Clinical Quality Strategy. A systematic approach to the development and maintenance of safe effective compassionate healthcare April

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1 Clinical Quality Strategy A systematic approach to the development and maintenance of safe effective compassionate healthcare April Liz Herring, director of nursing, quality & development Susan Hepburn, quality manager Approved: November,

2 Content 1.0 Introduction and context Clinical commissioning: strategic context National expectations Clinical effectiveness Patient experience Patient safety for compassion quality assurance framework Organisational leadership and governance for Compassion: areas for action We care about delivering the best outcomes for our patients The commissioning workforce has the courage to speak out about unsafe care and generate ideas to improve patient experience Commissioners communicate and engage across patients, partners and stakeholder to meet the needs of our patient population Services that are provided for the population of North Durham are committed to continuously improving the way they work We secure a competent workforce capable of commissioning the highest quality of care We commission with compassion and that the interests of patients are at the centre of our decision-making Supporting quality improvement, innovation & research Conclusion Appendix 1: Clinical quality systems and processes Appendix 2: Associated clinical quality policies and procedures

3 1.0 Introduction and context The nature of clinical quality and continuous improvement in a clinical commissioning organisation is twofold; not only is it to obtain assurance regarding commissioned services, it is to also make best use of evidence and patient experience in the way we design and procure new services for our patient population. North Durham Clinical Group (NDCCG) aspires to the highest standards of corporate behaviour and commissioning competence, to ensure that safe and effective services are commissioned. This clinical quality strategy couples these requirements to ensure the CCG is able to develop and manage commissioned services to deliver the best outcomes for patients and has robust systems in place to design and recognise services which need early intervention and improvement. The CCG also recognises its role to work with NHS England and its member general practices to ensure the delivery of high quality primary care services for the population of North Durham. Additionally the CCG is aware of its responsibilities to work closely with the local authority to ensure the appropriate assessment of local health need and the delivery of integrated health and social care. Our structured approach to clinical quality not only looks at the systems and processes aligned to managing clinical quality it also, looks at the outcomes and capability of staff who work within the commissioning processes themselves. A successful approach to clinical quality would mean that: 1. We care about delivering the best outcomes for our patients 2. The commissioning workforce has the courage to speak out about unsafe care and generate ideas to improve patient experience. 3. Commissioners communicate and engage across patients, partners and stakeholder to meet the needs of our patient population. 4. Services we commission are committed to continuously improving the way they work. 5. We secure a competent workforce capable of commissioning the highest quality of care. 6. We commission with compassion and that the interests of patients are at the centre of our decision-making. 1.1 Clinical commissioning: strategic context Clinical commissioners are in the business of commissioning care, structured with support of its member practices, commissioning staff and clinical leads to ensure that the needs of patients are understand and addressed. Ultimately, North Durham CCG s overarching aim is Better health for the people of North Durham. 3

4 The commissioning process that achieves this is captured in Figure 1. Not only is it the process to procure high quality services, it is also the route to continually improve services we already commission through the quality aspects of the contract. Figure 1: The commissioning process This clinical quality strategy sets out how we will aspire to continually improve against the national NHS Outcomes Framework (2013/14) and the patients and public we serve. In 2011, the National Quality Board described how healthcare organisations needed to have a systematic approach to clinical quality, reminding our-selves that High Quality of Care for All should be available for all. Continuously improving patient safety should be at the top of the healthcare agenda for the 21st century. The injunction to do no harm is one of the defining principles of the clinical professions... safety must be paramount for the NHS. Public trust in the NHS is conditional on our ability to keep patients safe when they are in our care. (Darzi, 2008) In our Clear and Credible Plan (NDCCG, 2012), we set our four primary objectives in relation to clinical quality. They were to: 1. Safeguard our patients from harm 2. Ensure continued development of appropriate high quality provision of services to the population 3. Secure rapid improvements to the quality of care in failing organisations, and 4. Drive up quality and foster a culture of safety, including across primary care. 4

