Bedfordshire Clinical Commissioning Group Quality Strategy 2014-2016
Contents SECTION 1: Vision 3 1.1 Vision for Quality 3 1.2 What is Quality? 3 1.3 The NHS Outcomes Framework 3 1.4 Other National Drivers for Quality Improvement 4 SECTION 2: The Strategy 6 2.1-2.1.5 Quality Assurance Framework 6-8 2.2 Patient & Public Involvement 9 2.3 Serious Quality Failure 10 SECTION 3: Contracts 12 3.0 Contractual Process 12 SECTION 4: Governance and Reporting 12 4.1 Responsibilities 12 4.2 Governance Structure 13 SECTION 5: Conclusion 14 APPENDIX 1 BCCG 2020 Strategy 15 APPENDIX 2 Quality Strategy 2014-2016 16 2
SECTION 1: Vision 1.1 Vision for Quality BCCG's strategic vision has, since its establishment, been to put quality at the heart of its purpose; To ensure, through innovative, responsive and effective clinical commissioning, that our population has access to the highest quality health care providing the best patient experience possible within available resources This strategy sets out how BCCG will realise this vision and the mechanisms by which it will assure patients, public and partners of the quality of services it commissions. 1.2 What is quality? The NHS has agreed that the definition of quality, as set out by Lord Darzi in High Quality Care for All (2009), is; Care that is; > Safe > Effective > Provides a positive experience for patients Quality care is achieved by encompassing all three aspects with equal importance on each. The definition now enshrined in legislation has the patient and the NHS Outcomes framework at the heart of this approach. The Care Quality Commission (CQC's) new inspection approach goes further to build on the three dimensions of quality by adding an additional two more dimensions: Organisational Culture & Leadership and Responsiveness. 1.3 The NHS Outcomes Framework The primary purpose of the CCG is to improve the health outcomes for its population. The NHS Outcomes Framework builds on the definition of quality and groups a wide set of outcome indicators into five domains: Each Domain has a set of overarching and more detailed indicators. Appendix 1 shows the CCG Outcome Indicator set for 2014/15. 3
1.4 Other National Drivers for Quality Improvement 1.4.1 The NHS Constitution The NHS Constitution established the principles and values of the NHS. It sets out the legal rights to which patients, public and staff are entitled and commits to pledges above the legal rights. 1.4.2 The National Institute for Health and Care Excellence (NICE) The care pathways launched by NICE in May 2011 addressed over 20 clinical conditions including chronic obstructive pulmonary disease, stroke and dementia. These pathways are designed to bring together all clinical best practice that relates to a specific condition or disease. We commission services in line with NICE guidance. 1.4.3 Care Quality Commission (CQC) Essential Standards The CQC is the regulator of health and adult social care in England. It is responsible for ensuring that providers meet essential standards for quality and safety and encouraging on going improvements by those who provide or commission care. There are 16 essential standards of quality and safety, which come under the following main areas of care. Involvement and Information Personalised care, treatment and support Safeguarding and patient safety Suitability of staffing Quality and Management The CQC will continuously monitor compliance with the essential standards as part of a responsive and robust system of regulation. 4
1.4.4 National Reviews and Reports The recommendations and lessons learned from the following reviews will be implemented and drive a shift of change towards how services are commissioned. These include: Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - 'The Francis Report' (February 2013) Patients First and Foremost - the 1st Government response to the recommendations of Robert Francis (March 2013) Hard Truths: The Journey to Putting Patients First - the 2nd Government Response to the recommendations of Robert Francis (November 2013) In June the CCG published its approach to implementing the Francis Report, Care and Compassion. It believes that an effective response will not be achieved solely through traditional 'action planning' but through a wide organisational development approach that includes culture and leadership as well as better quality and safety processes. The Quality Strategy, alongside our Organisational Development Plan, Communications & Engagement Strategy and the Plan for Patients are the key means by which the recommendations will be embedded within the organisation. Review into the quality of care and treatment provided by 14 Acute Hospitals, Sir Bruce Keogh (July 2013) Winterbourne View Hospital Don Berwick's Review into Patient Safety (August 2013) 5
SECTION 2: The Strategy To ensure, through innovative, responsive and effective clinical commissioning, that our population has access to the highest quality health care providing the best patient experience possible within available resources. Everyone Counts: planning for Patients 2014/15 to 2018/19 clearly states that Quality is in everything we do covering effectiveness, experience and safety. Commissioners must put quality at the centre of all discussions with providers. Our commissioning strategy and plans are the primary means of delivering improved outcomes for patients. The Bedfordshire Plan for Patients comprises a 5yr strategy and a supporting 2yr operational plan (2014-16). The delivery of the plan is through three work programmes; Helping children and young people start a healthy life Helping adults and older people maintain a healthy life as long as possible Supporting mental health and wellbeing throughout life Quality and Patient