Operational Framework for Quality within Lincolnshire East CCG

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CONTENTS

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1 Foreword 2 Introduction 3 Values of the CCG 4 The CCGs Values 5 Purpose of the Framework 6 Defining Quality 7 National Drivers for Improving Quality 8 NHS Outcomes Framework 8 Systematic Approach to Quality 9 Quality Governance Structure 10 Quality Assurance and Early Intervention 11 Use of Data 12 Reviewing the Quality of Service Provision 13 Commissioning for Quality (CQUINs) 14 Serious Incident Management 15 Quality Assurance Visits 16 Escalation Process 17Quality Surveillance Group 18 Patient and Public Involvement 19 Patient Experience 20 Continuous Listening Model 21 Listening Events 22 Safeguarding 23 Conclusion

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Appendices Appendix One National Policy Drivers Appendix Two Quality Governance Structures Appendix Three Key Performance Indicators

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1 Foreword I am delighted to present to you our revised quality operational framework for Lincolnshire East CCG. This framework has been written to provide a clear focus and ambition for Lincolnshire East CCG. It is intended that it will provide a compelling vision for quality, including the key drivers, the quality ambitions, and the infrastructure required to provide the necessary board level governance and assurance. The framework aims to achieve a shared understanding of quality and a commitment by the CCG to place quality at the heart of its business. It is anticipated that successful implementation of this framework will enable the CCG to ensure that the population of East Lincolnshire receives the best quality care. It will also enable the CCG to develop a credible reputation as a commissioner of quality health care

Brenda Owen Lay Member for Patient and Public Involvement Lincolnshire East CCG

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2 Introduction Lincolnshire East Clinical Commissioning Group (LECCG) is made up of 30 GP practices within three localities, Boston, East Lindsey and Skegness and Coast, covering an area of 1,060 square miles. It is our priority and mission to work together to provide and commission high quality health services to improve the health of the 241,246 people living in our area. We are passionate about the quality of care provided to our patients from the different providers of health and social care within Lincolnshire. It is essential therefore that we translate this passion into a strategy that clearly articulates the ambition of the CCG to achieve high quality care for all of our patients. 3 Mission of the CCG The mission of Lincolnshire East CCG is to ensure that the optimum health and wellbeing of the people that we serve, by commissioning high quality health services which support choice, promote healthy lifestyles and personal responsibility, reduce inequalities in opportunity, experience and health outcomes. Our values that lie at the heart of our work are:

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4 Values of the CCG

5 Purpose of the Framework This operational quality framework has been re written to provide a clearer focus and ambition for Lincolnshire East CCG. It is intended that this framework will provide a vision for quality, including the key drivers, the quality ambitions, and the infrastructure required to provide the necessary board level governance and assurance. The operational framework aims to achieve a shared understanding of quality and a commitment by the CCG to place quality at the heart of its business. It is anticipated that successful implementation of this framework will enable the CCG to ensure that the population of East Lincolnshire receives the best quality care. It will also enable the CCG to develop a credible reputation as a commissioner of quality health care. 6 Defining Quality The CCG’s duty to continuously improve the quality of care is enshrined in the Health and Social care Act 2012. The act identifies that Clinical Commissioning Groups must act with a view to securing continuous improvement in the quality or services provided to individuals. They must also act with a view to securing continuous improvement in the outcomes achieved in relation to: 

The effectiveness of treatment and care provided to patients, this is measured by both clinical outcomes and patient related outcomes

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The safety of treatment and care provided to patients

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The experience patients have of the treatment and care they receive

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7 National Drivers for Improving Quality The Health and Social Care Act (2012) places statutory duties on the Secretary of State, NHS England and Clinical Commissioning Groups to promote continuous improvements in the quality of health services. The three dimensions of quality are detailed below and all three must be present in order to provide a high quality service: 

Clinical Effectiveness – quality care is care which is delivered according to the best evidence as to what is clinically effective in improving an individual’s health outcomes;

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Safety – quality care is care which is delivered so as to avoid all avoidable harm and risks to the individual’s safety; and

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Patient Experience – quality care is care which looks to give the individual as positive an experience of receiving and recovering from the care as possible, including being treated according to what that individual wants or needs, and with compassion, dignity and respect.

