STRICTLY CONFIDENTIAL
Best and Safest Care
REPORT ON THE QUALITY AND PATIENT SAFETY NATIONAL WORKSTREAM OF THE NHS NEXT STAGE REVIEW
The Chief Medical Officer and his team. March 2008 CONTENTS
FOREWORD 3 EXECUTIVE SUMMARY 4 ABOUT THE REPORT 6
THE CASE FOR QUALITY THE NHS QUALITY JOURNEY SO FAR 7 WHERE WE ARE NOW 10 WHERE WE WILL BE IN 10 YEARS 10 WHY CHANGE? 10 INTERNATIONAL COMMISSIONS 11 HIGH PERFORMING SERVICES 17
RECOMMENDATIONS THE 14 RECOMMENDATIONS IN SUMMARY FORM 22 THE 14 RECOMMENDATIONS IN-DEPTH 24 PERSPECTIVES 38
APPENDICES THE CURRENT QUALITY LANDSCAPE 47 STANDARDS: TERMINOLOGY, TAXONOMY AND USE 57 PRINCIPLES OF THE NHS 59
RELATIONSHIPS WITH THE FUNCTIONS OF THE INSTITUTE OF MEDICINE NATIONAL QUALITY AND SAFETY FORUM NEVER EVENTS 62 PUBLIC CONSULTATIONS 63
2 FOREWORD
Over the last ten years, there have been major improvements in the NHS resulting in better access and more choice for patients, clear management accountability, more freedom for local services to plan and innovate as well as a more transparent financial regime. There have been substantial increases in the resources devoted to the NHS – financial, workforce, information technology and equipment.
The next steps of reform need to place quality and safety of care at the heart of the NHS – its policies, its plans, the ways its services are designed, delivered and funded. A key element of the transformation required is inspiring, motivating and empowering local clinical teams to assure and improve the quality and safety of the services they provide to patients.
Each of the high performing teams we have studied as part of the work for the Next Stage Review has displayed extraordinary clinical leadership, coupled with a hunger to achieve excellence and a curiosity to find out how the team is performing compared to the best. We were told that the NHS currently has ‘islands of excellence’ in a sea of often mediocre performance.
When this view was reflected to an audience of clinical staff in Somerset, a nurse stood up and told us ‘It is true that we have islands of excellence, but help us to build the bridges and ferry routes between them’.
In this report, we distil what we have learned about the state of quality and safety in the NHS. We acknowledge that the NHS quality framework built up over the last 10 years is greatly admired internationally. But we also make clear that quality and safety have not yet broken into the mainstream of the NHS.
We set out key proposals to take the next steps to turn the services the NHS provides from good to great.
Sir Liam Donaldson Chief Medical Officer 14 March 2008
3 EXECUTIVE SUMMARY
• This is the report of the national work Collaborative), the National Library for stream on quality and patient safety, Health, and the NHS Research and one of the major inputs to the NHS Next Development programme. The Quality and Stage Review. Outcomes Framework linked to payment to general practitioners has also been used • It is the work of the Chief Medical Officer to promote high quality in primary care. and his team, drawing on: the former’s 25 year experience in the field of healthcare • This decade-long programme of work on quality and safety; reviews of the present quality and patient safety has begun to state of quality improvement in the NHS address long-standing problems within the undertaken by three leading North NHS. Awareness has been raised American agencies; and in-depth studies of throughout the NHS of the importance of high performing services in the NHS and quality and safety. A culture of clinical elsewhere. governance (certainly an intolerance of bad practice) has infused many parts of the • This report culminates in fourteen NHS. Improvements have taken place as a interlinked recommendations that in aim result of compliance with key standards in to make quality the currency of the NHS. particular fields of care (e.g. cancer, heart disease) and in the primary care sector • Since 1998, the NHS has put in place and through the Quality and Outcomes developed a framework for healthcare Framework. Attention has also quality comprising: national standards (led been given to reforming traditional by the National Institute for Health and policies (e.g. on medical regulation and Clinical Excellence and through National medical litigation) to orientate them more Service Frameworks); local clinical effectively to patient safety and quality governance and a statutory duty of quality; assurance. robust mechanisms of inspection (overseen by the Healthcare Commission). • Despite these changes, serious problems of quality and safety remain (many of which • In addition to this core framework, further are shared by other healthcare systems action was taken to enhance the NHS around the world), for example: approach to quality in the late 1990s and - extensive variation in standards of care early 2000s. These included the persists around the country establishment of a patient safety - avoidable risks and serious safety programme (led by the National Patient incidents have not been adequately Safety Agency) and mechanisms to address controlled or eliminated poor practitioner performance (led by the - best practice and excellence is evident National Clinical Assessment Service). only in a minority of services Measures to identify and spread good - many patient complaints reveal ongoing practice and evidence of clinical problems such as bad interpersonal care effectiveness have included the work of and poor care coordination the Modernisation Agency (later the Institute for Improvement and Innovation), • The overall aim of this strand of work is to the Collaborative Programme (notably the mainstream quality and patient safety highly successful Primary Care within all aspects of the work of the NHS:
4 in policy-making, in planning and - Redesigning the funding flows and commissioning, in design and delivery of incentives within the NHS to reward services. The feedback from the higher quality and penalise poor or internationally commissioned work unsafe care showed major barriers that will need to be - Laying down a set of duties and overcome if this transformation is to take responsibilities for clinical teams to lead, place, for example: deliver and demonstrate quality - there are no quality improvement goals - Creating a patient safety initiative to take at system level life-saving action to reduce catheter- - there is a plethora of standards with related bloodstream infection nationwide confusion about their definition, use and and embed the use of evidence and importance measurement into patient safety - information on clinical quality is poor, so measures in the NHS too are clinical skills in improvement - Establishing within the new proposed science and performance assessment system of regulation of health and social - there is a great absence of patients and care services, a framework to promote family members in the planning and higher quality care commissioning of services - the commissioning function is not aligned • It is intended that the proposals in this to levering regular and sustained report will help NHS Next Stage Review to improvements in quality and patient make quality and safety the currency of safety the modern NHS in a way and on a scale that has not been possible in the past. • The studies of high performing services provided a clear and consistent picture of the nature of clinical teams that deliver excellence on a day-to-day basis. The challenge is how to do this throughout the NHS not as described by one member of NHS staff as only in ‘islands of excellence’.
• As a result of this context, experience and analysis, 14 proposals for action have been made aimed at: - establishing an accountability framework for quality and safety at the system level and applicable in all service settings - rationalising, defining and clarifying the standards used to drive higher quality, safer care and placing this in the hands of an independent, expert body - Simplifying the quality landscape to clarify roles, responsibilities and relationships of different bodies and agencies
5 ABOUT THE REPORT
1. This report has been compiled by the Chief e.discussion with a national stakeholders Medical Officer and his team at the request group and a national working group. of Lord Darzi to assist in the NHS Next Stage Review that he was asked to 4. With these inputs we set out in this report: undertake by the Prime Minister. a.the NHS quality journey so far; 2. The report is the output of the national work stream on quality and patient safety, b.where we are now, and where will be in one of the Review’s key programmes of 10 years; work. c. the case for further change to the way 3. The inputs to this work have included: that quality and safety are dealt with within the NHS; a. a series of commissioned pieces of work from leading North American health d.the cultural and practical barriers to the agencies – the Institute for Health achievement of a state where quality and Improvement (based in Boston), the safety are mainstream activities of all Joint Commission (based in Chicago), NHS organisations and staff; and the RAND Corporation (based in Santa Monica); e.proposals for achieving the transformation required. b. a short study tour of the East Coast of North America conducted by Lord Darzi and the Chief Medical Officer in Aims of the Work of Quality and November 2007; Patient Safety Strand of the NHS Next Stage Review c. in-depth visits and analysis of five high performing NHS services in England: the • To make quality and patient safety stroke unit of Guy’s and St Thomas’ NHS the common currency of the NHS Trust; the South Staffordshire mental through which services are planned, health assertive outreach team at South designed, managed, assessed and Staffordshire and Shropshire NHS funded Foundation Trust; the cardiothoracic • To ensure that every NHS division at James Cook University organisation’s business plan and Hospital, Middlesbrough; the general quality plan are one and the same practice surgery in Puddletown, Dorset document Primary Care Trust; and the paediatric • To achieve greater consistency in the oncology and bone marrow transplant delivery of accepted standards of best service at the Bristol Royal Hospital for practice Children; • To drive sustained reduction in the risks of healthcare d.front-line staff engagement events in Somerset and London;
6 THE CASE FOR QUALITY
THE NHS QUALITY JOURNEY SO FAR non-clinical areas of service).
5. The National Health Service (NHS) has been 8. The introduction of general management – the vehicle through which the majority of replacing the old system of administration Britons have received their health care for – in the mid-1980s followed a damning 60 years. At its outset, the NHS set no report by Sir Roy Griffiths pointing to the specific agenda for quality improvement inadequacies of leadership, accountability aside from developing the infrastructure of and control mechanisms in the health care and embracing clinical advances and service compared with other sectors and new technologies as they arose. In the services. Initially, focusing on executive early days, quality assurance was implicit posts, general management eventually was and based on an assumption that highly extended to clinical managerial roles with educated, well-trained staff would service the establishment of clinical directorates the needs of patients to a high standard. holding their own budgets and Medical and Nursing Directors with seats on the 6. The position remained much the same for Boards of hospitals and other health 20 or more years when there was a organisations. growing interest in concepts and measures of quality in health care. Much of the 9. The advent of general management stimulus to this new thinking was external. introduced more accountability and a Particularly important was the work of the stronger notion of health organisations as US quality pioneer, Donabedian, and his corporate entities. With this came a conceptualisation of the dimensions of tendency for mission statements and healthcare quality as structures, processes planning documents to make explicit their and outcomes. However, such influences intentions to improve quality. However, were largely on British health services this was infrequently backed up by the researchers and policy analysts and not on systems and methods within the those running the service. In the late 1960s organisation to ensure successful delivery and early 1970s, there was little flow of quality goals. through of new quality concepts into practice or health system design. However, 10. In 1990, there was a major redesign of the throughout the history of the NHS, health care system in Britain with the professionally-led quality initiatives, creation of an internal market splitting particularly clinical audit, have been purchaser and provider functions with carried out in many centres. contracts governing the funding and provision of care. This change arose after a 7. During the 1970s, the NHS remained period, in the late 1980s, in which a series centrally planned, demand-led and of well-publicised failures to provide administered rather than managed. funding for specialist services led to a Quality still remained largely implied in public outcry. The 1990 changes service goals. Implementation was based redesigned the structure and functioning on a philosophy of ensuring the presence of the NHS with the intention that it of skilled staff, the provision of good should simulate the incentives of the facilities and equipment backed up by market to achieve greater efficiency and procedural guidance (much of it covering more effective delivery.
7 11. There was no formal evaluation of the to light by a ‘whistleblower’ together with 1990 health system changes but they the media images of distressed parents became increasingly controversial and picketing the General Medical Council publicly criticised and were partly offices carrying cardboard children’s dismantled by the incoming Labour coffins, added to the sense that this event government in 1997. was a watershed in public and professional attitudes to quality in the NHS. The Bristol 12. Amongst the changes to the NHS affair was the subject of a public enquiry introduced by the Labour government was but many smaller scale incidents helped to a new duty of quality for all NHS form the view that the then mixture of organisations which aimed to address all professional self-regulation and employer elements of the quality curve represented disciplinary procedures no longer in Figure 1. commanded confidence.
Figure 1: Variation in the Quality of Health 15. There were further scandals: the most Organisations serious involved the serial killer, general practitioner, Dr Harold Shipman. Serious questions were asked about how his spree of killing could have gone undetected for so long.
16. A key element of the new quality strategy for the NHS introduced in the late 1990s was the concept of clinical governance. It is defined as:
A framework through which organisations are accountable for continuously Source: Scally G, Donaldson LJ. BMJ. 1998 Jul 4;317(7150):61-5 improving the quality of their services and safeguarding high standards of care by 13. Leading up to this was an undoubted shift creating an environment in which in public and professional attitudes to poor excellence in clinical care will flourish. quality in the NHS. It came through a series of high profile failures in standards of care 17. It required Boards explicitly to accept in a number of services. responsibility for assuring and improving clinical quality, and to approach this task in 14. Serious deficiencies in standards of care a systematic way. All NHS organisations were identified in the children’s heart were charged with developing local clinical surgery service in Bristol, England. Three governance arrangements comprising, as a doctors – two surgeons and the medically basic framework: qualified Chief Executive Officer – were removed from the Medical Register after - clear accountability arrangements for the longest running disciplinary hearing in clinical quality, including regular the General Medical Council’s history. The reporting to the Board and a published fact that the problems were only brought annual report
8 - a programme of quality improvement people, diabetes, renal disease). An activity, including participation in clinical inspectorate, the Commission for Health audit programmes, application of Improvement (later the Healthcare evidence-based practice and Commission) was charged with ensuring appropriately targeted continuing that local clinical governance professional development arrangements were working effectively and that key standards were in place. - clear policies for managing risks, including procedures for identifying and Figure 2: Setting Quality Standards remedying poor professional performance
18. Implementation of clinical governance was underpinned by a new statutory duty for quality, established in legislation. The duty required the principal NHS organisations – Health Authorities, NHS Trusts and Primary Care Trusts – to ‘put and keep in place arrangements for monitoring and improving the quality of the health care Source: A First Class Service: Quality in the new NHS. Department of Health 1998. they provide to individuals’.
21. With this framework in place, further 19. The implementation of clinical governance enhancements to the NHS approach to was a medium to long-term aim, requiring quality took place from the late 1990s sustained management effort and a through into the early years of the 21st fundamental shift in organisational Century. Investigations into failures in culture. More specific requirements of NHS standards of care in particular NHS services organisations were set out in management had identified various common factors guidance, and the creation of a statutory notably a culture of tolerance of poor duty for quality on NHS organisations was practitioner performance and a lack of intended to ensure that the development expertise in dealing with it. This led to the of clinical governance arrangements establishment of a specialist service to remained a priority. support NHS organisations (the National Clinical Assessment Service) in dealing with 20. With the centrepiece of the duty of quality poorly performing doctors and also a set of and local clinical governance radical proposals to reform the regulation arrangements, a new framework was of doctors set out in the Green Paper, Good created (Figure 2) to support the assurance Doctors, Safer Patients. and improvement of quality within the NHS. Clear standards were set by a 22. Support mechanisms to assist local NHS National Institute of Clinical Excellence organisations to improve quality were also (NICE) and through the creation of a series put in place: a Modernisation Agency of National Service Frameworks (NSFs) (later evolved into the National Institute covering major disease or population for Improvement and Innovation) and a groups (heart disease, mental health, older
9 series of Collaboratives. These approaches evidence of progress in developing the focussed on issues such as leadership, the culture, methods and accountabilities design of the process of healthcare and necessary to sustain high quality health ways of galvanising change. They were care. The last decade has been a essentially concerned with identifying and particularly active period. Despite all spreading good practice. these positive changes, four major problems stand out: 23. The other major development was the - Suboptimal and poor quality care is still introduction of a programme of patient endemic within the NHS safety through the publication of the - The quality landscape has become report, An organisation with a memory. increasingly complex with roles, This raised awareness of the high level of accountabilities and interrelationships of avoidable errors in health care (700,000 different organisations lacking clarity per year) and drew attention to the - Quality and safety is still not the systems nature of their causation. As a predominant culture of the NHS result a National Patient Safety Agency - The system levers, funding flows and (NPSA) was established and charged with incentives of the NHS are not designed to creating a reporting system to identify and support quality improvement analyse adverse events and draw out the lessons for action to reduce risk. The WHERE WE WILL BE IN 10 YEARS programme was reviewed and reinforced with new measures in a further report 26. The overall aim of the proposal set out in published in 2006, Safety First. this report is to create an NHS which has quality and safety of patient care at its 24. The creation of a national research and heart, by: development function within the NHS in - Refocusing on quality and safety the early 1990s played its part in the NHS - Reclaiming the responsibility for quality quality journey. It meant that the of patient care for clinical teams philosophy of evidence-based medicine - Removing barriers to clinical teams which started in North America but rapidly improving their services became international in its scope was - Providing a framework and help for embraced by the health service in Britain. clinical teams improving their service The difficulties of implementation were - Rewarding quality of care, not volume formidable, and remain so. The need for professional attitudes and behaviour WHY CHANGE? change, access to valid and appropriate information, the right infrastructure of 27. The NHS towards the end of the first information technology and training in decade of the 21st century in the year of its skills for critical appraisal and clinical 60th birthday is very different from the practice guideline use, being just some of one that started as a cornerstone of a new the developmental challenges. Welfare State in the years after the Second World War. WHERE WE ARE NOW 28. Its infrastructure of buildings, equipment 25. The NHS quality journey so far shows and staff has expanded and modernised.
10 The range of technologies and drugs events and near misses available to diagnose and treat illness has - less tolerance of poor practitioner burgeoned offering life and hope where performance when it threatens patient it was impossible midway through the safety or compromises the effective 20th century. The range of diseases and functioning of a clinical team the consequent demand for care has increased exponentially as the so-called 31. Despite the stronger quality and patient epidemics of modern living (e.g. cancer, safety ethos that exists in the NHS now heart disease, diabetes) and an ageing compared to 10 years ago, fundamental populating have generated pools of need problems remain, for example: on a much larger scale than when the - variation in standards of care around the NHS began. On top of all this, in country is extensive common with other developed countries, - some of the basics (notably cleanliness the proportion of the country’s budget and health care infection) have been devoted to health care has expanded neglected dramatically. - best practice (based on research evidence) is adopted too slowly and inconsistently 29. In the last decade alone, these trends - the avoidable risks of health care are still have continued with big extra too high investments in the NHS producing - incidents of serious failures in standards expansions in the numbers of doctors, of care still occur nurses and crucial equipment like - many patient complaints reveal repetition Magnetic Resonance Imaging (MRI) of the same problems: disrespect for scanners. In turn, this has helped to patients and their families, bad reduce access times, treat more people communication and poor coordination of and improve outcomes of care for many care patients. 32. All these factors lead to the inevitable 30. As described in the previous section, the conclusion that quality and patient safety development of a quality framework for are not yet embedded in the planning, the NHS over the past 10 years has design and delivery of NHS services. More brought a number of very important and sleep is still lost over financial matters than positive changes to the service, in about whether patients are treated with particular: dignity and respect, whether outcomes of - more extensive use of standards to care are genuinely world class and whether assure and drive improvement in service patients are properly protected from harm performance when they are being cared for. - programmes of regular review and inspection of standards of care 33. See Appendix 1 for details of current - greater awareness amongst NHS staff quality landscape that quality and patient safety cannot be improved unless they are explicitly INTERNATIONAL COMMISSIONS recognised as issues and targeted for action 34. With this background, the internationally - regular reporting and analysis of adverse commissioned work provided key insights
11 into the barriers that must be overcome to achieve further transformation. This • Confusion about definition, use and international work took the form of three importance of standards separate analyses of quality in the NHS, • Great absence of patients and family each looking at a distinct part of the quality members in planning, design and improvement process. The RAND delivery of services Corporation was commissioned to examine • Clinical skills in improvement science standard setting in clinical practice. The and performance assessment lacking Joint Commission, the leading accreditation • Commissioning function aligned to organisation in the USA, was commissioned setting tougher contracts rather than to examine inspection of quality in focussing on local systems planning to healthcare. The Institute for Healthcare generate faster, consistent quality Improvement was asked to examine support improvement for quality improvement. Separate reports • Culture of fear too prominent in are available covering their findings. management hierarchy • Mechanisms for oversight of quality 35. Each commission carried out a review of too fragmented and regulation current evidence of international best perceived as with overburdening with practice and an analysis of the current overlaps of functions situation in the UK, meeting with key stakeholders in the UK health system. During this process a total of 160 Islands of Excellence interviews took place, in 117 meetings involving 116 separate key stakeholders. 37. Local examples of superb performance at the departmental, service or practice level 36. A number of other key themes emerged were found in the NHS, but services from these reviews. These are discussed in performing at this level are relatively rare. the next sections of the report. The majority of services are functioning at a more moderate level, or simply do not have sufficient data to prove how well Barriers to further they are functioning. This concept, which transformation identified by the came from one of the NHS staff international commissioned interviewed, was expressed as ‘Islands of reports excellence in a sea of mediocrity’.
