Quality Assurance and Improvement Framework

Hardwick Clinical Commissioning Group Quality Assurance and Improvement Framework Hardwick CCG QAI Framework Contents Contents Introduction ........
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Hardwick Clinical Commissioning Group

Quality Assurance and Improvement Framework

Hardwick CCG QAI Framework

Contents

Contents Introduction ............................................................................................................................................ 3 Definition of Quality................................................................................................................................ 4 Drivers for Quality ................................................................................................................................... 5 HCCG Strategic Aims & Objectives .......................................................................................................... 8 Vision for Quality .................................................................................................................................... 9 Roles and Responsibilities ....................................................................................................................... 9 Structure ............................................................................................................................................... 11 Process .................................................................................................................................................. 11 Quality Assurance/improvement Process ............................................................................................ 15 Conclusion ............................................................................................................................................. 18 References ............................................................................................................................................ 19

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Introduction With the implementation of the Health and Social Care Act 2012 Clinical Commissioning Groups (CCGs) now have responsibility for commissioning safe, cost effective and high quality services, ensuring that quality is at the heart of the commissioning process.

The CCG’s vision is to improve the health for the population of Hardwick by commissioning the highest quality services, provided near to the patient, in an integrated approach and representing best value for money. We have quality at the centre of everything we do; patients1 and their quality of care are our focus and priority. Our role as a CCG is to drive continuous improvements in all services including primary care services provided by the general practices who are members of the CCG, so that all patients experience person centred care that is safe, effective and efficient.

We also understand that there needs to be a significant change in the way services are commissioned and delivered to ensure that those requiring NHS care are supported to have choice and control in their healthcare, effectively managing long term conditions in partnership with health and social care professionals and having access to more community based services that are flexible around the patient.

This change is needed to develop a care system that is built around the patient and their carers, which is informed by them and implemented by all local partners working together.

We believe the CCG is best placed to work across all providers of care including General Practice to ensure that Quality Monitoring, Assurance and Improvement are linked to the commissioning cycle as well as the strategic objectives of the organisation. This Quality Assurance Framework is built to deliver this vision

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In this context the term patient is used inclusively and covers Mental Health and Learning Disability services users and resident in care homes receiving NHS funded care

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Definition of Quality Lord Darzi (2008) defined quality in terms of safety, effectiveness and patient experience. 

Patient safety. The first dimension of quality must be that we do no harm to patients. This means ensuring the environment is safe and clean, reducing avoidable harm such as excessive drug errors or rates of healthcare associated infections.



Patient experience. Quality of care includes quality of caring. This means how personal care is – the compassion, dignity and respect with which patients are treated. It can only be improved by analysing and understanding patient satisfaction with their experiences.



Effectiveness of care. This means understanding success rates from different treatments for different conditions. Assessing this will include clinical measures such as mortality or survival rates, complication rates and measures of clinical improvement. Just as important is the effectiveness of care from the patient’s own perspective which will be measured through patient-reported

outcomes

measures

(PROMs).

Examples

include

improvement in pain free movement after a joint replacement, or returning to work after treatment for depression. Clinical effectiveness may also extend to people’s well-being and ability to live independent lives.

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Drivers for Quality National Drivers Francis Report The long awaited Francis report, published February 2013 and the Government’s response published in November 2013 examined the role of the culture and systems in the NHS, and how they failed to identify the events at Mid Staffordshire Hospitals between January 2005 and March 2009. Recommendations identified putting the ‘patient first,’ in an NHS that should be centred on common values in order to drive up the quality of care. HCCG echoes this collective commitment to ensure that patients are ‘the first and foremost consideration,’ and to ensure commissioned services by the CCG secure a consistent culture of compassionate care with patient’s interest at the very heart. Berwick Report (2013) Professor Don Berwick was asked by the Prime Minister to carry out the review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals. His report made recommendations for the NHS, its regulators and the government in building a robust nationwide system for patient safety rooted in a culture of transparency, openness and continual learning with patients firmly at its heart. At HCCG, we are working with clinicians to assess and understand what can go wrong in healthcare using analysis of hard and soft data and then develop new ways of working to make patients safer. Clinicians are reporting incidents and “near-misses”, however minor they may at first seem, to national systems. Reporting these incidents is not about punishment – it’s about making sure all parts of the NHS learn from one another, gaining a full understanding of what can go wrong and how it can be prevented in future. As Don Berwick makes clear in his report, an open, supportive culture where it is understood that humans make genuine mistakes, is key to this. First Stage Keogh Review During 2013, an additional review led by Professor Sir Bruce Keogh (National Medical Director for NHS England) reviewed the quality of care and treatment provided by fourteen hospital trusts in England identified as having higher than average death rates in the previous two years. The report showed that whilst 5

