quality, safety and patient experience strategy

Quality, Safety and Patient Experience Strategy

November 2015

www.castlepointandrochfordccg.nhs.uk

Quality, Safety and Patient Experience Strategy – Nov 2015

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Document Name Quality, Safety & Patient Experience Strategy

Version V7

Author/s Name

Job Title/s

Jenny Briggs

Interim Programme Director - Transformation

Executive Lead Tricia D’Orsi

Approved by Governing Body

26.11.2015

Review Date 2.11.2018

Change Record

Date Version Changes made

18.9.15 7, still in

draft

Addition of comments from Tricia D’Orsi

17.10.2015 Version 7 Comments added TD


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Contents

1. Foreword ........................................................................................................................................ 5

2. Introduction .................................................................................................................................... 6

2.1 Background and Context ..................................................................................................... 6

2.2 Defining Quality, Safety and Patient Experience............................................................. 6

2.3 Purpose of this strategy ....................................................................................................... 7

3. Our Commitment to Quality, Safety and Patient Experience ................................................ 8

3.1 Our Values............................................................................................................................. 8

3.2 Our Vision .............................................................................................................................. 8

3.3 Vision for Quality, Safety and Patient Experience........................................................... 9

4. Quality, Safety and Patient Experience through Commissioning ....................................... 11

4.1 Procurement ........................................................................................................................ 11

4.2 Incentivising and Monitoring Quality with our Providers ............................................... 11

4.3 Partnership Working .......................................................................................................... 12

4.4 Patient and Public Involvement ........................................................................................ 12

4.4.1 Commissioning Reference Group ............................................................................ 12

4.4.2 Patient Participation Groups (PPG) ......................................................................... 12

4.4.3 Governing Body .......................................................................................................... 13

5 National drivers for quality, safety and patient experience .................................................. 14

5.1 NHS Five Year Forward View .......................................................................................... 14

5.2 The NHS Outcomes Framework ...................................................................................... 14

5.3 Harm Free Care & the NHS Safety Thermometer ........................................................ 16

5.4 Summary Hospital-Level Mortality Indicators (SHMI) ................................................... 16

5.5 Care Quality Commission (CQC) – Essential Standards ............................................. 17

5.6 National Institute for Health and Care Excellence (NICE) ........................................... 17

5.7 Quality, Innovation, Productivity & Prevention (QIPP) ................................................. 18

5.8 National Reporting and Learning System (NRLS) ........................................................ 19

5.9 National Reports and Investigations ................................................................................ 19

5.10 “No Harms Event” ............................................................................................................... 20

5.11 Co-Commissioning ............................................................................................................. 20

5.12 Safeguarding adults and children .................................................................................... 20

5.13 Parity of Esteem ................................................................................................................. 21

6 Roles and Responsibilities for Quality Assurance................................................................. 22

6.1 The Role of the Clinical Commissioning Group ............................................................. 22


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6.1.1 Our Role as Co-Commissioners .............................................................................. 22

6.2 Group and Team Responsibilities for Quality, Safety & Patient Experience ............ 23

6.2.1 The Governing Body .................................................................................................. 23

6.2.2 The Quality and Governance Committee ............................................................... 23

6.2.3 The Clinical Quality Review Group (CQRG) .......................................................... 23

6.2.4 The Quality Support Team ........................................................................................ 23

6.2.5 The Role of Member Practices ................................................................................. 24

6.2.6 Quality Surveillance Groups (QSGs)....................................................................... 24

6.2.7 The Commissioning Support Unit (CSU) ................................................................ 24

6.3 Individual Roles and Responsibilities .............................................................................. 25

6.3.1 The Accountable Officer ............................................................................................ 25

6.3.2 The Chief Nurse.......................................................................................................... 25

6.3.3 All CCG Staff ............................................................................................................... 25

7. Quality, Safety and Patient Experience Assurance Processes ........................................... 26

7.1 Monitoring and Assurance for Commissioned Services ............................................... 26

7.1.1 Using data to assess and improve quality, safety and patient experience ........ 27

7.1.2 Complaints and patient feedback ............................................................................ 27

7.2 Quality Monitoring for New Projects and Services ........................................................ 27

7.2.1 QIA Tool and Process................................................................................................ 28

7.3 Other Quality, Safety and Patient Experience Mechanisms ........................................ 30

7.3.1 Safeguarding adults and children ............................................................................ 30

7.3.2 Information Governance and Caldicott ................................................................... 31

7.3.3 Clinical Audit ............................................................................................................... 31

7.3.4 Medicines Management ............................................................................................ 31

7.3.5 Domestic Abuse.......................................................................................................... 32

8. Next Steps and Developments ................................................................................................. 33


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1. Foreword

“Continuously improving patient safety should be at the top of the health

care agenda for the 21st century. The injunction to do no harm is the

defining principle of the clinical professions”

(Lord Darzi; High Quality Health Care for all 2008).

This Quality Strategy is to underpin the commissioning of the highest quality care services

for the people of Castle Point and Rochford.

The CCG wants the implementation of this Strategy to provide local pride in the NHS and

wants the people of Castle Point and Rochford to be confident that their healthcare services

are amongst the very best.

The CCG will strive to ensure that the high quality health care it commissions is provided on

the basis of its on-going commitment to equality of experience and outcomes, to everyone in

Castle Point and Rochford, no matter who they are or where they live.

The CCG vision “Quality Care First Time, Equitably Delivered in Response to Patients

Needs by Responsive Local Clinicians” puts quality at the centre of all that we do as an

organisation and as a result integrates the organisational functions of clinical, corporate and

financial governance.

By the integration of these functions the CCG will be able to recognise the early indications

of a failing service and give the appropriate support and take the necessary measures to

protect patients.