The commissioned work identified that in Figure 3: NHS Quality: where next? order to transform itself into a quality improvement organisation the NHS must address:
• The need for quality improvement goals at system level into which all activities can be integrated • Poorly developed information on clinical quality
12 Source: Achieving the vision of excellence in quality. Different organisations set different Institute for Healthcare Improvement. 2008. standards, using different methods and Standards with variable use of evidence. It is not clear which standards must be followed 38. The view reflected to the international and which are optional as a matter of local reviewers by the NHS stakeholders and discretion. The NHS lacks a clear staff when they spoke to us was that there overarching framework for quality to unite are too many standards in the NHS at these disparate standards. Table 1 shows a present. Their heterogeneity is unhelpful. selection of some of the major standards in
Type of Standard Purpose Who Uses? Nature of Evidence
Clinical performance Improve outcomes of Physicians, patients, Scientific, care managers professional consensus
Safety Reduce the likelihood Managers, clinicians, Epidemiology (either • Patient of harm regulators from literature of from • Staff reporting systems)
Access (e.g., waiting Reduce barriers to Patients, managers Patient preference, times) needed care; improve clinical evidence patient experience (delays that affect outcomes)
Service (e.g., patient Improve patient Patients, managers, cli- Patient preferences experience) experience nicians Regulatory Ensure minimal accept- Regulators, managers Consensus able levels of quality Professional Ensure fitness for prac- Licensing bodies, Professional tice regulators consensus Population health Motivate action to im- Public health profes- Epidemiology prove health sionals Financial Increase value of Purchasers, regulators Comparative health care product performance Data Enhance utility Standards setting Consensus bodies, vendors
the NHS, with a range of purposes, users responsible for setting standards and their and evidence on which they are based. acceptability. Those set by the Department Source: McGlynn EA, Shekelle P, Hussey P, Burgdorf J. of Health without involvement of outside Developing, disseminating and assessing standards in the groups are less acceptable to the NHS. National Health Service: An Assessment of Current Status and Opportunities for Improvement prepared for the NHS Despite a proliferation of standards in the Next Stage Review. RAND Corporation 2008. area of effectiveness, standards are not so well developed in the areas of fairness and 39. Some standards are credible and valued by personalisation. service providers. Others are not. A clear relationship exists between who is 40. Publication of standards is insufficient to
13 promote widespread uptake. A widely of (satisfactory) levels of performance or used routine mechanism for alerting results that can range from minimum doctors about new standards or assisting through acceptable to excellent’ them in putting them into daily practice is - Clinical or practice guidelines are needed. Current mechanisms include: ‘systematically developed statements to - decision support tools, such as checklists, assist practitioner and patient decisions exist but are not widely used about appropriate health care for - a number of organisations assess particular circumstances’ performance against standards (some are voluntary, others not) 44. The principal difference, then, is that - a number of organisations use standards standards set a particular level of clinical for accountability (the level of scrutiny performance that must be attained whilst varies) guidelines aim to promote good clinical performance. The relationship between 41. Whilst there is a need for terminological the two is close since standards will often clarity in this whole field, there is no need be derived from guidelines and be a more to start from scratch since an extensive explicit and measurable form of them. academic literature already exists. A There is further debate in the academic number of broad conclusions can be literature about ‘levels’ at which standards drawn. are set and whether the terms ‘minimum’, ‘acceptable’, ‘excellent’ are to be preferred 42. Two concepts are strongly embedded in over (say) ‘minimum’, ‘optimal’, ‘ideal’. the tradition of clinical quality Furthermore, researchers have examined improvement – standards and practice methods of constructing and developing guidelines. Good, formal definitions exist guidelines and standards as well as ways of each and whilst they have different of disseminating them and achieving purposes there is a strong relationship compliance. between them as processes for improving clinical quality. 45. One concept – clinical pathways – is not so clearly established as a quality 43. The field of standards, guidelines and improvement tool though it is in clinical protocols is dogged by different widespread use. Essentially, it focuses on understandings and interpretations. the process of care, varying in the extent to Clinical Pathways is a recent term and has which explicit standards are used and the not been subject to so much terminological extent to which the aim is more towards debate. Ironically, given that the everyday efficiency and consumer satisfaction (i.e. use of these terms is often confused, ‘re-engineering’ the process). misunderstood or used synonymously, they are underpinned by an extensive academic 46. The concept of clinical pathways can in literature where good formal definitions fact be traced back to the 1950s when a so- do exist. Probably the best were called Critical Path method was used in developed by the US Agency for Health other industries, but in the USA in the Care Policy and Research in the early 1990s 1980s the technique was first widely used and are as follows: in healthcare. The concept has been taken - Standards are ‘authoritative statements up more recently in the UK. Again it is a
14 term that means different things to more that three to five – which must all be different people. Essentially though, implemented in the same space of time to creating a pathway involves concentrating achieve clinical improvement. on the process of care so as to: - make it more evidence-based 50. Thus, in the years ahead, four clinical - coordinate more effectively the different quality assurance and improvement tools: stages of care and remove redundant standards, guidelines, clinical pathways, steps and care bundles, are likely to remain - make it more ‘patient friendly’ widely used in this country and overseas. - allow different practitioner groups to To a large extent they can also be used in understand how their roles and those of local clinical audit programmes. others are contributing to the overall plan of care 51. There are a number of other issues central to the debate about how these tools are 47. A more recent concept – the ‘care bundle’ used in the future, the most important of – has not been formally defined nor which is the extent to which they are set widely applied and evaluated but is nationally (and who is involved) or locally simple in its construction involving (and how this is undertaken). A number of grouping together evidence-based points can be made about this: interventions and applying them - purely ‘top-down’ standard setting collectively. seldom achieves clinical ownership - local standard-setting exercises that ‘take 48. This was initially created in a Veterans or leave’ evidence are wasteful and Health initiative in the USA to improve the detrimental to quality improvement quality of care to patients in intensive care - designing standards into broader units. It drew together the evidence-based pathways of care is particularly measures known to be effective in challenging task for which there is limited reducing ventilator-associated pneumonia expertise in the clinical world in such patients. Four practices were chosen: 52. It is probably simplistic to believe that the - elevation of the patient’s head to 30 – 45 quality and safety of care can be controlled degrees solely by the setting of national standards - daily sedation vacation and assessment of or that a watertight distinction can be readiness to extubate made between terms such as pathways, - peptic ulcer disease prophylaxis guidelines, protocols and standards. - deep vein thrombosis prophylaxis See Appendix 2 for definitions and taxonomy 49. The concept of care bundles has been of the concepts discussed in this section. developed further and widely promoted by the Institute of Health Improvement and others in the USA. So far they have mainly been used in relation to central lines, ventilator-associated pneumonia and sepsis. The care bundle comprises a number of evidence-based practices – no
15 Establishing and agreeing a pathway to - ‘all pre-hospital procedures should be achieve consistently high quality can within Joint Royal Colleges often be a very complex process Ambulance Liaison Committee and covering: Ambulance Association guidelines’ - the desired flow of patients through a - ‘all in-hospital procedures should meet local or regional health system the latest British Cardiovascular - detailed procedural guidance Intervention Society (BCIS) and British (includingclinical protocols) Cardiovascular Society guidelines for - explicit standards staffing, surgical cover and procedure - guidance on the organisation and numbers’ infrastructure of the service - ‘bare metal stents and drug-eluting stents should be used in accordance A good example of this is the pathway of with NICE guidelines’ care for patients with acute myocardial infarction (heart attack). Patients who suffer acute myocardial infarctions can be Regulation treated in a number of ways depending on the nature and severity of their 53. Notwithstanding confusion about the coronary artery disease, other illnesses volume and diversity of current standards, they are suffering from, how quickly their there is also concern amongst front-line heart attack is recognised and where they NHS staff and local managers about the are in the country at the time. range of current inspection, regulation and accreditation functions. Too many National ‘guidance’ sets out the patient organisations have the right to visit, to ‘flow’ as pre-hospital and hospital stages make judgements about services and to of care for people who have had heart call upon the organisation to do something attacks. Depending on their symptoms, about any shortcomings identified. guidance directs that patients should go into ‘pathways’ such as for angioplasty, 54. Most activity is perceived on the front-line surgery or observation. At some points as overburdening, producing double guidance is expressed in quite specific jeopardy and sustaining overlapping roles ‘protocol’-style terms for example: ‘if the of inspectorial bodies. ECG shows ST segment elevation or bundle branch block, then ambulance staff Using Data shall make a pre-alert call to the hospital’. At other points the guidance is expressed 55. Quality improvement, whether through more as a standard, for example: ‘the time competition by providers to be selected by from call for professional help to informed consumers, or by the effect on treatment with angioplasty (‘call-to- reputations of public information, requires balloon time’) should be no more than good measure of performance that are three hours’. At other points, the readily available to those making decisions. guidance directs that more detailed This is not currently achieved in the NHS. guidance should be followed, for example:
16 56. The quality of much of the data is poor, HIGH PERFORMING SERVICES including significant amounts of both missing and inaccurate data. Some types 60. The visits to high performing services of data that would be useful are not around the country provided insights into routinely collected (e.g. procedure-specific how teams within the NHS can mortality, patient outcomes, patient demonstrate excellence. These units were experience). Information is not always identified by a process of triangulation, presented in ways that can be used by using objective evidence of clinical different audiences (e.g. clinicians, outcomes, the opinions of clinical experts, managers, patients). and a measure of patient satisfaction.
57. Those who produce the data generally do Stroke Service at St Thomas’ Hospital, London not use it. These data are sent up the line in response to administrative requirements 61. The Stroke Service as St Thomas’ Hospital but little data flow back or are used locally. stands out as a leader in the field, pursuing Those who produce the data have little an uncompromising quest for the gold sense of ownership locally, which creates standard. A combination of dynamic problems with data quality in collecting clinical leadership, excellent working accurately, correcting errors or flagging relationships with management, a highly- problems. Data collection is seen as skilled multi-disciplinary team and the ‘feeding the beast’ rather than a path to rigorous use of audit have combined to a quality improvement. produce a service that consistently emerges at the top of the national audit of stroke 58. The need for a national data information services. The team demonstrates an infrastructure is recognized. In particular, enterprising use of service redesign, patient choice and commissioning registries, nurse practitioners and tele- initiatives require considerably more ability medicine. to use data by different audiences than is available today. 62. This team, in common with all the high performing services visited, uses locally- 59. There is considerable skepticism in the NHS driven real-time collection of data to great about the possibility of meeting the need effect. Important clinical indicators, for a national data system. Improving data including those identified as needing local use locally requires culture change and improvement, are monitored, with results training. Managers do not always respect displayed publicly on the walls of the ward, the importance of clinical information. and used in planning and monitoring Doctors do not respect the importance of improvement strategies. management information. The skills and capacity to analyze and use data are very 63. One theme which emerged strongly at this limited at local levels. unit was the emphasis placed on role development for all members of staff. For example, the stroke specialist nurse role has been extended to cover many highly skilled tasks; and the stroke specialist nurse, in turn, mentors other nurses
17 through presenting at conferences and improve all aspects of patient care, from educational opportunities. delivering a primary angioplasty service for heart attacks to ensuring continuity of 64. The Stroke Service at St Thomas’ Hospital nursing care throughout the patient’s has also boldly embraced innovation and journey. technology to improve the services it offers to patients. Thrombolysis improves the Figure 5: Mortality is lower than expected at outcome of a patient who has an ischaemic the James Cook University Hospital stroke: but must be delivered within 90 Cardiothoracic Division minutes of the stroke. To meet this challenge, the team has set up a telemedicine facility whereby all patients can be assessed by a consultant by videolink, increasing the timeliness of senior assessment and resulting in more patients receiving the best treatment (Figure 4) .
Figure 4: Telemedicine has increased the number of stroke patients receiving thrombolysis at St Thomas’ Hospital
66. One theme demonstrated particularly clearly by this team is the value of thorough use of quality management techniques for continual self-evaluation. A dedicated governance team is trained in audit, research, information technology and quality improvement skills. The team Cardiothoracic Service at James Cook makes exceptional use of real-time data to University Hospital, Middlesbrough identify problems as soon as they arise.
65. The James Cook University Hospital, 67. Another theme is the value of participation Middlesbrough, has built up an exemplary in research. It is well established that cardiology service in a deprived region of academic centres perform well. What was the country. The South Tees Hospital NHS observed in this series of visits was the Trust has received national recognition for involvement of the whole multi- the high quality of services it delivers. The disciplinary team. This generates a culture Cardiothoracic Division is a forward- that is receptive to, and aware of, best looking and innovative team, who deliver practice, as well as an eagerness to put a service that is now acting to reduce the research into practice and adopt change to inequalities compared to the national deliver the best possible care to patients. average. Particularly impressive was the continual search for opportunities to
18 General Practice in Puddletown Surgery, 69. Continuity of senior staff, clinical and Dorset managerial, was a key component of this team’s success. Stable relationships had 68. Puddletown Surgery, Dorset, is an example been built between the clinical and of excellent general practice. They have managerial staff in the General Practice achieved some of the highest patient surgery and in the Primary Care Trust. satisfaction levels in the country, with 98% Mutual trust allowed staff to work as a of their population satisfied with opening team across the organisations, and to hours and only one complaint in the last 10 support each other in their roles in years (Figure 6) . By working closely with a organising and delivering local care; a supportive Primary Care Trust and contrast to the reported management developing exemplary links with the ‘culture of fear’ in some other parts of community through a network of the NHS. volunteers, they have demonstrated an effective and viable model of semi-rural Figure 6: Patient Satisfaction at Puddletown general practice. Surgery
Paediatric Oncology and Bone Marrow 71. The team demonstrates clinical ownership Transplant Service at the Bristol Royal over their service performance. The Hospital for Children Toyota Lean methodology was applied by a cross-section of all members of the team, 70. The Bristol Children’s Bone Marrow including porters, doctors, domestic Transplant Service demonstrated how a workers and nurses. The aims are culture of excellence can flourish in a expressed in a clinically relevant context; previously troubled hospital. The unit is using Toyota Lean methodology to design a service built around maximising efficiency, and improving the experience of all the patients passing through. The team was the first in Europe to start a programme of paediatric unrelated donor bone marrow transplant. Their experience is reflected in the excellent leukaemia-free survival rates of their patients.
19 the simplification of the patient journey 73. The team is committed to putting the aims to reduce inefficiencies not just for service user at the heart of its service. management reasons, but in order to Success has come through working with improve the patient experience by making patients and the wider community to the patient pathway smoother and with deliver a high-quality service that is led by greater continuity of care. the needs of its clients. Their highly service user-centred focus has led to strong multi- Assertive Outreach Service in South disciplinary and cross-sectoral relationships, Staffordshire for example with the police, housing association, inpatient services and social 72. The Staffordshire Mental Health Assertive services. This has led service users’ needs to Outreach Team showed how the often drive the creation of a joined-up service neglected area of mental health can use a across health and social care. patient-centred culture, team-based problem-solving skills, multidisciplinary relationship building and strong leadership International High Performing Teams to build a service held in high regard by both patients (Figure 7) and where 74. International examples also demonstrate performance stands up to objective high quality practice. Peter Pronovost, an assessment. The South Staffordshire and intensive care physician at Johns Hopkins Shropshire NHS Foundation Trust delivers a Hospital in Baltimore, USA, has shown how high quality of service and is rated very a multi-intervention programme to reduce positively in patient feedback. The South Catheter Related Bloodstream Infections Staffordshire assertive outreach team is can have a remarkable effect. recognised as an excellent unit that exemplifies the values of the Trust. 75. His team promoted the use of five interventions to reduce infection rates and Figure 7: South Staffordshire, as well as a check list to make sure each one was achieving excellent clinical outcomes assessed done every time. These were in the context by other means, is rated positively by its of a wider package of measures, including service users a daily goals sheet for improving communication among clinicians, a unit- based safety programme to generate a culture of patient safety and the coaching of a doctor and nurse to lead local implementation.
76. Using this series of interventions, he and his team have enabled a sustained reduction (up to 66%) in rates of catheter- related blood stream infections across the State of Michigan.
20 High performing clinical teams: key characteristics The high-performing teams had many factors in common, including: • Excellent clinical leadership • Management goals expressed as clinical benefits understood by the patient and the team • Clearly understood common culture • Clinical ownership of service performance • Strong emphasis on measurement and use of ‘real-time’ data • Eagerness to compare with other services • Continuity of senior staff • Workload managed to avoid excessive burden on staff • Quality improvement integral to work with skilled use of performance improvement techniques • Patient and family involvement strong • Jobs and individual developed through education, training and role development
21 RECOMMENDATIONS
THE 14 RECOMMENDATIONS IN SUMMARY FORM based on those where variable performance leads to substandard care 77. In the panel below, the 14 (e.g. stroke), where heavy resource recommendations in our report are consumption is associated with waste (e.g. summarised. The following sections of the cancer care) or where there are serious report then discuss the recommendations risks attached to the process of care. in greater depth. Recommendation five: An Institute of Medicine Recommendation one: An accountability An Institute of Medicine should be framework for better, safer care created to fulfil an independent role in A set of goals at system level should be standard setting, knowledge established to focus all policies, plans and management and support for quality activities within the NHS on quality and improvement. safety. Recommendation six: A regulatory Recommendation two: Clinical framework Dashboards A regulatory framework should be Each clinical team in the country should developed to assure quality and penalise be required to maintain a clinical poor standards of care. This would dashboard to monitor and benchmark require every provider of service within performance against standards agreed (or for) the NHS to be formally licensed to nationally and locally designed do so. Licences of this sort could be performance indicators. Clinical qualified (or ‘endorsed’) where there is dashboards would be statutory substandard care. In serious cases, requirements, publicly available and retention of Foundation Trust status presented in a common format that is could be qualified. A special programme easily understood. of regulation for the commissioning function itself would be established. Recommendation three: Rationalisation of existing standards and guidelines Recomendation seven: Funding higher Existing standards and guidance should quality, safer care be reviewed to produce a set of preferred Funding flows should be redirected to standards for all clinical areas. This support higher quality, safer care. process of rationalising and defining Through variations to the tariff (or extra- preferred standards would be expected tariff payments), the funding levels for to lead to the generation of outcome higher quality and safer care will be indicators for use in clinical team made bigger. A proportion of the dashboards. funding of NHS providers of care would be based on independently conducted Recommendation four: NHS Preferred surveys of patient experience of the Clinical Pathways service concerned. Agreed standardised pathways should be designed for a number of key illnesses
22 Recommendation eight: Commissioning of services will be linked to clinical Recommendation twelve: Employees as dashboards partners Dashboards should be used as a key A John Lewis-style partnership scheme component of the commissioning process. should be created to enable NHS staff to Commissioners will make choices share in the ownership of their NHS informed by clinical dashboards and organisation. The permanent staff of an assessed by the Care Quality Commission. NHS organisation would in effect ‘own’ the organisation and share in its income Recommendation nine: Clinical and benefits. Each staff member would governance duties for every clinical become a partner whose individual team contribution to the organisation is All clinical teams should have a specified recognised and rewarded fairly. range of clinical governance duties Recommendation thirteen: Never Events agreed to ensure the quality and safety Building on international experience, the of their service. NHS should agree a list of ‘never events’ that are serious, preventable and Recommendation ten: Expanding unacceptable. Systems should be excellence by making available proven developed to ensure that healthcare high performing clinical leaders providers do not receive payment if these Clinical leaders in services achieving events ever occur. proven levels of excellence in care should be made available to services delivering a Recommendation fourteen: A patient similar range of services to help them safety initiative raise their standard of care. These A patient safety initiative should be ‘change’ leaders would be Fellows of the launched to embed the use of evidence Institute of Medicine and will share and measurement into patient safety learning and lessons from their diverse measures in the NHS. The preferred fields of work. project would be called Matching They would be recognised as prestige Michigan, which would work across the appointees and this would be reflected in 218 adult general critical care units in the fast-tracking in the Clinical Excellence NHS in England and aim to reduce Awards Scheme. catheter-related bloodstream infections by 60%. Recommendation eleven: Reshaping the Clinical Excellence Award Scheme The Clinical Excellence Awards Scheme should be altered to strengthen the link between demonstrated quality of care and financial reward. More extensive use should be made of data to prove quality improvement in the assessment criteria of the scheme.
23 THE 14 RECOMMENDATIONS IN-DEPTH
Goals and system accountability Figure 8: Quality in tomorrow’s NHS Recommendation one: An accountability framework for better, safer care
78. During its review on the current status of quality improvement in the NHS, the Institute for Health Improvement repeatedly highlighted the lack of what they termed the ‘system picture’. The assessment was that there is currently no clearly articulated vision of quality in the NHS. 81. For example, instead of having detailed national targets for chronic disease, the It’s hard to answer the question about ‘How proposed quality aim for chronic diseases good is our quality’ because we don’t have (identifying early, slowing progression, an overall quality measurement framework, improving quality of life) describes the and so we only see what is under the lamp desired outcomes in holistic terms. This posts. What’s under those lamp posts seems approach serves to integrate all of the NHS to be getting better, but what about what’s in a simple purpose that can be well not under the lamp posts? understood by staff, patients, commissioners Stakeholder interviewee and the public. It can be applied in strategic discussions about the health status of a 79. Without a clear set of system level goals large population. Or it can be applied at that encapsulate the overall aims of the the front line, for example, within a service it is difficult to examine the quality specialised service where detailed metrics of services through a meaningful lens at might be used to test performance against national or local level. the system level goal for a patient being treated with epilepsy or diabetes: Was the 80. Establishing a set of system level goals to a disease identified early? Has progression framework would focus all policies, plans been slowed? Has the care delivered and activities on quality within the four improved the patients’ quality of life? domains as set out in Our NHS, Our Future – fair, effective, personalised and safe. This mechanism would put quality at the heart of planning, delivering, managing and funding healthcare systems, shifting the language of the NHS from that of finance and productivity to one based on quality. With quality as the currency of the NHS a structured approach can be created from vision, through goals to quantifiable metrics (Figure 8) .
