Draft. Advancing Quality Alliance (AQuA) Business Plan 2010/11 Version 6

Draft Advancing Quality Alliance (AQuA) Business Plan 2010/11 Version 6 1

Advancing Quality Alliance (AQuA) 1.1 Introduction The NHS is entering the most challenging period in its history. Responding to the challenges will require us to improve population health, outcomes and quality of services including patient experience. We know from the work we have already undertaken that the NHS in the North West can benefit from working collaboratively with health and social care partners to meet these challenges. The Advancing Quality Alliance (AQuA) is a vehicle for delivering this. This document sets out our business plan for our start up year, 2010/11. It builds on the responses we received as part the AQuA consultation process and reflects the impact of other key drivers. In particular it explains how we will: Operate as a not for profit member organisation which ensures quality is at the heart of the region s health care agenda. Promote and share best practice, provide improvement training to strengthen capability locally and develop and share benchmarked quality intelligence to stimulate innovation. Act as a resource to reduce costs whilst delivering sustainable quality improvements in healthcare service across the North West. Provide advice and support to all areas of service delivery domiciliary, primary, community hospital based as well as commissioning and provision. Bring together the various elements of the national, regional and local quality agenda in place across the North West in a cohesive and coherent way. During the coming months we will use it as a vehicle for discussion with member organisations and with the AQuA Board. Our aim is for this plan to be supplemented with a more comprehensive three year plan later in the year. 2

1.2 Who we are The Advancing Quality Alliance (AQuA) is dedicated to improving healthcare across the NHS in the North West. AQuA s main focus is commissioner and provider organisations within the NHS. We provide knowledge of best practice, intelligence on local services, and support for the development of local improvement capacity. AQuA will work with organisational leaders, boards and senior managers and clinicians, as well as with frontline staff. Our work is organised around four aims: best care; best health; best value and best place to work. These are underpinned by three cross cutting themes: AQuA Observatory; AQuA Associates and developing strategic partnerships. AQuA operates on a not for profit basis for and by the NHS. We have a small core permanent core team which is supplemented by a much greater number of AQuA Affiliates. AQuA Affiliates support delivery of AQuA s work programme and are employed on a range of non-permanent contracts. This arrangement provides us with an appropriate mix of stability and flexibility. In addition, we also work with AQuA Associates. AQuA Associates are a wider church of colleagues from member organisations who support our work on a voluntary basis. Formed in recognition that improvement has to be led from the front-line rather than be centrally imposed we take every step we can to minimise our costs. This ensures that the return on investment we provide for NHS NW healthcare organisations is as high as possible. In addition, we will market our successes so that we secure new sources of external funding. We will use the funds we attract to further improve the services we offer. Our planned income for 2010/11 is 10.1m. This matches our planned expenditure. We have several sources of income. Of these, our income from PCT s is the most material and represents 81% of our planned income. We are hosted by xxx NHS Foundation Trust. This provides us with a legal framework in which to operate. Being hosted by an NHS Foundation Trust brings the additional financial flexibility we believe is necessary for us to succeed. 3

1.3 Aim, mission, vision and objectives AQuA is dedicated to improving healthcare across the NHS in the North West. 1.3.1 Our mission Our mission is to: Stimulate innovation by providing intelligence to identify improvement opportunities and to set priorities. Spread and accelerate the adoption of best practice. Support the development of local improvement capacity by providing access to skills, training and support that enable staff to successfully lead local change. 1.3.2 Our aim Our aim is to accelerate the pace of improvement and help good practice to spread everywhere rapidly. 1.3.3 Our vision Our vision is ambitious and simple. We want the North West to provide the best possible healthcare services for its patients. We want to have healthcare services that our patients are proud to use, that our families and friends are proud to use and that we are proud to deliver. We want the healthcare services in the North West to be the envy of the world. We believe that the North West can genuinely shine as one of the world s leading providers of high quality healthcare. We can see examples of healthcare providers and systems that are regarded internationally as being at the leading edge of high quality care and treatment such as Intermountain Healthcare, JonKopping, Kaiser Permanente and Ascension Health. 4

Our aspiration is that the North West should compare favourably in this company. We know that there are examples of practice which are just as innovative and just as high quality as the best in the world distributed throughout the NHS in the North West. We recognise that the NHS will continue to evolve. We know that the NHS will face significant challenges in the next few years as it does so. However, we believe this strengthens the need for AQuA. By harnessing our collective talents, by agreeing achievable but stretching and measurable improvement goals and by focusing our resources we believe that together we can achieve our vision. 1.3.4 Our start up objectives We recognise the need to build rapidly on our existing programmes and to support the NHS to: Reduce emergency demand and manage elective demand more effectively. Improve productivity within both clinical processes and support functions. Develop GP commissioning in a way that allows continued delivery of QIPP objectives. Improve safety, quality and patient experience. Our objectives for 2010/11, our start up year, to support this are: Delivering AQuA s products and services Establish an integrated approach to the delivery of existing work programmes (e.g. Advancing Quality and Improvement Alliance). Develop new product and services. (e.g. AQuA Observatory, GP commissioning development, demand management and provider productivity). Concentrate resources and current staff skills on delivery of the above. Shaping AQuA s future role Establish the AQuA Board and implementing agreed governance arrangements. Recruit additional skilled staff to identified gaps in skills and capacity. Develop a three year business plan by autumn 2010 taking into account the post White Paper content. Relationship management 5

