UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST. Quality Standards National Institute for Health and Clinical Excellence

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1 UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST Quality Standards National Institute for Health and Clinical Excellence Report to: Trust Board - 20 th December 2011 Report from: Sponsoring Executive: Sponsoring Divisional Director: Aim of Report/ Principle Topic: Review History to date: Assurance Framework Strategic Objective Ref: Recommendation(s): Martin Stephens, Associate Medical Director, Clinical Effectiveness Michael Marsh, Medical Director not applicable To update trust Board on national policy for NICE Quality Standards (QS) and explain the Trust s response along with current performance. The quality Governance Steering Group (QGSG) supported proposals on how to respond to QS in August This has been built into local NICE policy and is being implemented. The Medical Director and Director of Nursing supported briefing Board on QS. This briefing paper has been reviewed at QGSG and the approach endorsed. Further updates have been made new QS are regularly published. The Trust Executive Committee has reviewed the paper. SO1 Trusted on Quality, SO2 Delivering for taxpayers, SO3 Excellence in Healthcare Trust Board is asked to: a) note the report and both the increasing importance and increasing quantity of NICE quality standards; b) note the progress made in assessing performance against the quality standards; c) propose any further action that would support the Trust s achievement of NICE quality standards and or scrutiny of our performance. d) agree that oversight of performance against NICE quality standards would be undertaken at the Trust Executive Committee and any areas of concern escalated to the Board. 1. Strategic context: The 2010 White Paper Equity and Excellence liberating the NHS set out a clear intent to build on the principles set out in Lord Darzi s work that high quality care is the central aim of NHS services and that outcomes, not process targets, would be the focus. A key aspect of the drive for high quality care is the production, by NICE, of 150 quality standards over the next four years. These will be specific, concise evidence based statements to ensure safe, effective patient care that provide a good patient experience; their application will also drive cost-effectiveness. The Health and Social Care Bill is going through the parliamentary process currently, that process may have an impact on the final arrangements for QS. Though the Bill does not (as far as ascertained) mention providers responsibility for QS it states that the Secretary of State and the NHS Commissioning Board will have to have regard for QS, prepared by NICE, as they discharge their duty of quality. The Operating Framework for the NHS in England 2012/13 states: Each of the five domains within the NHS Outcomes Framework will be supported by a suite of NICE QS which will provide authoritative definitions of what high-quality care looks like for a particular pathway of care (para 2.14). 1

2 The Trust is committed to providing excellence, affordably and in sustaining a reputation that means it is the hospital of choice in the services we provide. Implementing QS and being able to demonstrate we have done so is crucial to these aims. The Clinical Effectiveness and Outcomes Strategy sets out our commitment to delivering these QS. Process 2. Staff, Patient and Public Involvement: QS are developed by NICE with significant patient and public involvement, as well as engagement with a range of health professionals and representative bodies. Scrutiny of our performance against the standards will include a variety of groups some will have patient and public representatives. 3. Specific Detail: 3.1 NICE quality standards Details of the purpose, content and development of the standards can be found at but some key points are: Purpose: NICE quality standards are a set of specific, concise statements that act as markers of high-quality, costeffective patient care, covering the treatment and prevention of different diseases and conditions. Derived from the best available evidence such as NICE guidance and other evidence sources accredited by NHS Evidence, they are developed independently by NICE, in collaboration with the NHS and social care professionals, their partners and service users, and address three dimensions of quality: clinical effectiveness, patient safety and patient experience. This work is central to supporting the Government's vision for an NHS focussed on delivering the best possible outcomes for patients. NICE state that QS enable: Health and social care professionals to make decisions about care based on the latest evidence and best practice. Patients and carers to understand what service they should expect from their health and social care provider. Service providers to quickly and easily examine the clinical performance of their organisation and assess the standards of care they provide Commissioners to be confident that the services they are purchasing are high quality and cost effective Developing standards: Multi-disciplinary Topic Expert Groups develop the quality standards over a specific period of time. These groups review information on the topics referred to NICE in order to develop a NICE quality standard. The Quality Standards Programme Board provides quality assurance, consistency checking and advice on implementing the quality standards. The quality standard development process is designed to be open, transparent and timely, with input from stakeholders and key individuals. NICE also plan to consult on the interim process guide in the coming year and will give further information on how stakeholders can submit feedback soon What the standard looks like: Each quality standard contains quality statements describing key markers of high-quality, cost-effective care for a particular clinical condition or pathway. These statements may focus on prevention, as well as elements of health and social care, and will promote an integrated approach to improving quality. Each statement of quality will be accompanied by the following: A description of what the quality standards mean for people using health and social services. Quality measures, which should improve the structure, process and outcomes of health and social care. Quality measures are not new targets or mandated indicators for performance management. They are worded as high-level Quality Indicators and may be supplemented with indicators developed by the Information Centre through their Indicators for Quality Improvement Programme. If such Quality Indicators do not currently exist the quality measures should form the basis for audit criteria developed and used at local level to improve the quality of healthcare. At present there are limited health outcome 2

