience (at least 3 each) and o Selected ‘advance warning’ indicators challenged? o Adverse event reports/ serious untoward incident reports/ patterns of complaints o Measures of instances of harm (e.g. Global Trigger Tool)
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o o
Monitor’s risk ratings (with risks to future scores highlighted) Where possible/appropriate, percentage compliance to agreed bestpractice pathways o -Qualitative descriptions and commentary to back up quantitative information The Board is able to justify the selected metrics as being: o Linked to Trust’s overall strategy and priorities o Covering all of the Trust’s major focus areas o The best available ones to use o Useful to review The Board dashboard is backed up by a ‘pyramid’ of more granular reports reviewed by sub-committees, divisional leads and individual service lines Quality information is analysed and challenged at the individual consultant level The Board dashboard is frequently reviewed and updated to maximize effectiveness of decisions; and in areas lacking useful metrics, the Board
Quality Improvement Priorities In part 2, every Trust has to identify at least 3 priorities for improvement. The priorities should reflect engagement with patients, community groups and commissioners. Trusts also have to report on their progress against the priorities they set in 2010-11. Last year many Trusts did not follow best practice in describing their priorities. There should be 6 main components: 1. Rationale -why is this a priority? 2. Baseline - a measured starting point 3. A goal -what the Trust aspires to achieve in a prescribed timescale 4. Monitoring and reporting - a clear process for measuring progress and reporting to an appropriate group 5. How the goal will be achieved – what will the Trust do to achieve the goal 6. Responsible officer – a named person, or team, who is responsible for delivering the priority In the example (1) below, the Trust has described how it identified Clostridium Difficile as a priority, although it could have been clearer and brought the rationale out in its own section. The Trust has provided data showing progress and the baseline for 2010-11. It has set a clear goal to reduce this to no more than 161 in 2010-11. It has stated how it will monitor the target, although they do lack a statement as to how they will report it within the Trust, but they do give the names of the Board sponsor and operational lead. How they will achieve it is referenced to a previous part of the report.
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It is important that Trusts report their priorities clearly as they will be held to account in the subsequent year as to how well have they done. If the priority is not clear then it will be difficult for Trust to be clear as to how well they have delivered on their priorities. Example 1: A good example of how to describe a priority
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3. Engagement As mentioned above the priorities for Quality Accounts should be informed by an on-going discussion with patients and the community. This may result in proposed priorities that do not necessarily at first sight fit into the normal constructs of quality indicators. For example it may not be uncommon for patients and carers to describe their priority as being car parking. It is important that all priorities are considered and the rational for selection or setting aside are recorded, perhaps not in the actual quality account but formally in Trust papers. For example, here a Trust has reported the results of their ‘Big Conversation’ for three areas, but have informed the reader that the full report was presented to the board and referenced where to find it.
Example 2: Describing Engagement
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4. Continually learning Many Trusts found the statutory requirement to include national and local audits challenging to present. The Department of Health (DH) have changed the guidance this year so that it is no longer necessary to produce multiple tables when one would do. The table below (table 2) shows how it is possible to capture the information in one table. Acute hospitals must list all audits, as non participation is regarded as important as participation. For specialist hospitals and community units where you are only eligible for a small minority, it would be appropriate to list those audits for your clinical areas otherwise there would be a lot of redundancy in the table. The Quality Account is about demonstrating how the quality governance approach of the Trust and who is responsible for leading on it; therefore you might wish to give the lead clinician for the audit at the Trust. Trusts must give the percentage of patients submitted as required by the audit, rather than a statement such as ‘partial’.