Work closely with individual customers to understand and agree specific requirements. Engage with clinicians at all levels. Develop partnerships with a range of organisations. 6

1.4 Our strategy to deliver it We know to deliver our vision we need to harness talents, focus efforts and direct resources towards the most important priorities. As a result AQuA will focus on supporting improvements aimed at four bold aims: Best health. We will have delivered this when we are consistently achieving excellent health outcomes. Best care. We will have delivered this when every patient has an excellent experience every time. Best value. We will have delivered this when we are at the leading edge in productivity improvement. Best place to work. We will have delivered this when staff enjoy their work and are proud of what they do. Excellence in health outcomes Excellence in patient experience Best health Best care Best value Best place to work Excellence in productivity Excellence in joy and pride for staff Figure 1: AQuA s focus 7

1.5 Our products and services We are determined to use our place as the North West s quality improvement body to bring substantial local benefits. We have a unique opportunity to act as a catalyst for change across the North West. However, to deliver our vision we know that work must embody four principles: Improvement that is clinically led rather managerially imposed from above. Improvement in all settings and across all sectors. Improvement that is data driven and evidence based. Improvement that is owned and sustained by front line staff and by clinical and managerial leaders. The products and services that we believe will deliver our vision and meet these principles are summarised below in Figure 2. A summary of each product is described in the following section. Further details are provided in Appendix A and our work plan for 2010/11 is included at Appendix B. Safe care Reducing Harm events Reducing Hospital Mortality Advancing Quality Stroke 90:10 Right care Partnership with the H&WBA Best health Best care Improving the patient experience Value for money Demand management Productivity improvements Best value Lean in healthcare Best place to work Partnership with the Leadership Academy Engagement in improvement GP commissioning development Joy and pride for staff AQuA Observatory AQuA Associates Strategic Partnerships Figure 2: AQuA s products and services 8

Delivering best health Best health AQuA will support the delivery of best health by Working in collaboration with the newly established Health and Well Being Alliance and other partners to tackle the underlying determinants of poor physical and mental health. Developing Preventing Harm Workbooks. These will provide a range of materials to support local patient safety improvement initiatives. The initial topics will focus on areas where the international improvement track record demonstrate the greatest patient benefits ie venous thromo-embolism, safe surgery, pressure ulcers and medicine errors. Sharing and spreading the learning we gain from our Safety Networks Nodes Collaboratives. We currently run three Safety Network Nodes. Their improvement themes are: venous thromo-embolism (led by North Lancashire PCT), pressure ulcers (led by Salford Royal NHSFT) and management of head injury (led by the Walton Centre for Neurology). Sharing and spreading the learning we gain from our Reducing Mortality Collaborative. The expectation is that this collaborative will provide advice and guidance on the best way to reduce the most common causes of avoidable in-hospital mortality and to increase dignity and comfort to patients at the end of their life. Together, the improvements we make will lead to: Increases in life expectancy. Reduced avoidable mortality and needless harm. A safer service. 9

Delivering best care Best care AQuA will support the delivery of best care by Using Advancing Quality to improve the consistent delivery of effective care for patients with acute MI, CABG, community acquired pneumonia, hip and knee replacements and acute heart failure. Extending Advancing Quality to include stroke, early intervention in dementia and psychosis and community and primary care heart failure management. Working with PCTs and GP commissioners to make the Advancing Quality approach the basis for clinically led commissioning that is focused on quality improvements. Building on the work of the Inspiration NW team to improve patient experience by raising the awareness of service experience, benchmarking best practice and developing measures and metrics. Developing a multi-disciplinary approach to care pathway redesign aimed at improving the patient s journey from start to finish. Our Stroke 90/10 collaborative forms part of this work. The development of our Clinical Domain Workbooks aimed at supporting local clinical improvement initiatives starting with COPD, diabetes, falls/ fractured neck of femur and stroke. These will provide a mixture of intelligence, improvement know how and clinical best practice. Supporting the promotion of the nursing High Impact Actions and the Energise for Excellence programme. Together, the improvements we make will lead to: Improved patient reported outcome measures. Increased standardisation of care ensuring every patient receives the best possible care every time. An enhanced experience for patients especially when they are at their most vulnerable. 10