24 Leadership and clinical accountability and commissioners to make truly informed Recommendation two: Clinical Dashboards choices about healthcare. Recommendation nine: Clinical governance duties for every clinical team 83. The international commissions found that there is currently a gulf between clinicians and managers in their perception of what Proposed system level quality goals good quality care is. The system level quality goals address this problem but SAFE clinical teams also need to have a clear and • Make care safer by identifying the explicit understanding of what they are risks of care and taking action to responsible for. Building on the insights reduce them gained by observing the high performing services it is proposed that a formal set of PERSONALISED clinical governance duties for clinical teams • Embed a patient-centred philosophy is agreed. The list might look like this: of care in all processes, procedures and encounters (with patients and their families) Proposed quality responsibilities of clinical teams EFFECTIVE - Identify, report and analyse adverse • Ensure all clinical and care decisions events, sources of risk and near misses are appropriate to the patient’s and as a result demonstrably improve needs, evidence-based and cost- safety effective - Continuously assess clinical • Identify chronic diseases early and performance (outcomes and organise care so as to slow their compliance with processes of care) for progression, preventing complications the main conditions treated by the and maintaining health team, compare results against current best practice and demonstrate regular FAIR improvements • Strive to achieve and demonstrate the - Maintain a clinical dashboard to show highest standards and best outcomes clinical activity against standards of care when judged against the agreed by clinical specialty leading services in the world - Adopt (or work to adopt) NHS Preferred Clinical Pathways - Establish clinical governance arrangements to ensure that quality 82. Having established a quality framework for responsibilities are delivered the NHS, clinicians and patients should view its performance similarly. Clinicians and managers would be able to judge themselves and be held accountable for 84. The concept of a clinical team is at present their successes in meeting the quality not well developed but a working goals. The transparent display of definition is ‘all the healthcare staff performance data would enable the public sharing responsibility for the same core set
25 of patients’. The configuration of clinical that they themselves consider valuable. teams would be decided locally, in order to This would allow them to identify quality increase ownership of the process. A improvement needs and design initiatives clinical team in a hospital might be the to address them. staff working in an intensive care unit, or an antenatal clinic or an endoscopy service 88. Allowing clinicians access to data about for gastroenterology patients. their performance would help to make quality improvement a scientific 85. In primary care a clinical team could be endeavour. By showing highly motivated defined as the team in a single shared individuals variation in performance, practice. This would include all those curiosity and competition will drive working for the practice (including district change. Clinicians would be able to apply nurse, practice nurse, receptionist) not just academic rigour to quality improvement in the general practitioners. a way that they have not previously been able to. 86. Good clinical data will be key to enabling clinical teams to drive forward quality 89. For commissioners and patients the improvement. Currently data collection is dashboards would provide a real objective often seen as a ‘feeding the beast’ activity measure of the quality of one clinical team with no added value. Yet, a common compared to another, creating a healthy feature of high performing clinical teams is competitive spirit amongst those clinical that they take ownership of service teams. performance with service goals, express them as clinical benefits to patients and 90. Dashboards have been used to drive use data as an integral part of their work. quality improvement across a variety of They compare their performance over industries. Within the NHS Professor time, in relation to others and benchmark Arulkumaran (currently President of the against best practice. Royal College of Obstetricians and Gynaecologists) developed a dashboard in 87. Our key recommendation to enable all an initiative to turn around poor standards clinical teams to focus on quality in the quality of care in the Maternity improvement is the concept of a clinical Department at Northwick Park Hospital. dashboard. A dashboard would allow for real time visualisation of performance 91. The development of dashboards would be across a variety of measured variables. The a challenging task. Local teams would clinical teams would decide what is come together to create their dashboards important for their local services, and by selecting indicators at local level in choose indicators they wish to focus on to discussion with patient representatives, the improve quality. They could use data that public and commissioners to reflect local are already routinely collected and would concerns and interests. They would also also decide what additional data they rely on national standards and evidence of would like to collect to populate indicators best practice, nationally and reflecting local health population needs. internationally. Clinical teams would own and monitor their own performance against measures
26 92. A central issue would be the proportion of collaboration with the Connecting for locally defined metrics on the dashboard Health programme. At present compared to the nationally defined information technology infrastructure does standards and metrics. A combination not collect quality related data in many would be needed to ensure the correct areas. There would therefore be a balance between achieving local ownership requirement for local data collection and ensuring rigour in adhering to what is mechanisms. Existing data sources such as known nationally and internationally to the Confidential Enquiries and National achieve the best outcomes of care. Audits would also feed data into the dashboard system in certain clinical areas. 93. Dashboards would require well-developed, Currently work is under way in association reliable data sources if they are to be with Connecting for Health to develop effective. Sources used to power prototype dashboards, based on real dashboards would include data collected requirements of clinical teams. nationally and locally by information technology systems, as well as data sets created locally and held on local databases. Figure 9: An example dashboard for a Delivering dashboards would require close hospital team
94.A hospital would have a wide range of dials. In primary care, existing components dashboards reflecting the specialist services of the Quality and Outcome Framework they provide and clinical teams running could form a considerable part of the them. An overall picture could be gained dashboard. at a hospital or regional level by considering a combination of relevant
27 Standards, knowledge and support from well as knowing what it is essential to national level ‘standardise’ so that the best outcomes are Recommendation three: Rationalisation of assured. existing standards and guidelines Recommendation four: NHS Preferred Clinical 97. As a consequence of the Next Stage Pathways Review approximately 1500 clinicians have Recommendation five: An Institute of become involved in assessing and Medicine formulating ideas for local services, these Recommendation ten: Expanding excellence groups may be well placed to continue this by making available proven high performing role, supported by the Institute of clinical leaders Medicine.
95. One of the major barriers in developing a 98. There are a number of organisations who consistent approach to improve quality is currently set standards. Some existing the heterogeneity of standards and standards set by other organisations are guidelines in existence. The variety of greatly valued by clinicians, such as the standards, their dissemination through work of the Royal Colleges and the different access points and the lack of co- National Institute for Health and Clinical ordination across standards and Excellence (NICE), who produce high level, implementation tools makes great authoritative and widely respected difficulty for clinical teams. They have to guidelines. In implementing this find, identify and prioritise the standards recommendation care must be taken to that are most evidence-based, relevant to protect the stability and integrity of those them and likely to improve care for their organisations which produce standards patients. Under our recommendations, by and support which is valued at the front combining the standard-setting function line. The difficulty for clinical teams is in with the co-ordination of dashboard sifting through the large number of development there would be a coherent standards to identify which they should standard and method of measuring against adopt locally. it derived from a single body. 99. In order to preserve existing standards, 96. In reality, to ensure that patients with a and to enable clinicians to identify the particular condition receive the highest most relevant, the Institute of Medicine quality, safest care that can be promised would have the ability to ‘kitemark’ means looking at the design of the whole standards. This kitemark would indicate service. This can only be done locally but it that not only was that standard ‘NHS needs to draw in the best research preferred’ but also whether it was a evidence, the best knowledge of good standard of best practice or if it practice (much of it in formal guidelines). represented a world class level of service. It needs to use the best expertise in the design of processes of care and the 100. The formation of an Institute of experience and views of patients and Medicine with this function creates the families. The degree to which formal, opportunity for a rationalisation of the explicit standards are included in this organisations in the quality landscape. The service design is a matter of judgement as other organisations which currently pursue
28 activities related to the Institute of Institute for Health and Clinical Excellence Medicine are listed in Appendix 3. These (NICE); the National Institute for would be merged if their primary function Innovation and Improvement; the overlaps significantly with those of the national Clinical Excellence Award Institute. Scheme; ongoing work on National Service Frameworks; the national 101. Other organisations, statutory or non- Confidential Enquiries; the Centre of statutory, who wished to set standards Clinical Evidence and the Information would be required to submit these to the centre; the reformed medical education Institute of Medicine for kitemarking. and training function proposed in Sir John Alternatively, organisations could choose Tooke’s report, (Aspiring to Excellence). to handover standard development to the Institute of Medicine, and focus instead on 103. In addition to incorporating existing achievement of standards, and other bodies the new Institute would contain functions. Where standards were the proposed Center for Clinical Evidence, inadequate, the Institute of Medicine thereby drawing together knowledge would have the capability to produce or management, standard development, commission new standards. leadership fostering and improvement support. 102. The Institute of Medicine would incorporate the following existing functions and activities: the National Figure 10: The Institute of Medicine
The Institute of Medicine
Care Quality Commission Monitor NICE Links with Audit Commission regulatory National Audit Office The bodies General Medical Council NIII IC Nursing and Midwifery Council NSFs NLH
Submit standards External bodies may still develop standards and submit these for consideration for kitemarking
e.g. Royal Colleges National Patient Safety Agency NHS Litigation Authority Health Protection Agency
29 What will the Institute of Medicine do In all these areas the Institute of Medicine to rationalise standards? should have a close working relationship • Integrate clinical knowledge with the Royal Colleges and other • Review all standards specialty specific organisations. • ‘Kitemark’ the best standard in each clinical area What will the Institute of Medicine do to • Convert standards into a measurable support service improvement? format suitable for clinical teams to • Continue the function of the National use as a dial on local dashboards Institute for Improvement and • Set new standards where existing Innovation in promoting, supporting standards are lacking or inadequate and disseminating improvements and • Design preferred clinical pathways innovation where: • Fellowship scheme to promote clinical - key illnesses where variable leadership and spread best practice performance leads to substandard • Produce or commission toolkits to care (e.g. stroke) support the local implementation of - heavy resource consumption is dashboards associated with waste (e.g. cancer • Offer ‘on-the-ground’ assistance with care) local implementation and use for - there are serious risks attached to quality improvement of clinical team the process of care dashboards
30 104. The International Commissions have 106. The Institute of Medicine would recruit further reported barriers to spread and those with proven track records to become adoption of best practice. The Institute of Fellows of the Institute. These Fellows Medicine would also have a central role in would support or even turn around poorly addressing this. Perhaps the vital performing units or teams. These pioneers component of spreading good practice is would be encouraged and incentivised to clinical leadership. Clinical leaders in the use their knowledge and skills to assist current system face multiple barriers: lack other services in achieving of peer support, inability to respond to transformational change. By nurturing national standards which are not relevant clinical leaders in services achieving proven to their unit and a lack of incentives to levels of excellence in care, the NHS will improve the quality of their unit and share mobilise an enormous knowledge their learning more widely. The Institute resource. for Healthcare Improvement (IHI) in its international review of support available 107. Being styled as Fellows of the Institute of to improve quality identified the paradox Medicine these clinical leaders would have of an ever increasing response to national the authority to enact change as well as targets for quality diminishing the focus on establishing a network of individuals the community they serve and their views engaged in similar work. on the service they desire.
105. Clinical leadership needs to be promoted Recognising and rewarding excellence and supported at a local level so that Recommendation eleven: Reshaping the clinical leaders set clinical priorities. Where Clinical Excellence Award Scheme leadership is left to ‘the managers’ it is Recommendation twelve: Employees as difficult to develop outstanding services. partners There is a need to move beyond talk of ‘clinical engagement’ and take practical 108. Through the Fellowship a broader steps to develop a leadership cadre — or definition of clinical leadership can be ‘change leaders’. encouraged by formally recognising those who are currently leading. These clinical leaders would be recognised as prestige ‘NHS leaders should foster more confidence, appointees and this would be reflected in risk-taking, learning, and cooperation fast-tracking in the Clinical Excellence among system elements and roles. Creating Awards Scheme. As well as rewarding more will and capacity for NHS academic or research prowess the new organisational leaders to look ‘out’ toward scheme would favour leadership ability. patients and families for signals about their The Clinical Excellence Awards Scheme for priorities and ideas for improvement, consultants would be altered to strengthen instead of ‘up’ to please the NHS hierarchy, the link between demonstrated quality of will accelerate improvement, foster local care and financial reward. The reformed cooperation, and, probably, decrease waste.’ Awards allocation process would make more extensive use of data, including the Institute of health improvment clinical dashboard to demonstrate quality improvement activity to reward excellence.
31 109. Clinical Excellence Awards are an ownership of their NHS organisation and effective mechanism for incentivising to be financially rewarded as a team for consultants because they provide improving the quality of their service. significant financial rewards. Consultants are at the heart of clinical decision-making 113. Staff would own a share in their and service planning, and are therefore in organisation. They would receive a bonus a unique position to help embed high at the end of the year based on the quality care in the NHS. Focussing the organisation’s overall performance. The criteria for receiving Clinical Excellence percentage of salary that this represents Awards on quality improvement activities would be the same for the Chief Executive will create strong individual financial as a porter. This would motivate all staff to incentives to put quality improvement at focus on working together to improve the the centre of hospital consultant activity. quality outcomes of their services and hospital and generate a fascination with 110. Use of objective evidence of quality information reflecting quality and improvement would allow the award improvement. It would contribute to a process to become more transparent and culture of cooperation, staff engagement fair. Current criticism of the awards in quality improvement, and be a mandate suggests that measurable quality to all staff to be involved in improving improvement does not receive that quality. emphasis that it should do and that once awarded, they fail to provide continuing 114. The John Lewis experience has shown incentive to improve. that providing an organisational incentive, not only generates team spirit but also a 111. The proposed mechanism for introducing competitive drive, as teams strive for high objective evidence of quality improvement performance. activity to the award is to link the new clinical dashboards to the selection process. 115. The permanent staff of an NHS Recipients of awards would be required to organisation would in effect ‘own’ the demonstrate measurable improvements in organisation and share in its income and quality in their own clinical teams, or benefits. Each staff member would continuously high levels of quality, via their become a partner whose individual own dashboards or those of the services contribution to the organisation is they are visiting. Consultants would be recognised and rewarded fairly. In primary required to demonstrate maintained care many General Practitioners and quality improvement activity in order to Practice Managers are already partners in maintain their awards at high levels. This their General Practice. This would ensure that the momentum of recommendation would encourage quality improvement is continued extension of partnership to all members of throughout consultants’ careers. staff, including for example nurses, receptionists, cleaners and on-site 112. It is not just the team leader who should pharmacists. be recognised and rewarded for a team’s success. A John Lewis-style partnership 116. John Lewis has a reputation for quality in would enable all NHS staff to share in the its goods and customer service that the
32 NHS should aspire to. The John Lewis the scheme. The risk of treating this as a partnership model has been a success for cost neutral project is that it may lead to business reputation, organisational culture negative perceptions within the NHS in and profits. It has been widely imitated by which it is seen as penalising services who others in industry e.g. Pepsi Cola, Tesco’s are struggling as much as rewarding those and Royal Mail. The John Lewis reputation who are achieving. Alternatively, a budget for quality means that this could be allocated to providing bonuses, recommendation would reinforce the and salaries could vary between, for message that quality should be at the example, 100 – 104% of current levels. heart of the NHS, and this would be apparent to staff and the public. Regulation and Accreditation Recommendation Six: A regulatory framework 117. One of the barriers identified by several of the international commissions is the gulf 120. A Bill is currently going through between clinicians and managers. A John Parliament that proposes the merger of Lewis-style staff partnership would build the main regulators of the health and clinical teams around the shared goal of social care system, the Healthcare improving patient care and replicate the Commission and the Commission for Social features of the high performing units, Care Inspection. The Mental Health Act through a shared financial incentive that Commission will also be part of the merger. reflects progress towards the goal that all Under the new system requirements will clinicians and managers share: improving be set for health organisations providing patient care. services to NHS patients and inter alia for private health and social care providers 118. Staff partnerships should first be piloted (not described here) to be ‘registered’ with to develop a prototype and to evaluate the the Care Quality Commission. scheme. Chief Executives could be invited to volunteer to pilot staff partnership in 121. Current thinking within the Department their organisation. Foundation Trusts are of Health’s team dealing with regulation is likely to be suitable sites for the pilot. that most NHS providers will immediately General Practices in which partnership be registered under a ‘grandfather clause’. could be extended to all staff would also Those which the existing Healthcare be suitable. Commission has concerns about will be reviewed for fitness for registration. Also 119. Partnership could be designed as a cost within current thinking is the idea that neutral project, in which current salaries registration requirements or ‘essential may be paid between, for example, 98 – standards’ would be drawn out from a 102 % depending on performance and the broader-based quality improvement type bar is set such that the average is 100%. standard. Achieving this balance requires an estimation of the current level of quality to 122. For example, proposed standard 1 in the set the bar at an appropriate level. Pilot current draft of the consultation document sites could be ‘early adopters’ who may A framework for registration of health and have a higher level of quality than average adult social care providers is expressed and so pilot sites may earn more through thus:
33 ‘Ensure that people have their health organisations should be conducted and/or social care needs assessed, and that through the Care Quality Commission care and treatment is planned and delivered to appropriately meet those 124. As the functions of commissioning are needs, having regard in particular to increased, regulation of commissioners ensuring their health, safety and welfare may become necessary. A special and taking account of current evidence- programme of quality standards and based guidance for relevant professional or accreditation would be established for the expert bodies’. commissioning function itself. This would ensure a process of continuous 123. There are 17 other standards, most of improvement in the mechanisms and levers which are similarly broad-based making used by commissioners to secure higher the construction of one or two aspects of levels of quality and safety in the provider each as ‘essential standard’ an enormously organisations they relate to. challenging task. The approach risks falling into the difficulty that minimum 125. Positive incentives will provide a degree standards are being placed within a of motivation but without the framework of quality improvement. This development of censure the ability to creates a clash of philosophies. As one NHS ensure safe care will be curtailed. Every chief executive officer put it: ‘we don’t just provider of service within (or for) the NHS want to be ordinary, we want to be should be formally licensed. Registration excellent’. In aligning regulation with the licences could be qualified (or ‘endorsed’) quality and safety agenda set out in this where there is substandard care. In serious report we advise that: cases, retention of Foundation Trust status - basic registration requirements (‘essential could be qualified. Endorsing of licenses, in standards’) should be just that: a list of a similar way to driving licenses, may ‘must dos’ covering issues such as produce effect through public criticism; qualified personnel, clean environment, equally Foundation Trusts may put at risk kitemarked equipment their autonomy by failure to reach - basic registration requirements need to licensing standard. More radical options be consistent with the private healthcare include the ability of the licensing sector but not necessarily identical authority to remove management and - accreditation systems should be used by impose temporary suspension of bonuses the Care Quality Commission as an and additional remuneration. adjunct to registration - accreditation should be aimed at quality The Business of Quality improvement (as well as checking for Recommendation Eight: Commissioning of unsafe practice) based on standards set by services will be linked to clinical dashboards the Institute of Medicine and to a large Recommendation Seven: Funding higher extent using local clinical dashboards quality, safer care - the Care Quality Commission should act as the gateway for all accrediting 126. Clinical teams do not work in isolation. organisations to prevent over- At an organisational level, the current burdensome regulation: all data system of payment by results allows only collection in the NHS for accrediting the quantity of care delivered to be
34 rewarded. Refocusing financial incentives However commissioners would need to be onto the quality of care provided will allow wary that local indicators are not chosen organisations to focus fully on supporting only because success can be demonstrated their clinical teams to achieve high quality (i.e. set up to guarantee a ‘win’). It would care. be incumbent on the commissioners to ensure that the variety of indicators used is 127. Commissioners would be able to look at such that services are stretched to improve a clinical team’s dashboard when deciding within a local context. what service to commission. Commissioners would have improved Strengthening patient safety access to information on what ‘best’ looks Recommendation thirteen: Never Events like, through the Institute of Medicine’s Recommendation fourteen: A patient safety rationalisation of standards and guidelines. initiative Using the national and local indicators, commissioners would be able to identify 131. Based on the quality demonstrated by which services are providing high quality the clinical dashboard, commissioners care and commission care from them. would be able to choose which services to commission and vary the tariff to reflect 128. More than this, commissioners would be the quality of the service they are able to use the lever of commissioning to commissioning. There are occasions when effect change. Services that are not stronger action is called for. ‘Never events’ performing well face the challenge of are defined by the US National Quality failure to be commissioned, or alternatively Forum as ‘adverse events that are serious, hospital management utilising other levers largely preventable, and of concern to such as buying in clinical expertise to effect both the public and healthcare providers turnaround. The effect of commissioning for the purpose of public accountability.’ can be strengthened as an enabler of quality. 132. Consensus is growing that never events need greater recognition and action to 129. In addition to local commissioners prevent occurrence. In the United States, a deciding which service to commission, they wide variety of organisations have should be able to vary their tariff payment declared that they will not pay for an based on the quality of service episode of care where a ‘never event’ demonstrated by clinical dashboards. In occurs, and this has been successful in essence the commissioning contract would promoting patient safety. be able to vary to 102.5% based on achievement of locally set aims. High 133. Several States have enacted laws performing services would not only win requiring the disclosure of never events at contracts but their organisations would be hospitals and various remunerative or rewarded for maintaining and developing punitive measures for such events. their services in line with local needs. 134. A recent Leapfrog Group Study found 130. As many indicators would be locally that roughly half the 1,285 hospitals that determined, commissioning would responded to their survey waive fees for therefore be sensitive to local needs. never events, and that hospitals that do
