Quality, Safety and Patient Experience Strategy November 2015 www.castlepointandrochfordccg.nhs.uk
Document Name Quality, Safety & Patient Experience Strategy Version V7 Author/s Name Job Title/s Jenny Briggs Interim Programme Director - Transformation Executive Lead Tricia D Orsi Approved by Governing Body 26.11.2015 Review Date 2.11.2018 Change Record Date Version Changes made 18.9.15 7, still in draft Addition of comments from Tricia D Orsi 17.10.2015 Version 7 Comments added TD 2
Contents 1. Foreword... 5 2. Introduction... 6 2.1 Background and Context... 6 2.2 Defining Quality, Safety and Patient Experience... 6 2.3 Purpose of this strategy... 7 3. Our Commitment to Quality, Safety and Patient Experience... 8 3.1 Our Values... 8 3.2 Our Vision... 8 3.3 Vision for Quality, Safety and Patient Experience... 9 4. Quality, Safety and Patient Experience through Commissioning... 11 4.1 Procurement... 11 4.2 Incentivising and Monitoring Quality with our Providers... 11 4.3 Partnership Working... 12 4.4 Patient and Public Involvement... 12 4.4.1 Commissioning Reference Group... 12 4.4.2 Patient Participation Groups (PPG)... 12 4.4.3 Governing Body... 13 5 National drivers for quality, safety and patient experience... 14 5.1 NHS Five Year Forward View... 14 5.2 The NHS Outcomes Framework... 14 5.3 Harm Free Care & the NHS Safety Thermometer... 16 5.4 Summary Hospital-Level Mortality Indicators (SHMI)... 16 5.5 Care Quality Commission (CQC) Essential Standards... 17 5.6 National Institute for Health and Care Excellence (NICE)... 17 5.7 Quality, Innovation, Productivity & Prevention (QIPP)... 18 5.8 National Reporting and Learning System (NRLS)... 19 5.9 National Reports and Investigations... 19 5.10 No Harms Event... 20 5.11 Co-Commissioning... 20 5.12 Safeguarding adults and children... 20 5.13 Parity of Esteem... 21 6 Roles and Responsibilities for Quality Assurance... 22 6.1 The Role of the Clinical Commissioning Group... 22 3
6.1.1 Our Role as Co-Commissioners... 22 6.2 Group and Team Responsibilities for Quality, Safety & Patient Experience... 23 6.2.1 The Governing Body... 23 6.2.2 The Quality and Governance Committee... 23 6.2.3 The Clinical Quality Review Group (CQRG)... 23 6.2.4 The Quality Support Team... 23 6.2.5 The Role of Member Practices... 24 6.2.6 Quality Surveillance Groups (QSGs)... 24 6.2.7 The Commissioning Support Unit (CSU)... 24 6.3 Individual Roles and Responsibilities... 25 6.3.1 The Accountable Officer... 25 6.3.2 The Chief Nurse... 25 6.3.3 All CCG Staff... 25 7. Quality, Safety and Patient Experience Assurance Processes... 26 7.1 Monitoring and Assurance for Commissioned Services... 26 7.1.1 Using data to assess and improve quality, safety and patient experience... 27 7.1.2 Complaints and patient feedback... 27 7.2 Quality Monitoring for New Projects and Services... 27 7.2.1 QIA Tool and Process... 28 7.3 Other Quality, Safety and Patient Experience Mechanisms... 30 7.3.1 Safeguarding adults and children... 30 7.3.2 Information Governance and Caldicott... 31 7.3.3 Clinical Audit... 31 7.3.4 Medicines Management... 31 7.3.5 Domestic Abuse... 32 8. Next Steps and Developments... 33 4
1. Foreword Continuously improving patient safety should be at the top of the health care agenda for the 21st century. The injunction to do no harm is the defining principle of the clinical professions (Lord Darzi; High Quality Health Care for all 2008). This Quality Strategy is to underpin the commissioning of the highest quality care services for the people of Castle Point and Rochford. The CCG wants the implementation of this Strategy to provide local pride in the NHS and wants the people of Castle Point and Rochford to be confident that their healthcare services are amongst the very best. The CCG will strive to ensure that the high quality health care it commissions is provided on the basis of its on-going commitment to equality of experience and outcomes, to everyone in Castle Point and Rochford, no matter who they are or where they live. The CCG vision Quality Care First Time, Equitably Delivered in Response to Patients Needs by Responsive Local Clinicians puts quality at the centre of all that we do as an organisation and as a result integrates the organisational functions of clinical, corporate and financial governance. By the integration of these functions the CCG will be able to recognise the early indications of a failing service and give the appropriate support and take the necessary measures to protect patients. The purpose of the strategy is to ensure that patients and their assessed needs are at the centre of commissioning decisions to ensure commissioned services are safe, clinically effective and provide a positive experience for patients to assure the robustness of systems and processes in place to deliver safe services and positive experiences to ensure that measures of quality are focused on structures, processes and most importantly outcomes to confirm the collaborative arrangements that will be in place with other health commissioners and wider stakeholders to demonstrate that the CCG has the leadership and governance arrangements in place to meet its statutory requirements and responsibilities. This purpose will be upheld in the CCG s consideration of all commissioning decisions related to all health service provision for all client groups, children, adults, older people, people requiring mental health services and people with learning disabilities whether receiving care in acute, community or primary care settings. 5
2. Introduction 2.1 Background and Context Over the last 10 years healthcare quality, safety and patient experience have featured in a number of high profile national inquiries and reports and these have received significant media attention. Unfortunately many reviews have been prompted through failings in care; however, each report provides opportunities for learning to ensure that all NHS organisations can make improvements to quality of care and to reduce patient safety risks. In 2013, the Prime Minister invited Professor Donald Berwick, internationally known for his work on patient safety, to lead a review to make zero harm a reality in our NHS. The review considered the breakdown of care at the Mid-Staffordshire NHS Foundation Trust and the wider NHS quality and safety culture and landscape. In his report Professor Berwick calls on all leaders to prioritise quality and safety in all areas of their work: All leaders concerned with NHS healthcare political, regulatory, governance, executive, clinical and advocacy should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support (Professor Donald Berwick, published in August 2013) Castle Point and Rochford Clinical Commissioning Group is a group of local GPs and clinicians who commission (buy) services for our community which is around 182,000 people. This gives us both the opportunity and responsibility to ensure that quality, safety and patient experience is prioritised and protected as services are provided and developed within our health and care community. 2.2 Defining Quality, Safety and Patient Experience The Care Quality Commission, the independent regulator of health and social care in England, assess services against five criteria which provide a helpful definition of quality, safety and patient experience: 1. Are they safe? 2. Are they effective? 3. Are they caring? 4. Are they responsive to people s needs? 5. Are they well-led? We believe this wide definition extends to all aspects of care, and includes: privacy, dignity, care and compassion, politeness, respect, safeguarding and protection of vulnerable people as well as effective clinical treatment. Sometimes we call these areas the basics or fundamentals in care provision, and we believe that every person deserves these whoever 6