Delivering best value Best value AQuA will support the delivery of best value by: Supporting increases in provider productivity. Working in partnership with bodies such as the National Institute for Innovation and Improvement we will make available access to a range of improvement methodologies and processes. Promoting the use of Lean methodology to improve quality and productivity hand in hand. We will build a network of those pursuing Lean healthcare and form alliances with Lean experts in healthcare in the USA and other business sectors. Providing access to demand management skills, training and expertise for commissioners and providers. This will include the use of analytical tools, patient and clinical decision aids, new clinical technologies and IT alongside service redesign. Providing the intelligence to pin-point where the greatest savings can be made. This will build upon a range of initiatives we have been supporting to help organisations at all levels identify and deliver their productivity programmes. The work of the North West Intelligence Consortia forms part of this work. Together, the improvements we make will lead to: Improved performance against productivity benchmarks. I & E balance. A viable service that is reducing costs safely. 11

Delivering best place to work Best place to work AQuA will support the delivery of best place to work by: Engaging staff at every level in the service in campaigns to raise standards of health and care. Developing our AQuA Associates scheme. This will create opportunities for staff in member organisations to help AQuA run its work programme and to give them in-depth skills and experience of working across organisations in the North West and working with a bigger team of like-minded people. Building on and further developing current clinical engagement activities so that we develop and support strong networks at all levels across the North West s clinical community. Expand our approach to development in a way that supports the work we will be championing in other programmes. Building on our existing Commissioning and Provider Development programmes we will further develop the capability and capacity to lever sustainable change. Working with the Leadership Academy we will provide development support in improvement for Boards and for Chief Executives and their teams. This will include a particular focus on developing capacity and capability within the emergent GP Commissioning Consortia. Together, the improvements we make will lead to: Improved staff satisfaction. More staff trained to lead local improvements. A well motivated and engaged workforce. 12

Our work programme will be supported by three cross cutting initiatives. Our Quality Observatory will bring together the intelligence and knowledge to stimulate innovation. We will build on the extensive sources of data and information that already exist across the North West. We will draw in contributions from all sectors including care pathway groups and local authorities. We will provide intelligence on our services alongside clinical best practice and improvement know how. Our easy to access web portal will become the first place that staff will look for improvement information and support. Our AQuA Associates scheme and our Clinical Engagement Programme will harness the energy and enthusiasm of all NHS staff in the North West. We will use their professional knowledge and experience to make sure that all care is safe care. We will build on their ideas to make sure all care is the right care for every patient every time. We will use their passion for change to inspire others. The informal networks we foster will share and spread good practice faster than ever before. Our strategic partnerships will enable us to punch above our weight. We will act as advocate for the excellent work that is undertaken everyday in our communities, Hospitals and GP surgeries. We will work with organisations such as the Institute for Health Care Improvement, the National Institute for Innovation and Improvement and Premier to secure advice and support. We will develop relationships with organisations such as the Kings Fund, the Nuffield Institute and The Health Foundation to keep one step ahead and to lever change. We will build on our existing knowledge of what works, continually learn from the take up and usage of the products and services we provide, so that we stay ahead of the curve. In addition, Mental Health will be a theme running through all AQuA activities, the details of which will be co-designed with the range of Mental Health professionals. This will include mental health intelligence, care pathway redesign as well as the use of LEAN to achieve productivity improvements. 13

1.6 Our market analysis 1.6.1 Market characteristics NHS North West comprises 65 NHS healthcare organisations. Collectively these organisations meet the full range of health needs commissioning and provision - for the North West s population of just under 7m and differ in term of size, coverage, sector and geography. Collectively they employ 202,600 people. This includes 4,436 GPs, 17,422 doctors and dentists, 62,464 nurses and midwives, 10,623 Allied Health Professionals and 20,538 scientific, therapeutic and technical staff. 1.6.2 Key drivers We know that national policies will continue to change the health care market. The new White Paper alongside the productivity challenge and the local where possible; centralised where necessary ethos will drive the future health market and the way we deliver our services. We know that we will need to respond quickly to these changes and adapt the services we provide so that we continue to meet the needs of our members. Analysis of our environment reveals a number of challenges that will impact on local organisations in the near future. These include: Delivering greater productivity as a result of a tighter economic climate whilst also improving quality. Safely reducing costs will be a significant challenge for all organisations across the North West. Improving the patient experience. This was reinforced by the findings published in the review by Robert Francis QC of the patient experience at the Mid Staffordshire NHS Foundation Trust and underpinned by a raft of initiatives including World Class Commissioning core competencies. Improving health outcomes across the North West. From existing analysis we know that there is scope to raise the bar to ensure that people in the North West should have access to excellent standards of care, irrespective of where they live. The intention, as set out in the recently published White Paper, Equity and Excellence; Liberating the NHS, is to put patients right at the heart of decisions made about their care and to put clinicians in the driving seat on decisions about services via GP Commissioning consortia. 1.6.3 Our strengths, weaknesses, opportunities and threats Undoubtedly this will bring challenges to the NHS but these unprecedented challenges are matched by unprecedented opportunities. We believe as a not for profit organisation for and of the NHS we are well placed to capitalise on these opportunities to build a viable and sustainable improvement organisation. 14