The NHS Constitution establishes the principles and values of the NHS in England. It details rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieving. Patients have the right to expect NHS bodies to monitor, and make efforts to continuously improve the quality of healthcare they commission or provide. The NHS Outcomes Framework, alongside the Adult Social Care and Public Health outcomes frameworks, sits at the heart of the health and care system. It provides a national overview of how well the NHS is performing and is the primary accountability mechanism, in conjunction with the Mandate, between the Secretary of State for Health and NHS England. The framework drives up quality throughout the NHS by encouraging a change in culture and behaviour focused on health outcomes not process as depicted in Figure One below: Figure One

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NHS England planning guidance, Everyone Counts: Planning for Patients 2014/15 – 2018/19, sets out the ongoing commitment to the outcome based approach to commissioning healthcare levied in the Outcomes Framework and further reinforces quality as an essential characteristic of successful and sustainable health economies. It describes the vital aspects of quality services as patient safety, patient experience, compassion in practice, staff satisfaction, seven day services and safeguarding.

NHS Outcome Framework

Outcome Ambition

Quality Priorities

1: Securing additional years of life for the people of England with treatable  mental and physical health conditions 

2: Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions 3: Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital. 4: Increasing the proportion of older people living independently at home following discharge from hospital.

Improving access to cancer care and treatment Improving the management of Cardio Vascular Disease Improving the prevention and management of stroke Improving the percentage mental health patients on Care Programme Approach are followed up within 7 days of discharge from psychiatric in-patient care.

 Improved management of patients with diabetes  Improved identification and diagnosis for patients with dementia  Improving physical healthcare to reduce premature mortality in people with severe mental illness     

Improving Access to Psychological Therapies Increasing care and treatment delivered closer to home Every patient over 75 to have a named GP Improving the quality of discharge communication Supporting the development of Neighbourhood teams

5: Increasing the number of people  Implementation of Family & Friends Test (FFT) within having a positive experience of National timescales for all acute providers, including hospital care requirements regarding sample size  Encouraging implementation of FFT across all providers with adequate sample size. 6: Increasing the number of people  FFT scores to be in upper quartile, or realise significant with mental and physical health improvement year on year conditions having a positive  Implementation of Staff FFT in line with national requirements experience of care outside hospital,  Patient Reported Outcomes Measures to benchmark within in general practice and in the national expected range. community 7: Making significant progress  Mortality Rates to be within expected ranges towards eliminating avoidable deaths Provider to be within expected range or demonstrate in our hospitals caused by problems improvement against patient safety indicators of Staffing, in care Serious Incident reporting, Patient safety Alerts, VTE assessment, safety thermometer and Health Care Associated Infections as reported in NHS Choices  Improving provider compliance with Sepsis 6 bundle  Incentivising 7 day working across providers  Reducing medication errors

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Outcome Framework Domain Domain 1: Preventing people from dying prematurely

Domain 2: Enhancing quality of life for people with long-term conditions Domain 3: Helping people to recover from episodes of ill health or following injury

Domain 4: Ensuring that people have a positive experience of care

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

8 Systematic Approach to Quality In order for the CCG to deliver the vision of high quality services for our population we have adopted a systematic approach to the inclusion and embedding of quality at all stages of the Commissioning Cycle (Figure Two).

This will ensure that, as organisation, we are able to: 

Plan for high quality services

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Develop and commission high quality services

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Assure the services which are commissioned to deliver a quality service

The four CCGs in Lincolnshire have agreed to commission major service providers collaboratively and Lincolnshire East CCG maintains close links with fellow Lincolnshire CCGs to ensure a two way flow of intelligence and assurance is sustained with regard to all commissioned services.