they are and wherever they live. We are working with the providers of services to ensure this will be the case. 2.3 Purpose of this strategy The purpose of the strategy is: To ensure that patients and their assessed needs are at the centre of our commissioning decisions To ensure commissioned services are safe, clinically effective and provide a positive experience for patients To assure the robustness of systems and processes in place to deliver safe, effective services and positive experiences for patients To ensure that measures of quality are focused on structures, processes and most importantly outcomes To confirm the collaborative arrangements that will be in place with other health and care commissioners and wider stakeholders To demonstrate that we have the leadership and governance arrangements in place to meet our statutory requirements and responsibilities This strategy sets out our commitment, vision and aims to commission the highest quality care services for the people within Castle Point and Rochford so that people can be confident that their health and care services are amongst the very best. 7
Intermediate Care & Discharge Planning & Support Quality, Safety and Patient Experience Strategy Nov 2015 3. Our Commitment to Quality, Safety and Patient Experience 3.1 Our Values Our six values describe how we work. The diagram below shows how quality safety and patient experience are at the heart of each of our values. Our Values Value 1 Value 2 Value 3 Value 4 Value 5 Value 6 We listen to patients, members, staff and partners We are prepared to do things differently to improve care We are committed to working with our partners We are ambitious and innovative We are compassionate We are committed to making our plans happen Through listening to people who experience care we understand what matters to people and how we can improve quality, safety and patient experience We know that in order to make improvements to quality, safety and patient experience we need to do things differently If we work together with providers of care we can make a bigger difference for patients, carers and the public We want our health and care services to be among the best in the country We believe everyone deserves to be treated with kindness, care and compassion whoever they are and wherever they live We are determined to make sure our plans for improving health and care in Castle Point & Rochford will make a difference for real people in our community 3.2 Our Vision Our vision is to create a healthier and more sustainable future for people in Castle Point and Rochford. Our Vision Through commissioning the right care in the right place of a high quality we hope that over time we will see a shift from many people being acutely unwell and requiring complex care in hospital settings, to more people independently taking responsibility for their health and wellbeing, with more care being Specialist Planned and Unplanned Care Community Based Care Activity shift We know people want care closer home and we believe that our vision will improve patient experience as well as promote independence and reduce issues associated with hospital stays such as hospital acquired infections and institutionalisation. Home Not Hospital Care Closer to Home Primary Care Focus Self Care, Care & Independence Prevention & Health Promotion Activity shift 8
3.3 Vision for Quality, Safety and Patient Experience Our vision is that health and care services within Castle Point and Rochford will be: Effective: Meeting the needs of the person receiving care/treatment and supporting them at their time of need Safe: Without error, and in a way that protects people from harm, especially our most vulnerable people Compassionate: Offering a good experience for patients and treating them with dignity, respect and kindness We know nobody enjoys being unwell or injured, but we believe it is our responsibility to commission care that gives the best possible experience for people at their time of need. We are committed to ensuring that the services we commission fulfil our person centred quality statements that ensure patients and carers are at the forefront of our vision. Quality Statements People will have timely and easy access to responsive, integrated care and support People will be supported to manage their own health and wellbeing so that they are in control of what, how and where care and support is delivered People will receive care and support in the most appropriate environment that enables them to retain and regain their independence People will have a safe and positive experience of our services People will know what services are available to them and will be involved and engaged In all aspects of their care 9
We aim to continuously improve care for people within Castle Point and Rochford. There are five strategic themes we focus on, both internally and also through our relationships with patients and the public, providers of care, regulators and with partner commissioners. Strategic Themes for Improving Quality of Care, Patient Safety and Patient Experience 10
4. Quality, Safety and Patient Experience through Commissioning The diagram below shows the high level tasks involved in commissioning (buying) care, and how we make sure that quality, safety and patient experience is protected and prioritised at each stage. Quality, Safety and Patient Experience at each stage of the Commissioning Cycle We maintain strong relationships with our provider organisations and work with them to establish regular monitoring processes to ensure that patients continue to receive safe, effective care and good experiences. This includes direct patient feedback and monitoring of outcomes. Monitoring & Evaluation Setting Strategy Our organisational strategy is focussed on improving health & wellbeing, preventing illness, and maintaining independence where possible. We aim to offer care closer to home, and make sure hospital care is reserved only for those who need specialist input. We believe this will offer the best care and experiences for our community. For some ideas we pilot (test) the service to make sure it works in the way we planned. This means we can measure the quality safety and patient experience benefits before we commit to a long contract. Mobilisation Designing Services We are working with our providers to design services that are safe, effective and will meet the needs of our population. Quality and safety and patient experience are the main focus as we discuss new services or whether changes are needed. Sourcing Providers Review & Approval When we set up new health and care services we need to go through legal processes to select providers. Our selection process considers the quality and safety culture of the organisations we commission to ensure that our patients will receive safe, effective care and good experiences. All new ideas and service changes undertake a Quality Impact Assessment process that benefits and risks to quality, safety and patient experience. Clinical teams are responsible for reviewing these risks and ensuring that quality, safety and patient experience will not be compromised. 