Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business support to London’s NHS.Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business support to London’s NHS.

Quality indicators to support commissioning of unscheduled care

June 2009

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Unscheduled care is any unplanned contact with the NHS by a person requiring or seeking help, care or advice. It follows that such demand can occur at any time and that services must be available to meet this demand 24 hours a day.

Unscheduled care includes urgent care and emergency care.

Guidance for PCTs on commissioning a new delivery model for unscheduled care in London was published in October 2008. This document forms part of a toolkit developed to support PCTs in commissioning the new delivery model and

to promote a consistent approach across London.

Unscheduled care delivery model

Identifying indicators of quality in unscheduled care

Foreword

In June 2008, High Quality Care For All (the NHS Next Stage Review Final Report) put quality at the heart of the NHS. Subsequent guidance on measuring for quality improvement outlines the importance of measuring three dimensions of care: safety, effectiveness and a good patient experience.

There is a now a need to develop indicators which can demonstrate that the required quality and desired health outcomes are being achieved and improved. These indicators need to reflect not only volume throughput, which demonstrates the availability of care and performance of the system, but also the quality of the clinical episodes that comprise that throughput and the quality of the patient experience throughout the pathway of care including the health outcomes patients experience as a result of the care they receive.

Quality practice is difficult to measure (numerically or otherwise) and, as a result, valid and easily recorded quality measures are rare in healthcare. Despite the difficulties in developing effective indicators, measuring quality and clinical outcomes is crucial to the current health agenda.

Nowhere is this more necessary than in the management of unscheduled care. Users of these services are a heterogeneous group, frequently from disadvantaged communities, who present with a whole range of physical, mental health and social care problems, without warning, to a variety of NHS entry points with diverse service delivery models.

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In recognising these complexities and attempting to balance the achievement of meaningful, comparable quality indicators against an overly burdensome requirement for the collection of data, a number of metrics are proposed here. These have been developed on clinical principles and include a number of common clinical scenarios which are either direct or surrogate indicators of quality including, importantly, patient experience and outcomes.

There are many other conditions and metrics that could be used, but after consideration of a large number, those listed here are considered to provide the most value when balanced against the demand levied on everyday clinical life and the effort required to obtain them.

Dr Marilyn Plant, General Practitioner, Healthcare for London Clinical Advisory Group (Project Clinical Director)

Professor Peter Hutton, Professor of Anaesthesia, Healthcare for London Clinical Advisory Group

Professor Sir George Alberti, National Director for Emergency Access

Dr Andy Parfitt, Consultant in Emergency Medicine, Healthcare for London Clinical Advisory Group

Clinical members of the Unscheduled Care Project Board

Commissioning to improve quality in unscheduled care (1)

Commissioning is a key lever for driving improvements in quality.

Following publication of guidance for PCTs on commissioning a new delivery model for unscheduled care in London (October 2008) this document gives guidance on outcome measures and quality indicators that can be used to support commissioning and implementation of the unscheduled care delivery model

The delivery model guidance identified a strong case for change. Opportunities for improvement were grouped into five key themes:

1.More can be done to prevent people defaulting to the unscheduled care system to have their needs met

2.Access to care needs to improve and be more responsive to patients’ needs and expectations

3.The system needs to be less complex and easier to understand and navigate for patients and staff

4.Standards and quality can be more consistent and improved across the spectrum of care in community and hospital services

5.Improving the way the system works as a whole will improve care and patient experience and make better use of resources

The drive for change is more likely to be achieved if there are consistent messages and consistency in approach across London.

The London Commissioning for Quality Network1 has set out the context in which quality measurement and improvement should be undertaken in London and an approach involving local freedom and flexibility with support from regional and national levels. It has defined the roles of organisations as part of the wider health system, illustrated in Figure1. 4

Life expectancyInequalities

National

PCTs

Providers

Clinical teams

Pan-London quality indicators

Including World Class Commissioning indicators

Commissioning quality indicators within contracts (CQUIN)

Quality Accounts

NHS Choices

Clinical Quality Indicators PROMS Audit

Figure 1. Measuring quality at different points in the health system

This guidance recognises these different roles and proposes measures for PCTs, providers and clinical teams with the expectation that commissioners will play an overarching role in encouraging and, where appropriate, incentivizing measurement as part of a wider evaluation framework.

Improving unscheduled care at a system level will involve complex change. Learning and development cycles need to be an integral part of the change process and built in from the outset in order to understand whether the desired improvement goals are being achieved and sustained as well as the pace and scale of improvement.

1 The Network was set up in October 2008 to support the joint work of PCTs in using commissioning as a lever for quality in London.. It works on behalf of the London Directors of Commissioning Group

Commissioning to improve quality in unscheduled care (2)

Commissioning approach

Successful implementation of the delivery model will require a coordinated commissioning approach across health and social care, covering primary, community, mental health, acute, ambulance and social services. This could be led at borough or sector level; either option will require a very strong interface between relevant borough and sector functions. The approach to quality improvement and learning needs to be built into this commissioning process. Following the establishment of sector acute commissioning units there is likely to be benefit in this function being led at a sector level.

How PCTs can evaluate change

A variety of approaches can be employed:

1.The use of measures e.g. to measure what is important to patients, to enable PCTs to understand how the whole system is working. These can be supplemented with demographic data to build a richer picture. A recommendation from this work is to chose sentinel indicators from the selection proposed.

