Western Sussex Hospital Trust: 2012/13 CQUIN National Goals Goal Number Goal Name Description of Goal National Goals 0.5% 1 VTE National VTE Screening Goal 2 Responsiveness Patient experience to patient needs goal 3.1 Dementia National dementia screening goal Goal weighting (% of CQUIN scheme available) Expected financial value of Goal ( ) Quality Domain (Safety, Effectiveness, Patient Experience or Innovation) 0.125% TbC Safety, effectiveness 0.125% TbC Patient Experience 0.045% TbC Safety, effectiveness and experience 3.2 Dementia risk assessment National dementia goal 0.04% TbC Safety, effectiveness and experience 3.3 Referral for specialist diagnosis 4 Patient Safety Thermometer National dementia goal Implementation of patient safety thermometer 0.04% TbC Safety, effectiveness and experience 0.125% TbC Safety, effectiveness, innovation, 1
Goal 1 VTE risk assessment Description of indicator Numerator Denominator Rationale for inclusion Data source and frequency of collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period / date Baseline value Final indicator period / date (on which payment is based) Final indicator value (payment threshold) Final indicator reporting date Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones 90% of all adult inpatients who have had a VTE risk assessment on admission to hospital using the national tool. Number of adult (18 years or older) inpatient admissions reported as having had a VTE risk assessment on admission to hospital using the national tool. Number of adults who were admitted as inpatients (includes day cases, maternity and transfers; both elective and non-elective admissions). Need to define exclusions as above VTE is a significant patient safety issue, however outcome data on VTE is poor post mortem studies suggest that only 1-2 in every 10 fatal pulmonary emboli is diagnosed. Whilst work is underway to improve reliability of outcome data, the process measure of VTE risk assessment will set an effective foundation for appropriate prophylaxis. This gives the potential to save thousands of lives each year. Monthly return through Unify. Provider Trusts Monthly - Unify 2 reporting N/A N/A Financial Year 2012/13 TBA 20 days after month end Tbc Review each quarter for payment in that quarter. Payment will be based on average performance for each quarter. 1 month tolerance 2
Goal 2 Patient Experience (Acute) Description of indicator Numerator Denominator Rationale for inclusion Data source and frequency of collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period / date Baseline value Final indicator period / date (on which payment is based) Final indicator value (payment threshold) Final indicator reporting date Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date The indicator will be a composite, calculated from 5 survey questions. Each describes a different element of the overarching theme - responsiveness to personal needs : Involved in decisions about treatment/care. Hospital staff available to talk about worries/concerns. Privacy when discussion condition/treatment. Informed about medication side effects. Informed w ho to contact if worried about condition after leaving hospital Index-based score reflecting positive responses to the 5 questions within the composite indicator. N/A The indicator incorporates questions which are known to be important to patients and where past data indicates significant room for improvement across England. Adult inpatient survey, from the CQC nationally coordinated patient survey programme. The survey is conducted annually between October and January for patients who had an inpatient episode between July and August. Provider Annually: 1. Early local data (mid-january 2012) 2. Published data (April-May 2013) Adult inpatient survey 2011/12 (based on inpatient episodes between July and August 2011) To be confirmed Adult inpatient survey 2012/13 (based on inpatient episodes between July and August 2012. Target to be agreed with Commissioners Adult inpatient survey 2012/13 (based on inpatient episodes between July and August 2012. 50% of CQUIN payment to based on the results of the National Inpatient Survey (April-May 2012) The confidence interval associated with this data will be taken in to consideration (i.e. the Trust will not be penalised unless the data is outside the confidence range) 50% of CQUIN payment to be based on the results of the local survey results (mid January 2013) N/A 3
and/or in-year milestones 4
Goal 3. Dementia Note: This is the nationally mandated goal. The detail was published after the contract signature. Indicator number 3.1 Indicator name Dementia case finding Indicator weighting TBC (% of CQUIN scheme available) Description of indicator Numerator Denominator % of all patients aged 75 and above admitted as emergency inpatients who are asked the dementia case finding question within 72 hours of admission or who have a clinical diagnosis of delirium on initial assessment or known diagnosis of dementia. Number of patients aged 75 and above admitted as emergency inpatients, reported as having been asked the dementia case finding question within 72 hours of admission to hospital or who have a clinical diagnosis of delirium on initial assessment or known diagnosis of dementia. Number of patients aged 75 and above, admitted as emergency inpatients, minus exclusions.(excludes day cases, patients with a length of stay of less than 72 hours, transfers and elective admissions in year 1) Rationale for inclusion Exclusions: Those for whom the case finding question cannot be completed within 72 hours of admission for reasons of coma, critical illness, severe speech and language difficulties, sensory impairment, lack of translator, family or professional care giver. Re-admissions and frequent attenders without a diagnosis of dementia will be excluded if there is evidence of these patients having been assessed within the last 6 months. Dementia is a significant challenge for the NHS-25% of beds are occupied by people with dementia, their length of stay is longer than people without dementia and they often receive suboptimal care. Half of those admitted to hospital with 5
Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner dementia have never been diagnosed prior to admission and other causes of cognitive impairment such as delirium or depression are often missed. Referral out to appropriate specialist community services is often poor for these patients. Whilst work is underway to improve the nature of outcome data, the process of the dementia diagnostic assessment and referral will set an effective foundation for the timely diagnosis and appropriate management of patients allowing significant improvements in the quality of care and substantial savings. UNIFY2 monthly [Insert Provider name] Provider to submit a mandatory monthly data return Baseline period/date 1-31 March 2012 Baseline value TBC Final indicator period/date (on which payment is based) Any three consecutive calendar months from 1 April 2012-31 March 2013 Final indicator value (payment threshold) 90% Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Are there any rules for partial achievement of the indicator at the final indicator period/date? 20 working days after the end of each month [Insert locally agreed rules. Note that for this indicator all payments must be based on achievement of at least 90% each month] No Indicator number 3.2 Indicator name Diagnostic assessment for dementia Indicator weighting TBC (% of CQUIN scheme available) 6
Description of indicator Numerator Denominator Rationale for inclusion Data source % of all patients aged 75 and above admitted as emergency inpatients who have scored positively on the case finding question, or who have a clinical diagnosis of delirium and who do not fall into the exemption categories reported as having had a dementia diagnostic assessment including investigations. Number of admissions of patients aged 75 and above admitted as emergency, inpatients who have scored positively on the case finding question or who have a clinical diagnosis of delirium reported as having had a dementia diagnostic assessment including investigations. Number of patients aged 75 and above admitted as emergency inpatients who have scored positively on the case finding question or who have a clinical diagnosis of delirium. (excludes day cases, patients with a length of stay of less than 72 hours, transfers; and elective admissions) Dementia is a significant challenge for the NHS-25% of beds are occupied by people with dementia, their length of stay is longer than people without dementia and they often receive suboptimal care. Half of those admitted to hospital with dementia have never been diagnosed prior to admission and other causes of cognitive impairment such as delirium or depression are often missed. Referral out to appropriate specialist community services is often poor for these patients. Whilst work is underway to improve the nature of outcome data, the process of the dementia diagnostic assessment and referral will set an effective foundation for the timely diagnosis and appropriate management of patients allowing significant improvements in the quality of care and substantial savings UNIFY2 7
Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner monthly [Insert Provider name] Provider to submit a mandatory monthly data return Baseline period/date 1-31 March 2012 Baseline value TBC Final indicator period/date (on which payment is based) Any three consecutive calendar months from 1 April 2012-31 March 2013 Final indicator value (payment threshold) 90% Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Are there any rules for partial achievement of the indicator at the final indicator period/date? 20 working days after the end of each month [Insert locally agreed rules. Note that for this indicator all payments must be based on achievement of at least 90% each month] No Indicator number 3.3 Indicator name Referral for specialist diagnosis Indicator weighting TBC (% of CQUIN scheme available) Description of indicator Numerator Denominator % of all patients aged 75 and above, admitted as an emergency inpatient who have had a diagnostic assessment (in whom the outcome is either positive or inconclusive who are referred for further diagnostic advice/follow up. Number of all patients aged 75 and above admitted as an emergency inpatient who have had a diagnostic assessment (in whom the outcome is either positive or inconclusive who are referred for further diagnostic advice/follow up. Number of patients aged 75 and above who were admitted as an emergency inpatient who underwent a diagnostic assessment (in whom the outcome is either positive or inconclusive 8
Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner (excludes day cases, patients with a length of stay of less than 72 hours, transfers and elective admissions) Dementia is a significant challenge for the NHS-25% of beds are occupied by people with dementia, their length of stay is longer than people without dementia and they often receive suboptimal care. Half of those admitted to hospital with dementia have never been diagnosed prior to admission and other causes of cognitive impairment such as delirium or depression are often missed. Referral out to appropriate specialist community services is often poor for these patients. Whilst work is underway to improve the nature of outcome data, the process of the dementia diagnostic assessment and referral will set an effective foundation for the timely diagnosis and appropriate management of patients allowing significant improvements in the quality of care and substantial savings UNIFY2 monthly [Insert Provider name] Provider to submit a mandatory monthly data return Baseline period/date 1-31 March 2012 Baseline value Final indicator period/date (on which payment is based) Any three consecutive calendar months from 1 April 2012-31 March 2013 Final indicator value (payment threshold) 90% Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? 20 working days after the end of each month [Insert locally agreed rules. Note that for this indicator all payments must be based on achievement of at least 90% each month] 9