We know that we have a number of strengths which will provide us with a solid base for the future. Our products and services are aligned to the need to improve quality and productivity in a way that is supported by a sound evidence base. This gives us a credibility with clinical and managerial audiences. We have a strong team with a track record in the successful delivery of innovative developments. This gives us the confidence to know that we will succeed even when the going gets tough. Clearly, remaining innovative and ahead of the curve will be vital. However, we are confident that our collective experiences, and the knowledge and intelligence that we bring of what works, will enable us develop the products that meet customer requirements and for them to be quickly adapted in response to change in our environment. Furthermore, as Figure 3 shows, our products and services cover all sectors and all levels within those sectors. This gives us good reach into organisations and provides us with unique insights into cross boundary/ cross organisational issues. This umbrella coverage also provides us with a key role in helping others to understand the North West s organisational architecture and infrastructure. Sector Level Staff Geography Primary Care Individual organisation Front line Lancashire & Cumbria Acute Locality Clinical Cheshire & Merseyside Mental Health Footprint Managerial Greater Manchester Community Region Board NHS North West wide Figure 3: Coverage of our products and services Finally, we already have a number of well-developed external relationships which will help us deliver our vision. This gives us a platform from which to develop external funding streams to support our core business. Around 7% of our current income is derived from external sources so we have the experience to and the ability to develop this further. This will be crucial to mitigate our reliance on PCT levies to fund the majority of our work programmes (81% in 2010/11)and to buffer us from competition from other NHS and private organisations that provide improvement 15

support and advice. We expect the number of competitors to grow in light of the White Paper, Equity and Excellence; Liberating the NHS, with its stated ambition of greater budgetry control for GP s and their consortia alongside an ambition to open up new markets, particularly regarding the provision of information. We also believe that going forward there are a range opportunities that we can and will benefit from. Our existing and future approach to clinical engagement and relationship building through our AQuA Associates should ensure that we are well placed to work with GP Consortia to develop products to support their future requirements. As a not for profit operating at NHS rates we know that we also have a costs advantage when compared to external consultancies. The squeeze on private sector consultants, signalled in the White Paper, will also help us consolidate our market. Our desire to remain lean and fleet of foot, with a small core team who are supported by a wider range of AQuA Affiliates and AQuA Associates further strengthens this. In addition, as a body whose stated aim is for and of the NHS we know that we are in a privileged position of being closely aligned and supportive of member interests; uniquely here to deliver their improvement needs through a special partnership relationship delivering products that bring the greatest local benefit. 16

1.7 Our approach We recognise that in the coming years we need to make sure that we aligned and focus resources on delivery of value adding activities that bring lasting change. Our view is that we will have achieved this when we: Combine elements of AQuA s portfolio to amplify our ability to spread the adoption of best practice in a way that provides more benefit than could otherwise be achieved by the parts alone. Use wealth of skills and experience that exists in healthcare services across the North West to our collective benefit. Work with and through a range of external partners. Adopt best practice in our working practices. 1.7.1 Amplifying spread and adoption of best practice Our approach to spread and adoption is described in Figure 4. Observatory Sources of webenabled intelligence to support delivery Campaigns Tools of social marketing Associates Communities of Practice Programmes Engaging staff in change Figure 4: AQuA s approach to spread and adoption 17

We believe this approach will give us the best possible chance of amplifying the impact of our resources. When fully operational the key elements that need to be aligned and working in harmony are the: AQuA Observatory. This will provide sources of intelligence to stimulate innovation and support delivery. AQuA Associates. This will facilitate the development of Communities of Practice to share and speed up the adoption of best practice. AQuA Programmes. These will engage staff in quality improvements. AQuA Campaigns. These will use the tools of social marketing to bring about lasting change. 1.7.2 Using skills and experience to maximum benefit AQuA has a small core staff and we maximise our leverage in several ways. As Figure 5 shows, we encourage staff secondments to specific AQuA programmes (AQuA Affiliates) In addition, we work with a wide church of interested people to develop communities of interest that support ways to share and spread best practice quickly (AQuA Associates). AQuA Associates Involvement motivated by personal and professional interest Ad-hoc and voluntary AQuA Affilitiates Supporting delivery of AQuA programmes Time-limited involvement AQuA Core staff Managing AQuA programmes and supporting necessary corporate functions Continual involvement Figure 5: AQuA s approach to leverage 18