35 waive fees are much more likely to have providers, and to allow prevention perfect scores on the Leapfrog Safe measures to focus fully on one never event Practices Score survey. Minnesota’s at a time for maximum impact, the never hospitals have agreed to stop charging events could be phased in, perhaps one a patients and insurance companies for the year. 27 types of ‘never events’ first identified by the National Quality Forum in 2002. State 138. In the short term, providers would law has required hospitals to report them receive assistance with implementing since 2004. In 2006 Minnesota hospitals measures to prevent never events, but reported 154 of these ‘never events’, in 8 would have to pay the costs of episodes of million patient visits. care in which patients experienced never events. The Department of Health could 135. Health insurance companies have fund the assistance with preventive adopted different lists of never events to measures by reducing the funding to drive improvements in patient safety. In commissioners, as they would no longer be 2004, HealthPartners announced it would paying the cost of episodes of care in not pay for the National Quality Forum which never events were experienced. never events. Medicare has announced eight preventable conditions it will not pay 139. Care providers would have a financial for, including healthcare-associated incentive to focus on preventing serious infections. Only three National Quality preventable adverse events. This would Forum conditions are on the Medicare list. renew the focus on patient safety across the NHS. Staff would be encouraged and 136. This approach is likely to be most enabled to put best practice into practice. successful when the financial disincentive The funds made available to pump prime is combined with a renewed focus on measures designed to reduce never events implementing best practice guidance. would help clinicians and managers to This is demonstrated by the recent success improve the safety of their practice. at Geisinger Health System, a three hospital not-for-profit organisation in 140. A patient safety initiative should be Danville, USA. It offers coronary artery launched to embed measurement and bypass surgery for a flat fee that covers evidence into the approach to patient any complications occurring within 90 safety in the NHS. The preferred project days. As part of the programme, would be Matching Michigan, addressing surgeons adhere to 40 best practice catheter-related blood stream-infections in measures. After 117 cases, the death rate Intensive Care Units. A team from Johns had reduced from 1.5% to 0%, Hopkins School of Medicine led a readmission within 30 days of surgery programme to reduce catheter-related from 6.6% to 5.1% and length of blood-stream infections across 103 intensive readmissions and hospital charges were care units in Michigan, USA; infection levels reduced by 5.2%. were reduced by over 60% after 18 months (Figure 11). This would be an opportunity 137. The incidence of never events in the NHS to prove that quality improvement can be is unknown, but may be high. To avoid achieved within the NHS. sudden financial difficulties for care
36 141. Professor Peter Pronovost, an intensive 143. The methods used for promoting these care physician at Johns Hopkins Hospital, interventions included: clinician Baltimore, USA, led the catheter-related education; a checklist for infection-control bloodstream infection (CRBSI) reduction practices, enforced by preventing programme in 103 intensive treatment clinicians inserting catheters if they were units (ITUs), representing 85% of all ITU not following this checklist; consideration beds in Michigan State, USA. of catheter removal at every daily round; provision of a ‘cart’ containing all the 142. The five procedures promoted were supplies needed to insert a catheter hand washing, using full-barrier according to the guidelines; and monthly precautions during the insertion of and quarterly team feedback on the central venous catheters, cleaning the skin number and rates of CRBSIs. with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. These were selected based on evidence that they were effective in Figure 11: Reductions in ICU catheter-related reducing infections with minimal barriers bloodstream infections across the State of to implementation. Michigan USA
144. These were in the context of a wider infection decreased from 2.7 infections per package of interventions, including: a daily 1000 catheter-days at baseline to 0 within goals sheet for improving communication the first 3 months after implementation. among clinicians; a unit-based safety programme to generate a culture of patient 146. The Intensive Care National Audit and safety; and the coaching of a doctor and nurse Research Centre (ICNARC) estimates that to lead local implementation. there are 218 adult general critical care units in England. Matching Michigan in 145. This programme led to a sustained England would thus be on roughly twice reduction (up to 66%) in rates of CRBSIs the scale of Peter Pronovost’s work. that was maintained throughout the eighteen month study period. The median rate of catheter-related bloodstream
37 PERSPECTIVES the future, we need to hit these targets’. Dr Patel became increasingly demoralised and 147. The following perspectives show how questioned whether the values that he had the system would look to a doctor and a when he came into medicine were being patient before and after these reflected by the NHS. recommendations are implemented. One day, Dr Patel received an invitation to Through the eyes of a clinician attend a seminar hosted by the Chief Medical Officer in London to discuss ‘Quality in the Today 21st century NHS’. When he arrived to register for the meeting it was clear that his name had Dr Vijay Patel works in a busy respiratory unit been confused with someone else and he had of a District General Hospital. He was been invited in error. However, one of the appointed as a consultant 10 years ago and organisers told him that he should stay considers himself ‘mid-career.’ He has because he was ‘more in touch with reality struggled to improve the infrastructure of his than many of the other people here’. department. Some of the equipment is a little outdated, there is one other consultant in the Dr Patel found himself in a small group team but the workload would justify a third discussion in which all his frustrations poured consultant. The turnover of nursing staff is out. He was nominated to make the ‘flipchart very high with 15% agency nurses. His feedback’ on the barriers to good clinical representations to the medical director and quality. He identified: the disempowerment chief executive officer of the hospital were of the clinical team due to excessive listened to sympathetically but he was told managerial control; the absence of good data; that the priority was for cancer and heart the failure to manage to patient outcomes disease services. There were national targets and experience rather than numbers and for these conditions but not for respiratory money; and disagreement on what standards disease. Following the discussion he was should govern a service’s operation. awarded three ‘local points’ in the Clinical Excellence Award scheme in recognition of his As a result of his presentation, Dr Patel was hard work and commitment. asked to take part in a pilot study to implement some of the changes in the NHS Later that year, a new business manager, Next Stage Review. Thomas Knowle-Wheetall, was appointed to the Directorate of Medicine in the hospital. Tomorrow Knowle-Wheetall arranged a weekly meeting with Dr Patel in which he would set quarterly The hospital was proud of being selected to be targets on access times, the number of a pilot in implementing clinical dashboards as patients to be seen and the costs of clinical part of the NHS Next Stage Review. Dr Patel tests and investigations. Dr Patel tried to was asked to do a presentation to the Board. protest that these measures did not reflect the things that really needed to be done to He was able to describe the main groups of improve the service but was told by Knowle- respiratory disease that his service treated. He Wheetall that ‘if I’m going to get my annual expressed the strategic aims in relation to the bonus, and become a chief executive officer in NHS system level quality goals: slowing the
38 progress of chronic respiratory disease, discussion with the primary care trust monitoring standards for diagnosis, treatment commissioning team. They are considering and after-care as well as marking out what how to develop the service for respiratory excellence looked like. disease. In preparing for the Board presentation, Dr By this time, the team’s clinical dashboard is Patel felt that for the first time he had a plan well populated with data. Everyone for what his service should be achieving and acknowledges that: all standards are being how success could be judged, a plan that met in full and the service has gained quality made sense in clinical and patient benefit payments above the tariff. Patient satisfaction terms. falls short of what the team had hoped for. The service’s patient representative identified A team headed by a Fellow of the Institute of some key problems with the coordination of Medicine (who led on respiratory medicine) primary care follow up after hospital discharge visited Dr Patel’s Unit for a few days to help that is causing the greatest negative feeling him and his team construct their clinical amongst users of the service. The dashboard. Over this time Dr Patel and his commissioning team agrees to discuss this with team also constructed their own local pathway local general practitioners to find a solution. for patients with respiratory disease. A large part of the discussion turns on the For the clinical dashboard and pathway work, team’s aspiration to climb higher towards they identified the standards the team wanted excellence. The senior nurse in the team to use which blended evidence based best reports on her visit to the Mayo clinic in the practice with local ‘patient flow’ USA. She identifies five areas where, if considerations. They drew in information from improvements were made, the respiratory the latest patient experience survey of service could get from its present 65% of the respiratory services and they identified the Mayo Clinic’s performance to 85% over the best performing service in the world as their next two years. The Commissioning Team gold standard. Efficiency and financial agrees a modest extra investment to enable performance data were also included. Not all this and it is also decided to ask the Institute dashboard domains could be populated with of Medicine for help in reviewing the all the data the team suggested but a potential for necessary service re-design as the timetable was agreed through which the right team acknowledges that they need to revisit data would be available. their pathway of care against national standards and international best practice. The hospital’s Chief Executive Officer then facilitated a meeting where the team’s At the end of a long and very satisfactory day, infrastructure was reviewed against their Dr Patel goes home to his family knowing that capacity to deliver against standards in the he is leading a service that is delivering high dashboard and the NHS Preferred Clinical quality care to most of his patients. He also Pathways for respiratory disease. Major knows that his leadership and the changes were made and the team decided to commitment of his team could one day match establish beginning and end of the week the best in the world. timeouts to review performance.
A year later, Dr Patel and his team are in
39 Through the eyes of a patient Tomorrow
Today Clara Hempster was lucky for a second time. She read in the newspaper that South Clara Hempster is a 49 year old mother of Yorkshire was to be a pilot area for a new four. Apart from her childbirths, and an scheme in which assessment of the quality of occasional visit to her General Practitioner for the local NHS was going to be made available sore throats or coughs, she has hardly used to the public. the health service. Through the internet she was able to access On a sightseeing visit to London from her information on five diabetes services which home in Sheffield she collapsed outside the were within an hour of her home. Houses of Parliament. She was revived by a Information on their services was set out like a Member of the House of Lords, Lord car dashboard so she could see how each Dexterity of Keyhole, who told her she had compared to national standards set by the had a diabetic episode. She was deeply Institute of Medicine. She could also see how grateful to this gentleman. A policeman at far each fell short of international best the entrance to the House of Lords told her practice. She could check out how well each that she was very lucky because it was only at service controlled the progress of diabetes (eg, certain times of the day that Lord Dexterity how many patients had eye complications, patrolled the parliamentary precinct looking how many patients had regular high glucose for people who had collapsed or may be on levels and how many were overweight or the verge of collapse. obese). She could also see what feedback patients had given on the service. When she got back to Sheffield she went to see her General Practitioner to ask him to One of the five services stood out from the refer her to the best diabetic service in South others. All national standards were being Yorkshire. She had been advised by her complied with. Complications of diabetes husband, Freddy Greentree, a struggling were very low compared to the other services. actor, to press very hard to go somewhere Also the service had come third in the good because his agent had gone blind with ‘International Diabetic Service of the Year’ ‘diabetic eyes’, having had no check-ups for awards. Patient feedback was uniformly 10 years. positive. Clara clicked on the comments of the last 30 new patients to use the service and also Clara’s General Practitioner could give her no those of patients who had been treated for firm information about which was the best more than five years. There was only one diabetic service but told her that the one at the negative comment and that was from an local hospital was in his opinion “fair to elderly woman whose ambulance was middling”. Clara was disappointed. Since her delayed. diagnosis she had trawled the internet and realised that how long diabetics lived, whether Clara asked her General Practitioner to refer they went blind and their quality of life could her to this service. She was seen within the all depend on how good the service was that week and underwent a range of baseline cared for them and how closely it worked with assessment tests. Following that she had an in- the General Practitioner and his team. depth discussion with her diabetes team about
40 her future. She was given a lifetime plan with key milestones and advised of the steps she needed to take to slow the progress of her illness and the warning signs to look for. She was put in touch with the local Expert Patients Programme to help her to develop skills in self-management.
The nurse from her practice was present during this initial clinic visit and she agreed with Clara the follow-up arrangements with her primary care team. She was asked to telephone if she had any worries or problems but in any case she would be receiving a monthly telephone call from the hospital diabetic team checking on her progress.
Clara remained in the area for the rest of her life. She became something of an ‘anorak’ on diabetic clinical dashboards. She regularly looked at the dashboards of her own service but also other around the country, particularly the four in South Yorkshire and watched with interest as they all began to catch up with the best.
41 Through the eyes of the patient
NOW FUTURE
No information on the performance, Clinical dashboards available publicly in an complication or adverse event rate of the understandable way. For example, infection hospital or clinical team administering rates, readmission rates, mortality rates and treatment complications in surgery rates all available and easily comparable for the patient to make informed choices
Internet searches leading to multiple numerous Still lots of information available, but a websites and guidelines (governmental and nationally recognised and publicly available non) describing different standards and IOM gold standard and pathway and an pathways of care; what to expect and how to accompanying patient’s version explaining what deal with their disease the best they can expect should be
Hospitals and clinical teams not performance Hospitals and clinical teams accredited based on managed so not possible for patients to their performance on key metrics displayed on compare or understand ‘who’s best’ and ‘who’s the dashboard. Information publicly available worst’ so the patient can see who is accredited to a basic and high standard based on their performance and ultimately offering best care
Patients have little idea about which clinical A plethora of clinical leaders commissioned to teams perform to a high standard work in underperforming centres would be known by patients who would be able to have increased confidence in their local service realising that expert input was underway
Patient satisfaction not measured nationally or Patient satisfaction scores for every patient on taken notice of every admission feed into one of the main indicators on the clinical dashboard, meaning that if patients are satisfied staff are rewarded
Unsafe events in hospital not sufficiently Set of never events publicly available, national publicised and their causes explained promise that these events should never occur in hospital
42 Through the eyes of the clinical team
NOW FUTURE
Little objective measurement of the quality of Regular, systematic measurement of the quality care provided by the team of care provided by the team via dashboards
Quality improvement activity takes place on a Continuous approach to quality improvement sporadic and ad hoc basis facilitated by dashboards and system level quality goals
A lack of data to allow full assessment of the Data on quality collected and analysed quality of care provided by the team regularly by the team, creating a more scientific approach to quality improvement
No way to compare yourself against other Dashboards allow comparison between teams teams within the hospital and against similar and encourage a culture of competitiveness to teams in other units drive up standards
The team is measured against centrally set The team picks indicators to measure itself targets, some of which they do not agree with against that it feels are important to the local or are not appropriate to the local service service Teams feel ownership over their quality improvement activities
A lack of clarity about which standards should Clearly defined, ‘kite marked’ standards from be used to inform the clinical practice of the the Institute of Medicine give clarity about team what the team is aiming for
No team based reward if they provide high All members of the team rewarded for quality quality care, instead all reward goes to the care through a partnership model consultant via clinical excellence awards A lack of skills in quality improvement Teams supported by the IOM to implement quality improvement initiatives. If necessary clinical leader can be drafted in from high performing units to help
Clinical teams disengaged from the quality Clinical teams empowered and motivated to improvement process take part in quality improvement
43 Through the eyes of a director of commissioning at a PCT
NOW FUTURE
A lack of data on the quality of care provided Dashboards for all clinical teams provide by clinical teams, making decisions about who accurate and relevant information on to commission care from difficult performance in their service. Commissioners are empowered to put quality at the heart of the decision making process on the basis of objective evidence from the dashboards
Confusion about which standards represent Clearly defined ‘kite marked’ standards from best practice when commissioning services the Institute of Medicine provide definite examples of best practice. Commissioners able to identify those services providing best practice and then to buy their services
Very little flexibility to alter payments to Commissioning contracts which include an provider organisations to reward high quality element of variability in payment on the basis care of demonstrated quality of care provided, as measured on dashboards. The better the care, the more they get paid
Having to pay for care, even when it has gone No payment made to the providers when a disastrously wrong ‘never event’ occurs. And hopefully fewer never events occurring as providers do more to stop them from happening
44 Through the eyes of a hospital chief executive
NOW FUTURE
Erratic availability of data showing clear Clinical dashboards giving sense of basic measures of performance at the level of the measures for all clinical teams e.g. mortality clinical team rate, infection rate, specialty specific key indicators (e.g. hernia occurrence rates post- operatively in general surgery) Ability to aggregate dashboards at a hospital and level to inform where help is needed to improve performance
No way to hold clinicians accountable to A nationally recognised and publicly available practise best standards as best standards not IOM gold standard and pathway to use for clear performance measurement
Inability to prove minimum standards of care or Hospitals and clinical teams accredited based on clearly show improved performance their performance on key metrics displayed on the clinical dashboard
Regular disputes over unfair clinical excellence Clinical excellence awards based on awards performance measures on clinical dashboards, little room for dispute in face of quantitative fact Inability to summon support to improve services A plethora of clinical leaders commissioned to work in underperforming centres would be available to ‘buy in’ to improve local performance
Patient satisfaction not measured nationally or Patient satisfaction scores for every patient on taken notice of every admission feed into one of the main indicators on the clinical dashboard, meaning that if patients are satisfied staff are rewarded
Not able to reward staff for high performance All NHS staff in partnership arrangements with their hospitals (cf. John Lewis) with rewards for improved patient satisfaction and highly performing teams e.g. Improved pay, preferred medical treatment, air miles, membership at local gym, free dentist etc.
45 Through the eyes of government
NOW FUTURE
Erratic availability of data showing clear Aggregated clinical dashboards measures of performance at the hospital level Clear sense of basic measures for all clinical e.g. standards for better health, dr. foster teams e.g. mortality rate, infection rate, etc… specialty specific key indicators (e.g. hernia No data on clinical team performance occurrence rates post-operatively in general surgery) Ability to aggregate dashboards at a hospital and regional level to inform spending plans
Liaison with multiple bodies to determine the Still lots of information available, but a best standards of treatment and the views of nationally recognised and agreed existence of the medical profession on gold standard an IOM which houses all of the NHS’ treatment e.g. Royal Colleges, Societies, Arms knowledge, agrees and delivers the gold Length Bodies etc. standards for healthcare professionals and Complicated cross-governmental and non- patients and holds a fellowship of clinical governmental strategies to ensure all leaders who itinerantly improve performance stakeholders involved in key decisions across poorly performing services Regular embarrassment at significant No need to consult Royal Colleges, host duplication of work across commissioned multiple working groups and waste resources agencies duplicating work as the IOM will have universal ‘buy in’ and be the voice of the profession to government Inability to properly regulate hospitals and Hospitals and clinical teams accredited based healthcare professionals, prove minimum on their performance on key metrics displayed standards of care or clearly show improved on the clinical dashboard performance Ability to prove to the public that problems can be picked up early against measured standards and action taken
Regular disputes over unfair clinical excellence Clinical excellence awards based on awards performance measures on clinical dashboards, little room for dispute in face of quantitative fact
More than a million disillusioned, All NHS staff in partnership arrangements disenfranchised NHS staff with their hospitals (cf. John Lewis) with rewards for improved patient satisfaction and highly performing teams e.g. Improved pay, preferred medical treatment, air miles, membership at local gym, free dentist etc. Panic over media picked-up adverse events Financial levies applied to trusts for the that seem to occur repeatedly occurrence of never events, reducing their incidence and assuring the public action is being taken 46 APPENDIX 1
The current quality landscape have overlapping responsibilities. There are few examples of communication and An overview of the arms length bodies and cooperation to ensure complementary, rather other agencies tasked with monitoring, than redundant or contradictory, work to maintaining and improving the quality of improve quality in the NHS. healthcare services in the NHS in England reveals a quality landscape that is diverse with multiple quality foci. Several organisations Figure 12: The Current Quality Landscape
Key to acronyms:
GMC General Medical Council NHSLA National Health Service Litigation HPA Health Protection Agency Authority IRP Independent Reconfiguration Panel NICE National Institute for Health and Clinical Excellence MHRA Medicines and Healthcare Products NIHR National Institute for Health Research Regulatory Agency NLH National Library for Health MRC Medical Research Council NPSA National Patient Safety Agency NAO National Audit Office NSFs National Service Frameworks NCAS National Clinical Assessment Service ONS Office for National Statistics (part of NPSA) PCT Primary Care Trust PHOs Public Health Observatories SHA Strategic Health Authority
47 DATA The Health Protection Agency is a Special Health Authority, established in 2003, which The National Patient Safety Agency (NPSA) ‘protects the health and well-being of the aims ‘to put patient safety at the top of the population’. (www.hpa.org.uk) NHS agenda through encouraging greater transparency and accountability for the It provides support and advice to the NHS, provision of safer healthcare in all settings’ local authorities, emergency services, other (www.npsa.nhs.uk). Arms Length Bodies, the Department of Health and the Devolved Administrations on The NPSA has three divisions. The Patient infectious diseases, radiation, chemical and Safety Division collects patient safety incident environmental hazards and emergency reports from the NHS in England and Wales, preparedness. It is also developing its raises awareness of these, for example by involvement in international work. Its key publishing rapid responses, and works to areas of work are: infectious diseases; improve patient safety. The National Clinical chemicals and poisons; radiation; emergency Assessment Service advises NHS bodies who response; local and regional communicable have concerns about the performance of disease services; and a business support doctors and dentists. The National Research network which generates income. Ethics Service promotes an ethical approach to participants in research. It is accountable to the Secretary of State for Health, and subject to the Healthcare The NPSA was established in 2001, and Commission’s Annual Healthcheck. expanded to include the National Clinical Assessment Service and the National Research The Medicines and Healthcare Products Ethics Service in 2005. Regulatory Agency (MHRA) exists to ‘enhance and safeguard the health of the public by The NPSA manages the contracts for the three ensuring that medicines and medical devices Confidential Enquiries . These publish work and are acceptably safe’ anonymised data collected from institutions (www.mhra.gov.uk). on three specific clinical issues In April 2003 the Medicines Control Agency (http://www.saferhealthcare.org.uk/IHI/Progra and the Medical Devices Agency merged to mmesAndEvents/ConfidentialEnquiries). form the MHRA, which is an executive agency The Confidential Enquiry into Maternal and of the Department of Health. The MHRA Child Health (CEMACH) investigates maternal monitor medicines and devices and act on and perinatal mortality and is planning to safety problems. It has the power to withdraw start investigating into child health; the products from the market and to suspend National Confidential Enquiry into Patient production of medicines. The MHRA licences Outcome and Death (NCEPOD) examines the medicines for use in the United Kingdom, and quality of care delivery and recommends is responsible for regulating organisations that action based on peer review of data; and the licence medical devices. National Confidential Enquiry into Suicide and Homicide by People with Mental Illness The Healthcare Commission describes itself as (NCISH) investigates every suicide and the ‘Health watchdog for England’ who ‘check homicide within UK mental health services. that healthcare services meet the required standards in safety, cleanliness, waiting times
48 and many other areas’ They are planning work with the Healthcare (www.healthcarecommission.org.uk). Commission, Department of Health, NHS An independent body that inspects both NHS Connecting for Health and the independent and independent healthcare institutions in sector to agree a strategy for standardising England, it was launched on April 1st 2004 data collection between the NHS and the following the Health and Social Care Act 2003. private sector. Other projects include: identifying the proportion of drugs prescribed The Healthcare Commission runs an ‘annual but not collected, for NICE to include in their health check’ on NHS units, piloted in 2005/6 analysis of prescribing behaviours; extending and run fully in 2006/6. Each NHS trust is data collection to the private sector; awarded a performance rating on the basis of developing financial performance indicators; an assessment of the quality of the service promoting the adoption of the Electronic Staff provided. The Healthcare Commission also Record; planning the collection of social care publishes a wide range of reports, including data; and promoting data analysis at SHA and surveys of patients and staff, review of services clinician level. such as diabetes, and more wide-ranging reports on topics such as gender equality and The 12 Public Health Observatories (PHOs) complaints handling in the NHS. NHS monitor and forecast trends in health status, complaints that are not dealt with locally are disease and the effects of healthcare handled by the Healthcare Commission. interventions (www.apho.org.uk).
