2012/13 SSOTP CQUIN INDICATOR TARGETS INDICATOR REQUIREMENT 1. Patient Experience Milestone 1 (15th working day of April 2012) Identify a minimum of 4 theme areas which are considered to have caused concern for patients during 2012/13 Devise a real time patient experience questionnaire which includes questions regarding the identified themes and also the "net promoter" question - How likely is it that you would recommend this service to friends and family? Extremely Likely? Likely? Unsure? Unlikely? Not at all? Don t Know? Agreement with Commissioners and full implementation of organisation wide improvement plan, to address patient experience in general and the identified themes in particular. The plan must include promoting and using innovative ways of identifying and addressing patient stories e.g. the Patient Opinion website The plan must also include details of how the Net Promoter requirements from the SHA will be completely implemented by the end of the year and how this can also be rolled out beyond inpatient services *Monitoring of this indicator will include visits to service areas to review the implementation of the improvements. Using Questionnaire agreed with Commissioners in Milestone 1, undertake a questionnaire during June 2012 to establish the baseline information for: Milestone 7 - Net Promoter Question Milestone 8 - Responses relating to all identified themes Report on progress against plan agreed in 1
Report on progress against plan agreed in Report on progress against plan agreed in Milestone 7 Full achievement of plan agreed in Milestone 8 10 points Improvement in the score for the net promoter question between the baseline period (June 2012) and the final data collection period (March 2013) * The degree of improvement required will be determined when baseline figures are known Milestone 9 Improvement in the responses relating to all identified themes between the baseline period (June 2012) and the final data collection period (March 2013) *The degree of improvement required will be determined when baseline figures are known 2a - Safety Express - Data Collection Milestone 1-12 This CQUIN will require monthly surveying of all appropriate patients (as defined in the NHS Safety Thermometer guidance) to collect data on four outcomes (pressure ulcers, falls, urinary tract infection in patients with catheters and VTE). Data must be submitted to the region one week after the monitoring day (which is on, or around, the 15th day of the month) 2b - Safety Express - Roll out of Safety Express to Community Services Milestone 1 Milestone 8 Milestone 10 Milestone 12 Milestone 15 2
Milestone 17 Milestone 19 2 4 Percentage of Community Hospital patients who are free from harm (Target of 95% to be achieved by the end of March 2013) Milestone 9 Milestone 11 Milestone 13 Milestone 16 Milestone 18 0 3 5 Percentage of Community Services patients who are free from harm (Target to be determined once baseline has been established and to be achieved by the end of March 2013 Milestone 7 Milestone 14 1 6 Roll out of the Safety Express improvement plan (as detailed in Q4 2011/12) to Community Services. Targets for individual quarters must be achieved 7 95% of Community Hospital patients who are free from harm to be achieved by the end of March 2013 (update reports to be delivered monthly). 3
8 xx% of Community Services patients who are free from harm to be achieved by the end of March 2013 (update reports to be delivered monthly). Target to be determined once baseline (using data for March 2012 - June 2012) has been established 3. Dementia Milestone 1 Produce a development plan to be agreed with commissioners (in line with the local Dementia Strategies) to outline the ethos of care provision in community and community hospital teams. Achieve milestones outlined in the development plan (Note: as long as identified essential elements are achieved in the quarter, the milestone will be considered as achieved. There is the option for other actions to be rolled over to subsequent quarters.) Roll out screening tool, assessment and referral pathway across Community Hospital Wards *This milestone will be reviewed at the end of Q1 to ensure achievability if the milestone is felt to be unachievable an alternative milestone will be determined at the July CQRM) Pilot usage of screening tool, assessment and referral pathway in a selection of community based teams with trained staff to evaluate effectiveness. 4. Leg Ulcer Management Milestone 0 Audit brief to be agreed with commissioners for Milestone 1 audit. Brief will include the sample size, under the advisement of the clinical audit department, once the population of relevant patients has been identified Milestone 1 Audit of an agreed sample of District Nursing caseloads during April and May 2012(audit brief to be agreed with commissioners - the sample size will be agreed, under the advisement of the clinical audit department, once the population of relevant patients has been identified) to determine: 4