5 Each one of these primary objectives clearly requires the CCG to be able to recognise and respond to clinical quality concerns, but also ensure that services commissioned are safe at the outset, build upon sound evidence, offer value for money and address the health needs of our population. Our first clinical quality strategy (NDCCG, 2012) outlined the building blocks that underpin our systems and processes and policies and procedures summarised in Appendix 1 and 2. The learning from Mid Staffordshire clearly showed that clinical quality is more than just policy and procedure; it is about the workforces ability to observe, listen and take action and follow-up on action. The CCG assurance framework (NHSE, 2013) is central to assessing the ability to deliver against these expectations. 1.2 National expectations The recent learning from high profile organisational (Francis, 2013; Keogh, 2013) failures in care, clearly articulates the role of clinical commissioners in knowing whether the care patients are receiving is to the right standard and delivering the best outcomes for patients. The NHS Outcomes Framework (Figure 2) demonstrates the impact commissioning organisations should have on their patient populations. This framework should be at the heart of the evidence used to measure the difference being made to patients. Figure 2: NHS Outcomes Framework (2013/14) The NHS Outcomes Framework (2013/14) was derived from the three part definition of quality first set out by Lord Darzi as part of the NHS Next Stage Review (2008). 5

6 This definition is that high quality care comprises: clinical effectiveness, patient experience and patient safety. 1.3 Clinical Effectiveness Care should be based on the best clinical evidence. The role of the CCG is to ensure that providers have systems in place to measure, report and improve the prevention of illness and the clinical effectiveness of the treatments they provide, including supporting patients to get maximum gain out of any prescribed medication. In practice, this means; Understanding success rates from different treatments for different conditions. Assessing this will include clinical measures such as mortality or survival rates, complication rates and measures of clinical improvement. Just as important is the effectiveness of care from the patient s own perspective which will be measured through patient-reported outcomes measures (PROMs). Clinical effectiveness may also extend to people s well-being and ability to live independent lives 1.4 Patient Experience The experience that someone has of their treatment and care is intrinsically important to them and a key outcome. Patient experience is key to ensuring that patient safety and clinical effectiveness address the areas of need at the right time and for the right people. The role of the CCG is a pivotal focal point for the triangulation of patient experience information, through complaints, soft intelligence, practice information and reported incidents. In the wake of Mid Staffordshire, the national nursing strategy Compassion in Practice (DH, 2012) repositioned the importance of care and patient experience alongside that of effective treatment. In practice this reinforces the statement: Quality of care includes quality of caring. This means how personal care is the compassion, dignity and respect with which patients are treated. It can only be improved by analysing and understanding patient satisfaction with their own experiences 1.5 Patient Safety When patients are ill they will receive care that is as safe as we can make it. The role of the CCG is to ensure that both they and their commissioned providers have efficient systems and processes in place to identify potential and actual harm to patients. The CCG must also provide assurance that patients are not at risk from avoidable harm 6

7 and where incidents have occurred lessons are learnt and shared across the health economy. In practice this means: The first dimension of quality must be that we do no harm to patients. This means ensuring the environment is safe and clean, reducing avoidable harm such as excessive drug errors or rates of healthcare associated infections. In response to this, the CCG has developed a commissioning quality assurance framework that frames the components of effective commissioning, contract management and quality assurance as it is not enough to solely hold the provider to account. 2.0 for compassion is the starting point of securing excellent care; we have translated the principles of Compassion in Practice (DH, 2012) into the way we should operate as commissioners. In using this approach it aligns the principles that are being driven across nursing, into wider areas of the health system and establishes a common language that is about high quality patient care and experience. If we are successful in our practise, alongside our drive to be an effective learning organisation (OD, 2014) we will be able to evidence that: 1. We care about delivering the best outcomes for our patients 2. The commissioning workforce has the courage to speak out about unsafe care and generate ideas to improve patient experience. 3. Commissioners communicate and engage across patients, partners and stakeholder to meet the needs of our patient population. 4. Services we commission are committed to continuously improving the way they work. 5. We secure a competent workforce capable of commissioning the highest quality of care. 6. We commission with compassion and that the interests of patients are at the centre of our decision-making. Similar to the national nursing strategy, we have organised our strategic plan into, which clearly show how we need to continue to develop as a commissioning six areas for action organisation and strengthen the way are assured about the clinical quality of our commissioned services and that staff are confident and capable to act on concerns and commission the best outcomes. 7