Safety is a cross cutting theme to all aspects of our commissioning plans. Appendix 1 shows the CCGs 'Plan on a Page'. This demonstrates the CCG's strategic aim including the model for integration. Appendix 2 demonstrates the quality strategy on a page, including the vision purpose and the methods used to monitor quality. This quality strategy therefore underpins the delivery of our longer term vision and commissioning plans. It will do so, as detailed below, by establishing a series of monitoring, reporting and support systems whose common thread is the effective management of contracts via the NHS Standard Contract. The key components are described in our Quality Assurance Framework areas follows; 2.1 The Quality Assurance Framework BCCG has developed an effective framework for how quality assurance will be obtained. BCCG uses the principles and stages identified in the Keogh reviews. This enables a systematic, transparent and comprehensive methodology to be utilised (see below): 2.1.1 Data collection and analysis 2.1.2 Triangulation of information 2.1.3 Multi-disciplinary quality review 2.1.4 Support and Improvement 2.1.5 Incentives for quality improvement This approach offers BCCG a methodology with the aim of building a profile of a commissioned service by; Obtaining assurance of commissioned service quality Monitoring quality performance against agreed standards and outcomes The ability to carry out quality surveillance of safety, effectiveness, patient experience, leadership & culture and responsiveness No quality assurance framework offers a definitive conclusion about the quality of care but it allows for questions to be raised exploratory review to be undertaken and improvement to be supported. Transparency is essential to this approach and is based on support and improvement rather than blame. The aim therefore, working with the providers, is to shift services to the right of the bar and to greater 'excellence' and less substandard performance or failure. 6
Figure 2. Quality in the New Health System; National Quality Board 2012 2.1.1 Data collection and analysis BCCG collects a wealth of intelligence, gathered both formally and informally. This quality intelligence acts as a signal to investigate further if a provider is outside of expected limits. This data initiates enquiry in relation to obtaining further knowledge that can be triangulated to determine the need for quality improvement in a consistent manner and approach. Hard and soft intelligence are identified within the quality schedule that is agreed with each commissioned service through the contracting process. 2.1.2 Triangulation Quality cannot be seen in isolation but as part of a broader concern about performance and contracting. When information from one directorate is systematically combined and triangulated with another, this may point to potential problems that need further investigation. We therefore, for example, will combine; Data: i.e. mortality rates, admission/readmission rates, waiting times information, safety incidents including Never Events and Safeguarding Intelligence. With; Patient Experience feedback e.g. surveys, complaints, feedback through PPE structures And; Local intelligence e.g. feedback from our GPs using tools we have developed such as the 'yellow card' that highlight individual or common issues identified by practices. Triangulated these give a powerful and more accurate picture of the quality of a service and allows the CCG to intervene at an earlier stage to support the provider. 7
2.1.3 Multi- Disciplinary quality review There are different approaches taken to undertake multidisciplinary review; The Quality Review meeting is a formal contractual quarterly review held to monitor and discuss aspects of quality of care. These meetings form a detailed oversight and scrutiny process and include the following processes: The Commissioner Quality Walkabout enables informal dialogue and the ability to observe pathways and the care environment. This process also enables the interaction with patients and front line staff. An essential component in relation to data and soft intelligence. Regular conversation and meetings with essential stakeholder staff and provider leaders enables open sharing and transparency in relation to key areas of concern and /or follow up. Quality account process enables the feedback from commissioners in relation to the improvements and outcomes reported by the provider. Commissioning and Contract levers are used to ensure that quality is embedded throughout the commissioning and contracting cycle; a multidisciplinary approach is used at this stage to drive up quality of care. A detailed quality schedule is produced outlining the standards and requirements of the provider. Deep dive review may be undertaken into a specific clinical pathway if intelligence so indicates. Outbreak and incident meetings as a response to infectious outbreaks. A Risk Summit may be called by NHS England if concerns are escalated. Midlands and East Area Team Quality Surveillance group is a bi monthly meeting of all commissioners in the area, NHS England and all regulators to review and share intelligence on commissioner services. 2.1.4 Support and Improvement BCCG has identified improvement it wishes to secure in the quality of services commissioned, continuous quality improvement requires consistent, innovative approaches to be implemented across the system. Incentive schemes have been developed to meet future challenges on evidence from NICE Quality standards. 2.1.5 Incentives for Quality Improvement Commissioning for Quality and Innovation Framework (CQUIN) The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of a providers income to the achievement of national and local quality improvement goals. We monitor achievement of CQUIN standards throughout the year to ensure each provider is meeting or exceeding expectations. Quality Premium Local quality initiatives Quality premium is the incentive payment used to reward CCGs for their performance in achieving specific outcomes related to a number of clinical conditions. 8