Number of patients with a leg ulcer on each caseload Time to doppler Whether a management plan is documented in the clinical record Adherence to the management plan Compliance with wound formulary Patient/Carers information Development of a competency frame work Organisation wide improvement plan to be agreed with commissioner. The plan should: outline the actions required to achieve the measures detailed above with clearly identified targets for each of the 2 remaining quarters. address any issues identified within the Q1 audit. identify the roll out of the training package and the numbers/% of staff to be trained by the end of Q4 Development of advanced level training package Achievement of Q3 targets. To include roll out of training packages. (Note: as long as identified "essential elements" are achieved in the quarter, the milestone will be considered as achieved. There is the option for other actions to be rolled over to subsequent quarters.) Achievement of Q4 targets. To include training of % of advanced staff (Note: as long as identified "essential elements" are achieved in the quarter, the milestone will be considered as achieved.) 5. Outcome Measures Milestone 1 Report to be provided to the CQRM which outlines for each team outcome tools currently in use, frequency of analysis, how these measures are used to inform quality improvements. 5
Teams that have at least 12 months quality outcome data (Level 3) will devise a plan for materially improving outcomes by Q4. Plan for improvement will be submitted to July CQRM. Teams that have quality outcome tools in place but less than 12 months data (Level 2) will put in place robust systems for capturing outcome data and analysing it. Plan for this will be submitted to July CQRM. Teams that do not have robust evidence based quality outcome tools in place (Level 1) will develop / adopt such tools. Plan for this will be submitted to July CQRM. Confirmation that all targets in plans for Q2 have been met. Confirmation that all targets in plans for Q3 have been met. Level 3 services or teams must demonstrate that outcomes have measurably and materially improved from 2011/12 to Q4 (2012/13) (Move to Level 4) Level 2 services or teams must evidence that quality outcome data has been collected and analysed throughout the year and by 31 March 2013 have developed a plan to achieve focussed quality improvements to be delivered during 13 / 14 (Move to Level 3) Full payment will require that the vast majority [not 100% to avoid failing at first hurdle] of services and teams successfully meeting the goals set out in their agreed plan and move up one level by 31 March 2013. Target depends on number of services teams included e.g. 9/10 or 18 /20 etc Spot check observational audit to be carried out by commissioners during Q3 and Q4 to verify that at least 75% of planned changes can be demonstrated and that 75% of clinical professionals have a good understanding of the outcome tools being developed / used and the rationale behind them. 6. Patient Empowerment / Self Management Milestone 1 Organisation wide improvement plan to be agreed with commissioner. The plan should: outline the actions required to achieve the measures detailed above with clearly identified targets for each quarter. 6
cover actions required over a 2 year period and should include monitoring of readmission/re- referral rates. This information should be shared with Commissioners on a quarterly basis. The plan should be reviewed on a quarterly basis by the Trust and Commissioners. Carry out Staff Confidence survey to establish the baseline position for use in Milestone 7 Achievement of targets identified for Q2 (Note: as long as identified "essential elements" are achieved in the quarter, the milestone will be considered as achieved. There is the option for other actions to be rolled over to subsequent quarters.) Patient experience baseline Q2 survey Achievement of targets identified for Q3 (Note: as long as identified "essential elements" are achieved in the quarter, the milestone will be considered as achieved. There is the option for other actions to be rolled over to subsequent quarters.) Achievement of targets identified for Q4. This should include a full update plan for year 2 actions (Note: as long as identified "essential elements" are achieved in the quarter, the milestone will be considered as achieved.) Milestone 7 7. Case Management Milestone 1 Improvement in staff confidence survey results for Q4 from baseline in Q1 (target to be established once baseline survey has been completed in Q1) Organisation wide improvement plan to be agreed with commissioner. The plan should outline the actions required to achieve the measures detailed above with clearly identified targets for each quarter. The plan should as a minimum:- - Demonstrate how the initiative will be rolled out across the Trust commencing with the Early Adopter Sites and ensuring that roll 7