AQuA core staff will be responsible for commissioning and managing our products and services and will be responsible for delivery of our corporate functions like marketing and communications, strategy and performance management, research and development of new products, governance and administration, relationship management and people management. They will be employed on a full-time or part-time basis either as permanent employees of AQuA (via contracts with the host organisation) or on a secondment to AQuA. AQuA Affiliates on the other hand will be responsible for delivery of products and services. They are more likely to have a day to day interface with customers and members and be employed on value adding activities that have a direct relationship between the work they do and improvements in our bold aims of best health, best care, best value and best place to work. In this way the link between the work they do and the contribution they make to improving health care services, value for money and joy and pride at work across the north west will be clear. Like AQuA core staff they too will be employed on a part-time or full-time basis. However, the duration of their contract will be linked to the projects they support and so they will either be employed on a secondment basis or on a fixed term or sessional basis. Finally, AQuA Associates will work with AQuA as part of their personal and professional development on a voluntary basis. They will remain employed by their home organisation and will support AQuA in a variety of ways including providing time to teach AQuA courses, to develop Communities of Practice, to work with AQuA to provide quality assurance and to help AQuA test new products. 1.7.3 Work with and through a range of external partners We have identified a range of external partners with whom we need to maintain and further develop effective working relationships to successfully deliver our products and services. These external partners are shown in Figure 6. 19

NHS NW clinicians and their networks Regional QIPP Leads Leadership Academy NICE Health & Well Being Alliance Members Information Centre Local Universities National Institute for Innovation and Improvement External funders Expert partners (eg IHI, Dr Foster, CHKS) Figure 6: AQuA s key external relationships Through our Business Planning process we have indentified the actions we need to take to support these business critical relationships. These actions differ from relationship to relationship but include: Continual discussion and engagement with named points of contact to ensure strong strategic and practical partnerships. Membership to programme steering group. Shared project terms, terms of reference and performance management. Ensure mechanisms exist to continually test products and identify new areas for development. Networking. 1.7.4 Adopting best practice Our expectation is that AQuA will adopt the best practice from across the NHS and the public sector in developing its systems and processes. By way examples: Staff will be offered contracts of employment in line with standard NHS terms and conditions. Remuneration in line with national pay scales (e.g. Agenda for Change, Consultant Contract, VSM pay scale) 20

Secondments to AQuA from all member organisations will be actively encouraged. Annual planning, financial reporting etc will follow the Monitor guidance where applicable. Best value will need to be demonstrated in all cases. External procurements will be undertaken in line with best practice across the NHS and the public sector. 21

1.8 Governance 1.8.1 Corporate Governance AQuA will operate via a form of membership agreement/contract with all those organisations who contribute financially to AQuA. This will be underpinned by AQuA s Articles of Association which will define how AQuA will operate. The Articles of Association will set the tone for how we could operate in the future by ensuring that the arrangements we put in place at start up not only embed commercial disciplines but also have the flexibility for change. They will be complemented by our Corporate Governance Handbook which will ensure AQuA adheres to agreed and appropriate Corporate Governance standards. AQuA is in the process of agreeing our Host organisation. In determining the Host we are clear that: AQuA will be hosted by an NHS Foundation Trust. This will provide us with the financial flexibility necessary for it to invest and carry funds over at financial year end. The Host arrangements will be set out in a Host Organisation Contract/ Service Level Agreement. The Host will provide the statutory accountability for AQuA to operate. As an NHS organisation within the NHS AQuA will not have independent legal status until we decide otherwise. Although we believe that it may be appropriate in the longer term for AQuA to have its own legal personality we recognise that this will take time to develop. Rather than creating a delay to the start date for AQuA we suggest that in its early years AQUA does not seek to have a separate legal identify but creates governance arrangements that allows the migration to a formal legal personality at a later stage if required. The Host will act as the Employer for AQuA staff. The proposed Corporate Governance arrangements for AQuA is shown below Figure 7 together with the associated documentation we consider necessary to guarantee that AQuA has in place robust governance arrangements. 22

Members (NHS North West Boards) Governance - Articles of Association - Anual Busines Plan - Annual Report AQuA Board AQuA CEO and Management Team Host SLA - Employer /HR - Finance Budget - Statutory Requirement - Corporate Governance - Quality Assurance - CBS Governance handbook - SFIs - Scheme of Delegations - Appointments and Grading Figure 7: Proposed governance arrangements for AQuA and supporting documentation. 1.8.2 Accountability It is expected that AQuA will: Hold an Annual General Meeting. Publish an Annual Report and Annual Business Plan that has been agreed by the AQuA board. Have a 3 year long term business plan that is reviewed every 2 years. The biannual review will include a process for members to provide feedback on the services provided as well as the views about the future direction of travel. 23