Table 2: Reporting National Audits Lead clinician
Eligible
Participate
% submitted
Peri- and Neonatal Perinatal mortality (CEMACH) Neonatal intensive and special care (NNAP) Children Paediatric pneumonia (British Thoracic Society) Paediatric asthma (British Thoracic Society) Paediatric fever (College of Emergency Medicine) Childhood epilepsy (RCPH National Childhood Epilepsy Audit) Paediatric intensive care (PICANet) Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) Diabetes (RCPH National Paediatric Diabetes Audit) Acute care Emergency use of oxygen (British Thoracic Society) Adult community acquired pneumonia (British Thoracic Society) Non invasive ventilation (NIV) - adults (British Thoracic Society) Pleural procedures (British Thoracic Society) Cardiac arrest (National Cardiac Arrest Audit) Vital signs in majors (College of Emergency Medicine) Adult critical care (Case Mix Programme) Potential donor audit (NHS Blood & Transplant) Long term conditions Diabetes (National Adult Diabetes Audit) Heavy menstrual bleeding (RCOG National Audit of HMB) Chronic pain (National Pain Audit)
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Ulcerative colitis & Crohn’s disease (National IBD Audit) Parkinson’s disease (National Parkinson’s Audit) COPD (British Thoracic Society/European Audit) Adult asthma (British Thoracic Society) Bronchiectasis (British Thoracic Society) Elective procedures Hip, knee and ankle replacements (National Joint Registry) Bronchiectasis (British Thoracic Society) Elective surgery (National PROMs Programme) Cardiothoracic transplantation (NHSBT UK Transplant Registry) Liver transplantation (NHSBT UK Transplant Registry) Coronary angioplasty (NICOR Adult cardiac interventions audit) Peripheral vascular surgery (VSGBI Vascular Surgery Database) Carotid interventions (Carotid Intervention Audit) CABG and valvular surgery (Adult cardiac surgery audit) Cardiovascular disease Familial hypercholesterolaemia (National Clinical Audit of Mgt of FH) Acute Myocardial Infarction & other ACS (MINAP) Heart failure (Heart Failure Audit) Pulmonary hypertension (Pulmonary Hypertension Audit) Acute stroke (SINAP) Stroke care (National Sentinel Stroke Audit) Renal disease Renal replacement therapy (Renal Registry) Renal transplantation (NHSBT UK Transplant Registry) Patient transport (National Kidney Care Audit) Renal colic (College of Emergency Medicine) Cancer Lung cancer (National Lung Cancer Audit) Bowel cancer (National Bowel Cancer Audit Programme) Head & neck cancer (DAHNO) Trauma Hip fracture (National Hip Fracture Database) Severe trauma (Trauma Audit & Research Network) Falls and non-hip fractures (National Falls & Bone Health Audit) Psychological conditions Depression & anxiety (National Audit of Psychological Therapies) Prescribing in mental health services (POMH) National Audit of Schizophrenia (NAS) Blood transfusion O neg blood use (National Comparative Audit of Blood Transfusion) Platelet use (National Comparative Audit of Blood Transfusion)
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The other area which Trusts found challenging in regard to Audits was demonstrating how they responded to audit findings. There were very few examples of what changed and Trusts need to reflect on whether they can improve on this. Given the space constrictions in the Quality Account to fully report on the Trust reported and acted on the audits, Trusts could consider using online appendices on their websites to supplement the Quality Account. The reporting of local audits was challenging, more so than National Audits due to the larger number of audits undertaken. In the West Midlands this ranged from a reported 6 to 448 across the Acute Hospitals. Trusts should consider how best to demonstrate their commitment to local audit and how they improve care versus the requirement to list them all. It should be possible to highlight the most important local audits that changed practice in the account, and again make the complete list available via an appendix published separately online.
Clinical research Trusts in their reporting of clinical research did little more than give the numbers of patients enrolled in studies, although some did report the numbers of papers. The research section is an opportunity for Trusts to demonstrate how research is relevant to improving the quality of care. Trusts could look to provide evidence of how research has impacted on the care delivered or how it has contributed to wider understanding. If Trust staff have won prizes for their research, or have had their research covered in news programmes this should be mentioned. A research active Trust should be able to explain the benefits that partaking in research brings.
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5. A listening organisation Trusts were on the whole poor at demonstrating that they were fully aware of what patients and staff were saying about the organisation. There are 4 key data sources that should be reported: 1. 2. 3. 4.