4.1 Procurement We follow NHS Procurement Policy when we buy services and ensure that quality, safety and patient experience requirements are built into contracts to enable future robust quality monitoring. Our on-going monitoring of quality, safety and patient experiences of commissioned services enables us to hold providers to account for performance against those elements of the contract. 4.2 Incentivising and Monitoring Quality with our Providers We also utilise the national Commissioning for Quality and Innovation (CQUIN) framework to provide financial rewards (or penalties) for the achievement (or failure to achieve) quality goals to ensure that providers of care focus their efforts on delivering high quality and safe services that offer a positive patient experience. 11
4.3 Partnership Working We are working closely with all Clinical Commissioning Groups in Greater Essex, our Local Authorities and especially with those commissioning services for the South Essex population. We give and receive assurances to and from each other that there are robust systems and processes in place for managing and monitoring the quality, safety and patient experience of services within our contracts. Our commitment to improving quality, safety and patient experience is upheld in decision making for health and care service provision for all client groups, children, adults, older people, people requiring mental health services and people with learning disabilities whether receiving care in acute, community or primary care settings. We strive to ensure that the high quality health care we commission is provided on the basis of our on-going commitment to equality of experience and outcomes, to everyone in Castle Point and Rochford, no matter who they are or where they live. 4.4 Patient and Public Involvement Our aim is that patients, carers, community representatives, community groups and the wider public are involved in commissioning decisions at every level. We are in the process of building a database of people living in Castle Point and Rochford who would like to be involved or simply kept informed of any local decisions that could result in a change to the way local health services are provided. 4.4.1 Commissioning Reference Group Our Commissioning Reference Group is a formal advisory body. Its purpose is to support us in ensuring that the voice of our patients, (and their carers), and public, including seldomheard groups, is embedded in our business, embracing the no decision about me without me promise, and actively promoting the principles and values of the NHS Constitution. Members of the CRG group include patient representatives from GP practices, representatives from our local voluntary sector organisations, GPs, representatives from both the younger and older generations of Castle Point & Rochford, CCG staff and Health Watch Essex. The group is chaired by a lay representative. 4.4.2 Patient Participation Groups (PPG) We have been actively encouraging Patient Participation Groups (PPG) have developed in recent years in GP practices. These groups are an effective way for patients and GP surgeries to work together to improve services and to promote health and improved quality of care. Within the Castle Point and Rochford area there are a number of member practices 12
that have Patient Participation Groups. Information from our Commissioning Reference Group is fed back to our GP practices to help inform patients of our plans on a wider level. 4.4.3 Governing Body We also have lay representatives on the Governing Body so they are part of the key decision making processes for commissioning health and care services for our population. One lay member is the Chair of the Quality and Governance Committee. 13
5 National drivers for quality, safety and patient experience There are a range of national policy drivers that influence the quality, safety and patient experience agenda across the NHS and support us in our ambition to offer the best possible care. 5.1 NHS Five Year Forward View The Five Year Forward View, published in October 2014, by NHS England, sets out a positive vision for the future based around new models of care. The definition of quality in health care, enshrined in law, includes three key aspects: patient safety, clinical effectiveness and patient experience. A high quality health service exhibits all three. However, achieving all three ultimately happens when a caring culture, professional commitment and strong leadership are combined to serve patients, which is why the Care Quality Commission is inspecting against these elements of quality too. We do not always achieve these standards. For example, there is variation depending on when patients are treated: mortality rates are 11% higher for patients admitted on Saturdays and 16% higher on Sundays compared to a Wednesday. And there is variation in outcomes; for instance, up to 30% variation between CCGs in the health related quality of life for people with more than one long term condition. We have a double opportunity: to narrow the gap between the best and the worst, whilst raising the bar higher for everyone. To reduce variations in where patients receive care, we will measure and publish meaningful and comparable measurements for all major pathways of care for every provider including community, mental and primary care by the end of the next Parliament. We will continue to redesign the payment system so that there are rewards for improvements in quality. We will invest in leadership by reviewing and refocusing the work of the NHS Leadership Academy and NHS Improving Quality. To reduce variations in when patients receive care, we will develop a framework for how seven day services can be implemented affordably and sustainably, recognising that different solutions will be needed in different localities. As national bodies we can do more by measuring what matters, requiring comprehensive transparency of performance data and ensuring this data increasingly informs payment mechanisms and commissioning decisions. (Five Year Forward View, NHS England, published in October 2014) Quality, safety and patient experience are highlighted as integral to a high quality health care system and we are working on a range of initiatives and models of care in line with this plan, to reduce variation in care provision, improve service provision, and to consider how to incentivise and reward improvements to quality, safety and patient experience. 5.2 The NHS Outcomes Framework The NHS Outcomes Framework provides a national overview of how well the NHS is performing and is the primary accountability mechanism for improving quality throughout the 14
