CQUIN 01 CQUIN 02 CQUIN 03 CQUIN 04 CQUIN 05 CQUIN 06 CQUIN 07 CQUIN 09 CQUIN 10 CQUIN 11 CQUIN 12 CQUIN 13 CQUIN 14 CQUIN 15 Quality Bonus Payment 1 Quality Bonus Payment 2 CQUIN Performance Indicator 2010/11 Improvement in patients end of life experience 2a Intervention and prevention of smoking related diseases 2b Intervention and prevention of alcohol related diseases Reduction in First attendances seen resulting from hospital generated referrals Links Dignity of care quarterly audit Reduction in the Hospital Standardised Mortality ratio Implementation of AQ care pathway acute myocardial infarction (AMI) Implementation of AQ Care Pathway Heart failure (HF) Implementation of AQ care pathway Hip & Knee replacement Implementation of AQ Care Pathway Pneumonia Implementation of AQ Care Pathway for Stroke Improved Trauma care for patients in the NW with better outcomes Improvements in Patient Experience Reduction in Venous Thromboembolism (VTE) To deliver the benefits to the patient environment planned within the Tameside HIT PFI scheme Re-admissions indicator in Dr Foster Real Time Monitor Tool (with a "red bell" given for statistically significant levels of readmissions above the norm and a "green bell" for the converse Reduce the number of hospital cancelled outpatient appointments Maximise the number of patients with fractured neck of femur that are operated on within 24 hours To maximise the number of patients having a Consultant Review at least every third outpatient attendance (exclude obstetrics and paediatrics) Admitted Patient Care Discharge letters issued within 2 days of discharge (working days) A&E Discharge Summaries issues on day of discharge Diagnostic Results issued within 2 days of report being produced (working days) Number of MRSA bacteraemias identified within the hospital
CQUIN Performance Indicator 2011/12 END OF LIFE CARE 1a. 80% of patients who are diagnosed as dying by the hospital MDT are cared for using LCP VS12. Q1-40% Q2 60% Q3 80% Doctor or non medical prescriber to prescribe appropriate anticipatory medication in line with LCP usage. 1b. Once diagnosis of dying is made ward staff to contact GP practice to let them know and ascertain: i) Is there Advanced Care Plan/ Advance decision to refuse treatment in place and document this information. Also establish preferred place of care (to die). ii) Establish are they known to GP GSF meeting. 2a. 95% of staff signing the LCP must have documented training in its use by end of Q1 and maintained for the remainder of the year. Any new staff signing LCP must be trained within 3 months. 2b. Specialist palliative care education (hour long educational session by SPC from hospital or community) for all doctors to be undertaken annually. 100% of doctors by end of Q2 ( trajectory needed over 6 months) and 80 % of all new doctors within 4 months. 100% within 6 months. 2c. 80% of Tameside FT nursing staff and doctors involved in rapid discharge to be trained in end of life care by appropriate specialists by end of Q1. 100 % of staff to be trained by 31st August 2011. 80% new staff to be trained within 3 months as part of induction, 100% within 5 months. (adult wards only) 3a. For patients diagnosed as dying and being cared for using LCP, who want to go home, to be discharged within 4 hours of completion of discharge paperwork. Achieve 4 hours for 60% of patients by end Q2 (include trajectory) and 4 hours for 70% by 31/3/2012 ( include trajectory) 3b. Palliative care patients who want to go home to be discharged within 24 hours from the time that all patients' needs catered for. Trajectory of 50% in Q1, 60% in Q2, 65% in Q3 and 70% in Q4 3C. Trust to develop key actions and standards to support active and timely delivery of patient needs to facilitate earliest discharge. To be developed and agreed with rapid discharge team (social care/pct Provider) and representative from PCT by 31/05/11 3d Trust to evidence adherence through quarterly reports against own standards facilitating earliest discharge, Q1 25%, Q2 50%, Q3 75% and Q4 100% 3e. 80% of patients being discharged by ambulance to be discharged by 1pm ( to also be discharged within timescales as outlined above). Trust staff to complete necessary paperwork and instruct NWAS in appropriate timescale to meet 1pm time (need to agree what this is) 4a. 80% of palliative care patients deemed appropriate by SPC who receive multi professional toolkit and recorded on Medway system per quarter 5a. Twice yearly audit to be undertaken by independent clinician (member of medical staff not part of the palliative care team) to assess adherence and completion to LCP (appropriate sample audit to be agreed with rep from PCT). 5b. Results of audit to be shared with PCT and action plan developed as appropriate within year milestones for 1st audit within 2 months of audit completion 5c. Achievement of milestones. Agree audit dates to effect in year.