Patient surveys Staff Survey Complaints compliments
Patient surveys Depending on the service, Trusts should report the key findings from these surveys: Inpatient Services Outpatient Services Emergency Department Maternity Services Community Mental Health Services Cancer Patients' Experience In selecting the questions to report the Trust should reflect on their key patient experience priorities. If the Trust has not set patient experience priorities then being aware of what it is getting right and where it is less successful would be appropriate. It would not be appropriate to list performance without stating what the Trust’s action plan to address them is. In presenting any data it is important to provide trend data. Last year most Trusts presented the change from previous year. This is not sufficient to demonstrate that the Trust understands its performance. Trust should seeking to present the least 5 data points in any graph or table. To assist Trusts we have provided on the WMQI website the South East Coastal Quality Observatories Benchmarker tool for the Inpatient Survey (http://www.wmqi.westmidlands.nhs.uk/news/patient-experience-tracker)
Local patient experience Trusts are expected to be capturing experience in ‘real-time’, therefore Trusts should report the methods they use and what this is telling them and how it is used to inform changes in services. It is important however to consider the biases that may occur in local data collection and that it should not be presented as more accurate than the national surveys unless the Trust has had their methodology independently assessed.
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Other patient experience data Trusts also need to be aware and monitoring the independent collections of patient experience data such as that collected by Patient Opinion, NHS Choices and Iwantgreatcare. Trusts should be able to demonstrate how they track these systems and whether they act on them.
Staff survey Trusts should also be reporting what their staff are saying about working in the organisation. Research evidence has now established a clear relationship between staff satisfaction and patient satisfaction. Staff who are satisfied and engaged with their work are more likely to deliver a better quality of communication with patients. Trusts should look to report on the following questions: Staff working in a well structured team environment Staff reporting errors, near misses or incidents Staff working extra hours Staff witnessing potentially harmful errors, near misses or incidents in previous month Quality of work life balance Extent of positive feeling within the organisation (communication, staff involvement, innovation & patient care) Staff job satisfaction Work pressure felt by staff Staff intention to leave jobs
Complaints It is essential that all Trusts report the volume and nature of complaints received. The example below (3) gives a good example of how one Trust has reported its complaints. They show change from last year, it would of course be better to see longer time trends as it is impossible to say whether this is coming down from a high or within a consistent range. They have also reported the top 3 reasons, but have not clarified the difference between category and issues. Complaints should be reported by departments, sites or services with the most complaints. The ratio of complaints to activity should also be provided so that Trusts can be compared. WMQI would prefer ratio of complaints to 100 admissions, as this is keeping with NPSA reporting of incidents. The NHS Information Centre (NHS IC) publishes data on complaints here http://www.ic.nhs.uk/statistics-and-data-collections/audits-andperformance/complaints. Trusts should also give regard to the reports of the Health Service Ombudsman.
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Example 3: Reporting Complaints
Compliments The use of patient stories both positive and negative should be used throughout the account to highlight why change has been made in response to comments but also to highlight how successful change has been. The Quality Account should be a blend of quantitative and qualitative evidence. Quality cannot be measured by numbers alone as patient’s aspirations and expectations will be felt and expressed differently. Here (example 4) is how one Trust reported compliments received through the NHS Choices website. Although useful in commenting on the whole service the list approach is perhaps not the most enlightening way to use compliments. They could have used these comments alongside the patient survey results to provide some examples of why the Trust was well regarded by its patients.
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Example 4: Compliments
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Another Trust provided a table of compliments (example 5), which could be used to compare to the complaints data to judge whether their quality improvements were succeeding in improving patient experience. However as illustrating what patients think it is not very enlightening. Does the table provide enough information about what aspect of care that patients liked?
Example 5: Compliments
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6. Registration and External review Trusts struggled to compile with this section and the required text. Trusts have to comply with the statutory requirements and fit their response to fit with the prescribed text. Pages 35 and 36 of the DH Toolkit give further guidance on how to complete this section. Trusts can extend the section to give a fuller response and where the CQC has put in place conditions Trusts should provide details of their action plans to address them.
Peer Reviews Visits and reviews by peers are an important tool for assuring services. They should be reported in terms of how many by whom, and their findings. It is an opportunity for the Trust to demonstrate how it is a learning organisation by being open to external review, but also by releasing their staff to partake in reviews so that they can learn from others.