The purpose of the strategy is

to ensure that patients and their assessed needs are at the centre of commissioning

decisions

to ensure commissioned services are safe, clinically effective and provide a positive

experience for patients

to assure the robustness of systems and processes in place to deliver safe services

and positive experiences

to ensure that measures of quality are focused on structures, processes and most

importantly outcomes

to confirm the collaborative arrangements that will be in place with other health

commissioners and wider stakeholders

to demonstrate that the CCG has the leadership and governance arrangements in

place to meet its statutory requirements and responsibilities.

This purpose will be upheld in the CCG’s consideration of all commissioning decisions

related to all health service provision for all client groups, children, adults, older people,

people requiring mental health services and people with learning disabilities whether

receiving care in acute, community or primary care settings.


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2. Introduction

2.1 Background and Context

Over the last 10 years healthcare quality, safety and patient experience have featured in a

number of high profile national inquiries and reports and these have received significant

media attention. Unfortunately many reviews have been prompted through failings in care;

however, each report provides opportunities for learning to ensure that all NHS organisations

can make improvements to quality of care and to reduce patient safety risks.

In 2013, the Prime Minister invited Professor Donald Berwick, internationally known for his

work on patient safety, to lead a review to “make zero harm a reality in our NHS.” The

review considered the breakdown of care at the Mid-Staffordshire NHS Foundation Trust

and the wider NHS quality and safety culture and landscape. In his report Professor Berwick

calls on all leaders to prioritise quality and safety in all areas of their work:

“All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support”

(Professor Donald Berwick, published in August 2013)

Castle Point and Rochford Clinical Commissioning Group is a group of local GPs and

clinicians who commission (buy) services for our community which is around 182,000

people. This gives us both the opportunity and responsibility to ensure that quality, safety

and patient experience is prioritised and protected as services are provided and developed

within our health and care community.

2.2 Defining Quality, Safety and Patient Experience

The Care Quality Commission, the independent regulator of health and social care in

England, assess services against five criteria which provide a helpful definition of quality,

safety and patient experience:

1. Are they safe?

2. Are they effective?

3. Are they caring?

4. Are they responsive to people’s needs?

5. Are they well-led?

We believe this wide definition extends to all aspects of care, and includes: privacy, dignity,

care and compassion, politeness, respect, safeguarding and protection of vulnerable people

as well as effective clinical treatment. Sometimes we call these areas “the basics” or

“fundamentals” in care provision, and we believe that every person deserves these whoever


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they are and wherever they live. We are working with the providers of services to ensure

this will be the case.

2.3 Purpose of this strategy

The purpose of the strategy is:

To ensure that patients and their assessed needs are at the centre of our

commissioning decisions

To ensure commissioned services are safe, clinically effective and provide a positive

experience for patients

To assure the robustness of systems and processes in place to deliver safe, effective

services and positive experiences for patients

To ensure that measures of quality are focused on structures, processes and most

importantly outcomes

To confirm the collaborative arrangements that will be in place with other health and

care commissioners and wider stakeholders

To demonstrate that we have the leadership and governance arrangements in place

to meet our statutory requirements and responsibilities

This strategy sets out our commitment, vision and aims to commission the highest quality

care services for the people within Castle Point and Rochford so that people can be

confident that their health and care services are amongst the very best.


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3. Our Commitment to Quality, Safety and Patient Experience

3.1 Our Values

Our six values describe how we work. The diagram below shows how quality safety and

patient experience are at the heart of each of our values.

Our Values

3.2 Our Vision

Value 1• We listen to patients, members, staff and partners

Value 2• We are prepared to do things differently to improve care

Value 3• We are committed to working with our partners

Value 4• We are ambitious and innovative

Value 5• We are compassionate

Value 6• We are committed to making our plans happen

We know that in order to make improvements to quality, safety and patient experience we need to do things differently

We want our health and care services to be among the best in the country

Through listening to people who experience care we understand what matters to people and how we can improve quality, safety and patient experience

If we work together with providers of care we can make a bigger difference for patients, carers and the public

We believe everyone deserves to be treated with kindness, care and compassion whoever they are and wherever they live

We are determined to make sure our plans for improving health and care in Castle Point & Rochford will make a difference for real people in our community

Our Vision

IntermediateCare & Discharge

Planning & Support

Self Care, Care & IndependencePrevention & Health Promotion

Home Not HospitalCare Closer to HomePrimary Care Focus

Community Based Care

Specialist Planned and

Unplanned Care

Activityshift

Activityshift

Our vision is to create a healthier and more

sustainable future for people in Castle Point and

Rochford.

Through commissioning the right care in the right

place of a high quality we hope that over time we will

see a shift from many people being acutely unwell

and requiring complex care in hospital settings, to

more people independently taking responsibility for

their health and wellbeing, with more care being

delivered in the community and closer to patients’

homes. We know people want care closer

home and we believe that our vision

will improve patient experience as well

as promote independence and reduce

issues associated with hospital stays

such as hospital acquired infections

and institutionalisation.


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3.3 Vision for Quality, Safety and Patient Experience

Our vision is that health and care services within Castle Point and Rochford will be:

Effective: Meeting the needs of the person receiving care/treatment and supporting

them at their time of need

Safe: Without error, and in a way that protects people from harm, especially our

most vulnerable people

Compassionate: Offering a good experience for patients and treating them with

dignity, respect and kindness

We know nobody enjoys being unwell or injured, but we believe it is our responsibility to

commission care that gives the best possible experience for people at their time of need.

We are committed to ensuring that the services we commission fulfil our person centred

quality statements that ensure patients and carers are at the forefront of our vision.

Quality Statements

People will receive care and support in the most

appropriate environment that enables them to retain

and regain their independence

People will know what services are available to them

and will be involved and engaged In all aspects of their

care

People will be supported to manage their own health and wellbeing so that they are in

control of what, how and where care and support is

delivered

People will have a safe and positive experience of our

services

People will have timely and easy access to responsive,

integrated care and support


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We aim to continuously improve care for people within Castle Point and Rochford. There

are five strategic themes we focus on, both internally and also through our relationships with

patients and the public, providers of care, regulators and with partner commissioners.

