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What is Clinical Quality? The single common definition of quality which encompasses three equally important parts: • Care that is clinically effective- not just in the eyes of clinicians but in the eyes of patients themselves • Care that is safe • Care that provides as positive an experience for patients as possible 2

The Impact of Francis and Berwick on how the CCG Manages Quality The Francis Report has given CCGs and providers the impetus to assess how we manage quality and identify areas for improvement

Locally we have benchmarked ourselves against the Francis recommendations. A seminar was held with our Governing Body members to go through the key recommendations and benchmark where we are

A “lunch and learn” session was held with the CCG team to review the impact of Francis and what it means for Tower Hamlets CCG, our patients and carers

The benchmarking exercise led to the development of this Quality Framework

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Post Francis: Approach to Quality Assurance

Pre Francis Passive Reliant on provider self declarations Little patient involvement Few effective levers

Pro-active – looking for signs of concerns Independent triangulation which tests providers self declarations Patient experience key to quality assurance A range of levers for CCGs to intervene and ensure improvement

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Outline NHS Tower Hamlets CCG’s approach to clinical quality and improvement to our governing body members, the public and other key stakeholders Ensure that quality and quality improvement is placed at the heart of the health care THCCG commissions To provide a framework for embedding Francis recommendations

The purpose of the CCG quality framework

Ensure that there is a robust link between commissioning, clinical quality and performance so that the health needs of the local population (outlined in the Joint Strategic Needs Assessment) are met. Ensure there are systems and processes in place to provide internal and external assurance that the CCG is able to discharge its responsibilities. Provide a framework for the development and monitoring of contractual quality requirements with providers. 5

Tower Hamlets CCG Quality and Performance Team Dr. Sam Everington CCG Chair

Maggie Buckell Governing Body Registered Nurse Member & lead for Children's Safeguarding

Jane Milligan CO

Archna Mathur Shuma Begum

Director of Quality and Performance

Business Manager

(THCCG is quality lead across the BH CCG Collaborative)

Sandra Moore Senior Quality and Performance Manager

Justin Phillips Governance and Risk Manager

Dr. Judith Littlejohns Governing Body Member & lead for Adult Safeguarding

Richard Fradgley Director of Mental Health Commissioning and Adult Safeguarding Lead

Rob Mills Nurse Consultant Safeguarding Children and Designated Nurse

Owen Hamner Designated Dr for safeguarding children

Designated Nurse for Looked After Children

Named GPs for safeguarding

Ben Ko Designated Dr for looked after children

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Tower Hamlets CCG Programmes Mental Health Urgent Care Children and Young People Excellence in General Practice Integrated Care Long Term Conditions Maternity Last years of life Community Health Services Planned Care Prescribing Cancer

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Tower Hamlets CCG Accountability

Quality challenges

CCG Strategic Plan underpinned by quality of care to patients

Quality Intelligence and reporting

Accountability

Assurance mechanisms

Governing Body Membership

NHS Standard contract [Incentives and Penalties] & Risk and Governance

Improved patient experience and delivery of NHS Outcomes Framework

Providers 8

Organisations and Partnerships Tower Hamlets CCG work with a wide range of stakeholders to drive the quality agenda Local Authority HWBB, SAB LSCB, Public Health, OSC Healthwatch

THCCG, NELCSU Regulators CQC, Monitor National Trust Development Authority

Providers Barts Health, ELFT, Community Health Services, Voluntary Sector, Independent providers

NHSE, local area teams, specialist commissioning, primary care

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Quality & Performance Challenges 7 day working

London Quality Standards for Acute, Emergency and Maternity services

GP Feedback Service

Serious Incidents

CCG financial targets

Cancer targets and patient experience surveys

Patient & carer Experience, complaints and FFT

18 week waiting time targets

Mixed sex accommodation

CQC Inspection outcomes

Low levels of staff and patient satisfaction

Never Events

CQUINS

MRSA levels

Safeguarding Children and Adults

Impact of cost improvement programmes (CIPs) on quality and workforce

IAPT rates and quality of care for people with Dementia

Winterbourne view review

FT pipeline

SHMI rates

Community Health Services

Quality in Primary Care

Care Homes

Quality of Care in Maternity Services

Francis recommendations

The Berwick Report

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How do the CCG monitor and gain assurance on quality? The CCG need to ensure that services are meeting standards as identified by the CQC Safe