3 measures that can be used as quality measures: the focus of the quality measures is on improving health outcomes by improving care processes considered to be linked to health outcomes. 3.2 Current standards At the 6 th December 2011, the following thirteen QS are published (hyperlinks are included in e- document) Alcohol dependence and harmful alcohol use Breast cancer Chronic heart failure Chronic kidney disease Chronic obstructive pulmonary disease (COPD) Dementia Depression in adults Diabetes in adults Glaucoma Specialist neonatal care Stroke VTE prevention End of life care for adults Appendix A lists QS in development. 3.3 Process agreed in Trust QS fall under the remit of clinical effectiveness, with the medical director as responsible executive, supported by the Associate Medical Director Clinical Effectiveness. The NICE policy sets out our approach: the clinical effectiveness team will ensure a suitable clinical lead is nominated for each standard, then we assess our performance against that standard, set out a record of that performance (stored on a shared drive) and agree a suitable group to monitor (for example the thrombosis Group for VTE). It is proposed that if no specialised group exists and the QS does not relate to a PIF target, one of the divisional boards should be nominated to oversee performance. Where there is a shortfall in our performance against the standard an action plan would be required and the issues escalated. It is further proposed that oversight of performance against NICE quality standards would be untaken by the Trust Executive Committee with any items of concern escalated to the Board. 3.4 Current performance Trust performance against the thirteen published standards is reported in Appendix B. We do well in VTE prevention, glaucoma, chronic heart failure, chronic obstructive pulmonary disease (COPD) and are making good progress in stroke; six standards are yet to be ; depression in adults has been reviewed with liaison psychiatry and we have some improvements to make though the QS is not fully relevant to us. Specialist neonatal care is awaiting a network-focused discussion. The AMD Clinical Effectiveness has recently written to further named leads to seek an assessment of the details of our performance. The initial assessment, later review and action planning, takes significant effort. Where this fits with a current programme (for example VTE prevention) this may not be problematic, for other QS, the Trust may need to consider providing dedicated time to ensure we achieve the requirements agreed in our QS policy and, more importantly, conform to the QS. 3.5 Example Appendix C sets out an example of the statements made in a QS, chronic heart failure has been used. 3

4 Practicalities 4. Financial Information: Quality standards will be reflected in the new Commissioning Outcomes Framework and will inform payment mechanisms and incentive schemes such as the Quality and Outcomes Framework (QOF) and Commissioning for Quality and Innovation (CQUIN) Payment Framework. Performance on VTE is already included in CQUIN. The Operating Framework for notes an additional CQUIN national goal will be developed on improving diagnosis of dementia in hospitals detail is awaited but the relevant QS does include a requirement for referral to a memory clinic of patients suspected to be suffering from dementia. Investment may be required where we identify shortfalls in performance or consideration given to discontinuing that service if this is acceptable to commissioners and service users. The Trust may need to consider investment in clinical and administrative time to ensure we retain an effective process currently we have fewer than 10% of the planned QS to consider. 5. Risk Register Ref: Currently in Trust HQ 1047, graded as Amber, scoring Legal Implications: NICE state: NICE quality standards define what high quality care should look like. The statements and measures in a NICE quality standard together indicate a high quality clinical service. The delivery of high quality care is signalled by good performance across the breadth of all statements and measures. If an organisation is performing poorly on many or all measures, it may mean that an organisation is at risk of not meeting CQC's Essential Standards of Quality and Safety and of not complying with regulatory requirements. CQC may make use of data on Quality Standards measures in their risk estimation. Meeting QS should reduce the risk of claims against the Trust. 7. Trust Wide Impact & Assessments: This matter has been for potential impact on personal data and privacy: Yes This matter has been in relation to Equality & Diversity: Yes No concerns have been identified. 8. Carbon Management: No direct impact is foreseen though high quality care should reduce demands on the hospitals. 4