8 2.1 quality assurance framework Compassion in Practice (DH, 2012) outlined the fundamental principles to support professionals and care staff to deliver care excellent care. The CCG s commissioning quality assurance framework (Figure 3) provides clarity of the assurance and commissioning processes in relation to one another. It also acts as a framework to benchmark commissioning practise against each of our commissioned services. The quality assurance framework takes the fundamental principles of Compassion in Practice and positions them as one of the three foundation layers: knowledge and system understanding, commissioning principles, leadership and change within the commissioning quality assurance framework. Figure 3: North Durham s commissioning quality assurance framework Whilst the day-to-day leadership of clinical quality sits with the Director of Nursing, Quality and Development and Director of Quality and Safety, clinical quality is an integral part of all commissioning activities. The commissioning quality assurance framework provides a structure to assist all staff in understanding their role and contribution to high quality clinical and patient care. The framework also provides an overview of how the quality of service provision is understood and managed in 8

9 commissioning organisations: both key commissioning recommendations following the Mid Staffordshire inquiry (Francis, 2013). The end point of which is a commissioning organisation that is compassionate about patients and their health outcomes. 2.2 Organisational leadership and governance Whilst this clinical quality strategy emphasises the role of all staff in ensuring safe, clinically effective care and a positive patient experience, the Director of Nursing, Quality and Development and Director of Quality and Safety are responsible for the CCG strategic leadership of clinical quality across the commissioning process and of commissioned services - supported by the Quality and Development Manager and the North of England Support Unit Clinical Quality Team. The governance for quality within the CCG sits with the CCG Governing Body, which delegates the detailed work on clinical quality across the commissioning process and of commissioned services to the Quality, Research and Innovation Committee. This committee is expected to receive assurances that patients in commissioned services are as safe as possible, achieve the best health outcomes and have a positive experience of care. In turn the Quality, Research and Innovation Committee reports areas of serious risk or concern to Management Executive. The CCG will have annual forward plans to examine areas of quality in more detail and provide evidence and assurance to the governing body of the impact of their work. The CCG s arrangements for the governance of quality are shown in Figure 4. NDCCG Governing Body Progress with the quality strategy Strategic quality risks and high level operation risks as part of the Board Risk Assurance Framework Quality, Research and Innovation Committee Areas of serious risk or concern Management Executive Committee Prescribing Sub- Group Figure 4: Arrangements for the governance of quality 9

10 3.0 for Compassion: areas for action The areas for action described in this strategy describe the approach we will take to achieve a compassionate commissioning workforce. For each area, the strategy described the actions and expected outcomes. Starting with care, we will care about delivering the best outcomes for our patients. 3.1 We care about delivering the best outcomes for our patients Care is our core business and that of those who we commissioning healthcare from. Caring about those who we commission for defines us and our work and allows our patient population to receive the right standard of care. Areas for action 1 Annual review of patient health outcomes and service effectiveness 2 Development and delivery of an annual commissioner assurance visit programme 3 Annual review and analysis of the national measure for patient care and experience 4 Systematic approach to patient and public engagement, including a programme of patient survey s through contracting, CQUIN and primary care 5 Contribution of individual patient outcomes to clinical quality strategy 6 Services are commissioned against the national standard contract, with additional locally agreed performance measure s and service development plan as part of their standard contract 7 To have an agreed service level agreement from support services, public health and other support functions, to ensure we are able to monitor the performance of all services we commission 10