Commissioning for Quality and Innovation (CQUIN) Along with Statutory text set out in the regulations Trust should give consideration to providing more detailed indication of performance. This can be achieved in a simple table such as this one below (example 6). This table details the CQUIN, the goal and achievement. You could consider adding an icon such as a tick or a cross to assist readers to understand whether the goal has been achieved.
Accreditation for Inpatient Mental Health Services (AIMS) and ECT Accreditation Service (ECTAS) If Mental Health Trusts have achieved either of these accreditations they should include these, and their renewal dates. It the Trust is working towards achieving this or other accreditation such as Star Wards then they should also include their action plans.
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Example 6: CQUIN
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Patient Environment Action Teams (PEAT) PEAT is an annual assessment of inpatient healthcare sites in England that have more than 10 beds. It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of patient care including environment, food, privacy and dignity. Trusts should include their PEAT assessment, broken down by site where possible. It is another inspection and statement of compliance that provides a grading of the Trust’s environment. In the example (7) below the Trust has provided site specific data and an icon, the traffic light, to demonstrate achievement. The traffic light is visually appealing but you should check when considering such presentation tools whether its understanding is clear to the public and is legible when printed in black and white. The results for 2010 can be found at http://www.nrls.npsa.nhs.uk/patient-safety-data/peat/.
Example 7: PEAT
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7. Transparent and Open Incident reporting It is important that Trusts use the Quality Account to demonstrate the safety of their organisation. Trusts should report on the safety incidents and their severity. A simple and consistent format of presentation is already adopted by the NPSA (Example 8) as a minimum Trusts should present the same data in their quality accounts. In addition, Trusts should consider presenting the trends in incident reporting, and the level of incident reporting by directorate or service to demonstrate how incidents are reported from ward to board. Example 8: NPSA workbook
Source: http://www.nrls.npsa.nhs.uk/resources/?entryid45=76319&q=0%c2%acsupporting%c2%ac
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NHS Litigation Authority (NHSLA) Trusts should report their NHSLA Clinical Negligence Scheme for Trusts (CNST) level and any action plan to achieve the next level. Trusts should also give consideration to how they report the levels of claims made against them. This data is publically available and Trusts should be aiming to explain how they have learnt from the events. The most recent workbook of claims can be found on the NHSLA website (http://www.nhsla.com/NR/rdonlyres/7BDA0851-E6AC-4E50-BAC1CB32E28932E8/0/NHSLAFactsheet5200910.xls) and the Factsheet with CNST levels (http://www.nhsla.com/NR/rdonlyres/626DE33C-94C4-4BC3-8266BF4615CD03BA/0/Factsheet4201011February2011.xls&sa=U&ei=s5pvTerVA8LNhAeJusA&ved=0CA0QFjAA&usg=AFQjCNG-j4M5JezsDz_YVdqdZsTujLlUHw)
Mortality Whether you use the Hospital Standardised Mortality Ratio (HSMR), Risk Adjusted Mortality Index or another measure of mortality it is important that you are aware of it and how to interpret the results. The example below is a good example (example 9) of how a Trust is monitoring not just the RAMI but also considering the crude mortality. The Summary Hospital-level Mortality Indicator (SHMI) is unlikely to be published before the Quality Accounts have to be submitted to PCTs, OSCs, and LINks, however you should report how the board of your Trust assure themselves of the mortality at your Trust, remembering that such measures can only ever be useful when considered with other metrics. Trusts should be wary about attempting to explain variations in mortality solely due to coding without very good analysis to demonstrate this.
