Quality Framework 2015-2016 Healthier, Happier, Longer Telford & Wrekin Clinical Commissioning Group (CCG) makes quality everyone s business. Our working processes are designed to ensure we all have the patient at the centre of each service we commission for the population of Telford & Wrekin. We listen, shape, plan and learn from patients about the things that matter to them and their families. We aim to commission clinically effective, safe care that delivers a positive patient experience every time. Dr Michael Innes Chair Telford and Wrekin CCG Page 1 of 17
1. Quality, An integral part of NHS Telford and Wrekin CCG Priorities Ensuring the quality of services is fundamental to the delivery of the local priorities and values of NHS Telford and Wrekin Clinical Commissioning Group (CCG). As the CCG views quality as so fundamental to its purpose, we do not have a separate standalone quality strategy but rather look to embed quality throughout all our commissioning decisions delivered as part of our 2 and 5 year plans. The commissioning plans are directed towards achieving these priorities. Quality lead nurses, aligned to each of the three commissioning areas, work alongside commissioning managers to deliver these priorities. The importance of patient experience and patient views in these plans are reflected through the CCG adoption of the National 6 Cs, the local patient developed 18 Cs and the joint commitment between patients and the CCG as expressed within the CCG Patient Magna Charter. The three elements of quality, Patient Safety, Clinical effectiveness and Patient experience first defined by Lord Darzi ( High Quality Care for All : NHS Next stage Review 2008) are now enshrined within legalisation within Section 2 of the Health and Social Care Act 2012,as the core NHS definition of quality. Diagram 1 below demonstrates the alignment between the three traditional areas of quality and the five outcome domains of the NHS Outcomes Framework. The National Outcomes Framework, in conjunction with the Mandate, is the primary accountability mechanism between the Secretary of State for Health and NHS England. This National Outcomes Framework sits alongside the Adult Social Care and Public Health Outcomes Frameworks. Page 2 of 17
Diagram 1 National Agenda NHS Outcomes Framework and Quality Page 3 of 17
2. Expanding to five domains of Quality and the information available to monitor delivery. The three elements of quality as defined within the Health and Social Care Act 2012 have been previously identified as Patient Safety, Clinical Effectiveness and Patient Experience. NHS Telford and Wrekin CCG, in common with many other organisations, have chosen to expand these elements and consider the five areas of questioning of quality utilised by the updated Care Quality Commission (CQC) assessment framework. This decision reflects the learning from national enquires which have identified the importance of culture and strong leadership to create an environment where quality can flourish. For further information on these five areas refer http://www.cqc.org.uk/content/how-we- inspect-and-regulate-guide-providers#five-key- Diagram 2 provides a pictorial summary the sources of assurance available to inform the CCG Board in regard to these areas. Appendix One provides details of the sources of information cross mapped to both the NHS Outcomes Framework referenced in Diagram 1 and the areas of CQC enquiry above. The quality assurance framework described in this document relates to the quality of commissioned services. In addition to the dashboards produced as a result of the quality monitoring of existing contracts there will be separate reporting to Planning and Performance Committee (PPQ) with regard to the achievement of the Quality Premium targets. Quality indicators of improvement projects will form part of the reporting to the Programme Management Office structure currently under discussion. Page 4 of 17