NHS. The framework was initially developed in 2010, but is updated every year. Some indicators are shared with the Adult Social Care Outcomes Framework and/or the Public Health Outcomes Framework. The 2015/16 framework outlines 5 domains that form key drivers for our local priorities for commissioning and quality. These domains directly link to quality, safety and patient experience as shown below. NHS Outcomes Framework 2015/16 Domain Overarching indicators Improvement Areas 1. Preventing people from dying prematurely Potential years of life lost from causes considered amenable to healthcare Life expectancy at 75 Neonatal mortality and stillbirths Reducing premature mortality from major causes of death Reducing premature mortality in people with mental illness Reducing mortality in children Reducing premature death in people with a learning disability 2. Enhancing quality of life for people with long term conditions Health related quality of life for people with long term conditions Ensuring people feel supported to manage their condition Improving functional ability for people with long term conditions Reducing time spent in hospital for people with long term conditions Enhancing quality of life for carers Enhancing quality of life for people with mental illness Enhancing quality of life for people with dementia Improving quality of life for people with multiple long term conditions 3. Helping people to recover from episodes of ill health or following injury Emergency admissions for acute conditions that should not normally require hospital admission Emergency readmissions within 30 days of discharge from hospital Improving outcomes from planned treatments Preventing lower respiratory tract infections in children from becoming serious Improving recovery from injuries and trauma Improving recovery from stroke Improving recovery from fragility fractures Helping older people to recover their independence after illness or injury Improving dental health 4. Ensuring that people have a positive experience of care Patient experience of primary care (including GP services, GP out of hours services and NHS dental services) Patient experience of hospital care Friends and family test Patient experience categorised as poor or worse for primary care and/or hospital care Improving people s experience of outpatient care Improving hospitals responsiveness to personal needs Improving people s experience of accident and emergency services Improving access to primary care services Improving women and their families experience of maternity services Improving experience of care for people at the end of their lives Improving experience of healthcare for people with mental illness Improving children and young people s experience of healthcare Improving people s experience of integrated care 15
Domain Overarching indicators Improvement Areas 5. Treating and caring for people in a safe environmen t and protecting them from avoidable harm Deaths attributable to problems in healthcare Severe harm attributable to problems in healthcare Reducing the incidence of avoidable harm, (e.g. VTE related events, incidence of healthcare associated infection, falls and pressure ulcers) Improving safety of maternity services Improving the culture of safety reporting 5.3 Harm Free Care & the NHS Safety Thermometer The NHS Outcomes Framework and policy direction requires a national focus on a small number of key outcomes that the NHS is measuring together. The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and harm free care. The tool measures four high-volume patient safety issues which are also highlighted in domain 5 of the outcomes framework: Elimination of grade 3 and 4 pressure ulcers Falls in care Urinary infection (in patients with a catheter), and Treatment for venous thromboembolism Harm free care was incentivised as a national CQUIN in 2013/14 and 2014/15 and we continue to monitor these indicators as part of our performance monitoring with providers. 5.4 Summary Hospital-Level Mortality Indicators (SHMI) Summary Hospital-Level Mortality Indicators report on mortality at a trust level across the NHS in England using a standard and transparent methodology. SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust, and the number that would be expected to die, on the basis of the national average figures, given the characteristics of the patients treated there. (Hospital and Social Care Information Centre) SHMI covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die in hospital or within 30 days of being discharged from hospital. SHMI replaces the Hospitalised Standardised Mortality Ratio (HSMR) which covered deaths that occur in a hospital setting. A high SHMI will raise questions about whether there are underlying problems in the quality of care that a hospital is delivering to its patients and the 16
care they are receiving after they are discharged. This is a standing item on our Clinical Quality Review Group with providers and any variance is closely monitored. 5.5 Care Quality Commission (CQC) Essential Standards The Care Quality Commission is the independent regulator of health and adult social care in England. The CQC ensure health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve. The CQC does this by inspecting services and publishing the results on its website to help patients and the public make better decision about the care they receive. Registration with the CQC is a statutory requirement of all NHS providers, Independent Healthcare providers, Dentists and General Practitioners. The CQC Essential Standards require providers to declare compliance against those standards and the CQC undertakes planned and responsive inspections to monitor compliance. CQC compliance is an agenda item at our Clinical Quality Reference Group to ensure that non-compliance is supported by a monitored action plan. 5.6 National Institute for Health and Care Excellence (NICE) The National Institute for Health and Care Excellence is a Non Departmental Public Body which develops national guidance, advice and quality standards for health and social care. NICE s role is to improve outcomes for people using the NHS and other public health and care services and this work takes three forms: I. Producing evidence based guidance and advice for health, public health, and social care practitioners. This includes: o NICE guidelines: Preventing and managing specific conditions, improving health and managing medicines in different settings, interventions to improve health in communities, provision of social care to adults and children o Technology appraisal Guidelines (TAGs): To assess the clinical and cost effectiveness of health technologies such as new pharmaceutical and biopharmaceutical products, but also procedures, devices and diagnostic agents o Medical technologies and diagnostics guidance: To ensure that the NHS is able to adopt clinically and cost effective technologies rapidly and consistently o Interventional procedures guidance: Recommending whether interventional procedures are effective and safe enough for use within the NHS II. Developing quality standards and performance metrics for those providing and commissioning health, public health and social care services, including: 17