URGENT CARE TFT is expected to produce draft proposals for the following areas: a. Discussion and agreement at the ECN by 30/04/11. b. To be fully agreed with PCT by 30/05/11 2011. c. Proposals and trajectories confirmed 31/5/11 d. Standards will be measured from the baseline agreed minimum dataset (month one of data collection) which will be set after the date of approval with the ECN and PCT. Data to be collected from 01/05/11 based on Trust draft. e. The PCT and TFT will agree trajectories and audit schedules within 4 weeks of the standards being agreed. Actions to develop and implement the Integrated Discharge Team to support early discharge and admission avoidance : 2 a. Development and implementation of IDT by 30/04 b. Identify and agree appropriate minimum data set and data collection (15/4/11) c. Agree baseline 30/4/11 d. Agree trajectory and criteria for admission avoidance and early discharge by 31/5/11 (if failures occur that are not the fault of Tameside FT and the trust can evidence this as well as actions taken to rectify this then these will not be included in the figures). Establish high impact ambulatory care pathways:a. Agree the final 4 ambulatory care pathways with access to diagnostics available 7 days a week by 30/04/11 with ECN and PCT. Pathways to be targeted should be influenced by the Directory of Ambulatory Care and local data analysis including in the NEL admissions and A&E attendance review undertaken by the PCT. b. Two ambulatory care pathways to be designed by June 2011 and implemented by August 2011. Development of ambulatory care pathways for admission avoidance and reduced length of stay. Each of the following elements needs to be agreed with the Emergency Care Network and PCT:a. Agree: pathway with lead consultant/clinical assessment area/ diagnostics to support pathway/implementationb. Identify and agree appropriate minimum data set and collectionc. agree baselined. agree trajectory for admission avoidance/reduced length of stay through compliance of pathwaysc. ii. Two ambulatory care pathways designed by July 2011 and implemented by September 2011. Development of pathways for admission avoidance /reduced length of stay for ambulatory. Each element needs to be agreed with the Emergency Care Network /PCTa. Agree: pathway with lead consultant/clinical ass area/ Diagnostics and equipment to support pathway/implementationb. Identify and agree appropriate data collectionc. agree baselined. agree trajectory for admission avoidance through compliance of pathways 4. % target to be agreed by 30/4/11 for the delivery of specialty consultant or senior registrar (ST4 or above) review of patients in ED with agreed standard of 30 minutes from arrival in ED to consultant review. a. Agree minimum dataset and baseline by 30/4/11 b. Agree appropriate standards and trajectories to support this with Emergency Care Network and PCT by 30/4/2011 c. Delivery of trajectory of consultant/senior registrar review Tameside FT to develop Internal Professional Standards (IPS) that meet the minimum standards defined to support a coordinated approach to discharge with community services and TMBC. a) IPSs should be developed by 30/04/11 in alignment with the recommendations of the ECIST and agreed with the PCT and Emergency Care Network for:ed, MAAU, Integrated Discharge Team One IPS for all wards/specialtiesb) IPSs should be implemented by 31/5/11 for ED, MAAU, Integrated Discharge Team and Ward/specialties. c) Agree audit processes and trajectory for compliance of IPSs including 5 key components to be agreed with ECN and PCTd) Delivery trajectories of IPS as agreed specifically and individually for i) EDD - Delivering agreed timescale for recording date ii) EDD - Delivering agreed trajectory for achieving EDD iii) Delivering standards for ward rounds iv) Delivering standards for discharge planning v) Delivering standards for active case management Integrate discharge team to support facilitated discharge:
a. Agree appropriate data set and collection by 15/04/11 b. Agree baseline and trajectory by 30/04/11 for reduced length of stay and admission avoidance for example integrated discharge team to discharge x% (to be agreed) of non elective short stay patients within 24 hours and X% (to be agreed) of patients within 48 hours Delivery of the key measures listed in part 2 a) Agree baseline acute bed and surge beds by 30/5/11 b) Agree new target for reduced number of beds including surge beds. June 2011. c) Agree specific plan for bed reduction over 11 months to achieve target reduction in bed capacity.agree June 2011 and implement to agreed timelines. d) Closure of Acute beds and meeting agreed surge bed capacity (weighted to end of year) by 31/03/12 Achieve agreed trajectory for reduced admissions for individual areas agreed in CQUIN 2a and 2b and total target for reduced admissions Delivery of targets for reduced length of stay for individual areas agreed in CQUIN 2a and 2b and total target for reduced length of stay DISCHARGE LETTERS 1. 90 % completed as per Royal College of GP s standard = 100% payment, 75% = 40% payment 3 3. Discharge summary to include a) Smoking status / referral to cessation team Yes/Nob) to include section (yes/no) for fragility fractures c) Is this admission Alcohol, Smoking or Obesity related Patient Experience. For each domain: 1. All REDs to move to AMBER in both Domain and individual indicators by June & December 2011 Assessment dates 2. AMBER or GREEN with a score of number score 4 moves to a number score of 3 by June & December 2011 4 3 All AMBER/GREEN with a number score 3 maintains or reduces its score 4.AMBER severity score of 4 moves to GREEN by June & December 2011 5. All GREENs maintain GREEN during 2011/12 and by March 31st 2012. 1. 95% of AMI patients treatment meets the AQ data dictionary defined criteria (75%) 5 2. Data Assurance thresholds associated with new shadow measures (25%) 1. 75.08 % of HF patients treatment meets the AQ data dictionary defined criteria (75%) 6 2. Data Assurance thresholds associated with new shadow measures (25%) 1. 95 % of Hip & Knee patients treatment meets the AQ data dictionary defined criteria (75%) 7 2. Data Assurance thresholds associated with new shadow measures (25%) 1. 87.33 % of Pneumonia patients treatment meets the AQ data dictionary defined criteria (75%) 8 2.. Data Assurance thresholds associated with new shadow measures (25%) 1. % (to be defined by 30th May 2011) of Stroke patients treatment meets the AQ data dictionary defined criteria (75%) 9 2. Data Assurance thresholds associated with new shadow measures (25%) 10 1. 25% of AQ patients for AMI, HF, Hip & knee, pneumonia and stroke complete an AQ patient Experience survey TARN 1. Data completeness (target to be set in June 2011 when 2010/11 data is complete) 11 2. Data Accreditation (target to be set in June 2011 when 2010/11 data is complete)
Required composite score of 67.7 against 5 national survey questions:1. Were you involved as much as you wanted to bein decisions about your care? 2. Did you find someone on the hospital staff to talk to aboutyour worries and fears? 3. Were you 12 given enough privacy when discussing yourcondition or treatment? 4. Did a member of staff tell you about medication side effectsto watch for? 5. Did hospital staff tell you who to contact if you were worriedabout your condition? 90% of adults admitted as inpatients to have a VTE risk assessment using the national tool (DoH state this should be paid per 13 month achieved) 1 No more than 100% planned occupancy at any time on each ward 2 95% of inpatients episodes will not involve an external transfer within the hospital site 90% of inpatient episodes and outpatient attendances for children will take place entirely in facilities dedicated to the care of 3 children 95% of patients admitted on a day case basis will be cared for in dedicated day service facilities (ie will not utilise an inpatient 4 ward or theatre) 5 All new build wards will have a minimum single bedded complement of 33% FALLS 1. 30% reduction in number of patients who fall whilst an inpatient based on 10/11 data End of Q1 10% End of Q2 20% End of Q3 30% End of Q4 30% FALLS 2. Each clinical area will have access to a named Falls Champion who is available to provide expert advice on reducing 6 hospital falls and who will promote education on falls reduction and the ethos of falls are everybody s business. Reporting criteria to be agreed by end of April 2011 FALLS - 3. 