Diagram 2 Sources of Information to Assure CCG against CQC Domains Well-Led Patient safety Patient Engagement Quality Patient Engagement Responsive Caring Sources of CCG Assurance Clinical Effectiveness Quality Leads both gain assurance from and contribute to development of these areas Caring Patient & Carer Surveys PALS & Complaints Social Media Local Quality Schedules Healthwatch CQC Visits and observations Patient Safety Sign up to Safety Serious Incident/ Never Event Significant Event Reviews Safety Thermometer HCAIs NHS to NHS Concerns Medicine Safety Safe Care Shropshire Safeguarding Benchmarking Sharing best practice Responsive Patient Feedback Friends & Family Test Health Round Table Patient Participation Groups Themed Reviews Appreciative Enquiry New Models of Care Performance of constitutional targets Information governance Horizon scanning Well Led Workforce monitoring Workforce wellbeing Staff surveys Raising Concerns Quality Management Systems Visibility Organisational Culture Clinical Effectiveness Local Quality Schedules CQuINs Clinical Pathways QIPP NICE Compliance Procurement process West Midlands Quality Review Service Contractual Clinical Quality Reviews Clinical Audit Peer Review Academic Health Science Network Clinical Senates Quality Impact Assessments Page 5 of 17
3. Quality Assurance Framework NHS Telford and Wrekin CCG is committed to proactively monitoring the quality of services and taking action to respond to poor/unsatisfactory quality and patient experience. In order to do this, the wide range of data sources shared in Diagram 2 (pg 5) are collated and reviewed by the quality lead nurses in each of the three commissioning teams with Senior oversight/responsibility being provided by Executive Nurse, Lead for Quality & Safety supported by the Deputy Executive for Quality and Engagement. Challenge to providers is provided formally through the Clinical Quality Review Meeting (CQRM) process which provides the audit trail to evidence the discussions and subsequent action plans. Quality leads also work with providers through joint forums such as the Safe Care Board, planned care group meetings, urgent care group meetings and cancer assurance meetings to use partnership collaboration to address issues of concern. The quality leads are also responsible for the review and closure of root cause analysis completed by providers following serious incidents and will require assurance that learning from these is adopted by providers. Quality leads actively participants within Healthcare Infection Reviews, 12 hour trolley breach reviews and maternal/neonatal death reviews. To enable the Teams to triangulate and prioritise concerns, the degree of assurance and conversely potential for risk is considered across three levels of assurance. Diagram 3 details the actions that the Quality Leads undertake at each level. Diagram 3 Levels of Quality Assurance Level 3 Assurance Following formal assessment of risk further investigations will be initiated to obtain assurance. This may involve external agency review or concerns Level 2 Assurance This will involve challenging providers, escalating concerns, triangulating intelligence data and include planned visits based on the intelligence obtained through level 1 assurance Level 1 Assurance Information will be subject to thorough review as a matter of the regular formal contract quality review process Page 6 of 17
Routinely the CCG seeks quality assurance at levels 1 and 2. Level 3 will be normally be sought in the following circumstances: Concerns arising through examination of qualitative and quantitative data e.g. increased mortality rates, infection concerns or other patient harms. Alternatively a worrying set of workforce metrics or credible soft intelligence which is not readily accounted for by the provider. When a concern about quality has been identified and acknowledged by the provider and commissioner but where the mitigating actions to improve the situation are showing little signs of having an impact and patients continue to be at risk. Repeated failure to deliver agreed improvement plans. It is accepted there will be other sources of ad hoc information and triangulation of information that may cause the CCG to seek a greater level of assurance at any time. 3.1 Reporting The reporting element of the assurance framework is completed by the Quality Lead Nurses, who are responsible for the creation and maintenance of monthly dashboards aligned to their commissioning team portfolio alongside the information analysts attached to each commissioning team. The following are guiding