III. o Quality standards: A precise set of statements with accompanying metrics, designed to drive and measure quality improvements within a particular area of care o Quality Outcomes Framework (QOF): An annual menu of potential indicators for inclusion in the quality element of our contract with General Practitioners o Clinical Commissioning Group Outcomes Indicator Set (CCGOIS): A framework for measuring health outcomes and the quality of care (included patient reported outcomes and patient experience) achieved by CCGs. Providing a range of informational services for commissioners, practitioners and managers across the spectrum of health and social care. This includes: o NICE evidence: An online search facility that identifies relevant clinical, public health and social care guidance, including access to a range of bibliographic databases and professional journals o Access to the British National Formulary (BNF) and British National Formulary for Children (BNFC), including smart phone access o Medicines and prescribing support: Advice and information on pharmaceutical products, their scope, licensing and practical advice on developing and maintaining local medicines formularies Healthcare professionals are expected to take NICE guidance fully into account when exercising their clinical judgment. The only guidelines which are mandatory are the Technology Appraisal Guidelines (TAGs), however we ensure that NICE guidance is considered in our commissioning decisions and implementation is monitored in commissioned services. 5.7 Quality, Innovation, Productivity & Prevention (QIPP) QIPP is a large transformational programme to support clinical teams and organisations to improve the quality of caring, through productivity, prevention and innovation, to improve the quality of care whilst delivering efficiency savings that can be reinvested into the NHS. QIPP represents a broad, policy agenda rather than a single, definable policy, however there are a number of national work streams within QIPP designed to support the NHS to improve care and lower costs. These range from improving commissioning, (or purchasing), of care for patients with long-term conditions, to improving how organisations are run, staffed and supplied. The specific changes required to meet the agenda have been left to local providers and commissioners to identify and implement. We are working with our local health partners to develop integrated QIPP plans that address our local quality challenges and make efficiency improvements. It is essential that the impact of productivity savings on the quality of care delivered is monitored closely and the CCG has developed a Quality 18
Impact Assessment tool and process to review all QIPP plans and identify quality impacts whether they are positive or negative and ensure risks are understood and mitigated appropriately. 5.8 National Reporting and Learning System (NRLS) Patient safety incident reporting is a vital mechanism for identifying downward trends in the quality of care, identifying failure and facilitating learning. The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports. Since April 2010, it has been mandatory for NHS trusts in England to report all serious patient safety incidents and the NRLS has now moved under the National Commissioning Board. Six monthly reports are then produced that benchmark providers in terms of types of incident and levels of harm. Since the NRLS was set up in 2003, over four million incident reports have been submitted and information is analysed to identify hazards, risks and opportunities to continuously improve the safety of patient care. 5.9 National Reports and Investigations The Department of Health and health related organisations publish reports following enquiries, inquiries, reviews and evaluations of health care provision. We review the recommendations from these reports and assess the implications to the CCG and its commissioned services and ensure that any recommendations and lessons learnt implemented and embedded into local processes. Two key reports that we are monitoring progress against are: Transforming Care: A national response to Winterbourne View Hospital, published in December 2012. Although two years have passed since the report was published, the recommendations included in the report contain long term commitments to strengthening accountability and corporate responsibility for the quality of care and improving quality and safety, so we continue to monitor the work streams that were established in response to this report. The Francis Report: Outlining the Public Inquiry into the failure in NHS care at Mid Staffordshire hospital, chaired by Sir Robert Francis QC, which was published in 2013. This report identifies warning signs that were evident at Mid Staffs hospital, and should have alerted the wider system to the problems that led to such a catastrophic failure in care. The key recommendations that are relevant directly to commissioners fall into 5 themes: 1. Setting and monitoring standards 2. Learning and improvement 3. Data quality and information 19
4. Organisational culture 5. Patient experience Patients First and Foremost: An initial overarching response on behalf of the health and care system as a whole to the Mid Staffordshire NHS Public Enquiry and the Francis Report. It details key actions to ensure that patients are the first and foremost consideration of the system, and everyone who works in it. It calls for the NHS to return to its core humanitarian values, setting out a commitment and a plan to eradicate harm and promote excellence. The Berwick Report: Released in August 2013, the Berwick report was a review commissioned by the Prime Minister and carried out by Professor Don Berwick and international expert in patient safety. The review contains ten recommendations with the aim of making the NHS a system devoted to continual learning and improvements in patient care, top to bottom, beginning to end. Among the recommendations were adopting a culture of learning, ensuring adequate staffing levels and creating a new criminal offence for recklessness. We will continue to monitor any other high profile cases which provide on-going reminders of the role in safeguarding the care of vulnerable people, both for adults and children. 5.10 No Harms Event Across South East Essex a quarterly meeting takes place where all providers can meet to discuss events where things have gone wrong or very right to ensure that the system can learn and develop as a result. NHS England as well as all CCG s are in attendance. 5.11 Co-Commissioning We are the only CCG in Essex to have been granted fully delegated co-commissioning responsibility for primary care. Co-commissioning offers an opportunity to raise standards of quality within general practice services including: Clinical effectiveness Patient experience Patient safety This includes work on reducing unwarranted variation in quality and enhancing patient and public involvement in developing services. We aim to support our member practices. 5.12 Safeguarding adults and children Safeguarding means protecting people's health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect. It's fundamental to high-quality health and social care. 20