2.2 Patient and Public Involvement The CCG has a Patient and Public Engagement Strategy that has been developed in parallel with and complements the Quality Strategy. In particular there are shared processes and structures to improve patient experience. 2.2.1 Patient Experience This is a significant national and local priority and is reflected in the national Outcomes Framework. The CCG has developed an integrated approach to combining patient experience data and information with soft intelligence shared by Localities and information collated through the patient engagement forums within the localities. Localities will be able to forward patient experience examples via a secure electronic system so that a rich source of live data is available to support the national approach i.e. Friends and Family test and National surveys. In order to communicate the outcomes of this approach the development of the Insight Dashboard is underway the aim being to provide a framework and mechanism to collate patient experience and Public engagement intelligence in a meaningful and usable way. The work to improve patient experience is undertaken jointly with the Communications and Engagement Directorate. The Patient Experience Group brings this work together (see figure 3). 9
2.2.2 Patient Advice and Liaison Service The CCG has a Patient Advice and Liaison Service (PALS). The CCG triangulates data and from PALS queries, complaints and other patient experience measures to gain an understanding of how patients view their services. The CCG uses communications and engagement to ensure the public know how they can interact with the CCG (including PALS and Complaints), and ensure the public are kept informed of the outcomes resulting from these insights. 2.2.2 CCG Complaints Service The CCG have arrangements in place for dealing with patient complaints in accordance with national statutory requirements. These have been reviewed and strengthened in light of the recommendations in the Francis Report. The CCG will take action as a result of complaints and share the lessons learnt via the monthly CCG patient experience group. A quarterly complaints report is also produced which is presented to the CCG Patient Safety and Quality Committee. 2.3 Serious Quality Failure 2.3.1 Serious Incidents (including Never Events) In order to ensure mistakes in practice do not repeatedly occur, providers are required to ensure that policies and procedures are robust enough to identify risks, manage those risks and create a learning culture. Serious Incidents are communicated to BCCG in order to agree an appropriate performance management protocol relevant to the severity of the incident. All Serious Incidents have a Root Cause Analysis and lessons are shared across the CCG. Incidents and Serious Incidents are analysed for trends and reported to the Patient Safety and Quality Committee, Serious Incidents are reported to the CCG Governing Body. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. We take these extremely seriously and ensure that contractual penalties are applied should they occur. 2.3.2 Safeguarding Vulnerable Adults and Children BCCG ensures that its providers have arrangements in place to safeguard and promote the welfare of adults and children in line with national policy and guidance. We require providers to demonstrate that policies and procedures are in place and implemented. Staff training is reviewed to ensure staff know how to report safeguarding concerns. Our Safeguarding leads and Designated Dr are actively involved with the local authorities in all health related cases to ensure appropriate- safeguards are in place and that providers are responsive and continually learning from incidents that may occur. The CCG continues to play an active role on the Local Safeguarding Children's Boards for Bedford Borough Council and Central Bedfordshire by; Ensuring active engagement in the Safeguarding partnership, with sign up to the agreed priorities Active Engagement in Safeguarding Vulnerable Adults Board Continue to monitor data and soft intelligence to ensure we have effective early warning signs in place. Agree a plan to work in collaboration with Bedford Borough and Central Bedfordshire in response to acting to safeguard residents if any home needs to close and residents moved. 10
2.3.3 Care Home Quality A comprehensive plan is underway to visit and assess care delivered and patient experience in all the Nursing and Care Homes within Bedford Borough and Central Bedfordshire. This work is led by the Adult safeguarding team working closely with Continuing Health care staff, infection control Specialist Nurse, Public Health and the Local Authorities. Intelligence is shared with Bedford Borough Council and Central Bedfordshire Council in relation to the quality of Care in Nursing Homes so that a proactive approach to ensuring a safe service is delivered for elderly residents. The aim being to be proactive in relation to services, offer specialist support when required and therefore gaining assurance in relation to safety of these residents. This work is overseen by our Integrated Safeguarding meeting and reported to the Patient Safety and Quality Committee. Significant concerns are reported to the Governing Body via our risk and assurance reporting mechanisms. Examples of the areas covered include: Patient centred documentation Pressure Ulcer management Falls management Infection Control Mental Capacity Act requirements 11