5 Appendix A NICE quality standards in development NICE quality standards are currently being developed for the following topics (hyperlinks included where available): Acute coronary syndromes including myocardial infarction Antenatal care Asthma Bacterial meningitis and meningococcal septicaemia in children Colorectal cancer Drug use disorders Falls in a care setting Head injury Hepatitis B Hip fracture Intrapartum care Intravenous fluid therapy Lung cancer Osteoarthritis Nutrition support in adults Ovarian cancer Patient experience in generic terms Prostate cancer Reflux disease (gastro-oesophageal reflux disease) Schizophrenia Service user experience in adult mental health Stable angina The following topics have also been referred to NICE by the Department of Health and development will commence shortly: Bipolar disorder in adults Bipolar disorder in children and adolescents Diabetes in children Epilepsy in adults Epilepsy in children Migraine/headache Postnatal care Pressure ulcers Pulmonary embolism Safer prescribing NB as at 6 th December

6 Appendix B Summary of current performance Quality Standard Date issued UHS Lead Status Comments Alcohol dependence August 2011 To be identified To be Covers health and social and harmful alcohol use care but many relevant Breast cancer September 2011 To be identified To be Chronic heart failure June 2011 Peter Cowburn Broadly Chronic kidney disease March 2011 Mary Rogerson To be Chronic obstructive pulmonary disease July 2011 Simon Bourne & Tom Wilkinson Dementia June 2010 James Adams & Jill Young Depression in adults March 2011 Liaison psychiatry with Martin Stephens Broadly To be Some improvement required Diabetes in adults March 2011 Mayank Patel Broadly End of life care November To be identified To be 2011 Glaucoma March 2011 Alex MacLeod & Broadly Jacob Aby Specialist neonatal care October 2010 Mike Hall To be Stroke June 2010 Pamela Crawford Some actions to achieve full compliance VTE Prevention June 2010 Martin Stephens Broadly to UHS. Covers a range of items to which we should conform. Some items are for primary care. Includes items relevant for long-term haemodialysis units Few of the criteria apply to UHS but better identification of depression required. Not all items apply to UHS. Some network-wide issues identified further discussion planned 6

7 Appendix C An example of a quality standard headline statements Chronic heart failure The quality statements: 1 People presenting in primary care with suspected heart failure and previous myocardial infarction are referred urgently, to have specialist assessment including echocardiography within 2 weeks. 2 People presenting in primary care with suspected heart failure without previous myocardial infarction have their serum natriuretic peptides measured. 3 People referred for specialist assessment including echocardiography, either because of suspected heart failure and previous myocardial infarction or suspected heart failure and high serum natriuretic peptide levels, are seen by a specialist and have an echocardiogram within 2 weeks of referral. 4 People referred for specialist assessment including echocardiography because of suspected heart failure and intermediate serum natriuretic peptide levels are seen by a specialist and have an echocardiogram within 6 weeks of referral. 5 People with chronic heart failure are offered personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wish. 6 People with chronic heart failure are cared for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with appropriate competencies from primary and secondary care, and are given a single point of contact for the team. 7 People with chronic heart failure due to left ventricular systolic dysfunction are offered angiotensinconverting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase. 8 People with stable chronic heart failure and no precluding condition or device are offered a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support. 9 People with stable chronic heart failure receive a clinical assessment at least every 6 months, including a review of medication and measurement of renal function. 10 People admitted to hospital because of heart failure have a personalised management plan that is shared with them, their carer(s) and their GP. 11 People admitted to hospital because of heart failure receive input to their management plan from a multidisciplinary heart failure team. 12 People admitted to hospital because of heart failure are discharged only when stable and receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge. 13 People with moderate to severe chronic heart failure, and their carer(s), have access to a specialist in heart failure and a palliative care service. 7