immediate safety issues were dealt with straight away, it also called for a coordinated effort to improve care and accountability in the longer term. Boards and leadership of provider and commissioning organisations need to consider a broader set of triggers spanning the three dimensions of quality. This includes the sharing of soft intelligence, particularly between clinical commissioning groups and regulators for the forensic pursuit of quality improvement. National Quality board Following the failings of Mid-Staffordshire NHS trust, the National Quality Board (NQB) reviewed the systems and processes in place in the NHS for safeguarding quality and preventing serious failures. This review was followed by the publication of the ‘Review of Early Warning Systems in the NHS’ in 2010 and the report from the NQB, ‘Quality in the new health system – maintaining and improving quality from April 2013’. The NQB is confident that by operationally implementing its recommendations the early identification of potential failings in patient care will be better assured. However, the NQB recognises that no system can be 100% failsafe, particularly in one as complex as the NHS, and that not every serious failure may be entirely prevented. It is therefore crucial that management and regulatory responses are aligned with clear leadership and on-going coordination in order that in such circumstances the overall system is able to respond in a way that safeguards patients, ensures continued provision of services to the population and secures rapid improvements in the quality of care at any failing organisation. NHS Outcomes Framework The Commissioning Outcomes Framework is a national framework to drive local improvements in quality and outcomes for patients. The 2012-13 indicators cover five domains: 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 people have a positive experience of care

Domain 5

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

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This is the core framework against which NHS Hardwick CCG set the yearly quality standards; these are then translated into contracts with providers. Care Quality Commission (CQC) Essential Standards CQC is the regulator of health and adult social care in England. It is responsible for ensuring that providers meet the CQC essential standards for quality and safety and encourage on-going improvements by those who provide or commission care. There are 16 essential standards of quality and safety, which come under the following main areas of care: 

Involvement and Information



Personalised care, treatment and support



Safeguarding and patient safety



Suitability of staffing



Quality and Management

HCCG reviews CQC assessments as an integral part of our quality assurance review of providers. NHS England Assurance Framework NHS England published the CCG Assurance Framework in May 2013, which outlined the process to provide assurance that CCGs are delivering quality and outcomes for patients, both locally and as part of the national standards, as well as being the basis for assessing that they are continuously improving from the start point of authorisation. The lessons for future commissioning from the Francis, Keogh and Berwick reports are that commissioners have a critical role in driving quality. This quality assurance framework reflects the recommendations of the key reports and the Governments response in relation to how HCCG commissions for quality, including the crucial ability to recognise and act early on any systematic deterioration in care within a provider organisation.

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HCCG Strategic Aims & Objectives The health status of NHS Hardwick CCG’s population is relatively low in comparison to neighbouring areas and its geographic footprint includes some of the most deprived areas in the country. Therefore the overarching mission of HCCG is to ‘Lift the Health of the People of Hardwick’.

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Vision for Quality The NHS Hardwick CCG Quality Assurance Framework is built around the strategic aims and objectives identified previously. These support the CCG’s vision of achieving and then sustaining healthcare outcomes that are responsive to the needs and expectations of the people of Hardwick. The organisational aims and objectives set the overarching framework in which we work and our approach to quality is based on the principle that healthcare services must be person centred; safe; effective; efficient; equitable and timely. Four key principles have informed the development of our quality assurance framework: 

Quality is everyone’s business



Patients come first



Patients must be involved and their voices heard



We, and the organisations we work with, should be open and honest, share information and intelligence and work collaboratively

Our overall vision for the quality assurance/improvement framework is based on the clarity of Roles and Responsibilities: Structures and Processes. It is these 3 elements that ensure a robust approach to the quality monitoring and assurance framework.