11 Measures for compassionate care and quality outcomes Proposed measure /indicator Source Success criteria Progress 1. We care about delivering the best outcomes for our patients The number of people who die under the age of 75 Hospital Standard mortality rate (HSMR) Reduction in the under 75 mortality rate For CCG decisions to be informed by patient experience measures NEQOS Friends and family test Patient experience kiosk surveys Increase in patient satisfaction National patient survey The inclusion of quality health outcomes in services specification and quality requirements of the contract The annual review of the Clear and Credible Plan is based on the Joint Strategic Needs Assessment Service specification Schedule 4 of NHS contracts JSNA Clear and Credible plan 100% of specifications and contract reviewed by QRI 3.2 The commissioning workforce has the courage to speak out about unsafe care and generate ideas to improve patient experience Courage enables us to do the right thing for the people we commission healthcare for and speak up when we have concerns. It also enables us the share new ideas to improve the way we do things. 11

12 Areas for action 1. To share our commitment to the Speak-out Safely campaign and share our whistleblowing policy more widely 2. Increase shared learning from incidents 3. Broaden our safeguarding responsibilities to those most vulnerable across primary care 4. Develop our soft intelligence process further and use the learning to inform our commissioning and contracting decisions 5. Educate our staff and member practice further in the reporting and management of incidents and commissioning concerns 6. The ability to recognise and act quickly on clinical concerns 7. CCG involvement in the review and reporting all provider serious incidents and complaints Measures for compassionate care and quality outcomes 2. The commissioning workforce has the courage to speak out about unsafe care and generate ideas to improve patient experience Proposed Measure / Indicator The number of staff trained in the reporting and management of incidents The number of staff trained in safeguarding Number of soft intelligence concerns reported Source North of England Support North of England Support North of England Support Success Criteria 100% staff trained in the recognition and reporting of clinical quality concerns 100% staff educated against the safeguard training standards Annual increase in soft intelligence concerns reported Progress 12

13 for compassionate care and quality outcomes Proposed Measure / Indicator Number of appropriate clinical incident reported Source North of England Support Success Criteria Annual increase in number of appropriate clinical incidents reported Progress Response time to understanding clinical concerns Distribution of lessons learnt from complaints and incidents across primary care and commissioning teams Number of commissioning improvement ideas trialled and evaluated Bi annual learning event North of England Support Quality and Development Team Medication Safety Officer and Development Team Quality and Development Team Medication Safety Officer Annual Reduction in severity of incidents reported Number of clinical concerns reported within 2days Compliance against national reporting standards Lessons learnt to be included within all primary care quality improvement quarterly report and cascaded through Constituency and Operations Group meeting Successful evaluation of staff attendance 13

14 for compassionate care and quality outcomes Proposed Measure / Indicator The reporting and response to serious incident and complaints Source North of England Support Success Criteria 100% involvement in serious incidents and complaints Progress 3.3 Commissioners communicate and engage across patients, partners and stakeholder to meet the needs of our patient population Communication is central to the way we engage and listen to patients, stakeholders and partners, demonstrating we are listening and acting on a wide range of views. Communication is an essential part of us being effective as an organisation, ensuring that all staff understand their role and contribution to safe commissioning practices. Areas for action 1. Standard approach to patient engagement and involvement in commissioning process, developments including consultations about services 2. Standard measures for patient experience and their results in commissioning decision-making 3. Use of poor patient experience to inform commissioning improvements 4. Standard approach to communicating lessons learnt to patients and member practices 5. An effective complaint process, that addresses patient and carer concerns, and looks to prevent reoccurrence 14