The Information Centre ’s (The IC) mission is ‘to PHOs publish a range of reports, briefings, be the recognised source of authoritative information and develop indicators of comparative data, providing an independent particular public health issues such as alcohol perspective on the quality, validity and misuse. They develop training programmes application of information to support for health intelligence staff and respond to improvement in health and social care’ enquiries about public health. They publish (www.ic.nhs.uk). guides to monitoring and analysing public health data, for example providing modelling It is an independent NHS Special Health tools for NHS organisations to assess the Authority that provides facts-and-figures to impact of different strategies on meeting help the NHS and social services run targets such as the Public Service Agreement effectively. They collect data from across the targets. sector, analyse it, and convert it into useful information. The data collected, such as In England each PHO receives a core resource Hospital Episode Statistics and many of the from the Department of Health and is audits funded by the Healthcare Commission, accountable via its Regional Director of Public are routinely used in healthcare delivery, Health to the Chief Medical Officer. PCTs, management, policy and research. SHAs, the Department of Health and Information is aimed at NHS frontline government, and other bodies also management, clinicians, information and care commission the PHOs to deliver specific professionals, policy makers, patients and the additional work. media. Information needs across healthcare are monitored to guide the collection of data.
49 They are co-ordinated by the Association of on Hospital Episode Statistics and an annual Public Health Observatories (APHO) across questionnaire, used to form the Hospital England, Scotland, Wales, Northern Ireland Guide annually. It also runs databases of and the Republic of Ireland. Public Health consultants, infertility clinics (with the HFEA), Observatories are also working with their local diabetic services (with diabetes UK), breast cancer registries, health protection agencies cancer clinics (with Breast Cancer Care) and and other colleagues to develop a more complementary therapists. integrated health intelligence function for their respective areas. For healthcare services, Dr Foster provides tools for analysing and using data, such as the The Office for National Statistics (ONS) Clinician Outcomes and Benchmarking Tool collects and publishes official statistics about and Real Time Monitoring. Clinician Outcomes the UK’s society and economy, including and Benchmarking (COB) is an web-based tool administering the ten-yearly census designed for consultants and medical (www.statistics.gov.uk). directors. It presents monthly outcome data, casemix adjusted for age, gender and The Health Statistics Quarterly publication deprivation . It automatically alerts clinicians includes data on deaths, childhood mortality, to potential problem areas where their cancer survivial, abortions, congenital performance has varied significantly from the anomalies and morbidity, as well as feature departmental or national average. Data articles on public health topics such as alcohol- presented for common procedures and related deaths. diagnoses include in-patient mortality rates, lengths of stay, and readmissions. The UK National Audit Office (NAO) scrutinises public spending on behalf of Parliament (www.nao.org.uk). It is currently examining the results of the NHS Arms Length Body Review 2004, and is due to report early in 2008.
Dr Foster Intelligence is a public-private partnership between Dr Foster LLP and The Information Centre. Launched in February 2006, it aims ‘to improve the quality and efficiency of health and social care through better use of information’ (www.drfoster.co.uk).
For the public, Dr Foster Limited provides a service to compare hospitals by clinical outcome factors such as average length of stay, readmission rates for common operations, staffing levels, as well as more patient-centred standards such as mixed sex bays and pleasant surroundings. This is based
50 STANDARD SETTING NICE is an independent organisation The Medicines and Healthcare Products established following the 2004 White Paper Regulatory Agency (MHRA) and the National ‘Choosing health: making healthier choices Clinical Assessment Service (NCAS) in the easier’. It replaced the National Institute for National Patient Safety Agency (NPSA) have Clinical Excellence (NICE), which was set up in roles in standard setting, outlined under their 1999. The tasks of the Health Development description in the ‘Data’ section. Agency (HDA) moved to NICE on 1 April 2005. It produces guidance on health technologies National Institute for Health and Clinical and clinical practice for the NHS, and on public Excellence (NICE) has the role of ‘providing health for a wider audience. Topics may be national guidance on promoting good health suggested online by any interested parties to and preventing and treating ill health’ inform the Department of Health in (http://www.nice.org.uk). commissioning guidance
Centres Topic Countries Status
Clinical Practice Clinical Practice NHS England & Wales Authoritative
Health Technology Technology Appraisals NHS England & Wales
Intervention NHS in England, Wales procedures and Scotland
Public Health Public Health England Under development Interventions and Programmes
NICE also runs a research and development an insurance company, but manages which commissions research, and has set up an indemnity schemes for NHS bodies. implementation support programme. NHS Membership is voluntary and was universal in organisations in England and Wales have been 1995. NHSLA strands of work include handling required to fund medicines and treatments negligence claims against the NHS in England, recommended by NICE in its technology active risk management to raise NHS standards appraisals guidance since January 2002. Three and reduce negligence claims, monitoring months are allowed for implementation. human rights case-law, handling family health service appeals and dealing with equal pay The NHS Litigation Authority (NHSLA) claims for the NHS. manages indemnity schemes for NHS bodies. One of its functions is to ‘contribute to the As part of risk management, it produces incentives for reducing the number of NHSLA Standards for different clinical areas, negligent or preventable incidents’ based on evidence assessed by other statutory (www.nhsla.com). bodies such as the MHRA. The focus of these The NHS Litigation Authority is a Special standards is on strategies with the potential to Health Authority established in 1995. It is not reduce negligence claims.
51 The General Medical Council (GMC) sets and Entrance to a medical specialty is by achieving regulates standards of professional behaviour membership of a college examination; for doctors (www.gmc-uk.org). examinations for this are set and administered All doctors must be registered with the GMC by the relevant college, who are thus directly to practise in the United Kingdom. If the GMC involved in standard setting for medical judges that a doctor has breached the practice. Colleges issue guidelines on clinical standards it sets in Good Medical Practice it topics and more general issues such as medical may issue a warning, place conditions on the education. National audits are often led by doctor’s registration or remove or suspend the the colleges, for example the Royal College of doctor from the register. Physicians’ Lung Cancer Programme. Organisations such as National Institute for The GMC also set and monitor standards for Health and Clinical Excellence (NICE) and the education and training in the UK as an Department of Health often use the colleges undergraduate and in the first year of as a source of medical expertise for standard training. Medical schools are inspected to setting committees. ensure the standards in Tomorrows Doctors are met in training and assessment. This is The Academy of Medical Royal Colleges is achieved through inspection visits and annual formed of representatives from all the colleges submission of information from the medical (medical and surgical, including those in schools. Scotland and Northern Ireland). It issues reports and guidance to doctors and The Nursing and Midwifery Council (NMC) healthcare organisations on healthcare issues sets standards for professional conduct and relevant to all specialties, such as continuing maintains a register of qualified nurses and professional development. midwives (www.nmc-uk.org). The Nursing and Midwifery Council judges National Service Frameworks ((NSFs) are ‘long allegations of misconduct or unfitness to term strategies for improving specific areas of practise, and has the power to remove nurses care. They set measurable goals within set from the register. The NMC also sets standards time frames’ for nursing and midwifery education and has (http://www.dh.gov.uk/en/Policyandguidance/ appointed HLSP, a healthcare consultancy, for Healthandsocialcaretopics/DH_4070951). quality assurance of education. NSFs set out standards that should be achieved Royal Colleges exist for most specialties of and propose mechanisms for doing so. They medicine. The most active in the quality field are developed by an external reference group, are arguably the Royal College of Physicians of managed by the Department of Health. Topics London and the Royal College of Surgeons of covered so far include cancer, mental health, England. Colleges also exist for general diabetes, renal services, chronic obstructive practitioners, pathologists, ophthalmologists, pulmonary disease (COPD), paediatric obstetricians and gynaecologists, radiologists, intensive care and coronary heart disease. anaesthetists, paediatrics and child health, NSFs are one of the main mechanisms of occupational medicine and public health implementing the NHS Improvement Plan medicine. Several of the colleges are UK wide, 2004. Earmarked funds are available to but the surgeons and physicians have separate Primary Care Trusts (PCTs) for implementation colleges in the devolved administrations. of the NSFs.
52 Condition specific charities play diverse roles assigns a risk rating to each of the 77 in the quality landscape, but some are foundation trusts for its finance, governance particularly significant in standard setting, and mandatory service provision. It can such as the British Thoracic Society (BTS intervene in trust management if they are www.brit-thoracic.org.uk), which publishes failing to comply with their terms of authoritative clinical guidelines for respiratory authorisation. conditions, as well as educational material and audit tools. Others play a more indirect role in Primary Care Trusts (PCTs), Trust Boards and standard setting, by lobbying to represent the Strategic Health Authorities have statutory interests of patients with particular conditions. responsibilities regarding the quality of services they provide. INSPECTION The Confidential Enquiries (administered by Primary Care Trusts are responsible for the National Patient Safety Agency, NPSA) and ensuring quality services are delivered by the Healthcare Commission play significant healthcare providers, through commissioning roles in inspection, described when they and contracting of services. PCTs in turn are appear in the ‘Data’ section. accountable to Strategic Health Authorities, and to their local populations directly and The Audit Commission is ‘an independent through Overview and Scrutiny Committees public body responsible for ensuring that (OSCs). PCTs are led by Trust Boards, which public money is spent economically, efficiently, have a lay majority. and effectively’ (www.audit- commission.gov.uk). Strategic Health Authorities (SHAs) are The Audit Commission audits NHS trust, responsible for ensuring that PCTs deliver a primary care trust and strategic health high quality service. SHAs monitor through authority financial systems, and produces assessments and performance management, reports on financial management and have the power to regulate performance improvement. It is currently implementing the through commissioning and contracting data assurance framework for payment by arrangements. results, which includes developing benchmarks for the quality of the data that is used to SUPPORT measure the quality of care. The Medicines and Healthcare Products Regulatory Agency (MHRA) and the NPSA’s Monitor is an ‘independent regulator of NHS Research Ethics branch play some role in Foundation Trusts’ (http://www.monitor- support, outlined when these organisations nhsft.gov.uk). were included in the ‘Data’ section. Monitor assesses applicants for NHS foundation trust status, and regulates The NHS Institute for Innovation and foundation trust management. It was Improvement (NIII) exists ‘to transform established in January 2004 and its role is set healthcare for patients and the public by out in the National Health Service Act 2006. rapidly developing and spreading new ways of working, new technology and world-class Inspection of foundation trust performance is leadership’ (www.institute.nhs.uk). carried out by the Healthcare Commission. Monitor receive the inspection results and
53 The NIII develops packages of tools to support discovery to adoption’ (Our NHS, Our Future). NHS providers and managers in achieving high The Health Innovation Council will lead and quality service delivery. The ‘No Delays’ advocate the introduction of high-technology package is designed to help service providers devices, diagnostics and drugs in the NHS. It and commissioners achieve the target for will be chaired by Lord Darzi; NICE, the maximum waits of 18 weeks in all NHS services. National Institute for Health Research and the It includes an online statistical analysis tool and NHS Institute for Innovation and Improvement a range of products designed to help services will all participate. improve their patient flow. ‘Care Outside Hospital’ is a package in development to aid The Independent Reconfiguration Panel (IRP) implementation of care in the local community. was established as ‘the independent expert on ‘Quality and Value’ offers assistance in NHS service change’ (www.irpanel.org.uk) comparing benchmarking several indicators of The Independent Reconfiguration Panel was productivity. It also includes booklets which established in 2003 to provide independent focus on particular aspects of clinical care, such advice on contested cases of change in the NHS as acute stroke, giving advice about running service provision. To try to prevent these services effectively and efficiently. More events, it also offers advice throughout the generally, the ‘Building Capability’ programme NHS on implementing change in service offers tools for operations management in the provision, and spreading good practice. NHS. The NIII also provides a forum for sharing ideas and good practice; ‘NHS Live’. The National Institute for Health Research is committed to ‘establishing the NHS as an The National Institute for Improvement and internationally recognised centre of research Innovation incorporates the National excellence through supporting outstanding Innovation Centre (NIC), whose remit is to individuals, working in world-class facilities, ‘speed up healthcare technological innovations conducting leading-edge research focused on that give patients the greatest benefit’ the needs of patients and the public’ (www.nic.nhs.uk). (www.nihr.ac.uk).
The National Innovation Centre has three main It was established as part of the Best Research areas of work, known as ‘hubs’. The for Best Health government strategy, and is ‘Innovation Hub’ identifies areas of need for directed by the Department of Health’s new technology and supports NHS staff to Director General of Research and develop pre-market products that fit the Development. Its remit covers research identified need. The ‘Training Hub’, based in capacity development, developing research Imperial College, London, works with industry networks, reducing bureaucracy in research and universities to improve training in new governance, providing an infrastructure for technology use. The ‘Adoption Hub’ in research in the NHS and funding research Manchester identifies factors that enhance programmes. rapid adoption of new technologies by the NHS. The Office for Strategic Coordination of Health Research (OSCHR) will take an overview of the The Health Innovation Council was established budgetary division and research strategy of in Lord Darzi’s interim review, Our NHS, Our both the Medical Research Council (MRC) and Future, to be: ‘guardians of innovation, from NIHR.
54 The Medical Research Council is a publicly- The Health Foundation is an independent funded organisation dedicated to improving charity, ‘working to improve the quality of human health by funding medical research. It healthcare across the UK and beyond’ by funds biomedical and clinical research ‘bridging the gap between policy, practice and according to the priorities it identifies and research’ (www.health.org.uk). publishes in its strategy documents. It spends £20 million annually on funding Wellcome Trust is a charity funding research in projects to improve healthcare quality, for biomedicine, the medical humanities such as example initiatives to engage clinicians in ethics and the commercial application of quality improvement and the Safer Patient research technology. It also supports project Initiative, which aims to support healthcare promoting public engagement with science organisations improve patient safety. It also (www.wellcome.ac.uk). runs leadership schemes, including prestigious fellowships, and publishes reports on research, It plays a significant role in medical evaluations and public consultations. development, investing more than £400 million per year in biomedical research. Projects They are currently funding the Quest for funded by Wellcome Trust have included the Quality and Improved Performance (QQUIP). sequencing of the human genome, This initiative will provide independent reports development of the antimalarial artemisinin on a wide range of data about the quality and and the evidence base for steroid treatment performance of healthcare provided in the UK, for premature babies. which will be highly relevant to the Next Stage review. The King’s Fund is an independent charity, aiming to develop: ‘informed policy, by The Patients Association is a registered charity, undertaking original research and providing ‘committed to making a difference to the objective analysis; effective services, by ‘Patient Journey’’ by asking patients for their fostering innovation and helping put ideas into experiences of health services and sharing this action; and skilled people, by building with the NHS to try to improve services from a understanding, capacity and leadership’ patient perspective (www.patients- (www.kingsfund.org.uk). association.org.uk).
The King’s Fund publishes respected and Current campaigns centre on healthcare thorough reports and papers on health and associated infections, chronic pain in the social care policy and practice, runs leadership elderly, counterfeit medicines, increasing development courses, holds conferences, and voluntary organ donation, the GP contract, funds healthcare research in London. Recent access to dentistry, patients’ rights, and mixed reports include the Wanless Healthcare sex wards. Spending Review and Assessing the Implementation of Agenda for Change. Of relevance to the Next Steps review, it is Current projects include an examination of currently surveying patients views on the commissioning, providers, regulation and future of the NHS for its 60th anniversary. performance in the NHS.
55 The National Library for Health (NLH) exists ‘to help patients and professionals use best current knowledge in decision-making’ (www.library.nhs.uk).
The National Library for Health runs a single- point-access national digital library, as well as national specialist libraries. In each healthcare organisation it plans that a board member will be identified as Chief Knowledge Officer, each to be supported by a librarian working as Knowledge Manager; this scheme has received a commitment from 1,275 librarians.
56 APPENDIX 2.
STANDARDS: TERMINOLOGY, TAXONOMY AND USE
Selected clinical quality assurance and addressing the coordination of care improvement tools: definitions across its primary, secondary and community elements. Standards are short statements (sometime incorporating numerical data) Care bundles are sets of specific evidence- of the required level of performance of a based interventions or actions aimed at clinical service in relation to aspects of improving outcomes or reducing risks of diagnosis, treatment, technical procedure care in a defined area of care (e.g. or care. Standards may be set so as to intensive care, acute care, healthcare achieve minimal acceptable, optimal or infection). This relatively new quality ‘best’ performance and may be derived from research evidence (preferable) or professional consensus. Source: Donaldson L.J. (2008)
Practice or clinical guidelines are longer statements setting out optimal or ‘best’ practice in relation to the diagnosis, treatment or care of a particular illness or group of patients, the use of a particular intervention or the clinical organisation of a service. They aim to align practice with the guideline and thereby promote good practice. To achieve compliance with best practice in more specific terms. they can incorporate explicit standards or be used to derive them.
Clinical pathways are descriptions of the desired process of care for particular diseases or patient groups. This may be done in several ways: as a set of steps that should be incorporated (sometimes expressed as explicit standards), as a flow of care with each linked stage defined (again sometimes incorporating explicit standards) or as a formal algorithm or decision tree (with or without standards). Clinical pathways can cover the process of care within an episode, sector or institution or more widely, for example
57 Selected clinical quality assurance and improvement tools: a taxonomy
Concept Characteristics Purpose Necessary clarifications
Standard Short description of what is Achieve a particular • State whether to be achieved; may level of performance standard is minimal, incorporate numerical in relation to quality optimal or ‘best’ material as well as narrative of care. • Specify the criteria to statement. be used for assessment • State whether the standard is based on research evidence or professional consensus
Guideline Describes the preferred Promote good • State whether based treatment or approach to practice in specified on research evidence care of a disease or group field of care. or professional of patients. Often includes consensus algorithms or options for different subgroups of patients. May include or be used to define explicit standards.
Pathway Specifies process of care; in Standardise care to • Make clear which some cases limited to a improve outcomes, elements are national segment of the care (e.g. in efficiency, patient and which local hospital); in other cases convenience and embracing the whole of satisfaction. care including movement between sectors (primary, secondary, community); may or may not incorporate explicit standards.
Care Bundle Collection of evidence- Improve outcomes or • Must be evidence based processes known to safety of care in a based achieve particular outcomes service unit (e.g. • Interventions must all of care or reduce specific intensive care) or be applied together risks. across a group of service units (e.g. intensive care units in a region).