Well-led

Responsive

Effective

Caring

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Providers

CSU Reports

Trust Board Reports Improvement Plans and Trajectories Quality Accounts

Monthly quality and performance reports and weekly ‘Hot Topics’ Serious Incident and never event reports SHMI analysis and broader benchmarking

Staff satisfaction Surveys Patient experience surveys, complaints and FFT ‘Clinical Fridays’ and Internal Peer Review

HCAI reporting & analysis LAS to Care Home conveyance data Patient experience dashboard

CIP reports Mandatory Training Levels

Quality Intelligence Reporting External Intelligence

GP Membership and CCG Internal

CQC warning notices / inspection reports

Service Alerts

Healthwatch feedback

LMC feedback

National quality dataset

Practice Audits

NTDA intelligence

Feedback from practice visits

ECIST (Electronic Care Intensive Support Team)

Patient stories

NHS England direct commissioning

Patient Engagement events

GPOS indicators and GP High level indicators

Whistle blowers

NHSE (London) wide quality and performance benchmarking

Commissioning complaints

Patient Groups NHS Choices

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How intelligence relates to CQC standards never events, serious incidents, HCAIs, safety thermometer, staff survey, staffing levels, training

Safe Effective

HSMR, SHMI, mortality alerts, national clinical audits

Caring Responsive Well Led

inpatient survey, cancer patient survey, friends and family test, patient stories waiting time standards, cancelled operations, ambulance stays, analysis of complaints staff survey, staffing levels, flu vac rates, board minutes, risk registers 13

Governance and Assurance Mechanisms •Clinical Quality Review Meetings •Bi-weekly Performance Meetings •Contract reviews and associated incentives / penalties •Trust Board reports •Trust policies •Peer review visits •Provider recovery improvement plans and trajectories

•Quality leads forum •Quality Surveillance Group •CCC (Clinical Commissioning Committee) across WELC CCGs •Lead Commissioner arrangements and other NCEL CCGs •Grafton Group

Provider level

CCG Internal

Other Stakeholders and CCG Collaborative

External

•Finance, Performance and Quality •Governing Body Meetings •Serious Incident panels •Quality visit programme •Audit Committee •BAF •Safeguarding Commissioning Committee •Urgent Care Working Group •CCG policies •NHS Standard Contract

•NHS England Assurance Framework and CCG Balanced Scorecard •Overview and Scrutiny Committee •HWBB (Health and Well Being Board •Tri-partite panel (NHS England / TDA / ADASS) •NHS IQ (Improving Quality)

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Safer Staffing: An Example of Quality Assurance in practice

Intelligence from a patient on NHS choices identifies poor staffing levels on one particular ward

Information published on NHS choices and Barts Health website on levels of staffing at Royal London Hospital identifies a particular ward (same as identified by patient) as having poor fill rates and a number of vacancies

Action: CCG undertake quality assurance visit to that particular ward to identify what impact the levels of staffing are having on quality of care and patient experience

Action: Barts Health invited to THCCG governing body meeting to discuss staffing levels with members

Outcome: Action plan produced by Barts Health and implementation monitored by THCCG at CQRM to ensure actions are being implemented. Follow-up visit following implementation of actions to gain assurance on levels of staffing.

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Spotlight on safeguarding!

Tower Hamlets CCG has a statutory responsibility to make sure that organisations they commission services from are safeguarding children and adults at risk of abuse and neglect. We have in place the following:• Systems to train staff to recognise and report safeguarding issues • A clear line of accountability for safeguarding, reflected in our governance arrangements • Arrangements to work with local authorities through our Local Safeguarding Children Boards, Safeguarding Adult Boards and Health and Wellbeing Boards • Arrangements to share information between service providers, agencies and commissioners • Designated doctors and nurses who are responsible for safeguarding children and looked after children. A designated lead for adult safeguarding and the Mental Capacity Act • Two governing body members with a responsibility for safeguarding children and adults

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Safeguarding Governance and Assurance (2) External Assurance CQC and Ofsted

Governing Body

NHSE

Finance, Performance and Quality committee Internal Assurance Monitoring of safeguarding alerts and investigations Monitoring of training, serious incidents and other contractual obligations in relation to Safeguarding

THCCG Integrated Children and Adults Safeguarding Committee (CCG, provider and local authority membership)

Adults Safeguarding Board Local Safeguarding Children's Board

Learning Serious case reviews

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The NHS Standard Contract Quality requirements are included in the contracts with our providers. For 14-15 contracts we have included a range of local quality indicators to support quality improvement. There are also contractual levers we can use to support provider compliance with quality and performance. The following key documents inform the national and local quality requirements and support innovations in quality are:-

The NHS Constitution sets out the principles and values that guide how the NHS should act and make decisions. It also explains the rights and responsibilities of staff, patients and the public, and the NHS’s pledges to them.