SECTION 3: Contracts 3.0 Contractual Process The contract process includes an annual negotiation where national and local quality requirements for delivery are agreed. Monthly Contractual review and in depth quarterly quality reviews take place in order to ensure delivery. A detailed quality schedule is developed which reflects national and local performance and data requirements that the providers are required to provide to support the Quality Assurance Framework. Contractual levers are utilised and an escalation process to Executive leadership if standards are not met and information is not provided. SECTION 4: Governance and Reporting 4.1 Responsibilities for the CCG The CCG (its member practices) have a legal duty as to Improvement in Quality of Services (which includes effectiveness, safety and patient experience). It also has a legal duty as to the improvement in the quality of Primary Care. The Governing Body is responsible for setting strategy. The Accountable Officer is accountable for the delivery of the Quality within the CCG. The Chief Operating Officer is responsible for ensuring the CCG has structures and resources in place to deliver the strategy. The Patient Safety and Quality Committee is responsible for providing assurance to the Governing Body that the Quality Strategy and associated actions are implemented. The Executive Team is responsible collectively for the implementation of the actions and objectives associated with delivering the strategy. The Director of Nursing and Quality has delegated responsibility for operational delivery and actions The Quality Directorate delivers the day to day requirements of this strategy. Each provider and member practice remains accountable for the quality of services within their own organisation. Individual CCG members/staff have a responsibility to for quality and safety including to report incidents and respond to patient feedback in an open and transparent way in order to support improvement in our services. Outside of the Quality Team significant risks are identified, managed and monitored through the Executive Team (operational delivery), Governing Body (assurance) and Patient Safety & Quality Committee (detailed assurance). 12
4.2 Governance Structures The diagram below demonstrates the governance structure. It distinguishes management responsibilities and reporting (to the right) from assurance to the Governing Body (to the left) whilst maintaining clear line of sight of data flows and accountabilities. 4.2.1 Patient Safety and Quality Committee The role of this committee is to provide assurance through a mechanism outlined in the quality assurance process, in which actions are taken, lessons are learned, additional lessons from trends are identified, and best practice shared from the outcomes of national findings, complaints, incidents, near misses, Serious Incidents, Litigation, PALS, compliments, patient experience and public feedback, clinical audit, and findings from research and evaluation. This information will be collected from commissioned and contracted services and claims. The CCG will also ensure that the actions are completed and recommend further improvements in practice. The Director of Quality and Nursing will also ensure that this information is considered in commissioning decisions by the commissioning team. The membership of this committee will be representative of the organisational directorates including the Localities and will be chaired by a Lay member or a GP and is a subcommittee of the Governing Body. 13
4.2.2 Monitoring Quality Contracts and Performance Group This group functions at an operational level to ensure that key performance; finance and quality issues are considered in a triangulated methodology and managed effectively with the provider concerned. This group brings together the operational managers supported by Directors to ensure effective join up and management of key issues and concerns either via the contractual route or by further action taken by providers to give assurance on delivery. This group is jointly chaired by the Director of Contracts and Performance and the Director of Quality. Escalation of issues will be to the Patient Safety and Quality Committee or to the Integrated Quality, Performance, Finance Committee to ensure effective action and clear communication with Provider organisations. 4.2.3 Integrated Quality Performance and Finance Meetings with Providers The purpose of this group is to enable effective communication and resolution of issues at an Executive level of key areas of concern. This group will also be an enabler to support strategy development and the ongoing development of effective partnerships with Providers. This group will be chaired by the Chief Operating Officer of BCCG. SECTION 5: Conclusion This quality strategy aims to support BCCGs aim to embed quality in to every aspect of business as usual by making quality the focus of every aspect of service. For the quality strategy to be successful the ethos and values of BCCG need to be demonstrated in everyone's actions across BCCG. There is recognition that there is an organisational development need to embed the principles into every aspect of commissioning within BCCG. The Quality team structure has been developed to support the leadership and therefore delivery and further development of the implementation of the domains of quality in an integrated way in order to achieve all aspects of quality equally. An Organisational Development plan will be available and the implementation of the quality strategy will be incorporated. 14
APPENDIX 1: BCCG 2020 Strategy 15
APPENDIX 2: Quality Strategy 2014-2016 16