Safeguarding children and promoting their welfare includes: Protecting them from maltreatment or things that are bad for their health or development Making sure they grow up in circumstances that allow safe and effective care. Safeguarding adults includes: Protecting their rights to live in safety, free from abuse and neglect. People and organisations working together to prevent the risk of abuse or neglect, and to stop them from happening. Making sure people's wellbeing is promoted, taking their views, wishes, feelings and beliefs into account. 5.13 Parity of Esteem NHS England has established a Parity of Esteem programme as part of a call to action in order to focus effort and resources on improving clinical services and health outcomes for mental health. The emphasis is on ensuring that mental health is valued equally with physical health. The commissioning cycle offers the ideal framework to achieve this. 21
6 Roles and Responsibilities for Quality Assurance We have in place a range of groups, teams and individuals with responsibility for assuring and providing information on quality, safety and patient experience to ensure that interventions pursued are clearly and appropriately integrated, aligned and managed. 6.1 The Role of the Clinical Commissioning Group The Health and social Care Act 2012 sets out the role of CCGs in regard to securing continuous improvement in quality, safety, effectiveness and patient experience: Each clinical commissioning group must exercise its functions with a view to securing continuous improvement in the quality of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness. In discharging its duty a clinical commissioning group must, in particular, act with a view to securing continuous improvement in the outcomes that are achieved from the provision of the services. The outcomes include, in particular, outcomes which show (a) (b) (c) The effectiveness of the services, The safety of the services, and The quality of the experience undergone by patients (Health & Social Care Act 2012 c7 Part 1, Section 26, 14R) Our role in commissioning includes holding providers to account for delivery of their contractual obligations and quality standards. We must build the right quality standards into the contracts we place with providers, to ensure service delivery improves and that the providers we partner with have in place systems and processes to drive continual improvement. 6.1.1 Our Role as Co-Commissioners The NHS Five Year Forward View set out provision for CCGs to assume greater power and influence over the commissioning of primary care medical care. Castle Point and Rochford CCG is one of a small number of CCGs in the country to be delegated full responsibility for commissioning general practice services. Delegated commissioning responsibilities exclude individual GP performance management, which NHS England retains, however the design of GP contracts, enhanced services, local incentive schemes and decisions on discretionary payments does now reside with the CCG. This gives opportunities to fully embed quality, safety and patient experience into primary care specifications as well as with our community, mental health and acute providers. 22
6.2 Group and Team Responsibilities for Quality, Safety & Patient Experience 6.2.1 The Governing Body The CCG Governing Body is chaired by a practicing GP, and is made up of our Accountable Officer, the Chief Nurse, Executive Directors of the CCG, GP representatives and lay members. The function of the Governing Body is to ensure strong and effective leadership, management and accountability. Members of the Governing body must be assured that the systems and processes are in place to monitor quality in commissioned services. 6.2.2 The Quality and Governance Committee An integral component of our infrastructure for quality is the Quality and Governance Committee, a formal sub-committee of our Governing Body. This Committee has the role of assuring the Governing Body of the quality and safety of all health interventions that we commission. The Committee is the formal mechanism by which the CCG discharges its responsibilities for clinical quality and sets the strategic direction for clinical governance. The remit of the committee is to; Provide oversight and give assurance to the Governing Body that the patient and patient feedback is kept at the centre of all decision making Assure the quality and safety of the services commissioned To promote continuous improvement, learning and innovation with respect to, clinical effectiveness, safety of services and patient experience 6.2.3 The Clinical Quality Review Group (CQRG) We commission major provider contracts collaboratively with three other CCGs. Each major provider contract for which we lead is reviewed on a monthly basis through a Clinical Quality Review Group (CQRG) which is chaired by the CCG Chief Nurse and attended by members of the commissioning team, contracts team and representation for the quality and safety agenda for the organisation. The CQRG is part of the formal contract management process and the group has a set agenda built on the requirements for quality, safety and patient experience in the contract and any new national drivers and the minutes of the Group go the CCG Quality Committee. 6.2.4 The Quality Support Team We have invested in a Quality Support Team to build the necessary capacity and capability in monitoring quality, implementing and monitoring improvement projects, and supporting our 23
staff to ensure that quality, safety and patient experience are prioritised in our commissioning and day to day business. The Quality Support Team provides support, analysis of data and information to the CCG Chief Nurse on all aspects of patient safety and quality, including infection control, CQUIN, serious incidents and never events and safeguarding. The Quality Support Team review Quality Impact Assessments for new projects to provide challenge and feedback on mitigating actions being proposed. 6.2.5 The Role of Member Practices We are a membership organisation, which means clinical leaders, elected to our Governing Body by member practices agree the basic rules that make up our constitution. Member practices are expected to become fully engaged in our work around quality improvement, and each practice is responsible for the development of its own quality improvement plan within the context of the primary care. We support member practices and wider primary care to quality assure current standards, however each practice is remains accountable for the quality of services within their own organisation. Member practices receive monthly reports benchmarking their performance on key quality, performance and financial measures, and practices are expected to take action to demonstrate continuous improvement. We routinely survey and monitor patient experiences of using member practices. Practice patient participation groups are essential in capturing patient experiences to feed into the early warning processes and quality review meetings with providers. 6.2.6 Quality Surveillance Groups (QSGs) QSGs bring together commissioners, regulators and other parts of the system to share information and intelligence on quality in order to spot the early signs of problems and to take corrective and supportive action to prevent early problems becoming more serious quality failures. They are supported and facilitated by the NHS England are operational in each local area and region. The meeting is attended by the Chief Nurse and Accountable Officer and representatives from a range of organisations including the Care Quality Commission, Monitor, Local Authority, HealthWatch and the East of England Deanery. 6.2.7 The Commissioning Support Unit (CSU) The North East London Commissioning Support Unit provides expert support and advice to help clinical commissioners to deliver improved health services to local populations. The CSU role in promoting quality assurance and improvement for us is to: 24