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Example 9: Mortality
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8. Clear and easy to follow Trusts in writing their Quality Account are free to choose whatever format they feel appropriate for their audience. There are a wide range of possibilities from a formal report following the three part structure of the regulations; this can be modified into a patient focused two part account with a separate regulation section (e.g. Birmingham Children’s Hospital); or in a newspaper format (e.g. Wolverhampton PCT). Whichever style you choose to use section 6 of the Toolkit provides clear guidance as to how to present data. Trusts should also consider: Using a simple and consistent format o
Avoid different graph and table styles that might confuse readers
o
Just because ‘Excel can’ does not mean it is necessarily an appropriate style for your audience
o
Checking for inaccuracies in graphs. Last year there were 120%s, missing series, and ½ patients in counts
o
Years should be in ascending order in tables, reading left to right
o
Avoid overcrowding graphs with too many series
o
Avoid small illegible graphs and text
o
Test what graphs and tables look like in Black and White, especially when Red-AmberGreen rating, try using Icons instead
o
Avoid 3D graphs
Avoids NHS speak o
Consider using a glossary, this could be on your website
Addresses accessibility issues o
Trusts do not need to translate or reprint the Quality Account in different languages or other forms; rather they should provide the opportunity for people to access services which can address individual accessibility needs.
Provides site specific data o
A patient’s geography is likely to be different to that off a Trust and data should be where possible made available at clinic or service level
Use of Staff/Patient anecdotes, feedback and stories to highlight issues Opportunity for feedback
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9. Robust external audit Writing the Quality Account is only one part of the process, the other key to the process is the robust challenge by the PCT, OSC, LINks. Trusts should work to those organisations’s timetable when planning the writing process. Trusts need to ensure that these organisations have sufficient time to consider and respond, and to also leave the Trust time to reflect and accommodate their concerns.
The OSCs, PCTs, and LINks should be considering these questions in their responses: Are you assured that the Trust has appropriate quality assurance mechanisms in place? What engagement was there in the priority setting? Were you included in the process? Are there issues that you are aware off that have not been considered in the Quality Account? Has the Trust recognised its areas for improvement and does it have adequate action plans to address them? Is the document presented in transparent and open fashion?
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10. Indicator list To support Trusts in their submissions WMQI has brought together a list of the indicators that Trusts may consider for inclusion in their quality accounts. The indicators have been selected as the best fit between nationally available data and quality outcomes framework. There are a set for All providers, Acutes, Community services and Mental Health. WMQI is striving to populate these indicators, with national benchmarks. They are not designed to be neither exhaustive nor prescriptive. Some of the acute trust measures, indicated with *, will be published by the Quality Observatories in a new quality scorecard. The expectation is that this will be available by 24th March. This timescale may not be sufficient for inclusion for all indicators in this year’s Quality Account. The other indicators are should be available within Trusts.
A list of hyperlinks to the national webpages for most of the data sources in provided in section 12.
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All Providers
Topic
Indicator
Staff Survey
% staff working in a well structured team environment % staff reporting errors, near misses or incidents % staff working extra hours % staff witnessing potentially harmful errors, near misses or incidents in previous month Quality of work life balance Extent of positive feeling within the organisation (communication, staff involvement, innovation & patient care) Staff job satisfaction Work pressure felt by staff Staff intention to leave jobs
Inpatient Survey
Overall, did you feel you were treated with respect and dignity while you were in the hospital? (All) Q71. Overall, how would you rate the care you received?