Strategic Themes for Improving Quality of Care, Patient Safety and Patient

Experience


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4. Quality, Safety and Patient Experience through

Commissioning

The diagram below shows the high level tasks involved in commissioning (buying) care, and

how we make sure that quality, safety and patient experience is protected and prioritised at

each stage.

Quality, Safety and Patient Experience at each stage of the Commissioning Cycle

4.1 Procurement

We follow NHS Procurement Policy when we buy services and ensure that quality, safety

and patient experience requirements are built into contracts to enable future robust quality

monitoring. Our on-going monitoring of quality, safety and patient experiences of

commissioned services enables us to hold providers to account for performance against

those elements of the contract.

4.2 Incentivising and Monitoring Quality with our Providers

We also utilise the national Commissioning for Quality and Innovation (CQUIN) framework to

provide financial rewards (or penalties) for the achievement (or failure to achieve) quality

goals to ensure that providers of care focus their efforts on delivering high quality and safe

services that offer a positive patient experience.

Setting Strategy

Designing Services

Review & Approval

Sourcing Providers

Mobilisation

Monitoring & Evaluation

Our organisational strategy is focussed on improving health & wellbeing, preventing illness, and maintaining independence where possible. We aim to offer care closer to home, and make sure hospital care is reserved only for those who need specialist input. We believe this will offer the best care and experiences for our community.

We are working with our providers to design services that are safe, effective and will meet the needs of our population. Quality and safety and patient experience are the main focus as we discuss new services or whether changes are needed.

All new ideas and service changes undertake a Quality Impact Assessment process that benefits and risks to quality, safety and patient experience. Clinical teams are responsible for reviewing these risks and ensuring that quality, safety and patient experience will not be compromised.

We maintain strong relationships with our provider organisations and work with them to establish regular monitoring processes to ensure that patients continue to receive safe, effective care and good experiences. This includes direct patient feedback and monitoring of outcomes.

When we set up new health and care services we need to go through legal processes to select providers. Our selection process considers the quality and safety culture of the organisations we commission to ensure that our patients will receive safe, effective care and good experiences.

For some ideas we pilot (test) the service to make sure it works in the way we planned. This means we can measure the quality safety and patient experience benefits before we commit to a long contract.


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4.3 Partnership Working

We are working closely with all Clinical Commissioning Groups in Greater Essex, our Local

Authorities and especially with those commissioning services for the South Essex

population. We give and receive assurances to and from each other that there are robust

systems and processes in place for managing and monitoring the quality, safety and patient

experience of services within our contracts.

Our commitment to improving quality, safety and patient experience is upheld in decision

making for health and care service provision for all client groups, children, adults, older

people, people requiring mental health services and people with learning disabilities whether

receiving care in acute, community or primary care settings. We strive to ensure that the

high quality health care we commission is provided on the basis of our on-going commitment

to equality of experience and outcomes, to everyone in Castle Point and Rochford, no matter

who they are or where they live.

4.4 Patient and Public Involvement

Our aim is that patients, carers, community representatives, community groups and the

wider public are involved in commissioning decisions at every level. We are in the process

of building a database of people living in Castle Point and Rochford who would like to be

involved or simply kept informed of any local decisions that could result in a change to the

way local health services are provided.

4.4.1 Commissioning Reference Group

Our Commissioning Reference Group is a formal advisory body. Its purpose is to support us

in ensuring that the voice of our patients, (and their carers), and public, including seldom-

heard groups, is embedded in our business, embracing the ’no decision about me without

me’ promise, and actively promoting the principles and values of the NHS Constitution.

Members of the CRG group include patient representatives from GP practices,

representatives from our local voluntary sector organisations, GPs, representatives from

both the younger and older generations of Castle Point & Rochford, CCG staff and Health

Watch Essex. The group is chaired by a lay representative.

4.4.2 Patient Participation Groups (PPG)

We have been actively encouraging Patient Participation Groups (PPG) have developed in

recent years in GP practices. These groups are an effective way for patients and GP

surgeries to work together to improve services and to promote health and improved quality

of care. Within the Castle Point and Rochford area there are a number of member practices


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that have Patient Participation Groups. Information from our Commissioning Reference

Group is fed back to our GP practices to help inform patients of our plans on a wider level.

4.4.3 Governing Body

We also have lay representatives on the Governing Body so they are part of the key decision

making processes for commissioning health and care services for our population. One lay

member is the Chair of the Quality and Governance Committee.


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5 National drivers for quality, safety and patient experience

There are a range of national policy drivers that influence the quality, safety and patient

experience agenda across the NHS and support us in our ambition to offer the best possible

care.

5.1 NHS Five Year Forward View

The Five Year Forward View, published in October 2014, by NHS England, sets out a

positive vision for the future based around new models of care.

“The definition of quality in health care, enshrined in law, includes three key aspects: patient

safety, clinical effectiveness and patient experience. A high quality health service exhibits all

three. However, achieving all three ultimately happens when a caring culture, professional

commitment and strong leadership are combined to serve patients, which is why the Care

Quality Commission is inspecting against these elements of quality too.

We do not always achieve these standards. For example, there is variation depending on

when patients are treated: mortality rates are 11% higher for patients admitted on Saturdays

and 16% higher on Sundays compared to a Wednesday. And there is variation in outcomes;

for instance, up to 30% variation between CCGs in the health related quality of life for people

with more than one long term condition.

We have a double opportunity: to narrow the gap between the best and the worst, whilst

raising the bar higher for everyone. To reduce variations in where patients receive care, we

will measure and publish meaningful and comparable measurements for all major pathways

of care for every provider – including community, mental and primary care – by the end of

the next Parliament. We will continue to redesign the payment system so that there are

rewards for improvements in quality. We will invest in leadership by reviewing and refocusing

the work of the NHS Leadership Academy and NHS Improving Quality. To reduce variations

in when patients receive care, we will develop a framework for how seven day services can

be implemented affordably and sustainably, recognising that different solutions will be

needed in different localities. As national bodies we can do more by measuring what

matters, requiring comprehensive transparency of performance data and ensuring this data

increasingly informs payment mechanisms and commissioning decisions.”