Ensure that there is a clear information on provider performance that all parties understand Provide support and advice on service redesign and QIPP initiatives Support the annual and on-going contract negotiations Coordinate contract monitoring and support the challenge on over performance, targets, CQUINS, quality standards, QIPP, KPIs and demand management Implementation of Super CQUIN 6.3 Individual Roles and Responsibilities In addition to the above groups there are some individual roles within the CCG that have responsibility for quality, safety and patient experience assurance and monitoring. 6.3.1 The Accountable Officer The Accountable Officer (AO) holds ultimate responsibility for ensuring that the CCG is meeting its statutory requirements for quality and safety and that there are mechanisms in place for the CCG to recognise where there are concerns or failures in commissioned services or in the CCGs ability to monitor the quality and safety of services. The AO reports directly to the Governing Body. 6.3.2 The Chief Nurse The Chief Nurse has responsibility for giving assurance to the CCG in relation to the quality and safety of services being delivered to the local population. The Chief Nurse oversees the processes and systems to ensure all national and local requirements to maintain and improve quality, safety and patient experience and will be expected to report to the Governing Body any concerns. The Chief Nurse has responsibility for signing off all Quality Impact Assessments for new projects, and is the Caldicott Guardian for the CCG. 6.3.3 All CCG Staff All staff in the CCG regardless of their function will have a role to play in supporting us to commission high quality services. This includes ensuring that their safeguarding, equality and diversity and information governance training is up to date so they are in a position to recognise any concerns or early warnings that they may come across as part of their day to day business. 25
7. Quality, Safety and Patient Experience Assurance Processes We have internal quality assurance and early warning systems in place which provide information about risks to quality, safety and patient experience of the services we commission. A formal Quality Impact Assessment process is used to identify quality, safety and patient experience impacts and risks associated with any new services that are considered and/or established. This allows us to be proactive in identifying concerns early, and take action where standards fall short, and to ensure that new projects prioritise and protect quality, safety and patient experience. Quality Reporting is a regular agenda item for our Governing Body, and a formal written quality report is presented by the Chief Nurse. The Quality report provides an overview to the Governing Body of the continued focus that we place on quality and safety of services for our population. The Quality Report includes dashboards with month by month snapshots of the performance monitoring for providers, information on any serious incidents that have taken place, safeguarding issues, complaints summaries, patient experience data, National Reporting and Learning System (NRLS) incidents and any CQC reviews/inspection updates and key findings that have been received. We ensure that risks are managed in line with the aims, objectives and governance arrangements outlined in this Quality Strategy and through: Systematic programme of implementation of our Corporate Risk Management Strategy Reporting, investigation, management and learning from incidents Risk management Identification, reporting and management of risks Development of risk registers and monitoring of action plans to mitigate risks Quality and Safety risks are grouped on the risk register to make more explicit to the Governing Body the nature and scale of risks that exist in direct relation to the quality of care we commission. The CCG will therefore clearly see any quality risks that threaten our ability to achieve its objectives.7 7.1 Monitoring and Assurance for Commissioned Services We monitor each major provider contract monthly at the Clinical Quality Review Group (CQRG) described above. Commissioners also work with commissioned services to deliver 26
their annual Quality Accounts to give assurance to the public and provide commentary on the organisations commitment to governance, quality, safety and positive patient experience. As part of contract monitoring, we also undertake a series of announced and unannounced visits and the CCG Executive Nurses have developed a visit template to ensure consistency of monitoring. The outcomes of these visits are discussed at the CQRGs and are reported to the Quality and Governance committee. 7.1.1 Using data to assess and improve quality, safety and patient experience We require performance data from all the providers we commission, and monitor this for trends, themes and compliance with national requirements including: Acute hospitals Care homes Community providers Mental health providers Independent hospitals NHS 111 service Ambulance services Domiciliary care agencies Support and assisted living services We also use soft intelligence, regular and unannounced site visits and face to face dialogue with our providers to triangulate information to inform Key Lines of Enquiry (KLOE) for discussion at our formal meetings as part of our contract management. Any emerging or immediate areas of concern are escalated immediately. 7.1.2 Complaints and patient feedback We actively encourage feedback, and respect the views of patients using our commissioned services. We are keen to learn from patient experiences, good or bad and to put in place steps to ensure continuous improvements. The hospital providers have in place Patient Advice Liaison teams (PALS) who are available to all the community to advise and support patients, carers and families by providing information, and who capture learning and ideas. 7.2 Quality Monitoring for New Projects and Services We are an innovative and ambitious CCG, with plans to develop new services and make improvements. With all new ideas we expect that quality, safety and patient experience will be prioritised and protected to ensure that standards remain high and risks are understood, mitigated and managed. 27