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9 Quality Governance Structure The CCG Governing Body

The Governing Body has agreed a quality assurance framework for identifying, monitoring and challenging quality within commissioned services. The CCGs local framework for quality is informed by national policy and is set against three main drivers: 

Planning for high quality services

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Developing and commissioning high quality services

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Assuring the services that are commissioned deliver a quality service

The process of quality assurance of commissioned services has a number of interrelated component parts. The CCG has established a Quality and Patient Experience Committee which has a central role in the oversight and monitoring of this quality framework. The committee has a strong core membership from each of the CCG localities, as well as membership from the wider health and social care partners. This enables the committee to harness the expertise and knowledge of a wide range of individuals to enable it to discharge its responsibilities effectively. The committee is chaired by the lay member for patient and public involvement. The committee has established a work programme, which ensures the effective reporting of information to the committee. Regularly review and manage the CCGs risk register in relation to quality, including ownership and delivery of actions. 9|Page

A regular report is provided to the Governing Body on the programme of work undertaken by the Quality and Patient Experience Committee. In addition, a combined quality and performance report, which incorporates a quality dashboard, is provided to the Governing Body on a monthly basis. The quality governance structure is depicted in appendix two. 10 Quality Assurance and Early Intervention The CCG has established a system for quality monitoring and early warning processes which provides information about the safety, effectiveness and experience of commissioned services. This system enables the CCG to be proactive in identifying early signs of concern and take action where standards do not meet the expected level.

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11 Use of Data The CCG monitors provider quality information and data for trends and themes, and compliance with local requirements for all providers of NHS funded care, these include:       

Acute inpatient care Community and Mental health services Out of hours services Ambulance Services Patient Transport Services End of Life Care Care homes providing Continuing Health Care and Nursing Care

The CCG then undertakes detailed analysis, interpretation of both hard and soft intelligence to support continuous quality improvement with those services. This is then triangulated with regular announced and unannounced visits to providers to inform key lines of enquiry for follow up with providers at quality review meetings, and where necessary escalation of immediate or emergent risks or concerns. 12 Reviewing the Quality of Service Provision The CCG holds regular formal quality review meetings with health care providers. The purpose of these meetings is to undertake a systematic review of the service against a range of quality performance information, which focuses on the three key areas, patient safety, patient experience and the effectiveness of service provision. This enables the CCG to systematically measure performance improvement, and quality outcomes for patient. The outcomes of these meetings are then formally reviewed by the Quality and Patient Experience Committee, and the contract compliance meetings. 13 Commissioning for Quality (CQUINs) In order to deliver the vision of reduced inequalities and improved health by securing high quality services for the population of Lincolnshire East, the CCG has developed a systematic approach to the inclusion and embedding of quality at all stages of the commissioning cycle. A valuable tool for driving improvements in quality is through the use of CQUIN schemes with provider organisations, the scheme enables commissioners to reward excellence by linking a proportion of healthcare providers’ income to the achievement of local quality improvement goals. CQUIN schemes form part of the contract between the CCG and their providers of health care, and acts as a focus for driving improvements in patient safety, experience and outcomes. 14 Serious Incident Management Serious incidents are reported by provider organisations are systematically analysed for themes and trends to ensure that a robust investigation has been undertaken and appropriate lessons learned. A Root Cause Analysis (RCA) investigation is carried out and reported to the CCG, this is then scrutinised by the serious incident review group, prior to closing. The CCG has a zero tolerance policy towards never events, any that do occur within provider organisations are subjected to a greater level of scrutiny, including a never event risk summit. This risk summit focuses on the level of learning within the organisation, and review of systems and processes in the organisation.

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Provider organisations report incidents via the National Learning and Reporting System to enable wider learning and the embedding of learning with the organisation. These incidents are trended and themed by the Federated quality team provide regular patient safety reports to the CCG QPECs. The team will also analyse the reporting levels within provider organisation, which provides a proxy to the CCGs in relation to the reporting culture within those organisations. A key area of work for the CCGs has been on increasing reporting levels from provider organisations to ensure effective identification and management of incidents within those organisations. 15 Quality Assurance Visits An integral part of the CCGs approach to intelligence gathering regarding the quality and safety of services provided to its population, is the programme of provider Quality Assurance Visits. The Quality Assurance Visit full reports are taken through the Quality and Patient Experience Committee and summary reports provided to the Governing Body on a quarterly basis for review, and further challenge and scrutiny in relation to the quality and outcomes for patients in relation to commissioned services. . The CCG utilises the following framework for Quality Assurance Visits:

16 Escalation Process If any part of the local system indicates there may be a serious quality failure within a provider organisation which cannot be addressed through established and routine operational systems, in conjunction with the Lincolnshire Quality Surveillance Group, a risk summit may be triggered (in line with the Nation Quality Board Guidance). The Risk Summit is a meeting of senior leaders to shape a programme of action which is focused in sharing information willingly to help achieve consensus about the situation under scrutiny and the actions required to mitigate the identified risks. 17 Quality Surveillance Group Quality Surveillance Groups (QSGs) systematically bring together the different parts of the health and care system across a geographical area to share information regarding the quality of providers and are a proactive forum for collaboration. This whole system approach provides the health economy with a shared view of risks to quality through sharing intelligence; an early warning mechanism of risk about poor quality; and opportunities to coordinate actions to drive improvement, respecting statutory responsibilities of and ongoing operational liaison between organisations. Lincolnshire QSG is made up of senior representatives from NHS England Area Team, CCGs, Health Watch, Care Quality Commission, Monitor, Local Authority, NHS Trust 12 | P a g e

Development Authority, Public Health England, and the Local Education and Training Board. The CCG is an active member of this group and is represented by the Accountable Officer and the Chief Nurse 18 Patient and Public Involvement Lincolnshire East CCG has always strived to be close to our patients. The organisation has developed a wide range of patient engagement opportunities such as listening events, youth workshops and the use of a bus for health checks. It is anticipated that these opportunities will continue to grow and develop. There is a programme of patient stories taken to the Governing Body on a quarterly, basis, which is focused on ensuring that the Governing Body is able to listen to and connect with the patient experience of health care services across Lincolnshire. They provide the opportunity for assessing the effectiveness of any commissioned services and also provide the opportunity to share information with providers and improve the quality of the patients experience in the future. The CCG has recently developed a Patient Council.

The expectation is that the Patient Council will provide further opportunity for the CCG to engage with patients and the public in commissioning decisions; this is done in a meaningful way and as part of a continuous process. The purpose of the Patient Council is to: 

Provide a mechanism to feed patient and public voice into decision making within the CCG

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Collate the views of a wide range of groups by drawing on the networks of Patient Participation Groups (PPGs), Health Watch, voluntary and community groups and others

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Provide scrutiny of the CCG’s engagement and consultation activity

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Enable existing networks for involvement to have a voice in decision making around health and care issues

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Provide a channel for outgoing communication and engagement to patients and members of the public.

19 Patient Experience In order to listen to our patients, their families and carers, to learn about their experience, we have a number of approaches in place such as: 

Complaints, concerns and compliments

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Local and national surveys

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Quality visits

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Listening events

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Patient stories

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Patient council

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Youth workshops

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Themed workshops

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Journey mapping

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Health bus

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Lincolnshire show

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NHS Choices

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Patient Opinion.

20 Continuous Listening Model The continuous listening model depicts how our Governing Body will be able to listen to the views, opinions and experiences of the population of East Lincolnshire in terms of our GP practice patients, staff and the wider population. Each of our practice PPG’s will be represented by a member on the relevant PPG locality group and these representatives will report regularly to the CCG Locality Committees. Patients have the opportunity to feedback their experiences of health services through the practice based patient experience systems that are in place in each of our 30 GP Practices. This feedback is reported regularly to relevant Locality Committees. The wider population voice is heard through Locality Committee members’ involvement with Health watch locality groups and the Health and Wellbeing Partnerships Groups.

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The CCG Quality and Patient Experience Committee receive the systematic local patient experience intelligence reports which include complaints, national patient experience survey results and feedback from public feedback mechanisms such as NHS Choices. Both the Quality and Locality Committees report regularly to our Governing Body.

21 Listening Events The Listening Events Programme is a collective response by the Lincolnshire health community to the Keogh Review and to the statutory framework for patient and public involvement. It represents a real commitment to capturing patients’ experiences, in their own words, and feeding these into decisions about health services in the area. The events themselves are designed to enable patients to share their experiences with a range of health providers and commissioners. The Listening Events are CCG led but owned by providers and commissioners jointly, with all local health organisations having a stake in the findings. The programme has a strong focus on quality and aims to help each CCG and participating provider understand how services are experienced by patients. Positive and negative experiences are shared, captured and reported back in a way that can highlight issues with quality of care. 22 Safeguarding In March 2013 NHS England issued a document: Safeguarding Vulnerable People in the Reformed NHS – Accountability and Assurance Framework. The purpose of this framework was to set out the statutory responsibilities of organisations in the reformed NHS. The role of Clinical Commissioning Groups is made explicit within this framework, they are required to ensure that: 