Roles and Responsibilities The roles and responsibilities for individuals and organisations for quality are established by statute (2012) and neatly summarised by the National Quality Board (2013). We have further refined these to take account of our local position as a lead/associate commissioner of services and the wider system. Hardwick CCG for its population Hardwick CCG is responsible for commissioning services that meet the needs of our local population and we must: 

assure ourselves of the quality of the care that we have commissioned and that all services commissioned meet, as a minimum the CQC essential standards for Quality and Safety 9



take proactive and coordinated action to address potential or actual quality failures within providers and inform the Care Quality Commission (CQC) of any concerns



contract with our providers to secure continuously improving quality care using local quality indicators



Participate in the Quality Surveillance Groups (QSG) at local levels. The role of these groups is to bring together local intelligence relating to particular service providers.

Hardwick CCG as Lead commissioner (see Appendix A) As lead commissioner we will monitor the quality of services provided by the organisations for all service users including those from outside Hardwick, including: -

Monitoring agreed quality indicators

-

Reporting exceptions to the HCCG and other CCG Governing Bodies

-

Overseeing that Quality Alerts, Incidents and Serious Incidents affecting patients registered at other CCGs are investigated and acted upon appropriately and reporting back to other CCGs as required

-

Provide assurance as appropriate to other CCGs whose patients access these services

HCCG as Associate commissioner (see Appendix A) -

Seek assurance as appropriate when there are concerns relating to the services accessed by our patients

Provider Organisations The leadership of a provider organisation is responsible for the quality of care delivered by the service and must: 

ensure that the organisation meets the CQC’s ‘essential standards of quality and safety’



foster a common culture shared by all in the service of putting the patient first



recognise that quality is as important as the management of resources



ensure that there are systems in place to drive continuous quality improvement



ensure that there are systems in place to allow staff to raise quality concerns 10

Individual Professionals Individual health and care professionals are ‘the first line of defence against quality failure’ and should: 

participate in clinical governance



continuously measure and monitor quality indicators of the care that they are delivering



ensure that the care they provide is compliant with National Institute of Health and Clinical Excellence (NICE) quality standards and clinical guidance



ensure that the care that they provide meets the CQC’s ‘essential standards of quality and safety’



raise concerns that they may have about quality of care with their relevant clinical leaders

Health Care Regulators The role of the CQC is to: -

register service providers that meet the ‘essential standards of quality and safety’

-

monitor services against the standards

-

listen to the patient’s voice

Structure The quality assurance process is outlined within Appendix B. This places the Quality Committee as the formal subcommittee of the board responsible for gaining assurance for HCCG commissioned services.

Process Provider Quality Assurance (Lead Commissioner) Provider assurance is undertaken at the Quality Assurance Group (QAG) held regularly with providers and constitutes a face to face, Commissioner-Provider quality review meeting. The meeting focus on the delivery of the quality standard, as outlined within the NHS Standard

Contract,

under

national

Quality

Requirements,

Local

Quality

Requirements, Never Events and CQUINs.

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In addition to these core requirements the QAG will review other sources of data, pertinent to the quality of services, such as patient experience, staffing and outcomes from quality visits etc. Lastly the group will look forward at the strategic concerns in relation to quality such as risks associated with the wider NHS system or potential changes to policy that may impact of quality. Provider Quality Assurance (Associate Commissioner) The CCG will, where possible, ensure that it is seated at the relevant provider QAG associated with the delivery of care to our patients. We will receive all relevant papers associated with these meetings and provide constructive support to the co-ordinating commissioner of services. Where there are any concerns with regard to the quality of services provided to our population, where we are an associate to a contract the CCG will require the lead commission to attend quality committee to provide the necessary assurance. Care Home Quality Nursing Homes in Derbyshire including Derby City are currently visited annually by a team of clinicians who complete a quality audit. This is often a joint visit with the Local Authority. As well as checking policies and procedures are in place to ensure the safe delivery care the visit includes a substantial element of observation of practice. Health, Adult Care and CQC all work closely together and share all information about care homes both informally and through a formal meeting process. Care Homes who have signed the National Care Home contract are also subject to monthly monitoring which not only collects data about the terms and conditions of the contract but contains a quality schedule which requires evidence Primary Care The CCG will support NHS England, as the lead commissioner for Primary Care. In improving the quality and safety of Primary care. This will be achieved through the 12