out is completed by March 2013. (to achieve 6000 patients case managed with a roll out of 500 per month for both North and South divisions i.e. 12,000 patients/1000 per month across the organisation.) - Include review of the tools/techniques used and identify areas for improvement at specified points e.g. at month 9 and 18 of the roll out. The plan should be reviewed on a quarterly basis by the Trust and Commissioners. Develop and implement a strategy for the early engagement with and identification of patients at risk of deteriorating health Achievement of targets identified for Q2 (Note: as long as identified essential elements are achieved in the quarter, the milestone will be considered as achieved. There is the option for other actions to be rolled over to subsequent quarters.) Achievement of targets identified for Q3 (Note: as long as identified essential elements are achieved in the quarter, the milestone will be considered as achieved. There is the option for other actions to be rolled over to subsequent quarters.) 8. Think Glucose Milestone 1 Achievement of targets identified for Q4 (Note: as long as identified essential elements are achieved in the quarter, the milestone will be considered as achieved.) Roll out of the Safety Express improvement plan (as detailed in Q4 2011/12) to Community Services. Targets for individual quarters must be achieved 9a. Timely and Safe Discharge Milestone 1 (April 2012) Improvement in the number of patients receiving an Estimated Date of Discharge (EDD) and care plan to achieve EDD as agreed 8
at MDT meeting (target to be established once baseline has been determined) to be achieved by Q4,4,6,12,13,15,21,22,24,29,30 and 32 The number of EDDs not complied with to be reported to each CQRM, along with themes impacting on achieving EDDs (the report must also include what action is being taken by the Trust to address these themes) Improvement in the % of EDD complied with (target to be determined once baseline has been determined) to be achieved by Q4,14,23 and 31 Improvement in the number of patients receiving an Estimated Date of Discharge (EDD) and care plan to achieve EDD as agreed at MDT meeting (target to be established once baseline has been determined) to be achieved by Q4 Milestone 7,16,25 and 33 Improvement in the % of EDD complied with (target to be determined once baseline has been determined) to be achieved by Q4 Milestone 8 Determine and agree with Commissioners how to monitor and report length of stay data (information thereafter to be reported on a quarterly basis) Milestone 9 and 18 (June 2012 and September 2012) Put in place a Trust-wide system to improve the standard of information submitted to Continuing Care Panels the system must be agreed with Commissioners by the end of Q1 and must be implemented by the end of Q2 Milestone 10, 19, 27 and 35 (June 2012, September 2012, December 2012 and March 2013) The provision of a report to CQRM on a quarterly basis identifying issues regarding discharges from other Trusts Milestone 11, 20, 28 and 36 (June 2012, September 2012, December 2012 and March 2013) 9
The provision of a report to CQRM on a quarterly basis identifying actions that have been taken as a result of reviewing the discharge issue reports provided by other Trusts within the Cluster in the previous quarter Milestone 17, 26 and 34 (September 2012, December 2012 and March 2013) Update on report monitoring and reporting length of stay data 9.b Discharge Summary Milestone 1 (June 2012) Agreement with Commissioners and full implementation of an improvement plan for improving against all aspects of the discharge CQUIN i.e. summaries, timely and safe discharge, effective discharges (including discharge information for patients) and patient experience. (Discharge information should comply with SAIL guidelines) The action plan should: address how communication in general can be improved with GP practices include roll out of requirements to Community Hospitals in Q2, roll out to Specialist Therapies in Q3 and the initiation of roll out to the rest of Community Services Teams in Q4 commencing with the Community Specialist Teams (the plan should indicate how this will be progressed in 2013/14) The Specialist Teams to be included in the scheme should be determined during Q1 in discussion with local CCGs (September 2012) (December 2012) Milestone 7 (March 2013) Update on implementation plan agreed in Q1 (September 2012) Completion of roll out of requirements into Community Hospitals (September 2012) Baseline audit to set the baseline position for the number of accurate and complete discharge summaries received by GPs on a timely basis (target to be established once baseline has been determined) - to be achieved by Q4 (Milestone 9) (December 2012) 10
Completion of roll out of requirements to Specialist Therapies Milestone 8 (March 2013) Completion of roll out to other Community Services Specialist Teams in line with the Implementation Plan Milestone 9 (March 2013) Improvement on the baseline position for the number of accurate and complete discharge summaries received by GPs on a timely basis (target to be established once baseline has been determined) - to be achieved by Q4 11