The organisation from which they commission services provide a safe system that safeguards adults at risk of abuse and harm

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They are required to be fully engaged with local safeguarding boards

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Have robust processes in place to learn lessons from cases where adults die or are seriously harmed and abuse or neglect is suspected

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They work in partnership with NHS England to ensure the health commissioning system as a whole is working effectively to safeguard and improve the outcomes for vulnerable adults

A Safeguarding Steering Group is in place which facilitates and coordinates a culture that embraces safeguarding as everybody’s business and ensures that the organisations from which services are commissioned provide a safe system that safeguards children and adults. The Group promotes and assists effective inter-organisation co-operation in order that statutory health bodies operating Lincolnshire co-operate and discharge their statutory responsibilities effectively relating to safeguarding children, young people and adults at risk. The safeguarding Adults Assurance Framework, Markers of Good Practice For Safeguarding Children and PREVENT are embedded into all provider contract monitoring processes. The Federated Safeguarding service ensures that the CCG meets its statutory requirements for safeguarding children, young people and adults. A number of key priorities have been identified aligned to our partnership arrangements which will ensure the CCG establishes clear lines of responsibility and accountability for safeguarding children, young people and adults at risk and has a comprehensive performance framework with particular emphasis on identifying and embedding best practice. They are: 

Ensure arrangements for safeguarding adults, children and young people are robust and fully integrated into existing clinical governance processes.

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Ensure safeguarding training and development programmes are in place, monitored and evaluated for all commissioned services and CCG Member Practices.

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Monitor dissemination and evaluate outcomes of all SCR action plans and SILPs of both single and inter-agency action to receive assurance that plans have been implemented.

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Strengthen processes and systems to ensure effective contribution to partnership arrangements

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23 Conclusion This document has been written to provide a clear understanding and ambition for operationalising the quality framework for Lincolnshire East CCG. The framework provides a clear vision for quality, including the key drivers, the quality ambitions, and the infrastructure required to provide the necessary board level governance and assurance. This framework will be reviewed on a yearly basis to ensure that the anticipated outcomes are achieved for the CCG.

Tracy Pilcher Chief Nurse Lincolnshire East CCG

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Appendix One National Policy Drivers for Quality and Patient Experience 

The NHS constitution sets out the standards of care and the rights that all patient have. In essence, the constitution outlines the minimum level of service a patient should be able to expect.

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The NHS Commissioning Outcomes Framework is a national framework to drive local improvements in quality and outcomes for patients.

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The Francis Report into Mid Staffordshire NHS Foundation Trust Public Inquiry chaired by Sir Robert Francis QC was published on 6 February 2013. The report identifies numerous warning signs that were evident, which should have alerted the wider system to the problems that led to the appalling failures.

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Patients First and Foremost published in March 2013 sets out an initial overarching response on behalf of the health and care system as a whole to the Mid Staffordshire NHS Public Inquiry and the ‘Francis Report’. It details key actions to ensure patients are the central and principle consideration of the system and everyone who works in it. It sets out a collective commitment and a plan to eradicate harm and promote excellence in patient safety and experience.

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The Berwick Report released in August 2013 made ten recommendations with the aim to make the NHS a “system devoted to continual learning and improvement of patient care, top to bottom and end to end”. The report recommended four guiding principles to help the NHS get better faster: place the quality and safety of patient care above all, engage, empower, and hear patients and carers, foster wholeheartedly the growth and development of all staff and unequivocal transparency.

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The Care Quality Commission Registration (CQC) remains the statutory regulator for the quality of health and social care in England. It will be responsible for registering and monitoring compliance of NHS and social care providers with the essential standards of quality and safety.

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The National Quality Board (NQB) is a multi-stakeholder board established to champion quality and ensure alignment in quality throughout the NHS. The Board is a key driver of work throughout the NHS that focuses on delivering high quality care for patients.

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Quality, Innovation, Productivity and Prevention (QIPP) is a large transformational programme for the NHS seeking, through productivity, prevention and innovation, to improve the quality of care the

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The National Institute for Clinical Excellence (NICE) care pathways launched in May 2011 provides national guidance and standards on the promotion of good health and social care and the prevention and treatment of ill health across a range of clinical care pathways.