(Five Year Forward View, NHS England, published in October 2014)

Quality, safety and patient experience are highlighted as integral to a high quality health care

system and we are working on a range of initiatives and models of care in line with this plan,

to reduce variation in care provision, improve service provision, and to consider how to

incentivise and reward improvements to quality, safety and patient experience.

5.2 The NHS Outcomes Framework

The NHS Outcomes Framework provides a national overview of how well the NHS is

performing and is the primary accountability mechanism for improving quality throughout the


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NHS. The framework was initially developed in 2010, but is updated every year. Some

indicators are shared with the Adult Social Care Outcomes Framework and/or the Public

Health Outcomes Framework. The 2015/16 framework outlines 5 domains that form key

drivers for our local priorities for commissioning and quality. These domains directly link to

quality, safety and patient experience as shown below.

NHS Outcomes Framework 2015/16

Domain Overarching indicators Improvement Areas

1. Preventing

people from

dying

prematurely

Potential years of life

lost from causes

considered amenable

to healthcare

Life expectancy at 75

Neonatal mortality and

stillbirths

Reducing premature mortality from major causes of

death

Reducing premature mortality in people with mental

illness

Reducing mortality in children

Reducing premature death in people with a learning

disability

2. Enhancing

quality of

life for

people with

long term

conditions

Health related quality

of life for people with

long term conditions

Ensuring people feel supported to manage their

condition

Improving functional ability for people with long term

conditions

Reducing time spent in hospital for people with long

term conditions

Enhancing quality of life for carers

Enhancing quality of life for people with mental illness

Enhancing quality of life for people with dementia

Improving quality of life for people with multiple long

term conditions

3. Helping

people to

recover

from

episodes of

ill health or

following

injury

Emergency

admissions for acute

conditions that should

not normally require

hospital admission

Emergency

readmissions within 30

days of discharge from

hospital

Improving outcomes from planned treatments

Preventing lower respiratory tract infections in children

from becoming serious

Improving recovery from injuries and trauma

Improving recovery from stroke

Improving recovery from fragility fractures

Helping older people to recover their independence

after illness or injury

Improving dental health

4. Ensuring

that people

have a

positive

experience

of care

Patient experience of

primary care (including

GP services, GP out of

hours services and

NHS dental services)

Patient experience of

hospital care

Friends and family test

Patient experience

categorised as poor or

worse for primary care

and/or hospital care

Improving people’s experience of outpatient care

Improving hospitals’ responsiveness to personal needs

Improving people’s experience of accident and

emergency services

Improving access to primary care services

Improving women and their families’ experience of

maternity services

Improving experience of care for people at the end of

their lives

Improving experience of healthcare for people with

mental illness

Improving children and young people’s experience of

healthcare

Improving people’s experience of integrated care


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Domain Overarching indicators Improvement Areas

5. Treating

and caring

for people

in a safe

environmen

t and

protecting

them from

avoidable

harm

Deaths attributable to

problems in healthcare

Severe harm

attributable to

problems in healthcare

Reducing the incidence of avoidable harm, (e.g. VTE

related events, incidence of healthcare associated

infection, falls and pressure ulcers)

Improving safety of maternity services

Improving the culture of safety reporting

5.3 Harm Free Care & the NHS Safety Thermometer

The NHS Outcomes Framework and policy direction requires a national focus on a small

number of key outcomes that the NHS is measuring together. The NHS Safety

Thermometer is a local improvement tool for measuring, monitoring and analysing patient

harms and ‘harm free’ care. The tool measures four high-volume patient safety issues which

are also highlighted in domain 5 of the outcomes framework:

Elimination of grade 3 and 4 pressure ulcers

Falls in care

Urinary infection (in patients with a catheter), and

Treatment for venous thromboembolism

Harm free care was incentivised as a national CQUIN in 2013/14 and 2014/15 and we

continue to monitor these indicators as part of our performance monitoring with providers.

5.4 Summary Hospital-Level Mortality Indicators (SHMI)

Summary Hospital-Level Mortality Indicators report on mortality at a trust level across the

NHS in England using a standard and transparent methodology.

SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust, and the number that would be expected to die, on the basis of the national average figures, given the characteristics of the patients treated there. (Hospital and Social Care Information Centre)

SHMI covers all deaths reported of patients who were admitted to non-specialist acute trusts

in England and either die in hospital or within 30 days of being discharged from hospital.

SHMI replaces the Hospitalised Standardised Mortality Ratio (HSMR) which covered deaths

that occur in a hospital setting. A high SHMI will raise questions about whether there are

underlying problems in the quality of care that a hospital is delivering to its patients and the


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care they are receiving after they are discharged. This is a standing item on our Clinical

Quality Review Group with providers and any variance is closely monitored.

5.5 Care Quality Commission (CQC) – Essential Standards

The Care Quality Commission is the independent regulator of health and adult social care in

England. The CQC ensure health and social care services provide people with safe,

effective, compassionate, high-quality care and encourage care services to improve. The

CQC does this by inspecting services and publishing the results on its website to help

patients and the public make better decision about the care they receive. Registration with

the CQC is a statutory requirement of all NHS providers, Independent Healthcare providers,

Dentists and General Practitioners. The CQC Essential Standards require providers to

declare compliance against those standards and the CQC undertakes planned and

responsive inspections to monitor compliance. CQC compliance is an agenda item at our

Clinical Quality Reference Group to ensure that non-compliance is supported by a monitored

action plan.

5.6 National Institute for Health and Care Excellence (NICE)

The National Institute for Health and Care Excellence is a Non Departmental Public Body

which develops national guidance, advice and quality standards for health and social care.