principles behind the dashboard: The range of indicators that are reported on a monthly basis will flex to reflect the range of sources that are available, i.e. narrative section is included to note outcome of visits of published surveys. In recording performance against selected indicators, the rating of the indicators will reflect performance against defined standards where these exist. The dashboards can be used to identify early warning signs of services which may be failing and identify potential risk informing the executive risk register and Board Assurance Framework. Variance and performance will be reported to CCG Planning Performance & Quality Committee (PPQ), Audit Committee and escalated to Governance Board and shared with NHS England Quality Surveillance Group if necessary. Page 7 of 17
The Quality dashboards are designed in a format that can be flexed and incorporated into joint performance monitoring frameworks as required. On occasion, significant system quality risk will be reported directly to Quality Surveillance Group (QSG), chaired by NHS England and may result in a whole economy risk summit. The Executive Nurse is a member of the QSG and will provide Board level assurance directly for these significant risks. Dashboard mock up for Secondary and Integrated Care are provided in Section 4.1 The actual dashboard indicators shared at PPQ on a monthly basis will reflect the availability of schedules of information. Quality reporting on smaller contracts in each portfolio will be provided in the narrative section by exception. The format of the report allows it to be integrated into wider performance and finance reports. The Dashboard for the Primary Care reported to Primary Care Committee differs as it simultaneously records elements of performance in addition to quality.the first stage of this has been approved at Primary Care Committee in July with the acknowledgement that further areas will be included as the CCG develops its delegated role for primary care services. The dashboard for the remainder of the Primary Care Portfolio is incomplete at the current time (September 2015) as there are proposed changes to commissioned services and indicators are not yet fully agreed/ developed. The range of quality indicators for reporting are shown in its current form in 4.2. It is proposed that there is an executive integrated quality and performance summary document for each of the three commissioning portfolio areas to highlight the main combined concerns to PPQ. Refer 4.3. Page 8 of 17
4.1 Sample dashboard to cover Secondary or Integrated Care ( smaller contracts reported in narrative section) Key for Dashboards Where a numerical target exists this will be shown on the dashboard Negative upwards trend Negative downwards trend Remains below expected level Positive upwards trend Positive downwards trend Remains at or above expected level Upwards trend neither negative or positive Downwards trend neither negative or positive Remains as previous month 1 Name of main Provider Eg SaTH RJAH or Shropcom Number of STEIS reportable serious incidents reported April May June July Aug Sept Oct Nov Dec Jan Feb Mar YTD CQC Domain Safe Care 2 Incident Reports (non STEIS) 3 Safeguarding Alerts 4 Safeguarding Alerts upheld 5 Pressure Ulcers Grade 2 6 Pressure Ulcers Grade 3 7 Pressure Ulcers Grade 4 8 Safety Thermometer-Harm Page 9 of 17
9 NHS 2 NHS Concerns ( about organisation) 10 Medicine Indicator 11 Never Events 12 MRSA Bacteraemia 13 C. Difficile 14 CQUINS 15 NICE Compliance Audit/Peer review visits 16 Yes/No See Narrative section 17 PROMS Announced and 18 Unannounced Visits (details in exception reporting) 19 Complaints and PALS 20 EMSA Breaches 21 22 Healthwatch Intelligence see narrative Compliance with National Cleaning Standards 23 Friends & Family Result 24 Regulation 28 Reports CQC Domain Effective Care CQC Domain Caring CQC Domain Responsive Page 10 of 17
25 26 Patient / Carer experience surveys Patient Led Assessment of Care Environment 27 Staff Appraisal rates 28 Workforce Monitoring 29 Staff Survey results CQC Domain Well Led Month Narrative Reports to complement visit and survey indicators. To include details of visits/concerns re smaller providers within contract area Area of Concern Action To Address Page 11 of 17
