CQUIN Supplement Quality Account 2011-2012
Introduction The CQUIN framework was introduced in April 2009 as a National Framework for locally agreed quality improvement schemes. It enables commissioners to reward excellence by linking a proportion of healthcare provider s income to the achievement of local quality improvement goals. The Framework aims to embed quality within commissioner-provider discussions and to create a culture of continuous quality improvement, with stretching goals agreed in contracts on an annual basis. This additional information relates to Sections 2.19 and 5.4 of the UHCW 2011/2012 Quality Account. The information below details performance against the 2011/2012 CQUIN goals for both the Arden Cluster (formerly NHS Coventry and NHS Warwickshire) and the West Midlands Specialised Commissioners. The 2011/2012 CQUIN Scheme was worth 1.5% of the overall outturn value of the activity delivered. 1. 2011/2012 CQUIN (The Arden Cluster) No. CQUIN description Target UHCW 1a National Patients are given a VTE Risk Assessment 90% 94% 1b Patients are given the appropriate chemical Prophylaxis following a VTE Risk Assessment 2 National Patient Experience - improvement on the overall composite score for the National Inpatient Survey or an improvement against 5 questions. 88.7% 89.5% 66.3 overall Q41-72.3 Q44-56.7 Q46-82.4 Q65-43.1 Q70-76.8 65.4 68.2 55.5 78.3 47.6 77.5 3 Preferred Prescribing List 75% 98% UHCW achieved an improvement against 2 of the questions this is classed as 2
CQUIN description Target UHCW 4a Implementation & delivery of Ambulatory Care pathways Pathway delivery against a trajectory Pathways delivered 4b Benchmark against the ambulatory care handbook Benchmark report Benchmark report provided 5a Implement the NHS Institutes Global Trigger Tool in 3 specialties 20 sets of case notes each month with evidence of reporting All notes reviewed and evidence provided 5b Implement a mortality review process for patients over 18 and under 75 75% 75% 6a Patients and carers will receive written information on discharge for 10 pathways & receive a follow up telephone call within 24-48 hours of discharge. 6b Patients will have the involvement of social care professionals at preoperative assessment (pre-admission) in defined specialties to facilitate earlier discharge planning. 95% for each pathway by Q4 95% for each pathway for Q4 8/10 pathways achieved 95% achievement for each pathway 2. 2011/2012 CQUIN (West Midlands Specialised Commissioners) No. Regional or CQUIN description Target(s) UHCW 1 National Patients are given a VTE Risk Assessment 90% 94% 3
Regional or CQUIN description Target(s) UHCW 2 National Patient Experience - improvement on the overall composite score for the National Inpatient Survey or an improvement against 5 questions. 3 Improving access to 7 day post surgery neurological rehabilitation 66.3 overall Q41-72.3 Q44-56.7 Q46-82.4 Q65-43.1 Q70-76.8 A project plan. An analysis showing the number and % patients that met the for 25% of Neurotrauma patients treated within that period 65.4 68.2 55.5 78.3 47.6 77.5 Met all Because UHCW achieved an improvement against 2 of the questions this is classed as 4 Improving the home dialysis rate Narrative report on proposed cognitive/beh avioural screening tool and steps taken to pilot this. 26% (rate of dialysis) 25.1% 5 Organs for transplant Submission of quarterly information Met all Failure 4
Regional or CQUIN description Target(s) UHCW 6 Screening babies at risk of severe retinopathy of prematurity 7 Audit of the management of West Midlands babies requiring neonatal services 95% Met the target Submission of complete data sets Met all The 2012/2013 CQUIN scheme is worth 2.5% of the total outturn value of the activity delivered. 3. 2012/2013 CQUIN Scheme agreed with The Arden Cluster No. CQUIN description Target 1a National Patients are given a VTE Risk Assessment 90% 1b Regional Patients who are prescribed chemical 90% Thromboprophylaxis who have a documented risk assessment. 2 National Patient Experience - improvement on the overall 65.4 composite score for the National Inpatient Survey or an improvement against 5 questions. 3a Regional Patient Revolution - establish Net promoter Undertake baseline Question and baseline 3b Regional Patient Revolution Board and Commissioner Demonstration of reporting 3c Regional Patient Revolution Weekly reporting of the net promoter score 3d Regional Patient Revolution improvement of Net Promoter score 4 Regional Safety Thermometer - Improve collection of data in relation to pressure ulcers, falls, urinary tract infections in those with a catheter and VTE 5a National % of emergency patients aged 75 and above who are asked a dementia screening question. 5b National % of emergency patients aged 75 and above who have been at risk of dementia to have a risk assessment 5c National % of emergency patients aged 75 and above who based on the risk assessment are referred to their GP. 6 Implementation of a Rapid Assessment Interface and Discharge Team (RAID) for patients who 5 reporting to Trust Board Evidence of weekly reporting from Quarter 2 10 point improvement on Net promoter score OR maintenance of upper quartile Perfomance. Submission of complete data sets 80% of referrals made to RAID from the
CQUIN description require mental health support. Target Emergency Department. 75% of referrals made to RAID from base medical wards 7a Introduction of morning board rounds 90% of agreed wards 7b Scoping of the to extend to 7 day Board rounds and evidence of one ward undertaking 7 day board rounds. Scoping document and evidence of 1 ward undertaking 7 day board round. 7c Introduction of multi-disciplinary discharge 90% meetings 7d Reducing internal waits To be agreed at end of Quarter 2 7e Criteria-Led discharge in 3 new pathways 75% of patients are discharged according to criteria led pathway 8a,b,c Introduction of appropriate virtual clinics in Rheumatology, Endocrinology and Urology. 9 Smoking status and Carbon monoxide test to be undertaken for pregnant women at booking. 10 Implementation of Oesophageal Doppler Monitoring in, Upper GI surgery, major vascular surgery, renal surgery, major trauma and emergency general surgery To be confirmed in Quarter 3 95% 3. 2012/2013 CQUIN Scheme agreed with West Midlands Specialised Commissioning Team 75% No. CQUIN description Target 1 National Patients are given a VTE Risk Assessment 90% 2 National Patient Experience - improvement on the overall 65.4 composite score for the National Inpatient Survey or an improvement against 5 questions. 3 National Improving diagnosis of dementia in hospitals as agreed with the Arden Cluster Regional Safety Thermometer as agreed with Arden Cluster Submission of complete data sets 4 local Implementation of clinical dashboards for specialised services Provision of dashboard information 5 Cardiac Surgery inpatient waits within 7 days To be agreed 6 Increasing use of home renal dialysis An increase on 11/12 outturn 7 (Neonatal) Improved timely TPN administration % increase on baseline 6
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