NICE’s role is to improve outcomes for people using the NHS and other public health and

care services and this work takes three forms:

I. Producing evidence based guidance and advice for health, public health, and social

care practitioners. This includes:

o NICE guidelines: Preventing and managing specific conditions, improving

health and managing medicines in different settings, interventions to improve

health in communities, provision of social care to adults and children

o Technology appraisal Guidelines (TAGs): To assess the clinical and cost

effectiveness of health technologies such as new pharmaceutical and

biopharmaceutical products, but also procedures, devices and diagnostic

agents

o Medical technologies and diagnostics guidance: To ensure that the NHS is

able to adopt clinically and cost effective technologies rapidly and consistently

o Interventional procedures guidance: Recommending whether interventional

procedures are effective and safe enough for use within the NHS

II. Developing quality standards and performance metrics for those providing and

commissioning health, public health and social care services, including:


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o Quality standards: A precise set of statements with accompanying metrics,

designed to drive and measure quality improvements within a particular area

of care

o Quality Outcomes Framework (QOF): An annual menu of potential indicators

for inclusion in the quality element of our contract with General Practitioners

o Clinical Commissioning Group Outcomes Indicator Set (CCGOIS): A

framework for measuring health outcomes and the quality of care (included

patient reported outcomes and patient experience) achieved by CCGs.

III. Providing a range of informational services for commissioners, practitioners and

managers across the spectrum of health and social care. This includes:

o NICE evidence: An online search facility that identifies relevant clinical, public

health and social care guidance, including access to a range of bibliographic

databases and professional journals

o Access to the British National Formulary (BNF) and British National Formulary

for Children (BNFC), including smart phone access

o Medicines and prescribing support: Advice and information on pharmaceutical

products, their scope, licensing and practical advice on developing and

maintaining local medicines formularies

Healthcare professionals are expected to take NICE guidance fully into account when

exercising their clinical judgment. The only guidelines which are mandatory are the

Technology Appraisal Guidelines (TAGs), however we ensure that NICE guidance is

considered in our commissioning decisions and implementation is monitored in

commissioned services.

5.7 Quality, Innovation, Productivity & Prevention (QIPP)

QIPP is a large transformational programme to support clinical teams and organisations to

improve the quality of caring, through productivity, prevention and innovation, to improve the

quality of care whilst delivering efficiency savings that can be reinvested into the NHS. QIPP

represents a broad, policy agenda rather than a single, definable policy, however there are a

number of national work streams within QIPP designed to support the NHS to improve care

and lower costs. These range from improving commissioning, (or purchasing), of care for

patients with long-term conditions, to improving how organisations are run, staffed and

supplied. The specific changes required to meet the agenda have been left to local

providers and commissioners to identify and implement. We are working with our local

health partners to develop integrated QIPP plans that address our local quality challenges

and make efficiency improvements. It is essential that the impact of productivity savings on

the quality of care delivered is monitored closely and the CCG has developed a Quality


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Impact Assessment tool and process to review all QIPP plans and identify quality impacts

whether they are positive or negative and ensure risks are understood and mitigated

appropriately.

5.8 National Reporting and Learning System (NRLS)

Patient safety incident reporting is a vital mechanism for identifying downward trends in the

quality of care, identifying failure and facilitating learning. The National Reporting and

Learning System (NRLS) is a central database of patient safety incident reports. Since April

2010, it has been mandatory for NHS trusts in England to report all serious patient safety

incidents and the NRLS has now moved under the National Commissioning Board. Six

monthly reports are then produced that benchmark providers in terms of types of incident

and levels of harm. Since the NRLS was set up in 2003, over four million incident reports

have been submitted and information is analysed to identify hazards, risks and opportunities

to continuously improve the safety of patient care.

5.9 National Reports and Investigations

The Department of Health and health related organisations publish reports following

enquiries, inquiries, reviews and evaluations of health care provision. We review the

recommendations from these reports and assess the implications to the CCG and its

commissioned services and ensure that any recommendations and lessons learnt

implemented and embedded into local processes.

Two key reports that we are monitoring progress against are:

Transforming Care: A national response to Winterbourne View Hospital, published in

December 2012. Although two years have passed since the report was published,

the recommendations included in the report contain long term commitments to

strengthening accountability and corporate responsibility for the quality of care and

improving quality and safety, so we continue to monitor the work streams that were

established in response to this report.

The Francis Report: Outlining the Public Inquiry into the failure in NHS care at Mid

Staffordshire hospital, chaired by Sir Robert Francis QC, which was published in

2013. This report identifies warning signs that were evident at Mid Staffs hospital,

and should have alerted the wider system to the problems that led to such a

catastrophic failure in care. The key recommendations that are relevant directly to

commissioners fall into 5 themes:

1. Setting and monitoring standards

2. Learning and improvement

3. Data quality and information


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4. Organisational culture

5. Patient experience

Patients First and Foremost: An initial overarching response on behalf of the health

and care system as a whole to the Mid Staffordshire NHS Public Enquiry and the

Francis Report. It details key actions to ensure that patients are the “first and

foremost” consideration of the system, and everyone who works in it. It calls for the

NHS to return to its core humanitarian values, setting out a commitment and a plan to

eradicate harm and promote excellence.

The Berwick Report: Released in August 2013, the Berwick report was a review

commissioned by the Prime Minister and carried out by Professor Don Berwick and

international expert in patient safety. The review contains ten recommendations with

the aim of making the NHS a system devoted to continual learning and

improvements in patient care, top to bottom, beginning to end. Among the

recommendations were adopting a culture of learning, ensuring adequate staffing

levels and creating a new criminal offence for recklessness.

We will continue to monitor any other high profile cases which provide on-going reminders of

the role in safeguarding the care of vulnerable people, both for adults and children.

5.10 “No Harms Event”

Across South East Essex a quarterly meeting takes place where all providers can meet to

discuss events where things have gone wrong or very right to ensure that the system can

learn and develop as a result. NHS England as well as all CCG’s are in attendance.

5.11 Co-Commissioning

We are the only CCG in Essex to have been granted fully delegated co-commissioning

responsibility for primary care. Co-commissioning offers an opportunity to raise standards of

quality within general practice services including:

Clinical effectiveness

Patient experience

Patient safety

This includes work on reducing unwarranted variation in quality and enhancing patient and

public involvement in developing services. We aim to support our member practices.

