Clinical Quality Indicators – Martin Orton

Background

• IC changing to support front line services• New clinical focus with new Medical Director

– Dr Mark Davies• General desire to measure outcomes, not just

activity

• Next Stage (Darzi) Review – focus on Quality

High Quality Care for All Measuring Quality9. The next stage in achieving high quality care, requires us to unlock local

innovation and improvement of quality through information – information which shows clinical teams where they most need to improve, and which enables them to track the effect of changes they implement. After all, we can only be sure to improve what we can actually measure.

10. It is important that we have a national quality framework that enables us to publish comparable information on key measures. With the help and support of frontline clinicians, we have begun to identify comparable measures that are currently used by different parts of the service today, and will bring them together into an integrated national set. These national metrics will be developed through discussion with patients, the public and staff. We will announce the first set of quality indicators that will be used nationally by December 2008. And although we will begin with acute services, from next year, we will also develop and pilot a quality framework for community services.

11. The national metrics will be important, but it will be critical that local NHS organisations should sign up to the concept of quality metrics and feel motivated to augment the national indicators with their own measurements of quality. Our aim is for NHS organisations to freely develop the measures that will best help them to review the quality of the services they offer regularly. (p 50)

Darzi definition of Quality

• Patient safety• Safe & Clean• Minimising avoidable harm (e.g drug errors, HAI)

• Patient experience• Compassion, dignity & respect• Patient satisfaction

• Effectiveness of care• Survival rates• Complication rates• Measures of clinical improvement• PROMs

Levels and Uses of Indicators

Level 1: Locally-defined metrics for local use

Level 2: National standard definitions

4

Level 3

Level 4: National priorities for improvement

Mandatory data collection

We think there will be four levels of metrics, which range from the key national priorities (e.g. HCAI) to local defined and locally collected metrics.

ObjectivesPrimary Objective:• To develop a first set of indicators (“Phase 1”) of clinical quality and

outcome covering major NHS acute services, which will be available for use in FY 2009/10. The indicators’ primary use will be to guide quality improvement through comparison and benchmarking, to facilitate local improvement efforts.

Secondary Objectives:• To use the launch of the first set of indicators to signal the intention to

stimulate clinical stakeholders and the local NHS to develop better and more discriminating indicators over subsequent years (“Phase 2”)

• To identify well-defined indicators for which data collection is not fully complete, for potential incentivisation of data collection under CQUIN during 2009/10 (to allow use in 2010/11)

• Potential source in future for public-facing data e.g. “Quality Accounts”, perhaps some indicators carried over to NHS Choices etc.

• NOT for targets or traditional “performance management”

Clinical Quality Indicators

• Phase 1 • Best that can be produced with current data &

information for 09/10 – recognised as limited• Driven by Darzi & Keogh to show direction of travel

• Phase 2 • Clinically driven, meaningful measures of clinical

quality for local, regional & national use• Blank canvas• Will involve co-ordinated working within clinicians,

prof bodies, DH, CQC, NICE, CFH, NCAAG and others

CQI Governance

• Expected to come under the new Quality Board

• IC commissioned by DH Medical Director, Prof. Sir Bruce Keogh

Phase 1

• Focus on acute (Primary care already has QOF, gaps in community and social care)

• Also Mental Health & Ambulance• Must be measurable in 2009• Recognise indicators will have limitations• DH gone for lots, rather than a few which

could draw excessive focus and distort services

Phase 1 Indicators Gantt

June

Jul Aug Sept

Oct

Nov

Dec Jan Feb

Response from Medical & Nursing Dirs re BK letter

Publish indicator list for 09/10

NHS consultation on proposed indicators

Create 1st draft indicators list

Review responses and agree indicators

Implement indicator tool

Mar

Phase 1 CategoriesApprox 400 indicators across 13 categories

• Cancer (42 indicators)• Cardiovascular (59 indicators)• Children, Families and Maternity (9 indicators)• Healthcare Acquired Infections (37 indicators)• Long Term Conditions (23 indicators)• Mental Health (15 indicators)• Mortality (65 indicators)• Patient Experience (92 indicators)• Patient Reported Outcome Measures (4 indicators)• Patient Safety (35 indicators)• Readmissions (31 indicators)• Revisions (17 indicators)• Timeliness (7 indicators)

