The Cardiac Disease National Service Framework and Quality Requirements Cardiac Networks Coordinating Group

The Cardiac Disease National Service

Framework and Quality Requirements

Cardiac Networks Coordinating Group

Presentation Contents

• Overview of the updated Cardiac NSF• Outline of the Cardiac Quality Requirements (QRs)

– Aims– Structure– Using the QRs

• Involving others• Self assessing• Planning

– FAQs

THE CARDIAC DISEASE NSFSETTING THE STANDARDS OF HIGH QUALITY CARE

The Cardiac Disease National Service

Framework• The original CHD NSF was published in 2001

• Updating began in late 2005 to:

– Take account of Designed for Life, Review of Health and Social Care in Wales and Health Evidence Bulletin Wales: CHD.

– Take account of developments in clinical practice– Include arrhythmia and adult congenital heart disease

services

• The updated Cardiac NSF has been developed by an inclusive process involving a range of clinical, managerial and patient groups.

The Seven Standards

SETTING THE STANDARDS OF HIGH QUALITY CARE

1: Promoting healthy hearts

2: Managing risk factors for cardiovascular disease : Preventing further heart damage in those with high risk factors or established disease

3: Managing the care of patients with coronary heart disease

4: Managing the care of patients with chronic heart failure

5: Managing the care of patients with arrhythmias and families of young victims of cardiac arrest

6: Providing cardiac rehabilitation

7: Managing the care of adults with congenital heart disease

Cross-cutting interventions

• User involvement

• Care Pathways

• End of life and palliative care

• Workforce

• Facilities and equipment

• Data collection and audit

• Information technology

• Medicines management

• Research and development

• Planning, delivery and monitoring

THE CARDIAC QUALITY REQUIREMENTS (QRs)

DESCRIBING THE STANDARDS OF HIGH QUALITY CARE

The Quality Requirements

• Support Standards 1 – 7 and Cross-Cutting Interventions

• Support Designed for Life

• Produced to help implementation of NSF

• Help to answer question: “How will I know that each service addresses the Standards set out in the NSF?”

• Suitable for use in self-assessment or peer review.

Quality Requirements Aim to:

• Achieve a balance between:– clear, unambiguous requirements – reasonable flexibility and responsiveness to local

circumstances and settings

• Avoid duplication with the other review systems (including QOF)

Refer to objectives in NSF if there are any queries over interpretation.

Key elements of each QR• Reference number:

– Unique to each QR– Used for cross-referencing– Re-numbered in 2009

• Short title – quick guide to content of QR

• Quality Requirement

• Demonstration of Compliance

• Notes

• Service to which QR is applicable

Also available• Searching by:

– NSF Standard– Healthcare Standard– Topic:

• Audit• Clinical and referral guidelines• Health promotion• Information for patients• Patient involvement• Service organisation• Staffing and support services• Strategic planning• Training

– Old reference number (used in earlier versions)

• Weighting - initial work on risk scoring of QRs

USING THE QUALITY REQUIREMENTS

Step 1: Decide what sort of service you provide:

• Health Promotion • Primary Care Support • Ambulance Services • Acute Hospital Services

– Acute hospitals providing immediate treatment only (ITO) – Acute hospitals providing cardiac services

• District General Hospitals (DGH) • District General Hospitals with enhanced cardiac services (EDGH)

• Tertiary Cardiac Services (TCS) • Tertiary Cardiac Services including adult congenital heart disease

specialist teams [TCS (A)] • Community based Local Heart Failure Teams (LHFT)• Cardiac Rehabilitation Teams • Planning and Funding • Cardiac Networks

Step 2: Choose the QRs applicable to your

serviceYou can identify these by going through the WORD document and

noting the QRs relevant to your service.

The Excel spread sheet will allow you to search the QRs by service.

You can also search by NSF Standard and by topic. The

instructions on how to do this are given in the Excel file.

A web-based directory will be available next month which will allow

you to search and print off those QRs which apply to your service

and to export data into your own record.

Step 3: Involve staff and patient groups

The Quality Requirements are here to help us:

– improve the quality of our service to patients and their carers

– improve working arrangements for staff

– provide our Board and our local population with assurance that our services are of high quality and address the requirements of the NSF.

Step 4: Self-assess

Once you have identified the services relevant to you, you need to establish whether you comply with the relevant QR.

The Cardiac QRs are provided as a directory (or a catalogue) for your use. This is not a data entry system for external submission although this may develop in the future.

You will need to use your self assessment to inform the Local Delivery Plans being developed by each new LHB.

The Introduction to the QRs contains further detail on:– Responsibilities– Definitions– Document control

Step 4: HintsRemember:

– “We judge ourselves by our intentions and others by their actions.” ...... Would an outsider who didn’t know your service agree with your assessment?

– The ‘demonstration of compliance’ is indicative – you may choose to meet the QRs in other ways.

– Policies, procedures and guidelines should be in your usual format (one guideline may cover several QRs OR one QR may require several guidelines)

Suggestions:

– Involve staff and patients / carers

– Involve others who have experience of similar assessments (eg. cancer services, pathology services, governance leads)

Step 5: PlanHow are we going to achieve this QR?

– Who needs to be involved?– Do we need additional resources – or not?– Who is responsible?– When will it be achieved?