5.12 Safeguarding adults and children

Safeguarding means protecting people's health, wellbeing and human rights, and enabling

them to live free from harm, abuse and neglect. It's fundamental to high-quality health and

social care.


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Safeguarding children and promoting their welfare includes:

Protecting them from maltreatment or things that are bad for their health or

development

Making sure they grow up in circumstances that allow safe and effective care.

Safeguarding adults includes:

Protecting their rights to live in safety, free from abuse and neglect.

People and organisations working together to prevent the risk of abuse or neglect,

and to stop them from happening.

Making sure people's wellbeing is promoted, taking their views, wishes, feelings and

beliefs into account.

5.13 Parity of Esteem

NHS England has established a Parity of Esteem programme as part of a “call to action” in

order to focus effort and resources on improving clinical services and health outcomes for

mental health. The emphasis is on ensuring that mental health is valued equally with

physical health. The commissioning cycle offers the ideal framework to achieve this.


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6 Roles and Responsibilities for Quality Assurance

We have in place a range of groups, teams and individuals with responsibility for assuring

and providing information on quality, safety and patient experience to ensure that

interventions pursued are clearly and appropriately integrated, aligned and managed.

6.1 The Role of the Clinical Commissioning Group

The Health and social Care Act 2012 sets out the role of CCGs in regard to securing

continuous improvement in quality, safety, effectiveness and patient experience:

“Each clinical commissioning group must exercise its functions with a view to securing

continuous improvement in the quality of services provided to individuals for or in connection

with the prevention, diagnosis or treatment of illness.

In discharging its duty a clinical commissioning group must, in particular, act with a view to

securing continuous improvement in the outcomes that are achieved from the provision of

the services.

The outcomes include, in particular, outcomes which show –

(a) The effectiveness of the services,

(b) The safety of the services, and

(c) The quality of the experience undergone by patients”

(Health & Social Care Act 2012 c7 – Part 1, Section 26, 14R)

Our role in commissioning includes holding providers to account for delivery of their

contractual obligations and quality standards. We must build the right quality standards into

the contracts we place with providers, to ensure service delivery improves and that the

providers we partner with have in place systems and processes to drive continual

improvement.

6.1.1 Our Role as Co-Commissioners

The NHS Five Year Forward View set out provision for CCGs to assume greater power and

influence over the commissioning of primary care medical care. Castle Point and Rochford

CCG is one of a small number of CCGs in the country to be delegated full responsibility for

commissioning general practice services. Delegated commissioning responsibilities exclude

individual GP performance management, which NHS England retains, however the design of

GP contracts, enhanced services, local incentive schemes and decisions on discretionary

payments does now reside with the CCG.

This gives opportunities to fully embed quality, safety and patient experience into primary

care specifications as well as with our community, mental health and acute providers.


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6.2 Group and Team Responsibilities for Quality, Safety & Patient

Experience

6.2.1 The Governing Body

The CCG Governing Body is chaired by a practicing GP, and is made up of our Accountable

Officer, the Chief Nurse, Executive Directors of the CCG, GP representatives and lay

members. The function of the Governing Body is to ensure strong and effective leadership,

management and accountability. Members of the Governing body must be assured that the

systems and processes are in place to monitor quality in commissioned services.

6.2.2 The Quality and Governance Committee

An integral component of our infrastructure for quality is the Quality and Governance

Committee, a formal sub-committee of our Governing Body. This Committee has the role of

assuring the Governing Body of the quality and safety of all health interventions that we

commission. The Committee is the formal mechanism by which the CCG discharges its

responsibilities for clinical quality and sets the strategic direction for clinical governance.

The remit of the committee is to;

Provide oversight and give assurance to the Governing Body that the patient and

patient feedback is kept at the centre of all decision making

Assure the quality and safety of the services commissioned

To promote continuous improvement, learning and innovation with respect to, clinical

effectiveness, safety of services and patient experience

6.2.3 The Clinical Quality Review Group (CQRG)

We commission major provider contracts collaboratively with three other CCGs. Each major

provider contract for which we lead is reviewed on a monthly basis through a Clinical Quality

Review Group (CQRG) which is chaired by the CCG Chief Nurse and attended by members

of the commissioning team, contracts team and representation for the quality and safety

agenda for the organisation. The CQRG is part of the formal contract management process

and the group has a set agenda built on the requirements for quality, safety and patient

experience in the contract and any new national drivers and the minutes of the Group go the

CCG Quality Committee.

6.2.4 The Quality Support Team

We have invested in a Quality Support Team to build the necessary capacity and capability

in monitoring quality, implementing and monitoring improvement projects, and supporting our


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staff to ensure that quality, safety and patient experience are prioritised in our

commissioning and day to day business.

The Quality Support Team provides support, analysis of data and information to the CCG

Chief Nurse on all aspects of patient safety and quality, including infection control, CQUIN,

serious incidents and never events and safeguarding.

The Quality Support Team review Quality Impact Assessments for new projects to provide

challenge and feedback on mitigating actions being proposed.

6.2.5 The Role of Member Practices

We are a membership organisation, which means clinical leaders, elected to our Governing

Body by member practices agree the basic rules that make up our constitution. Member

practices are expected to become fully engaged in our work around quality improvement,

and each practice is responsible for the development of its own quality improvement plan

within the context of the primary care.

We support member practices and wider primary care to quality assure current standards,

however each practice is remains accountable for the quality of services within their own

organisation. Member practices receive monthly reports benchmarking their performance on

key quality, performance and financial measures, and practices are expected to take action

to demonstrate continuous improvement. We routinely survey and monitor patient

experiences of using member practices.

Practice patient participation groups are essential in capturing patient experiences to feed

into the early warning processes and quality review meetings with providers.