1.9 Leadership and management 1.9.1 Leadership The first Chair of the AQuA Board will be the CEO of the Host organisation. Their initial term will be for three years and these arrangements will be reviewed in late 2012. AQuA s Board will set AQuAs strategic direction. The Board will ensure that the AQuA Business Plan is delivered. AQuA s the Articles of Association set out further details regarding the: Size and composition of the AQuA Board. Further roles and responsibilities of the Board and its members. Process to appoint Board members. The options for eligibility for non-aqua representatives. 1.9.2 Management David Fillingham was appointed as the first Chief Executive in March 2010. He is accountable to the AQuA Board for the day to day running of AQuA s business. He is supported by a small core team who work with staff across NHS North West to help all member organisations make sustainable improvements to the quality of the healthcare services in a way that offers value for money. The structure of the management team is given below in Figure 8. CEO David Fillingham Director Jennifer Butterworth Director Steve Henderson Director Julia Hickling Director Alan Horne Director Lesley Massey Director AN Other Figure 8: AQuA Management team 24

1.10 Finance, performance and risk management 1.10.1 Financial management AQuA operate as a not for profit, membership organisation with all of the 64 health organisations in the North West eligible for membership through payment of a subscription. During the course of 2010/11 we will: Developed a Medium Term Financial Strategy which recognises the challenging economic climate we face, and is based on realistic assumptions. This will take a measured view of the future market environment and future demand and include a downside scenario analysis. Manage our financial position to secure an underlying surplus that exceeds the net surplus in year. Integrate the budgets of the existing programmes into a single unified AQuA budget. Work with the host organisation to set up robust financial management procedures in line with the Standing Financial Instructions. Provide the AQuA Board with regular financial information (balance sheet, cash flow statement etc) and forecasts as part of our integrated approach to financial and performance monitoring. 1.10.2 Income and expenditure Planned Income Details of our planned income are given below in Figure 9. Income (k) Safety Node Collaborative 556 Stroke 90/10 Collaborative Advancing Quality levy 6014 Commissioning Development levy 548 NWIC levy 336 Membership levy 2600 Innovation award 10 TOTAL 10064 Figure 9: Planned income, 2010/11 25

Sources of income As Figure 10 shows, PCTs provide our main source of income. AQuA' sources of funding - 2010/11 12% 7% 81% Commissoners Providers Other sources Figure 10: Sources of planned income, 2010/11 Planned expenditure Details of our planned expenditure for 2010/11 are given below in Figure 11. Expenditure (k) Best Health products and services 556 Best Care products and services 6514 Best value products and services 654 Best place to work products and services 650 Cross- cutting programmes 1090 Support / infrastructure costs 600 TOTAL 10064 Figure 11: Sources of planned expenditure, 2010/11 26

performance monitoring and performance Objective setting Further details are provided in Appendix C. 1.10.3 Performance management We manage our business through a robust performance framework. The process we are putting in place will enable us to link corporate objectives to individual performance monitoring with delivery of our high level vision. It consists of four interlinked elements, described in Figure 12, which are: An objective setting process to make the link between corporate and individual objectives so that it will be clear how our jobs contribute to delivery A business planning process will enable us to match objectives with delivery so that we know our resources are aligned to our direction of travel. A performance monitoring and management process, to demonstrate that we are on track with the delivery of our commitments described in our individual and corporate objectives. An evaluation and appraisal process so that we learn and apply the lessons from the past. Evaluation and learning Corporate Vision and Aims Group Team Confidence about delivery Individual Planning for delivery Figure 12: AQuA s Performance Framework 27

In combination these interlinked element will enable us to: Understand how what we do fits into the bigger picture. Plan for the future as well as react to the present. Match resources with tasks and priorities. Enable us to track our performance against our promises. Discuss and agree policy and business plans before implementation so that we can all be clear what has been agreed and what has not. Enable our line managers to have the confidence to let us get on with the job, and Manage risks in a systematic way. 1.10.4 Risk management To manage our risks we have identified the operational risks for each work programme and identified the actions to mitigate them. Our top five risks are: [DN draft list has been developed but requires further discussion. A list of our top 5 risks and the mitigations will be included in the next version] The process we intend to implement will ensure that we: Review our key risks on a regular basis as part of our normal performance management process. Review our risk register every four weeks. A monthly summary is provided to the AQuA Board for discussion alongside the key strategic risks and the actions to mitigate them that the Board has identified. 28

1.11 Conclusion We have set out our vision for AQuA and our priorities in our first year. We will supplement this with a more detailed three year plan in the autumn. We believe that together we can make a transformational difference to the way in which the North West s healthcare services are provided. We believe that together we will be successful if we: Reduce unnecessary admission to hospital and shift the focus from acute intervention to prevention and chronic disease management. Ensure that when patients are admitted the care they receive is as good as it possibly can be. Make clinical and support processes more effective, efficient and patient centred. Support individuals and communities in improving their own health and wellbeing. Deliver better health and better care at lower costs. We know there is a lot to do but we believe that together we can create a healthier future. 29