75% of Falls risk assessment performed on patients over 60 years and/or those at clinical risk within 12 hours from admission hours using FRASE falls risk assessment tool, across all wards.20% Q140% Q260% Q375% Q4 FALLS 4. Root cause analysis for injury, fracture or death - quarterly report to be submitted demonstrating joint working between risk management/divisional staff and Falls Champions that includes RCAs, lessons learned and actions taken. ALCOHOL 1. Elective care and A+E patients to be assessed using a validated screening tool at pre operative stage of care. Elective 10% Q1, 20% Q2, 40% Q3 and 60% Q4 A+E 20% Q1, 30% Q2, 40% Q3 and 60% Q4 ALCOHOL 2. Assessments recorded with a score and action: 80% Q1, 90% Q2, 95% Q3 and 98% Q4 7 ALCOHOL 3. Assessments acted upon as per PCT score guidance: 40% Q1, 50% Q2, 75% Q3 and 95% Q4 ALCOHOL 4. 95% of Patients discharge letters to include assessment and action details and sent to GP's Q1 95%, Q2 95%, Q3 95%, Q4 95% ALCOHOL 5. 95% of patients who have been in TGH for more than 2 days with an alcohol specific diagnosis are seen by an internal alcohol worker or alcohol team on the ward Q1 95%, Q2 95%, Q3 95%, Q4 95% SMOKING 1. 95% of permanent staff in named areas (Maternity, Inpatients Cardiac, Respiratory & CCU, plus Pre-Operative Assessment, Chest Clinic) to be trained on Very Brief Advice re. Ask, Advise, Act by end of Q1 and maintained over remaining Quarters. 95% of temporary and fixed term staff to be trained on a regular rolling programme, every 6 weeks, provided by the 8 Specialist Smoking Cessation Service. SMOKING 2.Increase % against baseline (200 per quarter - confirmed by EM) of patients referred appropriately to the Stop Smoking Service:50% in Q1 (300)70% in Q2 (340)90% in Q3 (380)100% in Q4 (400)
SMOKING 3. % of Patients discharge letters (excluding maternity) to include assessment and action details and sent to GP's: 50% by end of Q1, 70% by end of Q2, 80% by end of Q3, 95% by end of Q4 ENHANCED RECOVERY 1 The aim of this indicator is to ensure that the Trust records comprehensive information about enhanced recovery patients on the national database. The following is a list of eligible procedures (report on all relevant and eligible procedures ): Colectomy Excision of rectum Abdominal hysterectomy Vaginal hysterectomy Prostatectomy Bladder resection Primary hip replacement (Best practice tariff) Primary knee replacement (Best practice tariff) A minimum data set (MDS) as required by ERP. The reporting requirement applies to all patients who are treated on a planned basis with relevant procedure codes to commence from the 1st May 2011 and 31st March 2012 (i.e. excluding urgent/emergency admissions). Data entry must be completed on implementation of an ERP procedure or best practice tariff and completed within one month of the procedure date. 9 10 Reporting must take place on a monthly basis commencing on the 1st May 2011. Trusts will be paid for each month where comprehensive database records exist for 95% of eligible patients. A breakdown of how payments are calculated is shown below. ENHANCED RECOVERY 2.Number of patients with a relevant procedure code who have surgery performed on the day of admission. The Trust will qualify for full payment if 80% of eligible patients are managed in this way. ENHANCED RECOVERY 3 The aim of the indicator is to ensure that the majority of patients admitted for colo-rectal surgery receive goal directed fluid therapy. The Trust will qualify for full payment if 80% of patients who have planned colo-rectal surgery performed also receive goal directed fluid therapy. Please note that although data collection on unplanned patients is not required, they equally benefit from this intervention and should receive GDFT. ENHANCED RECOVERY 4 Implementation of ERP in accordance with the agreed data measurement tool within the agreed specialties. Evidence that the new model is sustainable. Payment based on the last 3 months of 11/12 and shall be at or below the Enhanced Recovery Partnership Programme target: a) Colectomy average length of stay target level of 7.9 days b) Excision of rectum average length of stay target level of 9.1 c) Vainal Hysterectomy average length of stay target level of 2 d) Primary hip replacement average length of stay target level of 5.1 e) Primary knee replacement average length of stay target of 5 PRESCRIBING 1.