6.2.6 Quality Surveillance Groups (QSGs)

QSGs bring together commissioners, regulators and other parts of the system to share

information and intelligence on quality in order to spot the early signs of problems and to

take corrective and supportive action to prevent early problems becoming more serious

quality failures. They are supported and facilitated by the NHS England are operational in

each local area and region. The meeting is attended by the Chief Nurse and Accountable

Officer and representatives from a range of organisations including the Care Quality

Commission, Monitor, Local Authority, HealthWatch and the East of England Deanery.

6.2.7 The Commissioning Support Unit (CSU)

The North East London Commissioning Support Unit provides expert support and advice to

help clinical commissioners to deliver improved health services to local populations. The

CSU role in promoting quality assurance and improvement for us is to:


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Ensure that there is a clear information on provider performance that all parties

understand

Provide support and advice on service redesign and QIPP initiatives

Support the annual and on-going contract negotiations

Coordinate contract monitoring and support the challenge on over performance,

targets, CQUINS, quality standards, QIPP, KPIs and demand management

Implementation of Super CQUIN

6.3 Individual Roles and Responsibilities

In addition to the above groups there are some individual roles within the CCG that have

responsibility for quality, safety and patient experience assurance and monitoring.

6.3.1 The Accountable Officer

The Accountable Officer (AO) holds ultimate responsibility for ensuring that the CCG is

meeting its statutory requirements for quality and safety and that there are mechanisms in

place for the CCG to recognise where there are concerns or failures in commissioned

services or in the CCGs ability to monitor the quality and safety of services. The AO reports

directly to the Governing Body.

6.3.2 The Chief Nurse

The Chief Nurse has responsibility for giving assurance to the CCG in relation to the quality

and safety of services being delivered to the local population. The Chief Nurse oversees the

processes and systems to ensure all national and local requirements to maintain and

improve quality, safety and patient experience and will be expected to report to the

Governing Body any concerns.

The Chief Nurse has responsibility for signing off all Quality Impact Assessments for new

projects, and is the Caldicott Guardian for the CCG.

6.3.3 All CCG Staff

All staff in the CCG regardless of their function will have a role to play in supporting us to

commission high quality services. This includes ensuring that their safeguarding, equality

and diversity and information governance training is up to date so they are in a position to

recognise any concerns or early warnings that they may come across as part of their day to

day business.


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7. Quality, Safety and Patient Experience Assurance

Processes

We have internal quality assurance and early warning systems in place which provide

information about risks to quality, safety and patient experience of the services we

commission. A formal Quality Impact Assessment process is used to identify quality, safety

and patient experience impacts and risks associated with any new services that are

considered and/or established. This allows us to be proactive in identifying concerns early,

and take action where standards fall short, and to ensure that new projects prioritise and

protect quality, safety and patient experience.

Quality Reporting is a regular agenda item for our Governing Body, and a formal written

quality report is presented by the Chief Nurse. The Quality report provides an overview to

the Governing Body of the continued focus that we place on quality and safety of services for

our population. The Quality Report includes dashboards with month by month snapshots of

the performance monitoring for providers, information on any serious incidents that have

taken place, safeguarding issues, complaints summaries, patient experience data, National

Reporting and Learning System (NRLS) incidents and any CQC reviews/inspection updates

and key findings that have been received.

We ensure that risks are managed in line with the aims, objectives and governance

arrangements outlined in this Quality Strategy and through:

Systematic programme of implementation of our Corporate Risk Management

Strategy

Reporting, investigation, management and learning from incidents

Risk management

Identification, reporting and management of risks

Development of risk registers and monitoring of action plans to mitigate risks

Quality and Safety risks are grouped on the risk register to make more explicit to the

Governing Body the nature and scale of risks that exist in direct relation to the quality of care

we commission. The CCG will therefore clearly see any quality risks that threaten our ability

to achieve its objectives.7

7.1 Monitoring and Assurance for Commissioned Services

We monitor each major provider contract monthly at the Clinical Quality Review Group

(CQRG) described above. Commissioners also work with commissioned services to deliver


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their annual ‘Quality Accounts’ to give assurance to the public and provide commentary on

the organisations commitment to governance, quality, safety and positive patient experience.

As part of contract monitoring, we also undertake a series of announced and unannounced

visits and the CCG Executive Nurses have developed a visit template to ensure consistency

of monitoring. The outcomes of these visits are discussed at the CQRGs and are reported to

the Quality and Governance committee.

7.1.1 Using data to assess and improve quality, safety and patient experience

We require performance data from all the providers we commission, and monitor this for

trends, themes and compliance with national requirements including:

Acute hospitals

Care homes

Community providers

Mental health providers

Independent hospitals

NHS 111 service

Ambulance services

Domiciliary care agencies

Support and assisted living services

We also use soft intelligence, regular and unannounced site visits and face to face dialogue

with our providers to triangulate information to inform Key Lines of Enquiry (KLOE) for

discussion at our formal meetings as part of our contract management. Any emerging or

immediate areas of concern are escalated immediately.

7.1.2 Complaints and patient feedback

We actively encourage feedback, and respect the views of patients using our commissioned

services. We are keen to learn from patient experiences, good or bad and to put in place

steps to ensure continuous improvements. The hospital providers have in place Patient

Advice Liaison teams (PALS) who are available to all the community to advise and support

patients, carers and families by providing information, and who capture learning and ideas.

7.2 Quality Monitoring for New Projects and Services

We are an innovative and ambitious CCG, with plans to develop new services and make

improvements. With all new ideas we expect that quality, safety and patient experience will

be prioritised and protected to ensure that standards remain high and risks are understood,

mitigated and managed.


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We have established a robust Quality Impact Assessment process and associated tool to

assess whether quality, safety or patient experience will be impacted on by any

organisational change project. Our project management approach is shown below, QIAs are

initiated in gateway 2 and reviewed at gateways 3 and 4.