15 Measures for compassionate care and quality outcomes 3. Commissioners communicate and engage across patients, partners and stakeholder to meet the needs of our patient population Proposed Measure / Indicator The number of failures in patient experience Source North of England Support complaints monitoring Success Criteria Reduction in the number of complaints Progress 3.4 Services that are provided for the population of North Durham are committed to continuously improving the way they work Our commitment is to better the health of the people of North Durham, recognise failings in care and continually improve the experience of patients who access our commissioned services. Areas for action 1. A standard process in place for the involvement of clinical experts at the point of service design 2. A programme of work to drive up quality and patient outcomes in primary care 3. An annual programme of clinical audit to measure service effectiveness 4. Annual programme of commissioning innovations, delivered through the NHS contract 5. Annual programme of commissioner assurance visits with broad involvement of CCG staff 6. Annual review of incidents and contract quality requirements and embedding of learning from national inquiries and policy developments 7. Continuous review of the safe and effective use of medicines 8. Planned timely implementation and audit of NICE recommended treatments and care pathways 9. Support providers with innovative ideas and measurement of impact to inform future commissioning decisions, including encouragement to submit Measures expressions of interest and funding to create electronic systems that connect 15

16 for compassionate care and quality outcomes 4. Services we commission are committed to continuously improving the way they work Proposed Measure / Indicator Commissioner assurance visit programme Clinical audit programme Primary care quality improvement scheme Prescribing incentive scheme Source QRI North of England Support QRI North of England Support QRI Quality and development team QRI Medication Safety Officer Success Criteria Increasing attendance of commissioning and development team staff Delivery of commissioner assurance actions by providers Annual delivery against the programme of work Improved compliance against safeguarding standards Improved compliance against measures within the prescribing incentive scheme Progress Improved health outcomes in primary care innovations that address care and provision against the NHS Outcome domains Primary care web tool CCG primary care improving outcomes scheme QRI Annual agreement of provider CQUIN schemes 16

17 3.5 We secure a competent workforce capable of commissioning the highest quality of care Competence is our ability as commissioners to procure the best providers capable of delivering safe and effective care and our contract management of those providers against agreed standards of care. Areas for Action Areas 1. for Structured action approach to providing assurance that services we commission are safe, effective and based on strong clinical evidence 2. Greater alignment of the commissioning and development and clinical quality work-streams 3. Information sharing process that broadens the clinical quality knowledge and insight of commissioning staff 4. Staff understand their role and contribution to deliver the CCG strategic aims 5. Have a standard annual planning process, that engages all stakeholders and member practices and a standard process in place for in year planning decisions and use of non-recurring money 6. Ensure all CCG staff know the standard of services that should be delivered and the escalation routes when concerns are raised about care delivery 7. Provide ongoing training to ensure staff understand the CCG clinical quality assurance framework and that quality is everyone s role Measures for compassionate care and quality outcomes 5. We secure a competent workforce capable of commissioning the highest quality of care Proposed Measure / Indicator The measurement of patient views in the commissioning and quality assessment of services Source Success Criteria Progress Commissioner assurance visit programme National patient survey Annual programme of commissioner visits agreed by QRI Annual consideration of national patient survey and QRI actions for provider 17

18 for compassionate care and quality outcomes Proposed Measure / Indicator Source Success Criteria Progress improvement For commissioning staff to have the opportunity to take part in the commissioning assurance programme Evidence of patient engagement in the design of patient services The alignment of clinical quality and our approach to organisational development CCG involvement in provider quality assurance and contract processes assurance visit programme Services specification measures Quality research and innovation committee Denison Cultural Audit North of England Support Area Team 100% of staff to be offered 90% to take part in the annual programme of visits 90% of commissioning service development evidence patient engagement and views Increase in staff engagement and satisfaction 100% CCG representation at clinical quality review groups 100% CCG representation at quality surveillance groups 3.6 We commission with compassion and that the interests of patients are at the centre of our decision-making Compassion is how we engage with our patients to determine their health needs and design services that are accessible and of a high standard. 18

19 Area for action 1. To put in place how members of the public are visible and involved in governing body discussions. 2. The ability to share intelligence openly across the health and social care system 3. Publication of quality reports on the CCG website 4. Evidence of patient engagement and experience to be shared with members of the public through the CCG website 5. Agree a process with providers to ensure the CCG is directly linked to their complaints process, including responses to the complainant being shared with the lead commissioner in real time 6. Formalise the process with providers, through the contract, regarding concerns raised about providers or by providers, to support mitigating actions being put into place and quality service delivery being maintained Measures for compassionate care and quality outcomes Proposed Measure / Indicator Source Success Criteria Progress 6. We commission with compassion and that the interests of patients are at the centre of our decision-making. Evidence of patient and public involvement in our commissioning activities Patient experience of commissioned services and development team Patient, public engagement forums Provider friends and family test National patient survey 100% of our service development will recollect the needs and experience of users 90% of patient would recommend friends and family to those services we commission 19