Primary Care Quality Improvement Forum, which will 

Continually review the HCCG primary care quality strategy and associated audit plan



Receive information on performance measures and indicators for HCCG member practices

Serious Incidents In order to ensure mistakes in practice do not repeatedly occur, providers are required to ensure that policies and procedures are robust enough to identify risks, manage those risks and create a learning culture. NHS Hardwick CCG receives notification of serious incidents through the national Strategic Executive Information System (STEIS). In primary care, independent contractors are supported to use Significant Event Analysis (SEAs) to identify and learn from events. All Serious Incidents have a Root Cause Analysis and lessons are shared across the CCG. Incidents and Serious Incidents are analysed for trends and reported to the Quality Committee. Safeguarding Vulnerable Adults and Children NHS Hardwick CCG ensures that its providers have arrangements in place to safeguard and promote the welfare of adults and children in line with national policy and guidance. The CCG requires providers to inform them of all incidents involving children and adults including death or harm whilst in the care of a provider. HCCG collects evidence against regulations concerning Safeguarding set out in the Health and Social Care Act 2008. The Quality & Governance Committee receives an Annual Report on Safeguarding from the Adult and Children’s Safeguarding Leads. Population Assurance The CCG uses a Quality Committee for assessing the impact of the quality of services on the Hardwick population and providing assurance, or otherwise, to the Governing Body on the safety, effectiveness and patient experience resulting from its commissioning decisions.

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Where the Quality Committee is not assured of the quality of services exception reports will be raised for the Commissioning Delivery Group, the Governing Body and appropriate contract meetings as required. The CCG has developed a report for the Quality Committee which includes: -

Serious Incident Reports

-

Rates of healthcare-associated infections (HCAIs)

-

Central Alerting System Indicators

-

Patient Advice and Liaison Service (PALS) and Complaints Reports

-

Standardised Hospital-Level Mortality Index (SHMI)

-

Workforce

-

NHS Choices

-

Safety Thermometer

-

Care Quality Commission (CQC)

-

Monitor

-

Never Events

-

Results of Staff Surveys

-

Results of Patient Surveys

-

Reports from Healthwatch

GP Commissioning Concerns system NHS Hardwick CCG has a secure email GP Alert process where GP practices can raise issues relating to their patient care and treatment from a commissioned provider directly with the Quality team. Themes and trends are reported to the Quality and Governance Committee

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Quality Assurance/improvement Process There

are

three

distinct

elements

that

form

part

of

the

quality

assurance/improvement cycle.

Monitoring of hard and soft data points

Informing CQUIN Develop Informing Commissioning Delivery Group Informing Pathway redesign

Quality Improvment

Quality Monitoring

Objective and subjective views

Quality Assurance

Internal and External CCG reporting of lead provider arrangement Working with other CCGs to provide assurance of associate commissioner services

Quality Monitoring HCCG collects data as part of the NHS Standard Contract on a range of quality indicators. This data is then analysed and triangulated with patient experience information to identify possible lapses in care. Quality Assurance The process of quality assurance is providing HCCG Governing Body with the assurance that we have identified care delivery problems early and that plans are in place with providers to rectify these concerns within a specified time period. HCCG believe that the responsibility for the delivery of these actions rests with the provider

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whilst clearly demonstrating to the CCG that the relevant actions have been fully implemented. Quality Improvement The process by which change occurs based upon quality monitoring and quality assurance information. This will happen at a number of levels including: -

local provider driven change

-

Pathway redesign

-

System wide service change

Supporting quality improvement requires action at both a strategic level and through in year developments. Strategic Quality Improvement will be delivered through the CCGs strategic planning process including aims, objectives and priority setting based on include public health reports, national and local statistics and for example, NICE Resources to support commissioning decisions In Year Quality improvements include:

Quality Innovation Productivity and Prevention (QIPP) programme – agreed annually and reported through the CCG governance processes



Commissioning for Quality and Innovation (CQUIN) – agreed annually with providers and reported to Quality committee



Quality Outcomes Premium - agreed annually and reported through the CCG governance processes