Summarise:

– QRs achieved– QRs achievable by internal action– QRs achievable only by additional staff / resources– QRs achievable only by the action of others

Step 6: Informing your LDP

WAG has asked that your self assessment against the QRs is used

as a baseline and that these help to inform the Local Delivery Plans

for meeting the Cardiac NSF (Ministerial letter EH/ML/0019/09)

The QRs are NOT a comprehensive planning tool! An LDP will require you to consider other issues: resource

availability; demand; existing activity; clinical audit data…

The LDPs are to be submitted to Dr Phil Thomas as the LeadCardiac Clinician for Wales by the end of March 2010

Step 5: Hints

Many of the QRs do not require additional resources – but some will. Achieve the ones that you can now while, at the same time, trying for additional resources.

If you need very large additional resources – you may need to review the type of service which you think you should be (ie. go back to step 1).

Step 6: MonitorThe QRs have been developed as a helpful tool for the service.

You can provide regular updates for patients, staff and managers

– so everyone can see the progress you are making.

• You can remind everyone of the next steps.

• You can remind everyone of why you are doing this:

– To improve the quality of our service to patients and their carers

– To improve working arrangements for staff– To provide our Board and our local population with

assurance that our services are of high quality and meet the requirements of the NSF.

Frequently Asked Question 1

Q: What is the relationship between the QRs and the updated NSF?

A: The NSF is the policy document. It’s intended audience is informed members of the general public, senior policy makers, managers and clinicians.

The QRs describe in detail the quality of the services that should be in place when the NSF has been implemented.


Q I’m concerned that the QRs don’t give a comprehensive view of services. How can you plan a service without taking into account resources, demand and capacity?

A The QRs are not a comprehensive planning tool. They allow you to assess the quality of your processes and structures. Other measures need to be considered in developing local plans – including resource availability, demand etc. Resources are under pressure in the NHS: Many of the QRs do not require additional resources – but some will. Achieve the ones that you can now while, at the same time, trying for additional resources.


Q: There are so many QRs! They are too detailed! How can anyone understand them all?

A: Because the QRs are structured around services, most people will only need to look in detail only at the section relating to their own service. The Development Groups aimed for a level of detail that reflected the important aspects of the service.


Q: We’ve been using the interim QRs to look at our services already! Is this final set very different?

A: No. The full set of QRs has been re-numbered to make the order more aligned to a patient journey through cardiac care. QRs on adult congenital heart disease have been incorporated.Minor amendments have been made within some QRs for clarity.


Q: The QRs are all about structure and process not about outcomes and isn’t it outcomes that matter?

A: The QRs do concentrate on structure and process; we know that outcomes are better when services are well structured and have good processes. They also give an immediate measure of the quality of the services. The impact of outcomes is often seen in the longer term. The QRs should be part of a wider system of quality assurance that looks at other aspects of service delivery eg outcomes and patient experience .


Q: Why do the QRs require written policies / procedures / guidelines? We all know what to do - and we all do the same thing. It’s a waste of time writing it down.

A: If policy / procedure / guidelines are not written:

– There is the potential for significant variations in practice (and we know this happens in practice)

– There is no basis against which to audit.


Q: Does it matter if it is called a policy, procedure, protocol or guidelines?

A: In general:

Policy: A course or general plan adopted by the organisation, which sets out the overall aims and objectives in a particular area.

Protocol / procedure: A document laying down in precise detail the tests/steps that must be performed.

Guidelines: Principles which are set down to help determine a course of action. They assist the practitioner to decide on a course of action but do not need to be automatically applied. Clinical guidelines do not replace professional judgement and discretion.

Use whatever term is most helpful to your service.


Q: What’s the point of having a policy / procedure if it isn’t implemented? Shouldn’t the QRs require evidence of implementation?

A: Implementation is, of course, very important. Requiring audit of all policies / procedures / guidelines places an unreasonable burden on services. Many services, will, however, want to do their own audits to assure implementation.


Q: Why do some QRs require agreement with other services?

A: Because they involve a relationship with another service. It is important to ensure that everyone has the same expectations (eg. referral guidelines).


Q: The QRs are suitable for use in peer review? Is this ever going to happen?

A: Peer review is one part of a comprehensive quality assurance programme and is something that should be considered in relation to cardiac services. There is positive evidence about the value of peer review systems coupled with computerised systems, audit and regular feedback, clinical buy-in and sustainable resourcing.


Q: Cancer Services have to comply with the National Standards this year and the final report will be submitted to WAG. Will similar compliance be imposed on Cardiac Services this year?

A: No. The self-assessment process this year is to inform your LDPs. Compliance is expected with the full NSF in 2015.


Q: Will we eventually have a system where compliance with the Cardiac QRs is entered into an online system and reports can be generated?

A: This is something we are hoping to develop. For now the QRs are available as a directory/catalogue only. Organisations will need to keep their own records of compliance.


Q: Can you tell me more about the weighting of the QRs?

A: This work is at an early stage but we have included the initial weightings as being useful to you in thinking about how to plan and prioritise your activity.The initial weights have been developed by a multidisciplinary group of clinicians. The risk score is derived from the consequence score multiplied by the likelihood score.


Q: Clinical evidence is always moving on and organisational change is inevitable! How will the QRs reflect changes in practice and organisation?

A: Discussion on the detail of the QRs has been extensive – but ongoing feedback is important so that they can be updated if necessary.

Finally…Always remember:

We are working towards achieving the Quality Requirements because we want:

– To improve the quality of our service to patients and their carers

– To improve working arrangements for staff

– To provide our Board and our local population with assurance that our services are of high quality and meet the requirements of the NSF.

Documents

The Cardiac Disease National Service Framework and Quality Requirements Cardiac Networks Coordinating Group