20 4.0 Supporting quality improvement, innovation & research The introduction of continuous improvement and innovation in commissioning is not new. The national agenda associated with quality, innovation, productivity and performance (QIPP) is about securing improved service provision, making best use of research and evidence in commissioning practices as well as offering better value for money. As a CCG, we have to be able to demonstrate the difference we have made for our patients and how we are actively providing them access to research trials. Whilst we have operational policies to safely govern research, we need to do more to use the information available to us and increases the number of patients being offered the opportunity to be entered into clinical research. For us to be systematic in our approach to continuous improvement, we need to ensure we have positioned continuous improvement as a central part of the commissioning process, and secured leadership buy-in, identified a common methodology to avoid confusion for staff and ensure that the drive for continuous improvement is orientated around adding value from the viewpoint of the patient, not solely for performance or finance. In order to secure quality improvement, innovation and research as part of everything we do. The primary aims of this work will be to: 1. View continuous improvement as central to our business strategy. 2. Position patients and carers at the heart of everything we do. 3. Have a standardised improvement process that measures the impacts of our work. 4. Have a standard process through which we recruit patients into research trials. 5. Actively encourage practitioners to participate in and publish research. 6. Standardise our approach to supporting and evaluating innovative ideas. 7. Communicate the difference we are making for patients and the public. In order to embed this way of working and thinking into day-to-day commissioning practice, the following key actions need to be taken forward: Key Actions: We need to ensure: 1. Value from the view point of the patient is established. 2. Build effective commissioning process, to accelerate improved services to patients. 3. Strategic sponsorship of our commissioning business. 4. We visually manage the work we do. 5. We provide on-the-job support to staff. 6. We establish a process that escalates problems with delivery. 20

21 7. We develop and agree a standard improvement process that sets clear objectives, understands the current state, develops the future state and plans to deliver against agreed milestones and measures. 8. We drive up quality across the health system, including primary care. 9. Staff understand their role in supporting innovative ideas and evaluating the impact. 10. We have a single process to share & gain support for innovative ideas. 11. We regularly report and consider the impact of innovative ideas being tested. 12. We have a mechanism to consider research proposals and the research opportunities for our patients. 13. We make the best use of contractual routes, such as CQUIN, service development plans and penalties, to drive up the quality and safety of our commissioned services. 14. Services delivered to our population are patient-centred and evidence-based. The implementation of the six clinical quality themes will be captured within an implementation plan. The Quality, Research and Innovation Committee will monitor the work against this implementation plan every quarter. 5.0 Conclusion Clinical quality is an integral part of what we do as a clinical commissioning organisation, but by making it everyone s business means we run the risk of it not being anyone s business. The purpose of this strategic plan therefore, and its supporting policies and procedures, is that we are explicit in how clinical quality forms part of everyone s job role and they understand their responsibilities as a commissioner. The measures of our success will be that we continue to raise concerns and manage incidents. A critical measure will be whether we would recommend the services we commission to our family and friends. 21