Appendix A: Supporting Best Health This Appendix sets a description of the products and services we will provide to support our bold aims of best health, best care, best value and best place to work as well as our cross-cutting themes. Supporting Best Health Our Best Health portfolio currently includes the following programmes: Aim Preventing avoidable hospital mortality Preventing Avoidable Harm Delivered by Reducing Mortality Collaborative Safety Networks Node Collaboratives Preventing Harm Workbooks Supporting organisations to take part in the DH QIPP learning events and roll out for Safe Care. Support the implementation of the Nursing High Impact Actions and Energise for Excellence. Collaborating with the Health and Well being Alliance (H&WBA) Close liaison with the H&WBA as it develops Reducing Mortality Collaborative AQuA enables and supports the 9 acute providers participating in the Reducing Mortality Collaborative. The collaborative aim is a decrease in avoidable deaths in these organisations and an improvement in patient care and safety. AQuA s role is to design and deliver a collaborative approach and then to lead the development of a change package of material to quickly share and spread the lessons learnt. Participating teams will build both capacity and capability within their care systems for service improvement and redesign. AQuA supports the participating organisations in a number of ways. It provides: Training in improvement techniques that are known to be effective. Ways to share the lessons learnt between the participating organisations as they explore how best to reduce avoidable mortality. Access to evidence based practice from national and internationally accepted sources. 30

AQuA will collate the lessons learnt and use them to develop a package of material. This package will draw on both the local experience and make available the national and international exemplars and materials that were used in the collaborative. The package should enable other provider organisations to rapidly improve patient outcomes by reducing avoidable deaths through the delivery of even safer patient care. As well as the direct clinical actions that need to be taken the change package will also draw on the experiences of the participating organisations in terms of adopting a board to bedside approach to improvements and how best to give local teams the platform, skills and knowledge to make sustained improvements. In addition, the collaborative and subsequent package will provide AQuA with an opportunity to influence national work streams/reviews and for the North West s work to be recognised Key objectives for 2010/11 are: To support participating organisations to reduce their mortality rates by at least 10 points by 1 April 2011. To have collated the lessons learnt and to be preparing a package of material that can be shared with other providers to quickly reduce avoidable deaths. Safety Network Node Collaborative AQuA supports the 3 health economies that are participating in the Safety Network Node Collaboratives. This series of collaborative is planned to run for twelve months. The improvement themes will vary from Node to Node and include: venous thromo-embolism (led by North Lancashire PCT), pressure ulcers (led by Salford Royal NHSFT) and management of head injury (led by the Walton Centre for Neurology). In addition to the system benefits the work will bring AQuA s hope is that approach will provide a novel way to provide future collaboratives. AQuA supports the participating organisations in a number of ways by providing: Training in improvement techniques that are known to be effective. Ways to support track and monitor progress of the three collaboratives. Ways to share the lessons learnt between the participating organisations as they explore how best to achieve the objectives of each node. AQuA will support each node team to collate the lessons learnt and use them to develop a package of material. This package will draw on both the local experience and make available the national and international exemplars and materials that were used in the collaborative. The package should enable other provider organisations 31

to rapidly improve patient outcomes relating to venous thrombo-embolism, pressure ulcers and the management of head injuries. As well as the direct clinical actions that need to be taken the change package will also draw on the experiences of the participating organisations in terms contributing to a networks approach to improvement and building improvement skills across organisational boundaries. It will also provide insights to support commissioning for quality and safety. Key objectives for 2010/11 are: To develop a process to deliver sustainable improvements in three areas (VTE (80% reduction in incidents of hospital related VTE by April 2011), head injury management (No avoidable deaths from head injury),and pressure ulcers (50% reduction in prevalence of pressure ulcers by February 2011). To quickly develop and put in place the mechanism to implement the improvement packages that follows across the North West. To provide the participating node teams and their sponsoring organisations with improvement expertise, leaving a legacy to promote sustainability for improvement initiatives going forward Preventing Harm workbooks AQuA is developing a series of Preventing Harm workbooks. The workbooks will provide core resource for local improvement initiatives. They will provide organisations with access to national and international material on a range of preventing harm topics. They will pull together the case for change alongside examples of organisations that have implemented lasting change and provide access to the materials they used to achieve it. The workbooks will provide a range of improvement materials that are centrally developed but that allow for local tailoring. The topics will include: Reducing the incidence of ventilator associated pneumonia. Reducing avoidable incidence of venous thrombo-embolism. Reducing the incidence of pressure ulcers. Reducing wrong site surgery. Reducing medicine errors. Key objectives for 2010/11 are: To develop and pilot first tranche of Preventing Harm workbooks. Collaborating with the H&WA 32