58 APPENDIX 3
PRINCIPLES OF THE NHS cycle of continuous quality improvement. Quality will not just be restricted to the The NHS Plan in 2000 was underpinned by a clinical aspects of care, but include the set of core principles, which key stakeholders entire patient experience. We will work supported. Some restated founding principles with our staff, our patients and the public, of the NHS, others reflected issues that were those commissioning care and the important at the time. regulators to make the care we provide ever safer and support a culture where we Principles of the NHS can learn from and effectively reduce As providers of care to NHS patients we mistakes. We will provide information commit ourselves to the following 10 about the outcomes of the treatment we principles: provide, complying with national inspections and regulation. 1. The NHS will provide a universal and comprehensive service with equal access 4. We will strive for the most effective and for sustainable use of resources. all, free at the point of use, based on We will continuously seek to improve our clinical need, not ability to pay. efficiency, productivity and performance in Healthcare is a basic human right. Unlike order to provide the best value for tax private systems, the NHS will not exclude payers’ money, recognising that best care anyone because of their health status or and best value go together. We are ability to pay. Access to the NHS will committed to the sustainable use of continue to depend upon clinical need, not resources and will aim to reduce our use of ability to pay. Unless a charge has been energy and other natural resources, specifically sanctioned by the NHS (eg for minimise production of waste and prescriptions or dental treatment), we will contribute to the sustainable development not charge a fee or require a co-payment of the wider community. from any NHS patient. We will provide appropriate care for all those referred to 5. We will treat every patient with dignity and us, within our clinical competence. respect. We will treat every patient, service user 2. We will help keep people healthy and work and carer as a valued individual, with to reduce health inequalities. respect for their dignity and privacy. Our We will continually seek opportunities to aim is to give each patient the care and promote health, as well as to treat illness. service we would want for ourselves and Recognising that good health also depends our families. upon social, environmental and economic factors such as deprivation, housing, 6. We will shape our services around the needs education and nutrition, we will work with and preferences of individual other services as appropriate to prevent ill patients, their families and their carers. health and reduce health inequalities. As far as possible, we will design our services around the needs of our users and 3. We will work continuously to improve their carers, rather than expecting them to quality and safety. fit around our convenience. Wherever We will ensure that services are driven by a possible, we will offer patients and the
59 public more choice and a greater say in 10. We will respect the confidentiality of their treatment, and will seek to engage individual patients and provide open them, individually and jointly, in designing access and improving services. to information about services, treatment and performance. 7. We are committed to equality and non- We will respect the confidentiality of discrimination. patients and service users throughout the We are committed to equality for patients process of care, including access to their and service users no matter what their age, information. Wherever possible, we will gender, disability, sexual orientation, race, provide high quality information and language, religion or national, ethnic or support to patients and the public about social origin. We will seek to provide services and treatments that are available, services that are culturally appropriate to and their performance, to improve the needs of different communities. transparency and accountability. Where 8. We will support and value our staff. technology can improve patient safety, we The strength of our organisation lies in our will use it. We will publish information staff, whose skills, expertise and dedication about our clinical and operational underpin all that we do. They have the performance to allow the NHS to assure right to be treated with respect and quality and enable patients to make dignity. We will continue to support, informed choices. recognise, reward and invest in individuals, providing opportunities for staff to progress in their careers and encouraging education, training and personal development. Professionals and organisations will have opportunities and responsibilities to exercise their judgement within the context of nationally agreed policies and standards.
9. We will work in partnership with others to ensure a seamless service for patients. We will work in partnership and co- operation with others providing and commissioning NHS and social care services, including in the public, voluntary and private sectors, to ensure a seamlessly co- ordinated, patient-centred service. We will share clinical information with other providers of care to ensure that patients receive a seamless service, wherever they are.
60 APPENDIX 4
RELATIONSHIPS WITH THE c. Support service improvement FUNCTIONS OF THE INSTITUTE OF xx. National Institute for Innovation and MEDICINE Improvement xxi. Medicines and Healthcare Products Organisations which currently pursue activities Regulatory Agency related to Institute of Medicine functions xxii. The King’s Fund include: xxiii. Health Foundation a. Integrate clinical knowledge systems to a d. Administer Clinical Excellence Awards single access point xxiv.the Clinical Excellence Award Scheme i. The National Library for Health ii. The Information Centre e. Accredite against preferred standards iii. Office for National Statistics xxv. Healthcare Commission iv. Public Health Observatories xxvi. Audit Commission v. National Patient Safety Agency xxvii. Monitor • Patient safety division xxviii. Confidential Enquiries • Confidential Enquiries vi. Medicines and Healthcare Products Regulatory Agency vii. Dr Foster (non-statutory) viii. National Audit Office ix. National Clinical Audit Advisory Group and national audits x. Healthcare Commission b. Set authoritative standards: xi. The National Institute for Health and Clinical Excellence xii. ongoing work on National Service Frameworks xiii. NHS Litigation Authority xiv. General Medical Council xv. Nursing and Midwifery Council xvi. Medicines and Healthcare Products Regulatory Agency xvii. National Patient Safety Agency xviii. Royal Colleges (non statutory) xix. Condition specific professional organisations and charities (non statutory)
61 APPENDIX 5
NATIONAL QUALITY AND SAFETY healthcare facility FORUM NEVER EVENTS (www.qualityforum.org)
1. Artificial insemination with the wrong 15. Infant discharged to the wrong person donor sperm or donor egg 16. Patient suicide, or attempted suicide 2. Unintended retention of a foreign object in resulting in serious disability, while being a patient after surgery or other procedure cared for in a healthcare facility 3. Patient death or serious disability 17. Maternal death or serious disability associated with patient elopement associated with labor or delivery in a low- (disappearance) risk pregnancy while being cared for in a 4. Patient death or serious disability health care facility associated with a medication error (e.g., 18. Patient death or serious disability errors involving the wrong drug, wrong associated with hypoglycemia, the onset of dose, wrong patient, wrong time, wrong which occurs while the patient is being rate, wrong preparation or wrong route of cared for in a healthcare facility administration) 19. Death or serious disability (kernicterus) 5. Patient death or serious disability associated with failure to identify and treat associated with a hemolytic reaction due to hyperbilirubinemia in neonates the administration of ABO/HLA- 20. Stage 3 or 4 pressure ulcers acquired after incompatible blood or blood products admission to a healthcare facility 6. Patient death or serious disability 21. Patient death or serious disability due to associated with an electric shock or elective spinal manipulative therapy cardioversion while being cared for in a 22. Any incident in which a line designated for healthcare facility oxygen or other gas to be delivered to a 7. Patient death or serious disability patient contains the wrong gas or is associated with a fall while being cared for contaminated by toxic substances in a healthcare facility 23. Patient death or serious disability 8. Surgery performed on the wrong body part associated with a burn incurred from any 9. Surgery performed on the wrong patient source while being cared for in a healthcare 10. Wrong surgical procedure performed on a facility patient 24. Patient death or serious disability 11. Intraoperative or immediately post- associated with the use of restraints or operative death in an ASA Class I patient bedrails while being cared for in a 12. Patient death or serious disability healthcare facility associated with the use of contaminated 25. Any instance of care ordered by or drugs, devices, or biologics provided by the provided by someone impersonating a healthcare facility physician, nurse, pharmacist, or other 13. Patient death or serious disability licensed healthcare provider associated with the use or function of a 26. Abduction of a patient of any age device in patient care, in which the device is 27. Sexual assault on a patient within or on the used or functions other than as intended grounds of the healthcare facility 14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a
62 APPENDIX 6
PUBLIC CONSULTATIONS
Recommendation Submission supports Submission identified recommendation recommendation theme as area of importance
1. Accountability and System • Monitor • Northgate level goals • NICE • Impress • Age Concern • Health Foundation
2. Dashboards • Director, Innovation, • British Heart Foundation Business Development and • Imperial College Performance, South West • Northgate Essex Primary Care Trust • Monitor • Royal College of • Royal College of General Obstetricians and Practioners Gynaecologists • Which? • NICE • University Hospitals of Leicester, Renal Unit • The Princess Royal Trust for Carers • Age Concern • Director of Information Systems, Addenbrook’s Hospital • Breakthrough Breast Cancer • MRSA Action UK • Deltex Medical Group • Appointments Commission • BUPA • Health Foundation • Asthma UK • Faculty of Public Health • NHS Confederation • Director of Clinical Development South Staffordshire and Shropshire Healthcare
3. Rationalisation of • NICE • Dignity in dying standards • Age Concern • Foundation Trust Network
63 Recommendation Submission supports Submission identified recommendation recommendation theme as area of importance
4. NHS Preferred Pathways • Novartis • Royal College Of Paediatrics and Child Health • Clinical Director, Mental Health Research Center, Durham University • St Thomas Medical Group Research Unit • Alliance Boots
5. Institute of Medicine • Centre for Evidence-based • Northgate Purchasing • Monitor • Royal College of • Breakthrough Breast Obstetricians and Cancer Gynaecologists • The Society of • Health Foundation Radiographers • NHS Confederation
6. Regulatory Framework • Royal College of Surgeons • RCGP Tamar Faculty of England • Health Professions Council • Royal College of General • Alliance Boots Practioners • • • Breakthrough Breast Tuke Institute of Medicine Cancer • Pharmaceutical Services • Health Foundation Negotiation Committee
7. Funding for quality • Royal College of Surgeons • Brook of England • Terrence Higgins Trust • Diabetes UK • Bliss • Deltex Medical Group • • Unison Monitor • Royal College of • ABPI Obstetricians and • Impress Gynaecologists • Milliman Care Guidelines
8. Commissioning • Monitor • Royal College of Surgeons • NICE of England • Unison • Macmillan Cancer Support • British Association for Perinatal Medicine
64 Recommendation Submission supports Submission identified recommendation recommendation theme as area of importance
9. Duties of a team • Health Foundation • Monitor • Social Enterprise Coalition • Impress • National Health Service Retirement Fellowship
10. Clinical leaders facilitating • British Heart Foundation change • Keep our NHS public (Oxford) • Monitor • Workforce Review Team • Health Foundation
11. Reshaping Clinical • Monitor Excellence Awards • NHS Confederation
12. Employees as partners • Cancer Reform Strategy • Keep our NHS public(Oxford) •
13. Never events • Monitor
14. Patient Safety Initiative
65 RESTRICTED - MANAGEMENT Next Stage Review: Quality and Safety National Group
Final Submission to Lord Darzi March 2008 Accompanied by report Best and Safest Care
66 Quality and Safety Workstream: Executive Summary Executive Workstream: Safety and Quality • • • • St Safety Patient and Quality of Work the of Vision • • Strand Safety Patient and Quality of Aims NHS Next Stage Review health of risks the in reduction sustained drive To a of delivery the in consistency greater achieve To pl business organisation’s NHS every that ensure To funded and assessed managed, designed, curre common the safety patient and quality make To the past; modern NHS in a way and on a scale that has not bee Stage Review to make quality and safety the currenc It is intended that the proposals in this report wi described by one member of NHS staff situation where there are only the isolated‘island this the norm throughout the NHS and to move away f excellence on a day-to-day basis. The challenge is and consistent picture of the nature of clinical te services. The studies of high performing services p making, in planning and commissioning, in design an patient safety within all aspects of the work of th The overall aim of this strand of work is to mainst – – – – – – in the planning and commissioning of services There is a great absence of patients and family mem patient safety regular and sustained improvements in quality and The commissioning function is not aligned to leveri assessment skills in improvement science and performance Information on clinical quality is poor, so too are unit and share their learning more widely and a lack of incentives to improve the quality of national standards which are not relevant to their barriers: lack of peer support, inability to respon Clinical leaders in the current system face multipl confusion about their definition, use and importanc Heterogeneity of standards and guidelines with There are no quality improvement goals at system le ll help NHS Next ams that deliver e NHS: in policy- s of excellence’ ream quality and rovided a clear how to make y of the d delivery of rom the n possible in d to clinical their e unit e ng bers vel care ccepted standards of best practice best of standards ccepted rand of the NHS Next Stage Review Stage Next NHS the of rand an and quality plan are one and the same document same the and one are plan quality and an •
ncy of the NHS through which services are planned, are services which through NHS the of ncy 67 action have been made aimed at: As a result of this context, experience and analysi Recommendations Establishing within the new proposed system of reg – Creating a patient safety initiative to galvanise – Laying down a set of duties and responsibilities f – Redesigning the funding flows and incentives withi – Simplifying the quality landscape to clarify roles – Establishing an accountability framework for quali – Rationalising, defining and clarifying the standar – higher quality care health and social care services, a framework to pro programme of safety the public, the health professionals and managers t that risk can be reduced and gain the commitment of teams to lead, deliver and demonstrate quality to reward higher quality and penalise poor or unsaf agencies responsibilities and relationships of different bod an independent, expert body drive higher quality, safer care and placing this i safety at the system level and applicable in all se s, 14 proposals for action, show , n the hands of ds used to ies and or clinical rvice settings ty and n the NHS e care mote o a ulation of patients, High-level vision for Quality and Safety and Quality for vision High-level From… NHS NextStaff Stage ReviewPublic Patients • • • • • • hospitals or clinical teams clinical or hospitals of rate event adverse or complication performance, the on information No adddressed: media panic when they occur they when panic media adddressed: fully or acknowledged openly not as public by perceived often events Unsafe local service local the to appropriate not are or with agree not do they which of some targets, set centrally against measured is team The staff NHS disenfranchised disillusioned, million a than More disease their with deal to how and expect to what unclear care; of pathways and standards different to leading searches Internet to attention paid or nationally measured not satisfaction Patient To… • • 68 • • • • their quality improvementactivities quality their overservice. Teamslocal ownership the feel to feelsare it importantthat team indicators picksThe teams performing highly and satisfaction patient improved rewards for with Lewis) John (cf. hospitals theirarrangements partnership NHSstaff with in All publicly available and understandable and available publicly metricskeyperformance Informationdashboard on teams their accreditedclinical on based teams.and Hospitals care clinical by delivered of demonstrate quality publicly dashboards Clinical patients are patients staffsatisfiedare rewarded if dashboard: clinical the to everyinput admission scoressatisfaction Patient everyfor on patient can be expectedbe can care of which quality best the explaining version patient’s accompanying an and standard gold IOMavailable publicly and recognised Nationally hospital never inoccurthese eventsthat promise should national available, never eventsof Set publicly Where we are today on Quality and Safety and Quality on today are we Where compared to 10 years ago, fundamental problems rema Despite the stronger quality and patient safety eth NHS Next StageSafe ReviewPersonalised Effective Fair Issue • • • • • • Where we are today are we Where Incidents of serious failures in standards of care care of standards in failures serious of Incidents hi too still are care health of risks avoidable The and communication bad families, their and patients sa the of repetition reveal complaints patient Many inconsistently adopt is evidence) research on (based practice Best neglected health and cleanliness (notably basics the of Some Variation in standards of care around the country i country the around care of standards in Variation 69 os that exists in the NHS now in gh still occur still s extensive s me problems: disrespect for disrespect problems: me poor coordination of care of coordination poor care infection) have been have infection) care ed too slowly and slowly too ed Where we are today on Quality and Safety and Quality on today are we Where NHS services Quality and patient safety are not yet embedded in NHS Nextinvolvement Patient quality improve to Drive Stagequality improve to Capacity Reviewpractice best of adoption and spread to Barriers standards Clear vision Shared Issue • • • • • • Where we are today are we Where commissioning of services of commissioning mem family and patients of absence great a is There safety patient and quality in improvements leveri to aligned not is function commissioning The assessment performance and science are too so poor, is quality clinical on Information widely more thei of quality the improve to incentives of lack a ar which standards national to respond to inability multipl face system current the in leaders Clinical importance and use conf with guidelines and standards of Heterogeneity le system at goals improvement quality no are There 70 the planning, design and delivery of clinical skills in improvement in skills clinical r unit and share their learning their share and unit r e barriers: lack of peer support, peer of lack barriers: e e not relevant to their unit and unit their to relevant not e ng regular and sustained and regular ng usion about their definition, their about usion vel bers in the planning and planning the in bers Overview of key recommendations and expected impact expected and recommendations key of Overview 2. Clinical Dashboards Clinical 2. accountability An 1. eomnainRationale Recommendation Each clinical team in the setA of goals at system level understood format that is easily presented in a common publicly available and statutory requirements, Clinical dashboards would be performance indicators. and locally designed standards agreed nationally performance against to monitor and benchmark maintain a clinical dashboard country should be required to quality and safety activities within the NHS on focus all policies, plans and should be established to NHS Next Stage Review care safer better, for framework • • their work patients and use data as an integral part of service goals in terms of clinical benefit to ownership of service performance, express performing clinical teams is that they take improvement. A common feature of high clinical teams to drive forward quality Good clinical data will be key to enabling of quality in the NHS There is currently no clearly articulated vision 71 • • Expected Impact on patients, public, staff public, patients, on Impact Expected choices about healthcare public and commissioners to make truly informed transparent display of performance data will enable successes in meeting the quality goals. The themselves and be held accountable for their them. Clinicians and managers will be able to judge improvement needs and design initiatives to address consider valuable and allow them to identify qualit performance against measures that they themselves Clinical teams will own and monitor their own quantifiable metrics approach can be created from vision, through goals quality as the currency of the NHS a structured finance and productivity to one based on quality. W systems, shifting the language of the NHS from that planning, delivering, managing and funding healthca This mechanism will put quality at the heart of y the ith of to re Overview of key recommendations and expected impact expected and recommendations key of Overview 5. patients, on Impact Expected Preferred NHS 4. Rationale of Rationalisation 3. Recommendation An An Institute of Medicine Agreed standardised Existing standards and quality improvement management and support for setting, knowledge independent role in standard should be created to fulfil an for a number of key illnesses pathways should be designed standards for all clinical areas to produce a set of preferred guidance should be reviewed NHS Next StageMedicine of Institute An Review Pathways Clinical guidelines and standards existing • • • governmental organizations duplication of functions between existing landscape. It will reduce waste in the form of Medicine will act to rationalise the current qualit many organisations. Creation of an Institute of care. There is significant overlap in the roles of management to describe the highest standard of improvement on the front line or in knowledge setting standards, providing support for role in healthcare quality in England, whether in A large number of organizations currently have a The quality landscape is cluttered and confusing. attached to the process of care (e.g. cancer care) or where there are serious risk resource consumption is associated with waste to substandard care (e.g. stroke), where heavy process of care where variable performance leads Pathways can be helpful to standardise the quality and standards of care to ignore leading to a high level of variation in t decide which to prioritise and adhere to and which overlap. Front-line clinicians are often left to statutory and non-statutory bodies that often guidelines issued to the NHS from a variety of There are a plethora of standards, pathways and 72 he y s • • • deliver, by providing tools and removing barriers allow staff to improve the quality of patient care joined-up help on implementing standards. This wil prioritise best practice guidelines and will have a they receive. Staff will find it easier to identify standards, and will be able to compare these to the Patients will have greater access to a single set o of care, ensuring the receive the highest quality o Patients with certain conditions will follow a set these pathways, adapting them to suit local needs. Staff will be able to model local service design ar to receive, as the preferred standard will be‘kite to understand the standards of care that they can e design of their services around this. Patients will care they should be aiming to provide, and base the Staff will be able to understand clearly the standa public, staff public, and pathway they marked’ be able ccess to ound f care rds of f clear care xpect l Overview of key recommendations and expected impact expected and recommendations key of Overview 8. Commissioning of Commissioning 8. 7. 