Written complaints
Number of complaints Rate of compliant per admissions Complaints closed within 25 days
Inpatient waiting times
Referral Time to Treatment (NHS Constitution breaches)
Staff
Turnover Sickness rates
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Acute providers Topic
Indicator
Organisational approach to quality
Palliative coding (ICD10 coding Z515) Rate*
Data completeness – Admitted Patient Care* Data completeness – Out Patient* Data completeness – Accident & Emergency* Elective - Depth of coding (mean number of secondary diagnosis)* Non-Elective Depth of coding (mean number of secondary diagnosis)* Preventing people from dying prematurely
Mortality from conditions amenable to healthcare*
Crude mortality per 100 provider spells* Elective Standardised Mortality Ratio (SMR)* Emergency SMR* Emergency SMR – Stroke* Emergency SMR – Chronic Obstructive Pulmonary Disease (COPD)* Emergency SMR – Myocardial Infarction* Emergency SMR – Fracture Neck of Femur Emergency SMR – Pneumonia* Emergency SMR – Heart Failure* Mortality in low risk Healthcare Resource Group (HRG)* Enhancing quality of life for people with long-term conditions
Relative length of stay for Dementia – absolute or relative %*
Mean number of attendances per year for patients attending more than once* Helping people to recover from episodes of ill health or following injury
% patients discharged to usual place of residence*
Emergency Readmission in 30 days following other admission* Emergency Readmission in 30 days following elective admission* Emergency Readmission in 2 days following other admission* Emergency Readmission in 2 days following elective admission* Stroke – 90% time on stroke unit Transient Ischaemic Attack (TIA) treated within 24 Hours Patient reported Outcomes Measures (PROMS) Hip replacements Patient reported Outcomes Measures (PROMS) Knee replacements
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Patient reported Outcomes Measures (PROMS) Varicose Veins Patient reported Outcomes Measures (PROMS) Groin Hernia Pulmonary Embolism Readmissions within 90 days post treatment Ensuring people have a positive experience of care
Elective Median wait – days
Cancer waits – 14 days GP referral to First Seen Cancer waits – 31 Day diagnosis to treatment Cancer waits – 62 day GP referral to first treatment A&E - 7 day reattendance A&E - Attenders who leave without being seen A&E - Mean Time to initial assessment A&E - Mean Time to treatment Single sex accommodation Cancellation of elective surgery for non-clinical reasons Outpatient Survey: Was the main reason you went to the Outpatients Department dealt with to your satisfaction? Outpatient Survey : How well organised was the Outpatients Department you visited? Outpatient Survey : Overall, did you feel you were treated with respect and dignity while you were at the Outpatients Department? Outpatient Survey : Overall, how would you rate the care you received at the Outpatients Department? Treating and caring for people in a safe environment and protecting them from avoidable harm
Caesarean section rate – Elective*
Caesarean section rate – Non elective* Emergency ambulatory care conditions – admission rate* Emergency ambulatory care conditions – readmission rate* Day case rate* % planned day case converted to Inpatient* Rate of complaints about Acute services per 10,000 admissions* Healthcare Associated Infection (HCAI)- MRSA Rate per 10,000 admissions Healthcare Associated Infection (HCAI)- CDIF Rate per 10,000 admissions Healthcare Associated Infection (HCAI) - MSSA Rate per 10,000 admissions Surgical Site Infections Fracture Neck of Femur operated on in 48 hours Venous thromboembolism (VTE) national CQUIN Rate of patient safety incidents reported in Trusts per 1000 bed days*
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Mental Health Topic
Indicator
Helping people to recover from episodes of ill health or following injury
Re-admission rates
Delayed transfers of care Proportion of adults on Care Programme Approach receiving secondary mental health services in settled accommodation Proportion of adults on Care Programme Approach receiving secondary mental health services in employment The proportion of users on new Care Programme Approach who have had a Health of Nation Outcome Score (HoNOS) assessment in last 12 months The proportion of those on Care Programme Approach reviewed in at least the last 12 months The number of episodes of absence without leave (AWOL) for the number of patients detained under the Mental Health Act 1983 Number of bed days recorded for people under 16 Organisational approach to quality
Data quality of ethnic group Data completeness of the Mental Health Minimum Data Set (MHMDS)
Ensuring people have a positive experience of care