Phase 2

• Consultation with phase 1 – to ensure clinicians know this follows phase 1

• To test ideas, and find out about existing work & clinician’s ideas

• Aim to set-up work this FY to start next FY

Phase 2

• Clinically driven• IC to lead the programme• Working with Clinicians, Prof. bodies,

CQC, DH, CFH, NICE, NCAAG, Patient groups

• Blank canvas, but using existing work and ideas where available

Phase 2 (cont.)

Potential methodologies• Better use of existing data (HES, QOF,

Audit, etc)• Extending PROMs (further surgical

procedures, long term conditions)• New audits / Specific treatment data &

information (German model)• Clinical assessment schemes• Pathways, outcomes & some process

measures

Patient Reported Outcome Measures PROMs• 4 surgical procedures from April 09• Hip & knee replacements, varicose veins and

groin hernias• Pre & post op questionnaires• Treatment specific & Quality of Life• Give measure of health gain• Various outcomes (after casemix adjustment)

• Thresholds for treatment• Different treatment comparisons• Unit/clinician comparisons• etc

PROMs contractual model

Aggregated data

Lot 3: “Analysis”

Lot 2: “Aggregation”Lot 1: “Administration” Information Centre: “Linkage” & “Repository”

identifiable

Pre-op

IC

OtherSUSNJR

Post-opScoring,

outcomesAggregation

Academic stakeholders

Case-mix adjustment

Develop adjustment

Record-level data

Healthcare stakeholders

Extract Service

LinkedPseud’sed

Aggregateddata

Record level data

PROMs timescales

• MOI out now for OJEU tenders• SLA for IC work Oct-08• Contracts by Dec-08• Needs to be running for April-09• Real data flows from Summer-09 (pre &

post op pairs) – 20k per month• Outcome outputs in 2010?

Supplier Opportunities

• Phase 1 Clinical Quality Indicators presentation system likely to be outsourced

• Clinical Quality Indicators available through syndication

QUESTIONS ?

Notes:•Overall process operated and owned by IC•Processes transparent, auditable and conform to care record guarantee

Tier 1 Tier 2 Tier 3

Value AddedInformation

Services

DataPresentation

ResearchServices

Services Operated byCommercial Providers

Other DataSources

ResearchData

FinanceData

Workforce Data (+ESR)

Managing input from

NHS Sources

NHS Spine Data (PDS)

(but could be PSIS,

Medication Record Etc)

SY

ND

ICA

TIO

N

Base Information presentation

HO

NE

ST

BR

OK

ER

AP

PR

OV

ALS

SIG

N P

OS

TIN

G

Services Operated by IC

SUSDatabase

IC Data & Information Future Access Model

Notes:•Overall process operated and owned by IC•IT Systems in Tiers 1 and 2 Procured and suppliers managed by NHS CFH•Processes transparent, auditable and conform to care record guarantee

Tier 1 Tier 2 Tier 3

Value AddedInformation

Services

DataPresentation

ResearchServices

Services Operated byCommercial Providers

Other DataSources

ResearchData

SUSDatabase

FinanceData

Workforce Data (+ESR)

Managing input from

NHS Sources

NHS Spine Data (PDS)

(but could be PSIS,

Medication Record Etc)

SY

ND

ICA

TIO

N

Base Information presentation

e.g. Perf. Benchmarking

(SIFTER)NHS

Comparators

HO

NE

ST

BR

OK

ER

AP

PR

OV

ALS

SIG

N P

OS

TIN

G

PROMs data Data linkage

Casemix adjust & analysis

Base information presentation

Linked HES, PROMs & NJR data

Services Operated by IC

PROMsIC Functions

IC overview and standards development