The NHS Outcomes framework acts as a catalyst for driving quality improvements and outcome measures. This provides focus for the local quality elements in the contract.

The key aim of the Commissioning for Quality and Innovation (CQUIN) framework is to secure improvements in quality of services and better outcomes for patients, whilst also maintaining strong financial management.

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Quality elements in NHS Standard Contract (The Particulars)

Description

Quality element

Schedule 2: The Services, (C) Safeguarding Policies

This section highlights the practice providers are expected to undertake to safeguard vulnerable children and adults

safety

Schedule 2: The Services, (K) Transfer of and discharge from care obligations

This part of the contract includes key discharge protocols and sets standards for discharge planning

safety and experience

Schedule 4: Quality Requirements (A) Operational Standards

This part sets out standards for services in relation to waiting times (RTT), ambulance response times, MSA breaches, cancellations

effectiveness and experience

Schedule 4: Quality Requirements (B) National Quality Requirements

This part sets out quality requirements in relation to HCAI, ambulance handovers, waiting times etc

safety, effectiveness and experience

Schedule 4: Quality Requirements (C) Local Quality Requirements

This section sets out the CCG local quality requirements

safety, effectiveness and experience

Schedule 4: Quality Requirements (D) Never Events

Events that are serious and largely preventable. This section includes a list of never events

safety

Schedule 4: Quality Requirements (E) Commissioning for Quality and Innovation (CQUINs)

This section outlines the quality targets that aim to stretch providers to deliver improvements in quality over and above what is expected. It includes both national and local schemes

safety, effectiveness and experience

Schedule 6: Contract Management, Reporting and Information Requirements

Reporting of serious incidents

safety

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Improving Quality through CQUINs

National CQUINs • Family and friends test • NHS Safety Thermometer (pressure ulcers) • Dementia • Improving physical healthcare to reduce premature mortality in people with server mental illness

Collaborative CQUINS • Delivering and enabling integrated care • 7 day working • COPD care plans • Improving patient experience • Workforce development • Improved carers assessments and communication • Person centred care (dementia)

THCCG Local CQUINS • Improving last years of life • Improving the quality of maternity services and outcomes • Diabetes inpatient care • Integrated care in mental health

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Quality Assurance Visits – embedding Francis We have implemented a programme of quality assurance visits to our providers – acute, mental health, independent sector providers, nursing and residential homes The visits are a useful tool for gaining assurance of the quality of services Tower Hamlets CCG commission Our visiting team include governing body members, local authority, GPs and staff from the CCG Our visits are guided by hard and soft intelligence we receive including feedback from patients and carers Feedback from the visits is given to our providers and we monitor any actions arising from the visits to ensure they are implemented

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Working with our programmes and partners to embed Francis Improved of management of serious incidents – workshop, regular meetings with our providers to support closure of SIs

Ensuring newly developed specifications have a robust quality dashboard

SI workshop for primary care and development of local guidelines Board to Board conversations – safer staffing, cancer

Supporting improved quality in maternity services – through CQUINs, working with CSU to improve the quality and performance reporting

Development of a joint quality dashboard for nursing and residential homes Ensuring quality is embedded into community health services – robust quality dashboard

Improved local quality dashboard for mental health contract Keeping primary care informed of quality issues – through the newsletter, primary care involvement in QA Improving patient experience for mental health service users – MCA and DoLs training 22

Key priorities moving forward Continue to work collaboratively with Waltham Forest and Newham CCGs Approach of joint working with our providers to drive quality improvement – local quality discussions, workshops and events, regular meetings Board to board Facilitate and support implementation of actions within the CQC action plan for Barts Health Working with providers to reduce serious incidents Improve patient pathways – focus on cancer and emergency care and community health services Reduce incidence of pressure ulcers 23