Community Mental Health Service User Survey: Did this person treat you with respect and dignity? Community Mental Health Service User Survey: Do you know who your Care Coordinator (or lead professional) is? Community Mental Health Service User Survey: Have you been given (or offered) a written or printed copy of your care plan? Community Mental Health Service User Survey: Does your care plan set out your goals? Community Mental Health Service User Survey: In the last 12 months have you had a care review meeting to discuss your care plan? Community Mental Health Service User Survey: Crisis Care: The last time you called the number, did you get the help you wanted? Community Mental Health Service User Survey: Overall, how would you rate the care you have received from Mental Health Services in the last 12 months? Regional Patient Experience CQUIN
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Community Services
Topic
Indicator
Ensuring people have a positive experience of care
Percentage of all deaths that occur at home
Single sex accommodation Regional Patient Experience CQUIN Helping people to recover from episodes of ill health or following injury
Participation rates in the Cardiac Rehabilitation Audit
Proportion of sites with a community stroke team for longer term management attached to the stroke multidisciplinary team Proportion of stroke patients who see occupational therapist within 4 working days Proportion of stroke patients who see Physiotherapist within 72 hours of admission People who in last 6 months, have had enough support from local services or organisations to help manage long-term health condition(s) (GP satisfaction survey) Treating and caring for people in a safe environment and protecting them from avoidable harm
Healthcare Associated Infection (HCAI)- MRSA Rate per 10,000 admissions
Healthcare Associated Infection (HCAI)- CDIF Rate per 10,000 admissions Healthcare Associated Infection (HCAI) - MSSA Rate per 10,000 admissions
Produced by
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11. References Quality Accounts toolkit 2010/11. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume nts/digitalasset/dh_122540.pdf Quality Accounts – Survey of providers http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/di gitalasset/dh_122542.pdf Quality Accounts – Survey of PCTs/SHAs/LINks/OSCs http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/di gitalasset/dh_122544.pdf NCAs for inclusion in Quality Accounts 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/ dh_121087.pdf
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12. Data Sources Cancelled Operations http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/Cancelledo perations/index.htm Cancer waiting times http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/HospitalW aitingTimesandListStatistics/CancerWaitingTimes/index.htm Community Mental Health Survey http://www.cqc.org.uk/aboutcqc/howwedoit/involvingpeoplewhouseservices/patientsurveys/communi tymentalhealthservices.cfm Complaints http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/complaints. Diagnostic waiting times http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/HospitalW aitingTimesandListStatistics/Diagnostics/index.htm Emergency department survey http://www.cqc.org.uk/aboutcqc/howwedoit/involvingpeoplewhouseservices/patientsurveys/emergen cydepartments.cfm HCAI (MRSA and C Diff) http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1274089052145 Incidents http://www.nrls.npsa.nhs.uk/resources/?entryid45=76319&q=0%c2%acsupporting%c2%ac Inpatient Survey Benchmark tool: http://www.wmqi.westmidlands.nhs.uk/news/patient-experience-tracker CQC:http://www.cqc.org.uk/aboutcqc/howwedoit/involvingpeoplewhouseservices/patientsurveys/inpa tientservices.cfm Maternity Service Survey http://www.cqc.org.uk/aboutcqc/howwedoit/involvingpeoplewhouseservices/patientsurveys/maternity services.cfm
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Mental Health Performance Indicators (MHMDS) http://www.ic.nhs.uk/services/mental-health/mental-health-minimum-dataset-mhmds/routinequarterly-mhmds-reports NHSLA: Claims http://www.nhsla.com/NR/rdonlyres/7BDA0851-E6AC-4E50-BAC1CB32E28932E8/0/NHSLAFactsheet5200910.xls NHSLA: CNST levels http://www.nhsla.com/NR/rdonlyres/626DE33C-94C4-4BC3-8266BF4615CD03BA/0/Factsheet4201011February2011.xls&sa=U&ei=s5pvTerVA8LNhAeJusA&ved=0CA0QFjAA&usg=AFQjCNG-j4M5JezsDz_YVdqdZsTujLlUHw Outpatient Services Survey http://www.cqc.org.uk/aboutcqc/howwedoit/involvingpeoplewhouseservices/patientsurveys/outpatien tservices.cfm PEAT http://www.nrls.npsa.nhs.uk/patient-safety-data/peat/ PROMs http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1295 Referral Time to Treatment http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/ReferraltoT reatmentstatistics/index.htm Single Sex Accommodation http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/MixedSexA ccommodation/index.htm Staff sickness http://www.ic.nhs.uk/statistics-and-data-collections/workforce/sickness-absence Staff Survey http://www.cqc.org.uk/aboutcqc/howwedoit/engagingwithproviders/nhsstaffsurveys/staffsurvey2009.c fm Stroke Sentinel Audit http://www.rcplondon.ac.uk/resources/national-sentinel-stroke-audit
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