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Breakout 2.4 Making the system work for you:Using levers and drivers to deliver change Lesley Kitchen
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Breakout 2.4 Making the system work for you:Using levers and drivers to deliver change Lesley Kitchen


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Breakout 2.4 Making the system work for you:Using levers and drivers to deliver change …

Breakout 2.4 Making the system work for you:Using levers and drivers to deliver change
Lesley Kitchen Advancing Quality, Programme Director
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

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  • 1. Making the system work for you: Using levers and drivers to deliver change Lesley KitchenAdvancing Quality, Programme Director 1
  • 2. 2
  • 3. NHS Outcomes FrameworkCCGOIS (previously COF)Clinical Commissioning Groups Outcomes Indicator Set 3
  • 4. An example… • A programme to improve the quality of care for patients in the North West • That uses existing system drivers and levers • An incentive scheme that rewards healthcare providers for providing high quality of care to patients • And that also appeals to commissionersThe north west • 24 PCTs / 34 CCGs • 24 acute trusts • Population ~7 million • 2 million(+) adult admissions per year • Outcomes improving but above national/ international average and gap wasn’t closing 4
  • 5. Some challenges…• How do we define quality?• How do we agree what ‘best’ looks like?• How do we close the gap in terms of patient and clinical outcomes?• How do we know we’re getting VfM in ‘improvement initiatives’?• How can we reliably benchmark and identify areas of good practice? Advancing Quality• Modelled on HQID in the US • AMI, Heart Failure, CABG, Hip & Knee replacement surgery, Community Acquired Pneumonia• Highly relevant to the North West population 5
  • 6. How it works... Clear Robust data evidence collection base Supporting Incentives change £££ Regional CQUIN Clear Evidence BaseAcute myocardial infarction (AMI) Community-acquired pneumonia (CAP) 1. Aspirin at arrival 1. Oxygenation assessment within 24 hours 2. Aspirin prescribed at discharge prior to or after hospital arrival 3. ACE or ARB for LVSD 2. Initial antibiotic selection 4. Smoking cessation advice/counseling 3. Blood culture collected prior to first antibiotic administration 5. Beta blocker at arrival 4. Antibiotic timing, first dose of antibiotics 6. Beta blocker prescribed at discharge within six hours after hospital arrival 7. Thrombolytic received within 30 minutes of 5. Smoking cessation advice/counseling hospital arrival 8. PCI received within 90 minutes of hospital arrival Coronary artery bypass graft (CABG) 1. Aspirin prescribed at discharge 2. Prophylactic antibiotic received within oneHip and knee replacement hour prior to surgical incision 1. Prophylactic antibiotic received within one 3. Prophylactic antibiotic selection for surgical hour prior to surgical incision patients 2. Prophylactic antibiotic selection for surgical 4. Prophylactic antibiotics discontinued within patients 48 hours after surgery end time 3. Prophylactic antibiotics discontinued within 24 hours after surgery end time 4. Recommended Venous Thromboembolism Heart failure (HF) prophylaxis ordered 1. Left Ventricular Systolic (LVS) assessment 5. Appropriate Venous Thromboembolism 2. Detailed discharge instructions prophylaxis within 24 hours prior to surgery 3. ACEI or ARB for LVSD to 24 hours after surgery 4. Smoking cessation advice/counseling 6
  • 7. Robust data collection• Need robust data – to identify opportunities to improve – to benchmark• Rules based / algorithmic approach – Identifying patient cohorts – every patient – Data dictionary & reasons for exclusion from a measure• Web based measure data collection – Utilise existing data where available (PbR flows) Identifying opportunities Patient 1 Patient 2 Patient 3 Overall Trust ScoresMeasure 1    2 of 3 = 66.6%Measure 2    3 of 3 = 100%Measure 3    1 of 3 = 33.3%Measure 4    3 of 3 = 100%Measure 5    3 of 3 = 100%Opportunities 4 of 5 5 of 5 3 of 5 12 of 15takenComposite 80% 100% 60% 80%Process ScorePatient 0 of 1 1 of 1 0 of 1 1 of 3AppropriateCare (all ornothing)Appropriate    33.3%Care Score 7
  • 8. A culture of change & collaboration • Regular collaborative learning events • Involvement from all organisations • Created networks of clinical and non clinical communities • A willingness to share and learn Incentives“In my job my incentive is to ensure that all my patients get first class treatment, and that every patient gets the right treatment every time”- Dr Paul Stockton, Respiratory Consultant 8
  • 9. CQUINs• “The Commissioning for Quality and Innovation (CQUIN) payment framework enables commissioners to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals” (DoH, 2008)• 2.5 % of overall contract value for all healthcare services commissioned through the NHS Standard Contract. • One fifth of this value (0.5% of overall contract value) is linked to national CQUIN goals (where applicable.) • Four fifths (2% of overall contract value) for local determination. AQ CQUINs• Regional CQUIN agreement across the north west for AQ conditions• Key principles: – Raising the bar on minimum attainment – Continuous improvement and stretch – Standardised methodology for threshold setting – Standardised financial value – Keep it simple! 9
  • 10. Marathon not Raised the bar with a sprint! a new measure!Rapid improvement, Steady improvement,sustained New sustained condition Reducing variation 10
  • 11. 900 fewer deaths “The introduction of pay for performance in all NHShospitals in one region of England was associated with a clinically significant reduction in mortality.”“Risk adjusted, absolute mortality for the conditions included in the pay-for-performance programmedecreased significantly with an absolute reduction of1.3 percentage points and a relative reduction of 6%,equivalent to 890 fewer deaths during the 18-month period.” 11
  • 12. Return on investment in health gain What next?• Whole systems / whole care pathways• Setting specific balanced with the common elements – “every place measures”• Worked with NW Respiratory Leads on COPDPrimary Admission Discharge Follow upCare 12
  • 13. COPD whole system levers• Evidence base• Regional CQUIN for acute and community services• Local Enhanced Service agreements (LESs) for primary care• CCG Quality Premium So what for respiratory?• Nationally the scene is set (NHS Outcomes Framework and CCGOIS)• There is a clear evidence base in respiratory – Clinical guidelines and standards• Hook into the financial and contractual levers that already exist 13