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Making the system work

for you: Using levers and drivers

to deliver change

Lesley Kitchen

Advancing Quality, Programme Director

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NHS Outcomes Framework

CCGOIS (previously COF) Clinical Commissioning Groups Outcomes Indicator

Set

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• A programme to improve the

quality of care for patients in the

North West

• That uses existing system drivers

and levers

• An incentive scheme that

rewards healthcare providers for

providing high quality of care to

patients

• And that also appeals to

commissioners

An example…

• 24 PCTs / 34 CCGs

• 24 acute trusts

• Population ~7 million

• 2 million(+) adult admissions per

year

• Outcomes improving but above

national/ international average

and gap wasn’t closing

The north west

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• How do we define quality?

• How do we agree what ‘best’ looks like?

• How do we close the gap in terms of patient and

clinical outcomes?

• How do we know we’re getting VfM in

‘improvement initiatives’?

• How can we reliably benchmark and identify

areas of good practice?

Some challenges…

• Modelled on HQID in the US

• AMI, Heart Failure, CABG, Hip & Knee

replacement surgery, Community Acquired

Pneumonia

Advancing Quality

• Highly relevant

to the North

West

population

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How it works...

Clear

evidence

base

Robust data

collection

Supporting

change Incentives

£££

Regional

CQUIN

Acute myocardial infarction (AMI)

1. Aspirin at arrival 2. Aspirin prescribed at discharge 3. ACE or ARB for LVSD 4. Smoking cessation advice/counseling 5. Beta blocker at arrival 6. Beta blocker prescribed at discharge 7. Thrombolytic received within 30 minutes of

hospital arrival 8. PCI received within 90 minutes of hospital

arrival

Hip and knee replacement

1. Prophylactic antibiotic received within one hour prior to surgical incision

2. Prophylactic antibiotic selection for surgical patients

3. Prophylactic antibiotics discontinued within 24 hours after surgery end time

4. Recommended Venous Thromboembolism prophylaxis ordered

5. Appropriate Venous Thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

Community-acquired pneumonia (CAP) 1. Oxygenation assessment within 24 hours

prior to or after hospital arrival 2. Initial antibiotic selection 3. Blood culture collected prior to first

antibiotic administration 4. Antibiotic timing, first dose of antibiotics

within six hours after hospital arrival 5. Smoking cessation advice/counseling

Coronary artery bypass graft (CABG)

1. Aspirin prescribed at discharge 2. Prophylactic antibiotic received within one

hour prior to surgical incision 3. Prophylactic antibiotic selection for surgical

patients 4. Prophylactic antibiotics discontinued within

48 hours after surgery end time

Heart failure (HF) 1. Left Ventricular Systolic (LVS) assessment 2. Detailed discharge instructions 3. ACEI or ARB for LVSD 4. Smoking cessation advice/counseling

Clear Evidence Base

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• Need robust data

– to identify opportunities to improve

– to benchmark

• Rules based / algorithmic approach

– Identifying patient cohorts – every patient

– Data dictionary & reasons for exclusion from a

measure

• Web based measure data collection

– Utilise existing data where available (PbR flows)

Robust data collection

Patient 1 Patient 2 Patient 3 Overall Trust Scores

Measure 1 2 of 3 = 66.6%

Measure 2 3 of 3 = 100%

Measure 3 1 of 3 = 33.3%

Measure 4 3 of 3 = 100%

Measure 5 3 of 3 = 100%

Opportunities

taken 4 of 5 5 of 5 3 of 5 12 of 15

Composite

Process Score 80% 100% 60% 80%

Patient

Appropriate

Care (all or

nothing)

0 of 1 1 of 1 0 of 1 1 of 3

Appropriate

Care Score 33.3%

Identifying opportunities

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A culture of change & collaboration • Regular collaborative learning events

• Involvement from all organisations

• Created networks of clinical and non clinical

communities

• A willingness to share and learn

“In my job my incentive is to ensure that all my patients get first

class treatment, and that every patient gets the right

treatment every time”

- Dr Paul Stockton, Respiratory Consultant

Incentives

CQUIN

www.advancingqualitynw.nhs.uk

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• “The Commissioning for Quality and Innovation (CQUIN) payment

framework enables commissioners to reward excellence by linking a

proportion of providers’ income to the achievement of local quality

improvement goals” (DoH, 2008)

• 2.5 % of overall contract value for all healthcare

services commissioned through the NHS Standard

Contract.

• One fifth of this value (0.5% of overall contract

value) is linked to national CQUIN goals (where

applicable.)

• Four fifths (2% of overall contract value) for local

determination.

CQUINs

• Regional CQUIN agreement across the north west for

AQ conditions

• Key principles:

– Raising the bar on minimum attainment

– Continuous improvement and stretch

– Standardised methodology for threshold setting

– Standardised financial value

– Keep it simple!

AQ CQUINs

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Rapid improvement,

sustained Steady improvement,

sustained

Raised the bar with

a new measure!

Marathon not

a sprint!

New

condition

Reducing variation

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“Risk adjusted, absolute mortality for the conditions

included in the pay-for-performance programme

decreased significantly with an absolute reduction of

1.3 percentage points and a relative reduction of 6%,

equivalent to 890 fewer deaths during the 18-month

period.”

“The introduction of pay for performance in all NHS

hospitals in one region of England was associated with

a clinically significant reduction in mortality.”

900 fewer deaths

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Return on investment

in health gain

• Whole systems / whole care pathways

• Setting specific balanced with the common elements –

“every place measures”

• Worked with NW Respiratory Leads on COPD

What next?

Primary

Care Admission Discharge Follow up

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COPD whole system

levers • Evidence base

• Regional CQUIN for acute and community services

• Local Enhanced Service agreements (LESs) for primary

care

• CCG Quality Premium

• Nationally the scene is set (NHS Outcomes Framework

and CCGOIS)

• There is a clear evidence base in respiratory

– Clinical guidelines and standards

• Hook into the financial and contractual levers that

already exist

So what for respiratory?