6. Recommendation Dashboards should be used as a dashboards clinical to Funding flows should be regulatoryA framework should be Commission and assessed by the Care Quality NHSinformed by clinical dashboards Commissioners will make choices commissioning process. Nextkey component of the linked be will services Stagewill be made bigger for higher quality and safer care Reviewtariff payments), the funding levels variations to the tariff (or extra- quality, safer care. Through redirected to support higher care safer quality, higher Funding penalise poor standards of care developed to assure quality and framework regulatory A Rationale Expected Impact on patients, public, staff public, patients, on Impact Expected Rationale • • • of commissioning to effect change commissioners will be able to use the lever care from them. More than this, providing high quality care and commission will be able to identify which services are national and local priorities, commissioners By using clinical indicators which cover both to boost organizational revenue will strive to deliver high quality care in order higher quality service. Healthcare providers incentivisehealthcare providers to provide a Paying more for high quality care will compared to care of a lower standard. do not financially reward high quality care Current Payment by Results (PBR) policies quality mixes essential standards with the pursuit of Current regulation is overburdensome and 73 • • • Accreditation will drive staff to improve quality i and needs. them to make choices right for their health status indicators how well services are doing, enabling public will be able to see clearly through the clin patients this will result in better, safer care. T commissioning and also quality improvement. For incentive for clinicians to take part in both as an enabler of quality. This should serve as an The effect of commissioning will be strengthened the best care receive the largest reward. The public will be reassured that those providing are motivated to provide a higher quality service. Patients will receive better, safer care as provide incentives can effect considerable change. can to maximise the income of their unit. Aligning Staff will be motivated to provide the best care th reached a certain standard of care service which have demonstrated that they have Accreditation will also empower patients to choose their units as they work to demonstrate excellence. an acceptable level of care. patients with a reassurance that they are receiving essential standards will provide the public and A strong regulatory framework with explicit he n ical rs ey Overview of key recommendations and expected impact expected and recommendations key of Overview 11. Reshaping the Clinical the Reshaping 11. excellence Expanding 10. governance Clinical 9. eomnainRationale Recommendation The Clinical Excellence Awards Clinical leaders in units achieving clinicalAll teams should have a NHSfinancial reward demonstrated quality of care and strengthen the link between SchemeNext should be altered to Scheme Award Excellence Stagecare to help them raise their standard of delivering a similar range of services Reviewshould be made available to units proven levels of excellence in care leaders clinical performing high proven available making by and safety of their service duties agreed to ensure the quality specified range of clinical governance team clinical every for duties • • • of hospital consultant activity incentives to put quality improvement at the centre activities will create strong individual financial clinical excellence awards on quality improvement in the NHS. Focussing the criteria for receiving a unique position to help embed high quality care making and service planning, and are therefore in Consultants are at the heart of clinical decision- leadership cadre“changeor— leaders” engagement”and take practical steps to develop a services. We need to move beyond talk of“clinical it ismanagers” difficult“the to develop outstandi set clinical priorities. Where leadership is left supported at a local level so that clinical leaders Clinical leadership needs to be promoted and care they provide to patients clinical teams to assess and improve the quality of improvement, and promote the accountability by understanding of their roles in quality that individual clinicians have a clear and explici quality of their service. Team duties will ensure Clinical teams lack a sense of ownership over the 74 to t ng Expected Impact on patients, public, staff public, patients, on Impact Expected • • • financial reward maximise the likelihood of achieving high levels of alter to focus on quality improvement in order to highest rewards. Consultant activity would be likel doctors providing the best service for the patients consultant workforce, by demonstrating that those improve the public perception of the awards, and th A reformed clinical excellence award would act to transformative change knowledge and skills to assist other services in ac pioneers will be encouraged and incentivised to use enormous knowledge resource. These entrepreneurial levels of excellence in care, the NHS will mobilise By nurturing clinical leaders in services achieving Institute of Medicine the facilitation of clinical teams to improve quali services for patients. These responsibilities will This will motivate staff, and improve the quality o empowered to take ownership of the quality agenda. teams will contribute to a culture in which clinici The articulation of quality responsibilities of cli nical ty by the ans are underpin f proven get the an hieving y to e their 14. A patient safety patient A 14. Events Never 13. partners as Employees 12. Overview of key recommendations and expected impact expected and recommendations key of Overview A patientA safety initiative should be Building on international experience, JohnA Lewis-style partnership infection nationwide reduce catheter-related bloodstream launched to take life-saving action to initiative and unacceptable events’ that are serious, preventable the NHS should agree a list of ‘never of their NHS organisation NHS staff to share in the ownership scheme should be created to enable NHS Next Stage Review Recommendation • • • Rationale based approach to patient safety ICUs will embed a measurement and evidence- Matching Michigan’s success in saving lives in towards unsafe care for the NHS, and provide a financial disincentive accountability, make explicit a standard of safety occurrence. This will increase public greater recognition and action to prevent Consensus is growing that never events need for high performance team spirit and competitive drive as teams strive Lewis experience has been that this generates should be at the heart of the NHS. The John for quality will reinforce the message that quality Emulating the John Lewis model with its reputation 75 Expected Impact on patients, public, staff public, patients, on Impact Expected • • • done infections; and Michigan’s example shows it can be practice to reduce catheter-related bloodstream encouraged and enabled to put best practice into will increase public accountability. Staff will be incidence of catheter-related bloodstream infection for patients. Openness in recording and reporting The implementation of the scheme will make care saf the focus on patient safety across the NHS to focus on preventing never events. This will ren events. Care providers will have a financial incen will be improved through better reporting of never Patients will receive safer care. Public accountab benefit from the fostering of a stronger team cultu quality. Patients will receive higher quality care be a mandate to all staff to be involved in improvi contribute to a culture of cooperation, engage staf Staff will own a share in their organisation. This and will ng re tive ility ew f and the s er High-level sequencing and associated cost outlines cost associated and sequencing High-level Clinical Pathways Clinical Preferred NHS 4. guidelines and standards existing of Rationalisation 3. Medicine of Institute An 5. framework regulatory A 6. Dashboards Clinical 2. quality, safer care safer quality, higher Funding 7. better, safer care safer better, for framework accountability An 1. NHS Next Stage Review Anticip sequence/timing Implementation Recommendation
• • Commission begins registration begins Commission • • • • • • • • • • • • • • 2008-9 IOM functions start up start functions IOM 2008-9 structure IOM Establish 08 July Spring 2010 Care Quality Care 2010 Spring framework regulatory Establish 2008-9 nationwide out Roll 2008-9 dashboards three Pilot 08 July 2009-18 Pathway development Pathway 2009-18 topics of Selection 2008-9 mechanism Establish 08 July July 08 Set framework Set 08 July 2009-14 Kitemarking programme Kitemarking 2009-14 topics of Prioritisation 2008-9 mechanism Establish 08 July 2009-12 Roll out nationwide out Roll 2009-12 2008-9 Pilot tariff variation tariff Pilot variability tariff Scope 2008-9 2008 76 • • • • • • • Could be cost neutral cost be Could accreditors other of behalf on collection data for gatekeeper the as acting than more cost may scheme accreditation an Running merged bodies existing and IOM the in included functions on depend will Cost mechanism and chosen pathways of number on depend will Cost standards rationalise to chosen mechanism on depend will Cost development dashboard of costs medium to short of estimate better inform will £1m) - (£500,000 Pilot negligible cost goals quality level system the Developing ated cost implication cost ated High-level sequencing and associated cost outlines cost associated and sequencing High-level Award scheme Award Excellence Clinical the Reshaping 11. leaders clinical performing high proven available Making 10. partners as Employees 12. 13. Never events Never 13. clinical team clinical every for duties governance Clinical 9. initiative safety patient A 14. clinical dashboards clinical to linked services of Commissioning 8. NHS Next Stage Review Anticip sequence/timing Implementation Recommendation
• • • • • • • • • • • • • • 2008-9 Reshape CEAs Reshape 2008-9 of Institute Establish Medicine 2008 (stagger: events one at a time) a at one events (stagger: reporting full Require penalty tariff Introduce 2009-18 events never Identify 2009 2008 duties Establish 08 July nationwide out Roll 2010-18 sites pilot dashboard at Run 2009-10 2008-9 Recruit Fellows Recruit 2008-9 of Institute Establish Medicine 2008 2009-14 Roll out nationwide out Roll 2009-14 Trusts volunteer in Pilot 2008-9 2008 Task NPSA Task 2009-10 2008 Matching Michigan Matching 77 • • • • • • • Initiative coordination Initiative saving cost term Long other by covered implement to Support low cost low infections saves costs saves infections bloodstream catheter-related Reducing tariff) on save incidence, event reduce to service (support neutral cost term Short invest if effective more be to likely but neutral cost as run be Could neutral Cost individuals of number small reward and support to cost Low recommendations cost negligible duties out Setting resources new few relatively require would goals quality level system the Developing ated cost implication cost ated NHS on quality and safety and quality NHSon fo to established be systemat goals Asetshould levelof b for framework accountability An 1: Recommendation patients’quality of life? Has the care delivered improved the Has progression been slowed? or diabetes: Was the disease identified early? goal for a patient being treated with epilepsy to test performance against the system level service where detailed metrics might be used at the front line, for example, within a specialise health status of a large population. Or it can be • • • • It can be applied in strategic discussions about th understood by staff, patients, commissioners and th integrate all of the NHS in a simple purpose that c the desired outcomes in holistic terms. This approa disease, the proposed quality aim for chronic disea For example, instead of having detailed national ta services through a meaningful lens at national or l overall aims of the service it is difficult to exam Without a clear set of system level goals that enca the NHS was that there is currently no clearly articulated the lack of what they termed the ‘system picture’. NHS, the Institute for Health Improvement repeatedl During its review on the current status of quality Stakeholder interviewee not under the lamp posts?” NHS Next Stage Review those lamp posts seems to be getting better, but wh and so we only see what is under the lamp posts. Wh because we have don’t an overall quality measuremen hard to answer“It’s the question about good ‘How i d applied ine the quality of vision of quality in improvement in the e The assessment an be well ocal level psulate the rgets for chronic ses describes ch serves to s our quality’ e public at about what’s y highlighted at’s under t framework, PERSONALISED, FAIR SAFE, EFFECTIVE, QUALITY cus all policies, plans and activities within the activitieswithin and plans policies, all cus HIGH LEVEL STANDARDS, SYSTEM GOALS GUIDELINES, PATHWAYS METRIC S procedures and encounters (with patients and their Embed a patient-centred philosophy of care in all p PERSONALISED to reduce them Make care safer by identifying the risks of care an SAFE goals quality level system Proposed FAIR health their progression, preventing complications and mai Identify chronic diseases early and organise care s patient’s needs, evidence-based and cost-effective Ensure all clinical and care decisions are appropri EFFECTIVE world outcomes of care when judged against the leading s Strive to achieve and demonstrate the highest stand 78
healthcare systems, shifting the language of t quality at the heart of planning, delivering, manag fair, effective, personalised and safe. This mechan within the four domains as set out in created which can focus all policies, plans and act By establishing a set of system level goals a frame based on quality that of finance and productivity to one quality With quality as the currency of the NHS a through goals to quantifiable metrics structured approach can be created from vision, etter, safer care safer etter, Our NHS, Our Future d taking action ate to the o as to slow rocesses, families) ards and best ntaining ervices in the he NHS from ing and funding ivities on ism will put work will be – requirements, publicly available and presented in a c a presentedin and available requirements,publicly design locally and standardsagreed against nationally to required be should country the team in clinical Each Dashboards Clinical 2: Recommendation • • • • curiosity and competition will drive change. For co performance will help to make quality improvement a monitor their own performance against measures that also decide what additional data they would like to local services, and choose indicators they wish to allow for real time visualisation of performance ac Dashboards will require well-developed, reliable da achieving local ownership and ensuring rigour in ad the dashboard compared to the nationally defined st national standards and evidence of best practice, n local level in discussion with patient representati The development of dashboards will be a challenging the quality of care in the Maternity Department at President of the Royal College of Obstetricians and Dashboards have been used to drive quality improvem one clinical team compared to another, creating a h Our key recommendation to enable all clinical teams NHS Next Stageas the Confidential Enquiries and National Audits w collect quality related data in many areas. There w dashboards will require close collaboration with th Reviewcollected nationally and locally by information tec practice benchmark Clinical outcomes Efficiency gis et- against best Locally chosen indicators Adverse risksevents, Compliance with Compliance and complaints and standards Patient Reported Outcome Patient Outcome Reported Productivity Measures Indicators practice benchmark National Clinical outcomes Compliance with Compliance gis et- against best standards ves, the public and commissioners to reflect local hnology systems, as well as data sets created local ross a variety of measured variables. The clinical Northwick Park Hospital e Connecting for Health programme. At present info mmissioners and patients the dashboards will provid focus on to improve quality. They could use data t collect to populate indicators reflecting local he ill therefore be a requirement for local data colle ta sources if they are to be effective. Sources us ationally and internationally. A central issue wil Gynaecologists) has developed a dashboard in an in ould also feed data into the dashboard system in ce ealthy competitive spirit amongst those clinical te hering to what is known nationally and internationa andards and metrics. A combination will be needed t to focus on quality improvement is the concept of scientific endeavour. By showing highly motivated task. Local teams will come together to create th they themselves consider valuable. Allowing clinic ent across a variety of industries. Within the NHS form a considerable part of the dashboard primary care, existing components of the Quality an a hospital or regional level by considering a combi they provide and clinical teams running them. An o A hospital would have a wide range of dashboards re ommon format that is easilyunderstood is format that ommon ed performance indicators. Clinical dashboards would dashboards Clinical performance ed indicators. maintain a clinical dashboard to monitor and benchmark and monitor to dashboard clinical a maintain 79 alth population needs. Clinical teams will own and concerns and interests. They will also rely on ction mechanisms. Existing data sources such l be the proportion of locally defined metrics on teams will decide what is important for their ed to power dashboards will include data ly and held on local databases. Delivering ams hat are already routinely collected and would lly to achieve the best outcomes of care rmation technology infrastructure does not e a real objective measure of the quality of a clinical dashboard. A dashboard would eir dashboards by selecting indicators at rtain clinical areas individuals variation in performance, ians access to data about their Professor Arulkumaran (currently o ensure the correct balance between itiative to turn around poor standards in nation of relevant dials. In verall picture could be gained at d Outcome Framework could flecting the specialist services be statutorybe performance indicators for use in clinical team dashboards clinical in use for indicators preferred standard defining and rationalising process of p reviewedto be should guidance standardsand Existing stand existing of Rationalisation 3: Recommendation • • find, identify and prioritise the standards that ar that standards the prioritise and identify find, implementati with and standards across coordination diss standards, of variety The standards. disparate clear a lacks NHS The discretion. local of matter st which clear not is It evidence. of use variable organisations Different unhelpful. is heterogeneity too are there that was us to spoke they when staff the to reflected view The guidelines. and standards t teams and clinicians to barriers major the of One NHS Nextguidelines respected (NICE) Excellence Clinical and Health for Institute Stagesuc clinicians, by valued greatly are organisations s currently who organisations of number a are There stan produce which organisations those of integrity Reviewrecommen this implementing In clinicians. by valued o are organisations other by set standards Existing bad is implementation for support and dissemination f A commissioning. are they service the of quality cause also can It patients. their for care improve s would be expected to lead to the generation of outcome of generation the to lead expected be to would s e most evidence-based, relevant to them and likely likely and them to relevant evidence-based, most e roduce a set of preferred standards for all clinical are preferredclinical seta of roduce all standards for andards must be followed and which are optional as as optional are which and followed be must andards confusion for commissioners when trying to assess assess to trying when commissioners for confusion overarching framework for quality to unite these unite to quality for framework overarching unction to co-ordinate the setting of standards, th standards, of setting the co-ordinate to unction h as the work of the Royal Colleges and the Nationa the and Colleges Royal the of work the as h set different standards, using different methods a methods different using standards, different set , who produce high level, authoritative and widely and authoritative level, high produce who , rying to improve quality is the heterogeneity of heterogeneity the is quality improve to rying many standards in the NHS at present. Their present. at NHS the in standards many emination through different access points and lack lack and points access different through emination f an internationally respected standards and greatl and standards respected internationally an f dards and support which is valued at the front line front the at valued is which support and dards international reviewers by the NHS stakeholders an stakeholders NHS the by reviewers international dation care must be taken to protect the stability stability the protect to taken be must care dation ly needed ly et standards. Some existing standards set by other by set standards existing Some standards. et on tools make it difficult for any clinician or tea or clinician any for difficult it make tools on 80 ards and guidelines and ards as. Thisas. to eir m to m nd with nd a . and y the of l d where therewhereare processrisksserious the of attached to stroke),careheavywhere resubstandard (e.g. to leads a for designed be Agreedshould pathwaysstandardised Pathways Clinical Preferred NHS 4: Recommendation • • • Creating a pathway involves concentrating on the pr UK. Again it is a term that means different things healthcare. The concept has been taken up more rec but in the USA in the 1980s the techniques was firs when a so-called Critical Path method was used in o The concept of that the best outcomes are assured judgement as well as knowing what it is essential t explicit standards are included in this service des and views of patients and families. The degree to best expertise in the design of processes of care a good practice (much of it in formal guidelines). I needs to draw in the best research evidence, the be NHS Next Stage Review the design of the whole service. This can only be d highest quality, safest care that can be promised m To ensure that patients with a particular condition coordinate more effectively the different stages o – make it more evidence based – Agreed standardised pathways should be designed fo – allow different practitioner groups to understand – make it more friendly’‘patient – process of care cancer care) or where there are serious risks atta heavy resource consumption is associated with waste performance leads to substandard care (e.g. stroke) number of key illnesses based on those where variab care roles and those of others are contributing to the o remove redundant steps clinical pathways can be traced back to the 1950s t needs to use the ign is a matter of to different people. receive the o ‘standardise’ so which formal, nd the experience one locally but it eans looking at t widely used in st knowledge of ocess of care to: ther industries, ently in the how their f care and verall plan of ched to the , where le (e.g. r a source consumption is associated with waste (e.g. cancer waste(e.g. associated is with sourceconsumption care number of key illnesses based on those where variablewhere those key on basedillnessesof number • National Stroke Strategy high quality can often be a very complex process co Establishing and agreeing a pathway to achieve cons 81 – – – – service guidance on the organisation and infrastructure of explicit standards protocols) detailed procedural guidance (including clinical health system the desired flow of patients through a local or reg vering: istently ional performance care) or the support for quality improvement quality for support inde an createdfulfil be to should Medicine of Institute An Medicine of Institute An 5: Recommendation • • • It is proposed that the Institute of Medicine shoul • • • What will the Institute of Medicine do to support s • • Tooke in his report, Aspiring to Excellence run the NHS Medical Education England body proposed accredit clinical teams administer the reformed Clinical Excellence Awards fostering and improvement support together knowledge management, standard development contain the proposed Center for Clinical Evidence, In addition to incorporating existing bodies the ne quality improvement of clinical team dashboards Offer ‘on-the-ground’assistance with local impleme dashboards Produce or commission toolkits to support the local other teams NHS Next Stage Review Run a Fellowship scheme of clinical leaders helping and innovation Innovation in promoting, supporting and disseminati Continue the function of the National Institute for improvement? k e i n h i s r e p o r t , A s p i r i n g t o E x c e l l e n c e Improvement and w Institute would d also ervice thereby drawing implementation of ntation and use for ng improvements drive change in : by Sir John , leadership pendent role in standard setting, knowledge management a knowledge setting, standard in role pendent those of the Institute.the of those overlapssignificantly primary their function if merged will These landscape. quality the in organisations the of rationalisation a for creates opportunity functions the these with Medicine of Institute an of formation The • What will the Institute of Medicine do to rationali • • • • • • • Integrate clinical knowledge to a single access poi standards Medicine would have the capability to produce or co for kitemarking. Where standards were inadequate th standards would be required to submit these to the Other organisations, statutory or non-statutory, wh organisations. relationship with the Royal Colleges and other spec In all these areas the Institute of Medicine should Design preferred clinical pathways where: Set new standards where existing standards are lack to use as a dial on local dashboards Convert standards into a measurable format suitable authoritative standards ‘Kitemark’ the best standard in each clinical area Review all standards 82 there are serious risks attached to the process of – heavy resource consumption is associated with wast – key illnesses where variable performance leads to – cancer care) care (e.g. stroke) se standards? have a close working to form a set of nt o wished to set ialty specific Institute of Medicine mmission new for clinical teams ing or inadequate e Institute of care substandard e (e.g. be nd with established (or formally be NHS the to for) (or service of within provider assure to q developed be frameworkAregulatory should framework regulatory A 6: Recommendation ‘endorsed’) where there is substandard care.substandard Aprogr therewhere is ‘endorsed’) Aligning regulation with the quality and safety and agenda quality the with regulation Aligning • • • •
