CQUIN scheme Hereford Hospitals Trust

CQUIN scheme Hereford Hospitals Trust Coordinating Commissioner Associate Commissioners NHS Herefordshire Shropshire County PCT, NHS Worcestershire Expected financial of Scheme 1,231,611 Goals and Indicators Goal no. Description of goal Quality Domain(s) 1 Indicator Indicator name SHA regional number 2 indicator 3 Indicator weighting 1 VTE risk assessment Reduce avoidable death, disability and chronic ill health from venousthromboembolism (VTE) 1 National CQUIN VTE Nationally mandated - Yes 2 Composite indicator on responsiveness to personal needs from the Adult Inpatient Survey Improve responsive to personal needs of patient (national toolkit available) Patient experience 2 National CQUIN Patient Experience Nationally Mandated - Yes 3 Increased numbers of people quitting smoking/reducing tobacco use which leads to reduction in ill health, premature mortality and healthcare need. 3 Regional CQUIN - Smoking Regional Recommended - yes 4 To implement best practice care in hospitals in the West Midlands for the care of inpatients with a secondary diagnosis of diabetes and as a consequence reduce associated healthcare costs. 4 Regional CQUIN Think Glucose Regional Recommended - yes

Goal no. Description of goal Quality Domain(s) 4 Indicator Indicator name SHA regional number 5 indicator 6 Indicator weighting 5 Missed doses - Failure to administer prescribed medicines as a result of non-availability of the medicine 5 Regional CQUIN Medicines Management Regional Recommended - yes 6 Prescribing the correct dose of warfarin 6 Regional CQUIN Medicines Management Regional Recommended - yes 11.2% of the 7 Number of admitted patients who had followed the Supportive Care pathway or Liverpool End of Life Care Pathway 7 Regional CQUIN End of life Regional pick list 8 Reducing falls in hospital will reduce unnecessary length of stay and further health deterioration. To achieve this it is expected that trusts will have a falls risk assessment process in place with appropriate care plans. 8 Regional CQUIN Falls Regional pick list 9 To promote effective discharge planning. Development and completion of a standardised discharge care plan. 9 Local CQUIN - Discharge Planning Local CQUIN

Indicator 1 VTE (national acute) Data source and frequency of Organisation responsible for data Frequency of reporting to commissioner Baseline period / date Final indicator period / date (on which payment is based) Final indicator (on which payment is based) % of all adult inpatients who have had a VTE risk assessment on admission to hospital using the national tool Number of adult inpatient admissions reported as having had a VTE risk assessment on admission to hospital using the national tool Number of adults who were admitted as inpatients (includes day cases, maternity and transfers: both elective and non elective admissions, exclusions may apply refer to guidance notes below) VTE is a significant patient safety issue, however, outcome data on VTE is poor post mortem studies suggest that only 1-2 in every 10 fatal pulmonary emboli is diagnosed. Whilst work is underway to improve reliability of outcome data, the process measure of VTE risk assessment will set an effective foundation for appropriate prophylaxis. This gives the potential to save thousands of lives each year. Month return through UNIFY http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicatio nspolicyandguidance/dh_088215 (revised 2 nd March 2010) http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicatio nspolicyandguidance/dh_116316 (updated 21 st May 2010) Hereford Hospital Trust Monthly No baseline set No Quarter 4 (January March 2011) 90% of adult inpatients admissions are reported as having a VTE risk assessment on admission to hospital using the national tool Final indicator reporting date 30 th April 2011 Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones

Indicator 2 Patient experience (National acute) Description of indicator The indicator will be a composite, calculated from 5 survey questions. Each describes a different element of the overarching theme; responsiveness to personal needs : Involved in decisions about treatment/care Hospital staff available to talk about worries/concerns Privacy when discussing condition/treatment Informed about medication side effects Informed who to contact if worried about condition after leaving hospital Index-based score reflecting positive responses to the 5 questions within the composite indicator Rationale for inclusion Data source and frequency of Organisation responsible for data Frequency of reporting to commissioner Baseline period / date Final indicator period / date (on which payment is based) Final indicator (on which payment is based) Final indicator reporting date Rules for partial achievement of indicator at yearend The indicator incorporates questions which are known to be important to patients and where past data indicates significant room for improvement across England. Adult inpatient survey, from the CQC nationally coordinated patient safety survey programme. The survey is conducted annually between October and January for patients who had an inpatient episode between July and August. Hereford Hospital Trust Annually 1. Early local data (mid January 2011) 2. Published data (April-May 2011) Adult inpatient survey 2009/2010 [based on inpatient episodes between July and August 2009) 68.8 baseline score Adult inpatient survey 2010/11 [based on inpatient episodes between July and August 2010] 72 score or over results in 100% of the CQUIN indicator payable Report June 2011 Final payment adjusted July 2011 Indicator score %age payment Min level: 64.0-66.9 30.0 67.0-68.9 74.0 69.0-71.9 87.0 final indicator : 72.0 100.0

Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date and/or inyear milestones

Indicator 3 - Smoking Brief Intervention in Outpatients (Regional recommended acute) Data source and frequency of Organisation responsible for data Frequency of reporting to commissioner Baseline period / date Final indicator period / date (on which payment is based) Final indicator (on which payment is based) Final indicator reporting date Percentage of smokers/tobacco users attending selected* outpatient clinic appointments receiving a brief intervention to reduce tobacco use including being given written advice as per NICE guidance which should at least include: simple advice to stop using tobacco an assessment of the patient s commitment to quit an offer of pharmacotherapy and/or behavioural support provision of self-help material and referral to more intensive support such as the NHS Stop Smoking Services * The selection of outpatient clinics determined is that the following are targeted: ENT; Vascular; Paediatrics (passive smoking); Cardiology; Respiratory; Diabetes. The number of patients attending selected outpatient clinic appointments recorded as smokers/users of tobacco who receive a brief intervention to reduce tobacco use including being given written advice as per NICE guidance. The brief intervention should be at the time of the clinic visit. All patients attending selected outpatient clinic appointments who are recorded as smokers/users of tobacco. Patients excluded from this denominator include those who do not attend an appointment, those who are mentally incapable of understanding the advice given (e.g. advanced dementia), are at the end of their life (expected to live for <6 months), those who are already engaged in a formal stop smoking programme or those that explicitly decline to discuss their tobacco use which must be recorded. Increased numbers of people quitting smoking/reducing tobacco use which leads to reduction in ill health, premature mortality and healthcare need. To be monitored via audit. Where providers have electronic means to collect this information (e.g. via outpatient codes on PAS) then these may be used where agreed with the commissioner and clearly defined and auditable for accuracy. Hereford Hospital Trust Quarterly reports on progress Payment based on Quarter 4 (January - March 2011) results 90% of smokers/users of tobacco attending selected outpatient clinics receive a brief intervention to reduce tobacco use April 2011

Rules for partial achievement of indicator at year-end Rules for any agreed inyear milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones 90%+ of smokers/users of tobacco attending selected outpatient clinics receive a brief intervention 0% reduction in overall payment 85-89.9% of smokers/users of tobacco attending selected outpatient clinics receive a brief intervention 25% reduction in overall payment 80-84.5% of smokers/users of tobacco attending selected outpatient clinics receive a brief intervention 50% reduction in overall payment <80% of smokers/users of tobacco attending selected outpatient clinics receive a brief intervention 100% reduction in overall payment

Indicator 4 Think glucose Compliance with Think Glucose guidance (regional recommended acute) Data source and frequency of Compliance with Think Glucose guidance To implement best practice care in hospitals in the West Midlands for the care of inpatients with a secondary diagnosis of diabetes and as a consequence reduce associated healthcare costs. The SHA has commissioned additional support as part of our call-off contract so the NHSI resource will be available to support every trust, although clearly participation also requires the commitment of time and resource from the Trust. More information on the NHS Institute Think Glucose Programme can be found at: www.institute.nhs.uk/quality_and_/think_glucose/welcome_to_the_website_for_thinkglucose.html The audit tool will be made available by the end of Q1 of 2010/11. Evidence of effective participation in the NHS Institute Think Glucose programme. Potential benefits identified in NHS Institute Think Glucose pilots sites include: Reduction in Insulin Drug Errors Reduction in inappropriate referrals to the Specialist Diabetes Team Reduction in length of stay by an average of 2 days for these patients. The financial of this 2 day LOS reduction for a typical district general hospital is estimated by the NHS Institute as being about 1m per annum. The NHS Institute has a tested improvement methodology for Think Glucose and a range of toolkits and resources to support organisations in the following areas: Assessment of the current baseline position in relation to care for this group of patients. Improvement techniques Monitoring and measurement tools Protocols to support the effective use of insulin Measurement of patient experience of care Best practice on coding to ensure that the right patients are identified Training materials for staff There is a commitment from the NHS Institute to support the region-wide rollout of the approach in every hospital. Within the QIPP Programme, the SHA is establishing a region-wide, clinically-led steering group to oversee this work. In 2010/2011 Q4, the PCT will organise an independent clinician with relevant experience to undertake a half-day visit to the Trust to look for evidence that the Trust is working in line with Think Glucose principles. The visit will use a short audit form as a guide to the audit and this will be designed and signed-off by the Regional Think Glucose Steering Group. It will look for evidence of effective management and information to patients in hospital who are not under the care of specialist diabetes teams. The audit will be designed to get a rounded assessment of whether the organisation has complied with Think Glucose guidance.