% of total statin and ezetimibe, less atorvastatin 80mg prescribing that is for generic simvastatin and pravastatin are not less than the PCT average with a further stretch of 2% over the PCT average PRESCRIBING 2. % of drugs acting on renin angiotensin system that are ACEi to remain above 75% with a further stretch target of 77% PRESCRIBING 3. % of all PPI prescribing that is for omeprazole or lansoprazole capsules is 90% with a further stretch of 2% higher than PCT average or 90% (whichever is higher) PRESCRIBING 4. 95% of antibiotic prescribing to follow TFT's antibiotic prescribing policy
11 12 PRESCRIBING 5. TFT microbiology department to notify GP if a patient has acquired Cdiff in 100% of cases within 2 weeks of results PRESCRIBING 6. Defined daily dosages of high risk antibiotic prescribing compared to bed occupancy to be no more than X and no more than Y PRESCRIBING 7. Reduce transactions of prescribing of Pregablin (used as anti convulsant and for neuro pathic pain) replace with gabapentin or amitriptyline (% of prescribing of pregabalin prescribed to be 40% of total gabapentin, pregablin and low dose amitryptyline prescribed with a further stretch target of 35% MATERNITY 1. Reduction in the rate of emergency admission/re-admission to hospital of baby's within 14 days of being born for jaundice or feeding problems. Baseline to be agreed by the 15th April 2011 Quarter 1 data set confirmed Quarter 2 TFT action plan developed and agreed Quarter 3 tbc% reduction expected based on baseline Quarter 4 tbc % reduction expected based on baseline info MATERNITY 2. Reduction in SCBU bed days by 320 to 4458 pa (baseline value 4778 from 01/01/10 to 31/12/10) MATERNITY 3. Achieve an increase in spontaneous vaginal deliveries to deliver the following outcomes ( as a % of total births) Baseline to be agreed by 15th April 2011 1. Caesarean section rate is <20%Normal deliveries rate is >70% which includes -Home deliveries 60 (as per home birth trajectory) -Midwife led deliveries 2% increase on 10/11 outturn plus implementation of plan to get to 20% by March 2014. (Baseline by 15th April 2011) OBESITY 1. Record of the Number of children reported on quarterly basis whose weight falls outside the 95% upper quartile on a UK national standard growth chart Q1 return Q2 return Q3 return Q4 return OBESITY 2. % of all adult patients elective to have BMI measured and recorded Quarter 1-50% Quarter 2-70% Quarter 3-85% Quarter 4-95% OBESITY 3. % of adult patients elective with a BMI over 35 (obese II) to receive dietary advice on the ward Quarter 1-50% Quarter 2-70% Quarter 3-85% Quarter 4-95% OBESITY 4. % of eligible patients (with a BMI of over 30 - obese I) are referred to weight management services Quarter 1-50% Quarter 2-70% Quarter 3-85% Quarter 4-95% OBESITY 5. % of Patients discharge letters to include BMI measurement and record of advice and referral sent to GP's:
13 14 15 50% by end of Q1, 70% by end of Q2, 80% by end of Q3, 95% by end of Q4 STROKE 1.Maintain average length of stay of 24 days from 1st July every month STROKE 2. Deliver TIA direct access clinics in line with Service Specification:- For TIA, Delivery of 5 day service from 1st April, 7 day service from July 2011 (participation in model of care across GM to deliver 7 day service) - All TIA patients referred to be seen within 24 hours. 75% from 1st April and 100% by 1st July. Exception criteria to be agreed by end of April 2011 STROKE 3.i. Development and implementation of a comprehensive pathway of secondary prevention to include medical and life style factors for Stoke & TIA patients by end of Q1 ii. Increase referrals into health improvements team X amount. (to be agreed by end of Q1) iii. Evidence of documentation and processes in place by end of July 2011 Maximise Proportion of diagnostic results issued within 2 days of report being produced - 90% of reports issued within 2 working days Increase number of day procedures 1) From 0-50% for Haemorrhoidectomy i) Increase number of procedures by 30% by 30th September 2011 ii) Increase number of procedures by 50% by 31st March 2012