NHS Next just wantdon’t to be ordinary, we want to be excel clash of philosophies. As one NHS chief executive placed within a framework of quality improvement. risks falling into the difficulty that essential st ‘essential standard’an enormously challenging task Stagebased making the construction of one or two aspects There are 17 other standards, most of which are sim bodies” current evidence-based guidance for relevant profes ensuring their health, safety and welfare and takin Reviewappropriately meet those needs, having regard in pa assessed, and that care and treatment is planned an “Ensure that people have their health and/or social adult social care providers consultation document For example, proposed standard 1 in the current dra broader-based quality improvement type standard requirements are standards’‘minimum would be drawn registration. Also within current thinking is the Commission has concerns about will be reviewed for under a‘grandfather clause’. Those which the exis regulation is that most NHS providers will immediat Current thinking within the Department of Health’s Quality Commission w providers (not described here) top be‘registered’ NHS patients and requirements will be set for health organisations p Commission will also be part of the merger. Under Commission for Social Care Inspection. The Mental of the main regulators of the Healthcare Commission A Bill is currently going through Parliament that p interalia A frameworkA for registration of health and is expressed thus: for private health and social care andards are being idea that registration roposes the merger roviding services to g account of lent” team dealing with ely be registered ith the Care ting Healthcare care needs the new system This creates a officer put it: “we . The approach ft of the sional or expert rticular to ilarly broad- d delivered to Health Act and the of each as fitness for out from a uality and penalise poor standards of care. This would care. standardsThis of poor penalise and uality amme of regulation for the commissioning function would would function commissioning the for ammeregulation of licensed to do so. Licences of this sort could be quali be could sort this Licencesof so. do to licensed As the functions of commissioning are increased, re • • • • • • we advise that: In order to align regulation with the quality and s they relate to secure higher levels of quality and safety in the p improvement in the mechanisms and levers used by co commissioning function itself. This will ensure a p quality standards and accreditation will be establi commissioners may become necessary. A special prog remuneration and impose temporary suspension of bonuses and addi include the ability of the licensing authority to r autonomy by failure to reach licensing standard. M through public criticism; equally Foundation Trusts licenses, in a similar way to driving licenses, may retention of Foundation Trust status could be quali ‘endorsed’) where there is substandard care. In ser formally licensed. Registration licences could be q curtailed. Every provider of service within (or for development of censure the ability to ensure safe c Positive incentives will provide a degree of motiva conducted through the Care Quality Commission data collection in the NHS for accrediting organisa accrediting organisations to prevent over-burdensom The Care Quality Commission should act as the gatew of Medicine and to a large extent using local clini checking for unsafe practice) based on standards se Accreditation should be aimed at quality improvemen Commission as an adjunct to registration Accreditation systems should be used by the Care Qu healthcare sector but not necessarily identical Basic registration requirements need to be consiste clean environment,kitemarked equipment that: a list coveringof ‘must dos’ issues such as Basic registration requirements (‘essential standar 83 emove management gulation of ) the NHS should be afety agenda, qualified personnel, cal dashboards rovider organisations produce effect shed for the rocess of continuous tion but without the ualified (or tions should be ds’) should be just may put at risk their fied. Endorsing of ious cases, are will be ore radical options nt with the private t by the Institute e regulation: all t (as well as ality ay for all mmissioners to tional ramme of fied require everyrequire be Funding flows should be redirected to support higher qu higher support redirected be to should flows Funding car safer quality, higher Funding 7: Recommendation providers of care would be based on independently con independently on based be care of providerswould safer and quality higher levels for funding payments),the • • but their organisations would be rewarded for maint for rewarded be would organisations their but Hi aims. set locally of achievement on based 102.5% the essence In dashboards. clinical by demonstrated ta their vary to able be should commissioners Local care quality high achieve organisatio allow will provided care of quality the delivered care of quantity the only allows results org an At isolation. in work not do teams Clinical NHS Next Stage Review needs ducted surveys of patient experience of the serviceexperiencesurveysthe patient ducted of conce of ality, safer care. Through variations to the tariff (or extr(or tariff the to variations safer ality, care.Through care will be made bigger. A proportion of the funding funding the of Aproportion madebigger. be care will ns to focus fully on supporting their clinical team clinical their supporting on fully focus to ns to be rewarded. Refocussing financial incentives o incentives financial Refocussing rewarded. be to anisational level, the current system of payment by payment of system current the level, anisational riff payment based on the quality of service of quality the on based payment riff aining and developing their services in line with l with line in services their developing and aining commissioning contract would be able to vary to vary to able be would contract commissioning gh performing services would not only win contracts win only not would services performing gh 84 e of NHS of s to s a-tariff rned nto ocal Dashboards should be used as a key component of the co the of as keyaused be component Dashboardsshould dashboards be will services of Commissioning 8: Recommendation by clinical dashboards and assessed and Caredashboards the by Qual clinical by • • • variety of indicators used is such that services ar services that such is used indicators of variety inc be will It demonstrated. be can success because be to need will commissioners However needs. local As many indicators will be locally determined, comm determined, locally be will indicators many As in buying as such levers other utilising management of challenge the face well performing not are that t use to able be will commissioners this, than More them from care commission identify to able be will commissioners indicators, stan of rationalisation Medicine’s of Institute the access improved have will Commissioners commission. te clinical a at look to able be will Commissioners NHS Next Stage Review of enabler an as strengthened be can commissioning ity Commission ity dards and guidelines. Using the national and local and national the Using guidelines. and dards mmissioning process. Commissioners will make choice process.Commissioners will mmissioning e stretched to improve within a local context local a within improve to stretched e which services are providing high quality care and care quality high providing are services which am’s dashboard when deciding what service to service what deciding when dashboard am’s failure to be commissioned, or alternatively hospit alternatively or commissioned, be to failure he lever of commissioning to effect change. Service change. effect to commissioning of lever he clinical expertise to effect turnaround. The effe The turnaround. effect to expertise clinical umbent on the commissioners to ensure that the that ensure to commissioners the on umbent issioning will therefore be aided to be sensitive t sensitive be to aided be therefore will issioning wary that local indicators are not chosen only chosen not are indicators local that wary quality to information on what ‘best’ looks like, through like, looks ‘best’ what on information to 85 linked to clinical to linked al s informeds ct of ct o s service cl of rangehave specified a teams should clinical All ev for duties governance Clinical 9: Recommendation • • • • • teams clinical of responsibilities quality Proposed • • • regular improvements regular result compare team, the by treated conditions main safety improve Establish clinical governance arrangements to ensur to arrangements governance clinical Establish Pat Clinical Preferred NHS adopt) to work (or Adopt acti clinical show to dashboard clinical a Maintain (outcomes performance clinical assess Continuously source events, adverse analyse and report Identify, the general practitioners general the (incl practice the for working team the all include uni care intensive an in working staff the be might increase to order in locally, decided be will teams governanceduties clinical setformalaof that proposed o understanding haveexplicit cleara to and need also system careThe leveis. quality good what of perception currentlthere is that found commissions international The In primary care a clinical team could be defined as defined be could team clinical a care primary In patients gastroenterology NHS Next Stage Review sam the for responsibility sharing staff healthcare we not present at is team clinical a of concept The inical governance duties agreed to ensure the quality a quality ensurethe agreed to governance duties inical uding district nurse, practice nurse, receptionist) nurse, practice nurse, district uding vity against standards agreed by clinical specialty clinical by agreed standards against vity ownership of the process. A clinical team in a hos a in team clinical A process. the of ownership e core set of patients”. The configuration of clini of configuration The patients”. of set core e t, or an antenatal clinic or an endoscopy service f service endoscopy an or clinic antenatal an or t, f what they are responsible for. To meet this need it is it need meet this To for. arethey responsible what f ll developed but a working definition is “all the is “all definition working a but developed ll the team in a single shared practice. This would This practice. shared single a in team the s of risk and near misses and as a result demonstra result a as and misses near and risk of s hways s against current best practice and demonstrate demonstrate and practice best current against s for clinical teams agreed is clinical for l quality goals address this problem but clinical teams clinical but problem address this goals quality l e that quality responsibilities are delivered are responsibilities quality that e and compliance with processes of care) for the the for care) of processes with compliance and y a gulf between clinicians and managers in theirmanagers and in clinicians between gulf ay 86 ery clinical team clinical ery nd safetytheir of nd not just not cal or pital bly bly recognised as prestige appointees and this would be re be would this and asappointees prestige recognised raise their standard of care. raiseTheseof standard their services leaderslevel proven in Clinical achieving leaders clinical performing high a making by excellence Expanding 10: Recommendation • • • change as well as a network of individuals engaged engaged individuals of network a as well as change Medicin of Institute the of Fellows as styled Being poor around turn even or support will Fellows These p with those recruit will Medicine of Institute The leading encouraged be can leadership clinical of definition r knowledge enormous an mobilise will NHS the care, leader clinical nurturing By change. transformative knowledge their use to incentivised and encouraged cadre — or “change leaders” “change or — cadre NHS Next Stage Review engageme “clinical of talk beyond move to need a is manag “the to left is leadership Where priorities. suppor and promoted be to needs leadership Clinical ‘change’ leaders would be Fellows of the Institute of of Institute the of Fellows be leaderswould Medi ‘change’ s of excellence in care should be made available to s madeto availablebe careexcellence of sshould in flected in fast-tracking in the Clinical Excellence Awards Clinical the fast-tracking in in flected roven track records to become Fellows of the Instit the of Fellows become to records track roven ers” it is difficult to develop outstanding service outstanding develop to difficult is it ers” e these clinical leaders will have the authority to authority the have will leaders clinical these e by formally recognising those who are currently are who those recognising formally by s in services achieving proven levels of excellence of levels proven achieving services in s ly performing units or teams. These pioneers will b will pioneers These teams. or units performing ly nt” and take practical steps to develop a leadershi a develop to steps practical take and nt” in similar work similar in and skills to assist other services in achieving in services other assist to skills and ted at a local level so that clinical leaders set c set leaders clinical that so level local a at ted esource. Through the Fellowship a broader a Fellowship the Through esource. 87 cine.These vailable proven vailable ervices to help them erviceshelp to clinical leaders will be leaders will clinical s. There s. Scheme enact ute. linical in p e Dashboards should be used as a key component of the co the of as keyaused be component Dashboardsshould Excellenc Clinical the Reshaping 11: Recommendation by clinical dashboards and assessed and Caredashboards the by Qual clinical by • • • • is to link the new clinical dashboards to the selec the to dashboards clinical new the link to is ev objective introducing for mechanism proposed The improve to incentive tha and do should it that emphasis that receive not awar the of criticism Current fair. and transparent wo improvement quality of evidence objective of Use momentum of quality improvement is continued throug continued is improvement quality of momentum awa their maintain to order in activity improvement Consultants dashboards. own their via quality, of t in quality in improvements measurable demonstrate impr quality put to incentives financial individual awar excellence clinical receiving for criteria the to position unique a in therefore are and planning, Consultants rewards. financial significant provide mechani effective an are Awards Excellence Clinical excellence reward dashb clinical the including data, of use extensive The ability. leadership favour will scheme new the NHS Next Stage Review reward. financial and care of quality demonstrated consultan for Scheme Awards Excellence Clinical The ity Commission ity mmissioning process. Commissioners will make choice process.Commissioners will mmissioning ovement at the centre of hospital consultant activi consultant hospital of centre the at ovement ds on quality improvement activities will create st create will activities improvement quality on ds tion process. Recipients of awards would be require be would awards of Recipients process. tion ds suggests that measurable quality improvement doe improvement quality measurable that suggests ds are at the heart of clinical decision-making and se and decision-making clinical of heart the at are oard to demonstrate quality improvement activity to activity improvement quality demonstrate to oard help embed high quality care in the NHS. Focussing NHS. the in care quality high embed help would be required to demonstrate maintained quality maintained demonstrate to required be would rds at high levels. This would ensure that the that ensure would This levels. high at rds reformed awards allocation process would make more make would process allocation awards reformed t once awarded, they fail to provide continuing provide to fail they awarded, once t As well as rewarding academic or research prowess research or academic rewarding as well As sm for incentivising consultants because they because consultants incentivising for sm uld allow the award process to become more become to process award the allow uld heir own clinical teams, or continuously high level high continuously or teams, clinical own heir idence of quality improvement activity to the award the to activity improvement quality of idence ts will be altered to strengthen the link between link the strengthen to altered be will ts hout consultant careers consultant hout 88 e Award Scheme Award e rong ty s informeds rvice d to d s s Dashboards should be used as a key component of the co the of as keyaused be component Dashboardsshould partners as Employees 12: Recommendation by clinical dashboards and assessed and Caredashboards the by Qual clinical by • partnership Lewis John The • • • andwillthis beandapparent public the staff to messagequality that should NHS,theheartthebe of at qualitymeansrecommendationthis that will reinforce the Tesco’sandRoyal JohnTheMail. Lewis reputation for widelyimitated othersbyin industry e.g. PepsiCola, reputation,organisational hasbee culture It and profits. Lewispartnership model hasbeen businesssuccessa for customerNHStheservice, should that JohnTheaspire to. JohnLewis hasreputationa quality for goodsinits and on-sitepharmacists includingexample for nurses,receptionists, cleaners and encourageextension partnership of all to members staff, of intheirGeneral Thisrecommendation Practice. will Practitionersand PracticeManagers arealready partners andrewarded primary In care fairly.many General individualcontribution organisationthe to isrecognised member willEachbenefits. staff become partnera whose organisationthe and share incomeinits and ‘own’ anpermanentTheNHS of organisation staff will ineffect bebemandateinvolveda to all to staff inimproving qual cooperation,engagement staff inquality improvement, and theirservices andwill hospital. It contribute culturea to onworking togetherimprove to qualitythe outcomes of ExecutiveThiswill porter.aasfocus to motivate all staff salaryrepresentsthis that will beChiefthesamethe for overall performance. percentageThe of organisation’s receivebonusa endtheyearthe at based of onthe will ownStaff sharea intheir organisation. willThey service. their of quality the improving for rewardedas teama financially be to and organisation NHS their of ownership the share staffin to NHS all enable will partnership Lewis-style AJohn NHS Next Stage Review ity Commission ity n of ity mmissioning process. Commissioners will make choice process.Commissioners will mmissioning • • • andmanagers share:improving patient care progressreflects that towards goalthe all that clinicians performingthroughunits, shareda financial incentive patientcareand replicate highthefeaturesthe of buildclinical aroundteams sharedthe goal improving of andmanagers.John Lewis-style partnership A staff will internationalcommissions gulfisthebetween clinicians barriersthe of One identified severalby the of currentlevels 104%of salariescould between,vary example, for 100 – budgetcould beallocated providing to bonuses, and rewardingthosewho areachieving. aAlternatively, penalisingservices who arestruggling muchasas perceptionswithin NHSthe in which isseenit as neutral cost leadmayproject it negative isthat to morethroughtreating riskof Thescheme.aasthethis levelquality of thanaverage and pilotso earnmaysites arewholikelyadopters’ havemaybe to highera ‘early qualityanbartheappropriate at set to level.Pilot site balancerequires anestimation currentthelevel of of averagethesuchbar that set is 100%.is Achievingthis example,102depending%98 onperformance and the – inwhich currentsalaries bemaypaid between, for Partnershipcould bedesigned neutral cost aas project, suitable partnershipcould beextended would all to staff also be suitableGeneralpilot.the for sites Practicesin which theirorganisation. Foundation arelikely Trusts be to couldbeinvited volunteer to partnership pilot to staff in prototypeandevaluate to Chiefscheme.the Executives partnerships Staff should bepiloted first develop to a 89 s informeds s Dashboards should be used as a key component of the co the of as keyaused be component Dashboardsshould events Never 13: Recommendation by clinical dashboards and assessed and Caredashboards the by Qual clinical by
NHS Next Stage• Review• • • accountability." public of purpose healthcarethe for providers and public the both to concern of and preventable, as"adverse Forum eventsare largelythat serious, Quality USNational the by aredefined events’ “Never of theirpractice of willhelp clinicians and managers improve to safetythe pumpprime measures designed reduce to never events practiceintofundsThepractice. made available to will beStaff encouraged and enabled bestput to willrenew onfocusthepatient across NHS.the safety preventingserious preventable adverse This events. Careproviders will have financiala incentive onfocus to experienced episodes of cost carein of which never eventswere commissioners,wouldtheyas nolonger bepaying the preventivemeasures reducingby fundingthe to DepartmentHealth of should fundassistancethe with whichpatients experienced neverThe events. wouldbut episodeshave of pay costs the to care in of withimplementing measures prevent to never events, providers term, shortthe In would receive assistance recognitionand actionprevent to occurrence Consensusisgrowing never that events need greater includeThey suchevents as: Patientdeath seriousor disability associated with – Stagepressure4or3 ulcers acquired after – Wrongsurgical procedure performed onpatient,a – a medicationa error admissionhealthcarea to facility ity Commission ity mmissioning process. Commissioners will make choice process.Commissioners will mmissioning ‘Never events ‘Never • • • • 90 of readmissions and hospital charges were reduced b readmission within 30 days of surgery from 6.6% to After 117 cases, the death rate had reduced from 1. of the programme, surgeons adhere to 40 best practi fee that covers any complications occurring within in Danville, USA. It offers coronary artery bypass GeisingerHealth System, a three hospital not-for-p practice guidance. This is demonstrated by the rec disincentive is combined with a renewed focus on im This approach is likely to be most successful when Medicare list infections. Only three National Quality Forum cond conditions it will notnotpay for, including healt Forum never events. Medicare has announced eight p HealthPartnersannounced it would not pay for the N events to drive improvements in patient safety. In Health insurance companies have adopted different l visits hospitals reported 154 of events”,these“never in required hospitals to report them since 2004. In 2 identified by the National Quality Forum in 2002. insurance companies for the 27 types of “never even Minnesota’s hospitals have agreed to stop charging perfect scores on the Leapfrog Safe Practices Score and that hospitals that do waive fees are much more hospitals that responded to their survey waive fees A recent Leapfrog Group Study found that roughly ha for such events events at hospitals and various remunerative or pun Several states have enacted laws requiring the disc promoting patient safety ‘never event’occurs, and this has been widely succ declared that they will not pay for an episode of c the UnitedIn States, a wide variety of organisatio ’ in the United States United the in hcare-associated surgery for a flat State law has 2004 006 Minnesota 8 million patient 90 days. As part for never events, rofit organisation itions are on the ent success at the financial losure of never 5% to 0%, 5.1% and length itive measures patients and survey. likely to have plementing best ational Quality ts” first ts” ce measures. ists of never ns have are where a lf of the 1,285 y 5.2% reventable essful in s informeds Dashboards should be used as a key component of the co the of as keyaused be component Dashboardsshould campaign safety patient A 14: Recommendation by clinical dashboards and assessed and Caredashboards the by Qual clinical by • • •
NHS Next Stage Reviewwork Pronovost’s Peterscale the of Michigan England. in carecriticalgeneral units Centre(ICNARC) estimates therearethat 218 adult Research and CareAudit Intensive National The NHSthe achievedimprovementwithin be can qualitythat prove to opportunity an be would This Care called Units Intensive stream-infections catheter-relatedin blood address will first The seriesainitiatives. by of supportedbe prevent never to Effortsevents should infections across the State of Michigan USA Reductions in ICU catheter-related bloodstream in England would thus be on roughly twice roughly on be thus would England in Matching Michigan Matching Matching
ity Commission ity mmissioning process. Commissioners will make choice process.Commissioners will mmissioning • • • • • Michigan coaching of a doctor and nurse to lead local implem based safety programme to generate a culture of pat daily goals sheet for improving communication among These were in the context of a wider package of int and rates CRBSIsof to the guidelines; and monthly and quarterly team f of a containing ‘cart’ all the supplies needed to i checklist; consideration of catheter removal at eve preventing clinicians inserting catheters if they w education; a checklist for infection-control practi The methods used for promoting these interventions implementation were effective in reducing infections with minimal unnecessary catheters. These were selected based o skin with chlorhexidine, avoiding the femoral site precautions during the insertion of central venous The five procedures promoted were hand washing, usi representing 85% of all ITU beds in Michigan State, (CRBSI) reduction programme in 103 intensive treatm Hospital, Baltimore, USA, led a catheter-related bl Professor Peter Pronovost, an intensive care physic within the first 3 months after implementation decreased from 2.7 infections per 1000 catheter-day period. The median rate of catheter-related bloods CRBSIsthat was maintained throughout the eighteen This programme led to a sustained reduction (up to 91 ’ s Example s nsert a catheter according ces, enforced by ere not following this if possible, and removing barriers to oodstream infection catheters, cleaning the ry daily round; provision eedback on the number erventions, including: a USA entation ian at Johns Hopkins ient safety; and the included: clinician ent units (ITUs), clinicians; a unit- n evidence that they ng full-barrier tream infection s at baseline to 0 66%) in rates of month study s informeds Cross-cutting issues identified and key interdepend key and identified issues Cross-cutting Excellence awards/ Excellence Patient Safety Commissioning
NHS Next Stage Review Dashboards Partnerships Regulation Institute of Medicine • • • • • • • partnership Lewis-s John a scope and Awards Excellence Clinical incentives and systems and workforce the Supporting initiative Michigan to Agency Safety Patient National the with Working of quality the to according tariff the varying for incl process, commissioning the drive to quality of to workstream incentives and systems the Supporting framework to workstream incentives and systems the Supporting stream work workforce the of programme Medi of Institute the of Fellowship the Integrating Evidence Clinical synergi explore to team innovation the with Working teams clinical for sites three in Working with the informatics informatics the with Working 92 workstream to develop and pilot local dashboards local pilot and develop to workstream encies care cine with the leadership the with cine uding developing mechanism developing uding develop a Matching a develop es with the Centre for Centre the with es work streams to reshape to streams work use objective measures objective use regulatory a develop tyle Summary of impact assessment impact of Summary • • • • •
NHS Nextattachedassessmentimpactthe in provided is detail More savingcost Stagesome and neutral cost be recommendationswill the of Many careunnecessary in variation Reviewpracticebestadherence guidelin to encouraging through caremore effectivecost produces also quality us Higher care quality Care Social safety and Healthand the as framed quality in essentithe NHSmove the beyond and underpinned be will impr Improvement System quality Quality a the in Byputting treatmentfurther fewercompl and occupancy bed lower asof resulta run care is quality higher that suggest evidenceto is There 93 cheaper in the long the cheaper in ications requiring ications e of resources, of e es and reducing esand Bill towards best towards Bill al requirements al of are potentially ovementagenda Summary of equality assessment equality of Summary • • • •
NHS Nextselectedimplementationfor reco when developed assessment be detailed More should Stagepracticebest of adoption acceleration of unnecessaryacrossine variation health care reducing Review to work improvementwill Asystemicquality to approach takenas be correctiveappropriate to action av routinely easilyand through identified be carewill addressed earlierand risks recognised be canhealth a through metrics of co-ordinated development the Through makeh to informed individuals allowing dataavailable createo creation the systemfairtransparenta and through improvementacrossorganisati provider specialtiesand a developing on focus report the recommendationsin The 94 ailable data allowingdata ailable . Unequal outcomes inoutcomes Unequal . ealth choices ealth quality through the through quality ons. They aim toaim They ons. reduce system quality of mmendations are mmendations f publiclyf national centre national