4.2 Sample DashBoard for Primary Care Portfolio not reported to Primary Care Committee Key for Dashboards Where a numerical target exists this will be shown on the dashboard Negative upwards trend Negative downwards trend Remains below expected level Positive upwards trend Positive downwards trend Remains at or above expected level 1 2 Upwards trend neither negative or positive Downwards trend neither negative or positive Remains as previous month NEPT= N,Shropdoc = S,WMAS = W April May June July Aug Sept Oct Nov Dec Jan Feb Number of STEIS reportable serious incidents reported Incident Reports (non STEIS) 3 Safeguarding Alerts 4 9 Safeguarding Alerts upheld NHS 2 NHS Concerns ( about organisation) 10 CQUINS 11 NICE Compliance N 1 W 2 S 3 CQC Domain Safe Care CQC Domain Effective Care Page 12 of 17
12 13 Audit/Peer review visits Yes/No See Narrative section Announced and Unannounced Visits (details in exception reporting) CQC Domain Caring 14 Complaints and PALS 15 Healthwatch Intelligence see narrative CQC Domain Responsive 16 Friends & Family Result 17 Patient / Carer experience surveys CQC Domain Well Led 18 Staff Appraisal rates 19 Workforce Monitoring 20 Staff Survey results Month Narrative Reports to complement visit and survey indicators. To include details of visits/reviews Area of Concern Action To Address Page 13 of 17
4.3 Combined Quality and Performance Summary Sheet for Areas of Concerns across CCG Portfolio Executive Summary Quality and Performance Dashboards insert name of commissioning Portfolio Authors Overall Highlights report Month Description of Concern Actions to Address Update This should detail what has This section will detail both the informal and contributed to concern ie formal actions taken including contractual particular visit survey or levers as appropriate combination of factors Note risks to the CCG are reported and recorded using ERR and BAF, 1 Date raised at PPQ 2 An update on each concern should be provided at every PPQ until concern is deescalated 3 4 Page 14 of 17
Appendix One Data reviewed by Quality Leads in Monitoring and Contributing to Improving Quality Sources of data - Reported as Actual FREQUENCY OUTCOME CQC SOURCE or by exception FRAMEWORK DOMAIN FUNDAMENTAL STANDARD STEIS reportable Serious Incidents Monthly 5 1 Commisioning Support Unit CSU STEIS Safeguarding Dashboard Monthly / Quarterly /Annual 5 1 Contract review Board CRB Schedule 4 of Standard NHS Contract part A, B C and D Monthly 1.2.3.4.5 1.2.3.4.5 CRB Infection Control Report Monthly 5 1.2.4.5. CSU Business Intelligence / IPC Team Safety Thermometer (VTE / pressure ulcers / catheters / falls) Monthly 5 1.2.3.4.5. CQRM / CRB Clinical Quality Review Meeting Service Quality Performance Report Monthly CQRM Incidents reports (other than those in Monthly / 5 1 CQRM Page 15 of 17
quality performance report) Complaints and PALS Quarterly /Annual Monthly / Quarterly / Annual 4 3 CQRM / Provider annual reports Every Contact Counts information (Complex Care Team feedback) Monthly 1.2.3.4.5 1 Complex Care Team Announced and Unannounced Visits Workforce report as per General condition 5.2 - Safer Staffing Never Events (NHS Standard Contract schedule 4 part D) Friends and Family Test External Assessment and Review ( CQC / Healthwatch / LA) EMSA Mixed sex accomodation breaches Monthly by exception Monthly by exception Monthly by exception Monthly by exception Monthly by exception Monthly by exception 4 & 5 1.2.3.4.5. Undertaken by CCG Quality team and external bodies 5 1 CQRM 5 1 CSU / CQRM 4 3 CQRM 4 & 5 1.2.3.4.5 CQRM / CCG 4 3.4 CSU / CRB / CQRM Page 16 of 17
CQUIN schemes Quarterly 1.2.3.4.5 1.2.3.4.5. CQRM Commissioning for Quality and Innovation NHS 2 NHS Concerns Quarterly 1.2.3.5 1.2.3.4.5 CCG Compliance with National Cleaning Standards Quarterly 4 & 5 1.2.4.5 CQRM Regulation 28 By exception 5 1 CQRM Patient / Carer Experience Surveys NHS Standard Contract Schedule 6 Part F Patient Led Assessment of Care Environment PLACE Quarterly / Annual 4 3.4 CQRM Annual 4 3.4 CQRM NICE Compliance Annual 1.2.3.4.5 2 CQRM PROMS Patient reported Outcome Measures As per Guidance 3 4 CSU Business Intelligence Mortality Indicators Annual 2 CSU Business Intelligence HCAI Reduction Plan Annual 5 1.2.4.5 CQRM Page 17 of 17