Are there any rules for partial achievement of the indicator at the final indicator period/date? No 10
Goal 4: Patient Safety Thermometer Description of goal what do you want to achieve? Description of indicator how will achievement be measured? Numerator This CQUIN incentivises the collection of data on patient harm using the NHS Safety Thermometer harm measurement instrument (developed as part of the QIPP Safe Care national work stream) to survey all relevant patients in all relevant NHS providers in England on a monthly basis Detailed information on the appropriate patients and relevant settings for use of the NHS Safety Thermometer are defined in the NHS Safety Thermometer guidance for use 1. The intention is for all NHS-funded providers, across community, mental health, acute and residential and nursing care, including NHS-funded independent sector providers, to use the Safety Thermometer, apart from where exceptions apply, as detailed in the guidance. This will allow nationally consistent data to be collected and published as well as facilitating local improvement activity. Where providers already have in place existing data collections that duplicate the measures in the tool, commissioners should use this CQUIN to incentivise transition to the safety thermometer tool to ensure data is produced that is consistent with the national collection. All relevant providers will be expected to have begun use of the national Safety Thermometer measurement tool by the end of 2012/13. Use of the Safety Thermometer will be mandatory in 2013/14. Where organisations are already submitting full data for the safety thermometer and there is no room for further improvement, commissioners should consider increasing the proportion of CQUIN payments available for the other national CQUIN goals. This CQUIN will require monthly surveying all appropriate patients (as defined in the NHS Safety Thermometer guidance) to collect data on four outcomes (pressure ulcers, falls, urinary tract infection in patients with catheters and VTE). Experience to date suggests data is best collected at the point of care by healthcare professionals (in accordance with guidance) using a point prevalence survey method (one day per month), entered into the instrument by administrative staff and aggregated at organisation level by performance teams or other suitable staff. Data should be submitted to the Information Centre quarterly. A completed Safety Thermometer survey for all relevant patients must be included for each month in the relevant quarter s submission to trigger payment. Number of months per quarter for which a complete record of Safety 1 Further guidance on the application of the Safety Thermometer, including appropriate settings for use and when it is clinically appropriate to exclude particular patients from the survey, will follow shortly. 11
Thermometer survey data covering all appropriate patients in all appropriate settings for all relevant measures is submitted. Denominator Total number of relevant months in the quarter (usually 3). Participation in data collection using the NHS Safety Thermometer is an important preparatory step for NHS-funded provider organisations in reducing harm. Incentivising use of the NHS Safety Thermometer will increase the participation in this data collection, establish a national baseline of performance on the four harms and provide information on the range of performance. This will allow the establishment of quality improvement aims Rationale for inclusion for year two (further details to follow) and contribute to the provision of data required for the Outcomes Framework and Government Transparency Agenda. Data source The intention is that further improvement goals relating to outcomes measured by the Safety Thermometer will be incentivised in future years. Data is from two primary sources according to the NHS Safety Thermometer guidance: a physical examination of the patient (including a conversation with them or their carer) and nursing / medical records (including pharmacy records). Frequency of collection Further information will be provided in due course on how to submit data. Data will be collated locally using the NHS Safety Thermometer tool on a single day per month (day to be determined locally in each provider). This monthly data will be uploaded by each provider to the NHS Information Centre on a quarterly basis (ie data representing the 3 constituent months in a single quarter uploaded to the IC quarterly) Organisation responsible for data collection Frequency of reporting to commissioner Baseline period / date Baseline value Final indicator period / date (on which payment is based) Final indicator value (payment Further information will be provided in due course on how to submit data. WSHT Quarterly - reporting use of NHS Safety Thermometer will be through direct submission of the data to the Information Centre. The commissioner will use the data published by the Information Centre to review performance for each relevant Quarter. Not applicable. The CQUIN incentivises correct use of the Safety Thermometer and therefore no baseline performance applies. Not applicable. The CQUIN incentivises correct use of the Safety Thermometer and therefore no baseline performance applies. Financial year 2012/13 Trajectory 12
threshold) Final indicator reporting date Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment Rules for delayed achievement against final indicator period/date and/or in-year milestones Q1 Providers to supply commissioners with a baseline number of wards/units/teams from which the trajectory will be measured. Q2 50% / Q3 75% / Q4 100% 30 working days after the end of the period See trajectory above Quarterly reconciliation against the trajectory above 1 month tolerance 13