AQuA and the Health Well-Being Alliance have been established by NHS organisations in the North West to promote innovation and spread best practice. They have distinct but complementary roles and will work in close co-operation in support of the NHS, its partners, communities and individual citizens. AQuA and the Health and Well-Being Alliance will work closely together in order to ensure that duplication of activities are minimised, and that complementary approaches are taken to issues such as knowledge management, engagement of frontline staff and mobilisation of support for large scale change. The Health and Well-Being Alliance has as its major focus tackling the wider determinants of ill health. It recognises that health and wellbeing are a function of individual lifestyle choices and environmental factors, not just a product of the quality of health care services. The Health and Well-Being Alliance will therefore work with the NHS but also with a wide range of external partners, including Local Authorities, voluntary sector, businesses and community groups, as well as with individual citizens. AQuA sees improved health as one of its work key aims, alongside best possible care, value for money, and joy and pride in work for NHS staff. Its main contribution to the delivery of improved health will be through the redesign of NHS services to reduce the need for acute intervention and promote more effective prevention and chronic disease management. Key objectives for 2010/11 are: [DN to follow. Discussion started between AQuA and H&WBA. shortly enable us to draft objectives for 2010/11.] This will Supporting organisations to take part in the DH learning events and roll out for Safe Care/ Supporting the delivery of the Nursing High Impact Actions and the Energise for Excellence programme AQuA will support organisations to take part in the DH learning events and roll out of the QIPP Safe Care programme. The DH programme aims to achieve: 80 % reduction in hospital acquired pressure ulcers (grade 3-4). 30 % reduction in community acquired pressure ulcers (grade 3-4). 50 % reduction in catheter-acquired urinary tract infections. 25 % reduction in falls in care. 33

In addition, AQuA will also support the implementation of the nursing High Impact Actions and the Energise for Excellence programme. Key objectives for 2010/11 are: To work with the DH QIPP Safe Care lead to roll out the DH developed learning package To support the implementation of the nursing High Impact Actions and the Energise for Excellence programme. 34

Supporting Best Care Our Best Care portfolio currently includes the following programmes: Aim Advancing Quality Reducing variation in care Improving the patient experience Delivered by Advancing Quality Programme Developing clinical domain workbooks Stroke 90/10 collaborative Working with Inspiration North West to improve the patient experience Advancing Quality The Advancing Quality programme supports all provider Trusts to: Ensure that effective care is delivered at the right time for all patients. Deliver year on year improvements in the scores and across the North West in each of the five focus areas. Deliver public facing data in relation to AQ which is transparent, meaningful and useful. Achieve the scores required for the payment of 2010/11 regional CQUINs. As a result, in a range of clinical areas providers are able to report at trust, ward, focus area and clinician level compliance with effective care and improved outcomes from a patient and clinical perspective and to use the data to focus improvement activities. To achieve these benefits AQuA supports participating organisations in a number of ways. It collects and reports data against clinician agreed quality measures, patient reported outcome measures and patient reported experience measures. It utilises the data and the information to determine opportunities to improve quality It works with the organisations in the North West to ensure that the quality objectives are met. The Advancing Quality programme currently has five focus areas: acute myocardial infarction; coronary artery bypass grafts; heart failure; hip and knee replacement and community acquired pneumonia. The measures that have to be achieved are listed in Appendix B. The next stage of the programme is to extend the coverage to 35

include: dementia and psychosis; stroke measures and heart failure community and primary care metrics. Key objectives for 2010/11 are: To continue to collect and report performance on the AQ five (AMI, CABG, Hip and knee surgery, pneumonia and heart failure). To develop a framework to link existing data sets with practice based commissioning level reporting. To further develop sets of metrics relating to stroke, mental health and community heart failure metrics, the tools needed to support their implementation and the processes needed to support improvement. To continue to develop patient reported outcome measures and patient experience measures. To further integration of the AQ and regional CQUIN programmes. Clinical Domain Workbooks AQuA is developing a series of Clinical Domain workbooks. The aim is to have a web enabled product that allows the user to choose how they view data, improvement know how and clinical best practice about the patient s journey through their care pathway within a locality for a range of clinical domains (eg stroke, COPD etc). The workbooks will provide core resource for local improvement initiatives. They will provide organisations with access to national and international material on a range of care domains. They will pull together a range of improvement materials that: Make the best use of the data and intelligence we currently collect. Set out information from end to end in key clinical domains. Combine that with improvement know how and clinical best practice as a resource to drive change. Provide a framework to capture the abundance of knowledge that already exists. They will provide intelligence to identify improvement opportunities in a structured way organised around three questions: What scope is there to reduce avoidable admissions? What is the scope for improving care for unavoidable admissions? What is the scope for maximising the time between readmissions / improving end of life care? 36