We have established a robust Quality Impact Assessment process and associated tool to assess whether quality, safety or patient experience will be impacted on by any organisational change project. Our project management approach is shown below, QIAs are initiated in gateway 2 and reviewed at gateways 3 and 4. Castle Point & Rochford Project Management Approach 7.2.1 QIA Tool and Process The QIA tool incorporates a checklist to determine what level of impact may be expected against 47 indicators either positive, no impact or negative impact. A full risk assessment is undertaken against any criteria that have potential to impact negatively on quality, safety and patient experience. The indicators are shown below: QIA Checklist Indicators Category Quality Indicators Patient safety Patient safety adverse events including avoidable harm and Patient Safety Alert Services Medicines management and safe administration of medicines Mortality, HSMR / SHMI Ay infection control issues including MRSA / Cdiff CQC visits and registration NHSLA / CNST Essential training 28
Workforce, vacancies, turnover, absence, revalidation Safe, clean, comfortable and well maintained environment/equipment Clinical effectiveness Patient experience Inequalities of care NICE guidance and Quality Standards e.g. VTE, Stroke, Dementia Helping people recover from ill health, injury and preventing people from dying prematurely Other outcome guidance e.g. PROMS Other external accreditation e.g. RCN National clinical audit / research and development Clinical outcomes Breastfeeding rates Emergency bed days Length of stay Emergency readmissions (30 day) Minor injuries standards Day case rates Patient feedback (e.g. FFT, NHS Choices, comments, compliments, concerns, complaints, national and local surveys) Patients, carers and public engagement Waits for admission / treatment Mixed sex breaches Delayed discharge End of life pathway Cancelled day case operations Waiting times for therapy services Making every contact count Access to services equality impact Variation in care provision Staff experience Workforce capability care and skills Working practice Staff satisfaction (e.g. FFT, annual staff survey / local surveys) Mandatory training compliance Targets & performance Promoting wellbeing (in the provision of care and support) Performance Achievement of local, regional and national targets Person s sense of personal dignity (including treatment of the individual with respect) Person s physical and mental health and wellbeing Abuse and neglect (safeguarding) Personal control over day to day life (including over care and support and the way it is provided) Opportunities for participation in work, education, training or recreation Social and economic wellbeing Domestic, family and personal relationships Suitability of living accommodation Personal contribution to society including sustainability Risk assessment is undertaken to outline: Description of the risk or negative impact Risk rating including likelihood and impact according to the corporate risk register rating 29
Mitigating actions and controls Residual risk rating Escalation and risk tracking Metrics used to track and monitor the risk Monitoring forum and risk owner Risks associated with QIAs are captured in project risk logs and departmental risk logs and are therefore subject to the corporate risk management processes. However risks identified through the QIA process are also managed and report by the Programme Management Office (PMO) to ensure they are tracked appropriately as projects progress through the gateway process. 7.3 Other Quality, Safety and Patient Experience Mechanisms 7.3.1 Safeguarding adults and children We have a clear governance process in place for safeguarding children and vulnerable adults. The CCG works in partnership with the local Authority and the Chief Nurse is a member of the Children and Adult Safeguarding Boards. The designate professionals for safeguarding children and adults are within the hosted arrangements for the South Essex CCGs and the Quality Support Team work closely with the safeguarding teams in the Local Authority. The structure below shows the inter-dependencies across health and social care for the management of safeguarding children and vulnerable adults. Our Chief Nurse is a member of the Children and Adults Safeguarding Board. 30
Safeguarding Structure within South Essex 7.3.2 Information Governance and Caldicott We ensure robust Information Governance arrangements through the implementation of the requirements of the Department of Health s Information Governance toolkit. The CCG Senior Information Risk Owner (SIRO) is the Chief Finance Officer and the Caldicott Guardian is the Chief Nurse. Information Governance support is through the Essex team hosted by Basildon and Brentwood CCG.. 7.3.3 Clinical Audit Audit is an essential tool for early recognition of failing systems and processes before it results in an incident that may cause harm. We monitor the robustness of clinical audit in commissioned services and are actively involved in auditing patient notes through information sharing agreements. 7.3.4 Medicines Management The Prescribing and Medicines Management Team provides expert knowledge to help make the best decisions around buying and prescribing high quality, cost-effective and safe drugs and medicines. The service also ensures that the appropriate and necessary governance around medicines use, are in place and that all legal obligations are met. This key service helps CCGs to improve safety and quality of care around prescribing and administration of medicines, and to manage the NHS drugs bill. 31
7.3.5 Domestic Abuse We are hosting an Essex-wide programme team focussed on improving outcomes for victims of domestic abuse and their children, reducing severe harm, and supporting victims to feel safer in their own homes. In addition a range of initiatives are being established to work with perpetrators to improve access to support programmes. The programme is a joint initiative, working across a range of organisations, Essex-wide; including Essex Police, Essex County Council, Local Housing Authorities, registered housing providers and the NHS and is expected to reduce police call outs, health costs associated with the physical and mental effects on victims and alternative accommodation costs for victims and perpetrators in addition to the quality and safety benefits. 32
8. Next Steps and Developments To achieve our quality ambitions we will require complete ownership within the organisation of quality improvement on behalf of our patients. Every member of staff needs to understand what needs to change, why it needs to change and how to make change happen. Quality is everyone s business and this strategy outlines the part to play of all. This process will be informed by all aspects of the commissioning cycle, relationships with our providers and our relationship with our local residents. Quality is everyone s business and everyone has a part to play. On-going evaluation of our performance year on year against our strategic quality objectives will be mandatory and will be led by the Quality and Governance Committee. The CCG will continue to review National and local standards to underpin the Quality agenda and this strategy will become the underpinning document to support the agenda. 33
NHS Castle Point and Rochford Clinical Commissioning Group 12 Castle Road Rayleigh Essex SS6 7QF Tel: 01268 464508 Email: cpr.ccg@nhs.net Twitter: @CPRCCG www.castlepointandrochfordccg.nhs.uk 34