Clinical pathway or programme –redesign, working across CCG and providers and responding to local or national audits or indicators of variation

EQUALITY AND DIVERSITY Equality and Diversity is an integral part in driving up improvements for the patients and communities we serve. We will strive to ensure that the services we commission are equitable, free from discrimination, advance equality of opportunity and foster good community relations for groups that are protected by law (Equality Act 2010). To improve access and outcomes for patients we will monitor the equality related

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performance of our providers through our quality contract schedules and we will monitor the performance of our providers in relation to meeting their specific duties under the Equality Act 2010. Furthermore providers will be contractually required to undertake the Department of Health’s Equality Delivery System (EDS). EDS is closely aligned with the NHS outcomes framework and CQC standards and is assessed by key community stakeholders including local LINk/Healthwatch.

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Conclusion The Quality Assurance Framework outlines how NHS Hardwick CCG will secure excellent quality within services it commissions on behalf of Hardwick patients. It provides the means by which the Governing Body can assure itself and its stakeholders of the clinical quality and responsiveness of the services it commissions and provides a means to establish where remedial action may be required. It is recommended that the Quality & Governance Committee review this Quality Assurance Framework, annually on behalf of the Governing Body to ensure that learning is taken on board and that the Framework prompts continuous improvement in support of delivery of the CCG’s mission and of its statutory responsibilities. Earlier review may be undertaken in light of new national guidance.

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References Berwick, D. (2013) A promise to learn – a commitment to act. Improving the Safety of Patients in England. London: HMSO. DH, (2008) High Quality Care for All: NHS Next Stage Review Final Report. HMSO. London. Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. TSO. London. The NHS Constitution (Interactive version) 2012. http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/n hs-constitution-interactive-version-march-2012.pdf The Health and Social Care Act 2012. http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted The National Quality Board (2013) Quality in the new health system. DH, London https://www.wp.dh.gov.uk/publications/files/2013/01/Final-NQB-report-v4-160113.pdf Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. TSO. London.

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Appendix A Hardwick CCG is the Lead Commissioner for: -

Derbyshire Healthcare NHS Foundation Trust (DHcFT)

-

Barlborough NHS Independent Treatment Centre

-

Improving Access to Psychological Therapy contracts

-

Care Homes and Mental Health

-

Learning Disability individual patient placements.

Hardwick CCG is also Associate Commissioner for: -

Chesterfield Royal Hospital NHS Foundation Trust (CRH)

-

Derbyshire Community Health Service (DCHS)

-

Derbyshire Health United (DHU)

Members of HCCG attend respective Quality Assurance Groups as Associate Commissioners. Hardwick CCG is also Lead Associate for Derbyshire CCGs for the following contracts: -

Sheffield Teaching Hospitals NHS Foundation Trust

-

Sherwood Forest NHS Foundation Trust

-

Sheffield Children’s NHS Foundation Trust

-

Doncaster & Bassetlaw NHS Foundation Trust

-

The Rotherham Foundation Trust

-

Leeds Teaching Hospitals

-

The Claremont and Thornbury

Hardwick CCG QAI Framework

Appendix B

Governing Body

Quality & Governance Committee

Contract Activity Performance CQUIN Achievement

Primary Care Quality Improvement Forum

Care Home Quality Monitoring Processes

Quality Schedule

Provider Quality Assurance Groups

Quality Committee The role of the Q&G Committee group is to provide assurance through a mechanism in which additional lessons are learned, additional lessons from trends are identified, and best practice shared from the outcomes of national findings, complaints, incidents, near misses, Serious Incidents, Litigation, PALS, compliments, patient and public feedback, clinical audit, and findings from research and evaluation. This information will be collected from commissioned and contracted services and claims. NHS Hardwick CCG will also ensure that the actions are completed and recommend further improvements in practice. The Chief Nurse Officer will also ensure that this information is considered in commissioning decisions by the commissioning team. The lessons learned will be fed back to the Quality and Risk Committees, staff and public.

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NHS Hardwick CCG Governing Body receives the minutes of the Quality and Safety Working Group as well as formal Quality reports plus any escalation reports as necessary. Challenge comes from the Audit and Integrated Assurance committee.

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