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Hard Truths - The Journey to Putting Patients First was the Government’s further response to the Mid Staffordshire NHS FT Public Inquiry and sets out how the whole health and care system will prioritise and build on significant changes that had already taken place to improve inspection, increase transparency, put a clear emphasis on compassion, standards and safety, increase accountability for failure, and build capability. This includes major new action on transparent monthly reporting of ward-by-ward staffing levels and other safety measures, clearly setting out how patients and their families can raise concerns or complain and reporting on complaints, a statutory duty of candour, legislate on Wilful Neglect – so that those

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responsible for the worst failures in care are held accountable and the introduction of a new criminal offence applicable to care providers that supply or publish certain types of information that is false or misleading, where that information is required to comply with a statutory or other legal obligation.

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Appendix Two

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Appendix Three

Quality Framework Key Permformance Indicators Quality Element

Patient Safety

Aim To ensure that Lincolnshire East Clinical Commissioning Group commission safe services for our patients

Quality Theme

Quality Priority / Outcome A year on year reduction of MRSA and Clostridium Difficile cases

Preventing Healthcare Associated Infections

All providers are compliant with the CQC infection control and prevention standards Full achievement of actions identified within the infection prevention and control plan Implementation of Safeguarding Strategy for Adults and Children

Safeguarding Vulnerable Adults and Children

Reduction in Avoidable Harm

Clinical Incidents and Risk

Full achievement of actions identified within the Safeguarding Strategy Safeguarding reflected in the Quality Schedule and reporting requirements of all provider contracts and monitoring in place

Harm levels are monitored and avoidable harm reduced. For all organisations to achieve 95% harm free care

A reduction in the number of incidents and serious incidents with the same contributory factors HSMR / SHMI rates for providers who are within expected levels

Mortality Rates

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Remedial action plans are developed and monitored where there is any deviation from acceptable limits

Quality Element

Clinical Effectiveness

Aim To ensure that all providers are treating patients in ways which work well and produce the best possible health outcomes for that patient

Quality Theme

Quality Outcome Implementation of NICE guidance monitored through the Trusts Annual Quality Accounts to ensure clinically effective services are provided

NICE Guidance

Business cases / service specifications demonstrate that proposed services meets NICE guidance / quality standards All providers compliance with approprriate NICE clinical guidance Monitoring of provider participation in local and national audtis establised through the Trusts Annual Quality Accounts

Clinical Audit Results of audits are monitored and learning embedded

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Quality Element

Patient Experience

Aim To ensure that we commission services that provide patients / care with a positive experience

Quality Theme

Quality Outcome Patient stories are used to influence and enhance commissioning within the CCG A reduction in the number of complaints with the same contributory factors seen in all providers

Patient Feedback Outcomes and improvements from patient experience surveys and Patient Related Outcome Measures (PROMS) are monitored Patient and public engagement is sought on all appropriate Quality and Safety issues Patient Engagement

The use of patient stories will be establised within the CCG Zero tolerance to same sex accommodation requirements

Privacy and Dignity

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Quality Element

Clinical Effectiveness

Aim To ensure that the CCG commissions services that are of the highest quality

Quality Theme

Quality in Contracts

Commissioning for Quality and Innovation (CQUINS)

Quality Outcome

Quality schedules agreed for all contracts reflect national and local priorities

CQUIN schemes agreed for all providers that reflect local quality improvement priorities Reports to Quality and Patient Experience Committee and Governing Body to monitor delivery of quality schedule and CQUINs

Quality Assurance to the CCG

Assurance of the quality of all services provided to Quality and Patient Experience Committee and Governing Body All business cases / service specifications have a quality impact assessment completed prior to approval All care homes visited and full assessment of quality undertaken

Care Homes

A reduction in the number of care homes in Lincolnshire in the serious concerns process A reduction in the number of acute hospital admissions from care homes Processes in place in collaboration with planned and primary care programme for the monitoring of quality in primary care

Primary Care

Communication and sharing of intelligence established with the Local Area Team as co- commissioners for primary care Quality schedules agreed for all locally enhances service specifications

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