Organisation responsible for data Frequency of reporting to Commissioners Baseline period / date Final indicator period / date (on which payment is based) Final indicator (payment threshold) Final indicator reporting date Rules for partial achievement of indicator at year-end Rules for any agreed inyear milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones PCTs will collaborate to organise the assessments, working with the Regional Think Glucose Steering Group Annual Quarter 4 of 2010/11 Quarter 4 (January March 2011) Evidence of effective participation in the NHS Institute Think Glucose programme. Quarter 4 (January March 2011) TBC to be confirmed following review of audit tool end of quarter 1 TBC to be confirmed following review of audit tool end of quarter 1

Indicator 5 - Delayed and missed doses of medicines for hospital in-patients (Regional recommended acute) Failure to administer prescribed medicines as a result of nonavailability of the medicine Data source and frequency of Organisation responsible for data Frequency of reporting to provider Baseline period / date The number of in-patients who have not missed doses due to a medicine not being available for more than 2 consecutive days on their current drug chart Number of in-patients (who have been admitted for more than 2 days) with regular medicines prescribed on drug charts available at time of audit. The omission of critical medicines has the potential to result in fatalities or severe harm to patients. Non-availability of medicines is one of the causes of missed doses. NPSA national priority. Baseline audit at 2 months (May 2010) First re-audit at 6 months (Sept 2010) Final re-audit at 10 months (Jan 2011) Hereford Hospital Trust Commissioner PCT spot check audits will be conducted Report at 4 months (July 2010) Report at 8 months (Nov 2010) Report at 12 months (Mar 2011) May 2010 Final indicator period / date on which payment is based Final indicator (payment threshold) 25% of CQUIN indicator payable on completion of baseline audit Jan 2011 Final indicator reporting date March 2011 At final audit achievement of at least 90% or over results in 75% of CQUIN indicator payable (for clarity: 90% or over of audited eligible inpatients have not missed doses due to medicines not being available for more than two consecutive days) Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment If 90% or over is not achieved at final audit but 80-89.9% outcome achieved 25% of CQUIN indicator payable. Less than 80% outcome results in zero payment Rules for delayed achievement against final indicator period/date and/or in-year milestones

Indicator 6 - Safer prescribing of warfarin (Regional recommended acute) Prescribing the correct dose of warfarin Percentage time in range (using the rosendaal measure). The Rosendaal method describes the total amount of time each patient has an INR within the therapeutic range. Warfarin is a high risk medicine. It has a narrow therapeutic index. Under or over treatment can lead to patient harm. It interacts with other prescribed, over the counter medicines and certain foods. It is a priority for the national Patient First campaign. Data source: DAWN system Data source and frequency of Organisation responsible for data 1. Baseline report due July 2010 (reporting on January March 2010 data) 2. Quarterly reports on progress due July 2010 (reporting on April-June data), October 2010 (reporting July-September data) 3. Final report on which final indicator payment is based due January 2011 (reporting on April December 2010 data) Hereford Hospital Trust Frequency of reporting to provider Quarterly reports to PCT commissioning as detailed above Baseline period / date Final indicator period / date on which payment is based Final indicator (payment threshold) January-March 2010 baseline report 25% of CQUIN indicator payable on production and delivery of baseline report to PCT commissioning by end of July 2010 April December 2010 (9 month period) 70-75% achieved, results in 75% payment of CQUIN indicator payable Final indicator reporting date January 2011 Rules for partial achievement of indicator at year-end 65-69.9% achieved, results in 50% payment of CQUIN indicator payable 60-64.9% achieved, results in 25% payment of CQUIN indicator payable Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones

Indicator 7 End of Life Care Pathway (Regional pick list acute) End of Life Care Pathway (CQUIN to relate only to patients aged 18 or over. "End of Life" to be documented within the notes e.g. "This patient is dying" or similar. Length of time expected to be on LCP would be at least 2 days/48 hours before death, or duration of stay if stay < 2 days. If patient not on LCP document but has documentation of: Anticipatory prescribing; communication with family on end of life; patient checked 4 hourly for symptom management - then patient deemed to have been cared for in accordance with LCP and will be counted as on the Pathway) Number of admitted patients identified as at end of life who had followed the Liverpool End of Life Care Pathway for (at least) the last 2 days or duration of their admission if less than 2 days. Number of patient deaths (who are eligible to be included in the audit based on criteria in above description of indicator and usage of clinical judgement) Supports the delivery of the strategic priority focusing on end of life care. Data source and frequency of Organisation responsible for data Frequency of reporting to Commissioners Quarterly audits (Baseline audit Q1) Hereford Hospital Trust Quarterly reports following audits. Baseline period / date Quarter 1 (April June 2010) Final indicator period / date (on which payment is based) Final indicator (payment threshold) 25% of CQUIN indicator payable on completion of baseline audit (Quarter 1) Quarter 4 (January March 2011) 75% of CQUIN indicator payable if achieved baseline plus *25% improvement depending on baseline. (*Final improvement percentage will be agreed following baseline quarter 1 audit results) Final indicator reporting date April 2011 Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones 50% of CQUIN indicator payable if achieved baseline plus *20% improvement depending on baseline 25% of CQUIN indicator payable if achieved baseline plus *15% improvement depending on baseline

Indicator 8 Reduction in Falls in hospital (Regional pick list) Reduction in Falls of patients admitted to hospital. Reducing falls in hospital will reduce unnecessary length of stay and further health deterioration. To achieve this it is expected that trusts will have a falls risk assessment process in place with appropriate care plans. Number of inpatients admitted to hospital who have a fall whilst an inpatient (regardless of whether they sustain an injury) Data source and frequency of Organisation responsible for data Frequency of reporting to Commissioners Total number of inpatients admitted to hospital Falls have a major impact on quality of life, health and healthcare costs. The National Patient Agency (NPSA) found that in an average 800 bed acute hospital trust there will be around 24 falls every week and over 1,260 falls every year representing the highest volume patient safety incident reported in hospital trusts in England (NPSA; 2007). 28,000 falls were reported by community hospitals. Falls are a major cause of disability and mortality for older people in the UK and the problem is likely to increase with an ageing population. 10% of all people that fall will die within a year according to Help the Aged (2008). However, research estimates that up to 30% of falls can be prevented.[c.f. NHS Institute: High Impact Actions for Nursing and Midwifery ] Collection of data via safety incident reporting. Audit of patient records to ensure that all falls are recorded as incidents. If audit shows that recording is less than 95% then forfeits 100% of the indicator. Hereford Hospital Trust Commissioning PCT to audit patient records alongside. Monthly reporting of data from safety incident reporting Audit report following audit of patient records. Baseline period / date Quarter 4 ( January March 2010) Final indicator period / date (on which payment is based) Final indicator (payment threshold) No Quarter 4 (January - March 2011) Audit of patient records to ensure that all falls are recorded as incidents. If audit shows that recording is less than 95% then forfeits 100% of the indicator. *20% reduction on baseline (may be adjusted depending upon the baseline ) will result in 100% of CQUIN indicator payable Final indicator reporting date April 2011 Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment *10% reduction on baseline (may be adjusted depending upon the baseline ) will result in 50% of CQUIN indicator payable *5% reduction on baseline (may be adjusted depending upon the baseline ) will result in 25% of CQUIN indicator payable

Rules for delayed achievement against final indicator period/date and/or in-year milestones

Indicator 9 Discharge planning (Local CQUIN) Discharge care plan (Part a) Development of a discharge care plan for inpatients at Hereford Hospital Data source and frequency of Organisation responsible for data Frequency of reporting to commissioner Baseline period / date Final indicator period / date (on which payment is based) Final indicator (on which payment is based) Final indicator reporting date Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones (Part b) Number of inpatients whose discharge care plan was *completed (Measured - following their discharge) (*definition to be agreed between PCT commissioning/ by July 2010) (exclusions apply to be agreed alongside ) (Part b) Number of inpatients discharged (exclusions apply) Improve patient safety/effectiveness of the discharge process (part a) Development of discharge care plan by July 2010 ` (Part b) First audit of care plan October 2010 Final audit of care plan February 2011. (Part a) Hereford Hospital to develop and agree contents of care plan alongside commissioning PCT (Part b) Hereford Hospital to complete audits. Commissioning PCT will review audit process and/or random audit check of CQUIN. (Part A) Discharge care plan to be agreed by July 2010 with commissioning PCT. (Part b) Audit report November 2010 Final audit report March 2011 (Part b) February 2011 (part b) 75% of CQUIN indicator payable if achieved 90% or over of eligible inpatients that have a completed discharge care plan (Measured - following their discharge) at the final audit (Part b) March 2011 (part b) 50% of CQUIN indicator payable if achieved 85-89.9% of eligible inpatients that have a completed discharge care plan (Measured following their discharge) at the final audit. (Part a) 25% of CQUIN indicator payable following the development of an agreed discharge care plan by July 2010.