Castle Point & Rochford Project Management Approach

7.2.1 QIA Tool and Process

The QIA tool incorporates a checklist to determine what level of impact may be expected

against 47 indicators – either positive, no impact or negative impact. A full risk assessment

is undertaken against any criteria that have potential to impact negatively on quality, safety

and patient experience. The indicators are shown below:

QIA Checklist Indicators

Category Quality Indicators

Patient safety Patient safety adverse events including avoidable harm and Patient Safety Alert

Services

Medicines management and safe administration of medicines

Mortality, HSMR / SHMI

Ay infection control issues including MRSA / Cdiff

CQC visits and registration

NHSLA / CNST

Essential training


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Workforce, vacancies, turnover, absence, revalidation

Safe, clean, comfortable and well maintained environment/equipment

Clinical

effectiveness

NICE guidance and Quality Standards e.g. VTE, Stroke, Dementia

Helping people recover from ill health, injury and preventing people from dying

prematurely

Other outcome guidance e.g. PROMS

Other external accreditation e.g. RCN

National clinical audit / research and development

Clinical outcomes

Breastfeeding rates

Emergency bed days

Length of stay

Emergency readmissions (30 day)

Minor injuries standards

Day case rates

Patient

experience

Patient feedback (e.g. FFT, NHS Choices, comments, compliments, concerns,

complaints, national and local surveys)

Patients, carers and public engagement

Waits for admission / treatment

Mixed sex breaches

Delayed discharge

End of life pathway

Cancelled day case operations

Waiting times for therapy services

Making every contact count

Inequalities of

care

Access to services – equality impact

Variation in care provision

Staff experience Workforce capability care and skills

Working practice

Staff satisfaction (e.g. FFT, annual staff survey / local surveys)

Mandatory training compliance

Targets &

performance

Performance

Achievement of local, regional and national targets

Promoting

wellbeing (in the

provision of care

and support)

Person’s sense of personal dignity (including treatment of the individual with respect)

Person’s physical and mental health and wellbeing

Abuse and neglect (safeguarding)

Personal control over day to day life (including over care and support and the way it is

provided)

Opportunities for participation in work, education, training or recreation

Social and economic wellbeing

Domestic, family and personal relationships

Suitability of living accommodation

Personal contribution to society including sustainability

Risk assessment is undertaken to outline:

Description of the risk or negative impact

Risk rating – including likelihood and impact according to the corporate risk register

rating


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Mitigating actions and controls

Residual risk rating

Escalation and risk tracking

Metrics used to track and monitor the risk

Monitoring forum and risk owner

Risks associated with QIAs are captured in project risk logs and departmental risk logs and

are therefore subject to the corporate risk management processes. However risks identified

through the QIA process are also managed and report by the Programme Management

Office (PMO) to ensure they are tracked appropriately as projects progress through the

gateway process.

7.3 Other Quality, Safety and Patient Experience Mechanisms

7.3.1 Safeguarding adults and children

We have a clear governance process in place for safeguarding children and vulnerable

adults. The CCG works in partnership with the local Authority and the Chief Nurse is a

member of the Children and Adult Safeguarding Boards. The designate professionals for

safeguarding children and adults are within the hosted arrangements for the South Essex

CCGs and the Quality Support Team work closely with the safeguarding teams in the Local

Authority. The structure below shows the inter-dependencies across health and social care

for the management of safeguarding children and vulnerable adults. Our Chief Nurse is a

member of the Children and Adults Safeguarding Board.


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Safeguarding Structure within South Essex

7.3.2 Information Governance and Caldicott

We ensure robust Information Governance arrangements through the implementation of the

requirements of the Department of Health’s Information Governance toolkit. The CCG

Senior Information Risk Owner (SIRO) is the Chief Finance Officer and the Caldicott

Guardian is the Chief Nurse. Information Governance support is through the Essex team

hosted by Basildon and Brentwood CCG..

7.3.3 Clinical Audit

Audit is an essential tool for early recognition of failing systems and processes before it

results in an incident that may cause harm. We monitor the robustness of clinical audit in

commissioned services and are actively involved in auditing patient notes through

information sharing agreements.

7.3.4 Medicines Management

The Prescribing and Medicines Management Team provides expert knowledge to help make

the best decisions around buying and prescribing high quality, cost-effective and safe drugs

and medicines. The service also ensures that the appropriate and necessary governance

around medicines use, are in place and that all legal obligations are met. This key service

helps CCGs to improve safety and quality of care around prescribing and administration of

medicines, and to manage the NHS drugs bill.


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7.3.5 Domestic Abuse

We are hosting an Essex-wide programme team focussed on improving outcomes for

victims of domestic abuse and their children, reducing severe harm, and supporting victims

to feel safer in their own homes. In addition a range of initiatives are being established to

work with perpetrators to improve access to support programmes. The programme is a joint

initiative, working across a range of organisations, Essex-wide; including Essex Police,

Essex County Council, Local Housing Authorities, registered housing providers and the NHS

and is expected to reduce police call outs, health costs associated with the physical and

mental effects on victims and alternative accommodation costs for victims and perpetrators

in addition to the quality and safety benefits.


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8. Next Steps and Developments

To achieve our quality ambitions we will require complete ownership within the organisation

of quality improvement on behalf of our patients. Every member of staff needs to understand

what needs to change, why it needs to change and how to make change happen. Quality is

everyone’s business and this strategy outlines the part to play of all. This process will be

informed by all aspects of the commissioning cycle, relationships with our providers and our

relationship with our local residents.

Quality is everyone’s business and everyone has a part to play.

On-going evaluation of our performance year on year against our strategic quality objectives

will be mandatory and will be led by the Quality and Governance Committee.

The CCG will continue to review National and local standards to underpin the Quality

agenda and this strategy will become the underpinning document to support the agenda.


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NHS Castle Point and Rochford

Clinical Commissioning Group

12 Castle Road

Rayleigh

Essex SS6 7QF

Tel: 01268 464508

Email: [email protected]

Twitter: @CPRCCG

www.castlepointandrochfordccg.nhs.uk

quality, safety and patient experience strategy

Documents