22 Appendix 1: Clinical quality systems and processes We continue to work with our neighbour CCGs and the area team to improve clinical quality. However, the clinical quality processes we have established ensure we have the ability to safely monitor and manage the health system, with the core processes of clinical quality well established. This includes: Safe commissioning of services: Specialist advice is provided to the CCG within the process for commissioning and procurement of new services - from the design of service specifications to the assessment of tender bids from willing providers to ensure they are evidence-based and deliver against the NHS Outcomes framework. Managing Healthcare Acquired Infection (HCAI): Supporting Public Health colleagues and the infection control teams to gain assurance that HCAI is being managed protectively across commissioned services, including audit and root cause analysis investigation of specific cases of harm. for Quality and Innovation (CQUIN) targets: coordinating the development and performance management of CQUIN targets, as the route to drive up quality through quality contracts. Setting quality penalties: assisting the CCG to shape financial penalties for standards of unacceptable care and non-compliance against zero tolerance thresholds. Effectively managing providers through Clinical Quality Review Groups (CQRG): These ensure delivery of North Durham s Clear and Credible Plan This will be achieved through working closely with partner organisations to measure and monitor quality improvement, safety and patient experience and by collating, monitoring and reviewing year on year the quality of services contracted between NDCCG and the major providers. Robust incident management, investigation and learning: All incidents reported to the commissioning support clinical quality team are assessed to ensure that the necessary actions have been taken by providers and independent contractors to prevent re-occurrence. Where further actions are required, support and advice is available from within the patient safety team to carry out root cause analysis investigations and identify the errors in processes and systems to ensure continual improvements and learning occur within the organisations responsible for the incidents. Robust management of safeguarding adults and children concerns: Liaise with partner organisations and internal leads in the investigation of safeguarding adults and children issues arising out of referrals to Social Services Direct. This also includes representation on the local safeguarding boards. Timely complaints management: The CCG provides the monitoring and management of complaints from primary care medical services and provider services, as well as the co-ordination of complex complaints responses made 22

23 about multiple organisations providing health and social care services. This service will be delivered with support from the commissioning support complaints team. Patient experience information gathered through these processes is analysed and triangulated with other streams of clinical quality information to ensure that patient safety is maintained. The management of primary care complaints now sits with NHS England area teams. Coordinate and support an annual audit plans: The major providers in primary, secondary and community healthcare are subject to a set of audits planned as part of the clinical audit forward programme, including; eg. NICE compliance, local medicines management, safeguarding adults and children and the quality and outcomes framework (QOF). Make best use of benchmarking information: eg Patient Reported Outcome Measures (PROMs), which measure quality from the patient perspective. Initially covering four clinical procedures, PROMs calculate the health gain after surgical treatment using pre and post-operative surveys. The four procedures are hip replacements, knee replacements, hernia and varicose veins. These will continue to be monitored through the CQRGs. Produce regular and meaningful clinical quality reports: Clinical quality reports are key reports that bring together an analysis of all of the available clinical quality information produced and obtained by the patient safety, advice and complaints and clinical effectiveness teams. This includes the interface with local authorities and the area team clinical quality members, so a full picture care is provided. Analysis and review of practice against National Review Recommendations: To ensure that recommendations that arise out of national reviews, such as Ombudsman reviews, Coroner Rule 43 verdicts and other independent inquiries are implemented across both the organisation where applicable and commissioned services. Appropriate and responsive management of professional performance concerns: The responsibility for the performance of independent contractors, both professionally and contractually, transferred to NHS England area team. There is a local role to listen to concerns raised to consider their onward referral for further investigation. Medication safety: The use of medication is the most common healthcare intervention. North Durham Clinical Group will promote a culture of quality and safety assurance with regard to the use of medicines by supporting high quality medicines governance and ensuring that mechanisms are in place to assure safe and effective medicines usage in healthcare services, reduce variation in prescribing, reduce medicines related healthcare acquired infections (C.diff and MRSA) and limit medication related hospital admissions. 23

24 Formulary of medicines: The maintenance of a single formulary across all healthcare providers to ensure consistent safe and efficient use of medicines and the timely introduction of new treatments and associated guidelines. Review of performance on medicines: Medicines optimisation dashboard. 24

25 Appendix 2: Associated clinical quality policies and procedures 1. Clinical Audit, Evaluation and Research Registration and Approval 2. Risk Management. 3. Safeguarding adults 4. Safeguarding children 5. Reporting and management of incidents 6. Reporting and management of serious incidents 7. Complaints 8. Professional performance triage 9. for quality and innovation 10. Domestic violence towards staff 11. Mental capacity act 25

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