2.Audit and case review – this could include a role for networks in supporting audits across services/the system as well as audits in a single service

3.Patient and professional experience of change – a range of methods can be used, including development of patient reported outcome measures

4.Use of PDSA2 tools to support a cycle of learning and feeding outcomes into future development plans; working with clinical networks with the aim of creating a self-generating quality improvement environment . 5

Next steps – recommendations for moving forward

The set of indicators proposed in this paper should be implemented and tested to consider their merit individually and collectively as indicators of quality improvement across the unscheduled care system. This process would involve in depth consideration of how and what indicators work in practice in order to refine the indicator set and inform future development. This would include developing and testing data collection instruments for indicators where these do not exist (or are not effective). This process could be carried out through a pilot project involving a number of PCTs across London or focused in one sector

In parallel, all PCTs should consider the indicators proposed and their use in the local context and select a minimum of 5-6 most relevant to local priorities for implementation; this will involve identifying necessary resources and allocating responsibilities to support the process locally (at PCT and sector levels).

PCTs should build these indicators into commissioning plans AND report them to the new London Quality Observatory (LQO) within Commissioning Support for London (CSL).

The LQO should provide technical support to PCTs e.g. data analysis and feedback of results for indicators reported; this could include benchmarking relevant indicators across PCTs to facilitate local assessment and to inform development of standards.

PCTs should consider what other support and expertise would be helpful in taking this work forward and whether this can be provided locally (e.g. through Public Health Departments, local partnership arrangements). CSL and the SHA should consider what support and expertise can be provided at a regional level e.g. expertise in developing PROMS, facilitating learning/sharing events across PCTs.2 e.g. The Institute of Healthcare Improvement PDSA tool http://www.ihi.org)

Proposed outcome measures and indicators to support implementation and commissioning of the unscheduled care delivery model

The delivery model for unscheduled care in London (illustrated on page 2) is a tiered approach encompassing three broad responses to patients’ unscheduled care needs: rapid/moderate, urgent and emergency. A key feature of this model is that, regardless of location, services should function as a single system supported by shared processes and infrastructure. The model is underpinned by eight principles:

1.The approach to care should be shaped around patients’ and carers needs and expectations

2.Developments should aim to reduce inequalities in access and improve choice, patient experience and outcomes – and these should be continuously assessed

3.Services should be delivered within a whole-systems model

4.Collaborative working arrangements, common protocols and processes and consistent standards are essential features

5.Patients and carers should expect 24/7 consistent and rigorous assessment of the urgency of their need and appropriate and prompt response

6.The response should support patients and carers to access the most appropriate service to meet their assessed need within a suitable timeframe – and follow through to conclusion

7.Care should be delivered in community settings close to home wherever possible – and at home wherever appropriate

8.Specialised care should be concentrated in fewer centres to improve standards and outcomes

These principles alongside the five improvement goals set out on page 4, set the framework for this work to identify outcome measures and quality indicators that support implementation and commissioning of the unscheduled care delivery model.

Approach to this workThe measures and indicators proposed have been informed by a process that included the following:

Pages 7-8 draw out some key points from areas examined through this process. Key findings and recommendations are summarised on pages 9 and 10.

Note 1: This involved reviewing: the outcome of interviews, focus groups and a workshop involving patients and the public in phase 1 of the unscheduled care project; responses to Consulting the Capital; relevant literature

Note 2: Not just a matter of time: A review of urgent and emergency services in England (September 2008 Commission for Healthcare Audit and Inspection) 6

The approach involved a review of relevant work and

opinion from a variety of sources

Experience and outcomes important to patients and the public in using unscheduled care servicesPriorities for patients and the public have been identified by drawing from a range of sources, including patient and public involvement in the unscheduled care project to date, and triangulating views expressed. The main sources were:

• Responses to the Consulting the Capital consultation from

PPI groups, individuals and community groups representing

patients and the public• Reports informing the consultation process

Consultation with Traditionally Under Represented’ Groups on the

Healthcare for London Proposals March 2008’(Healthlink)

Health Inequalities and Equality Impact Assessment of ‘Healthcare for London: Consulting the Capital’ (London Health Commission, March 2008)

• Findings from patient focus groups interviewed for A study

of Unscheduled Care in 6 Primary Care Trusts (April 2008)• Findings from an Unscheduled Care Project consultation

event on emerging proposals on a delivery model for

London (Healthlink July 2008)• Relevant literature e.g. Patient Views of the Emergency and

Urgent Care System, O’Cathain, A., Coleman, P. and Nicholl, J.,

ScHARR, 2007.• Not just a matter of time: a review of urgent and emergency

services in England (Commission for Healthcare Audit and

Inspection September 2008 )

These sources identified seven areas to be particularly important priorities for patients and the public in their use and experience of unscheduled care services. These are not presented in an order of priority.

Priorities for patients and the publicCleanliness: Clean and well maintained facilities are important and patients seek assurance that good hygiene and cleanliness are also important issues for staff e.g. hand washing.

Communication: A particular concern for some people e.g. older people, people with a learning disability, hearing impaired, people whose first language is not English. Other issues include lack of information about services available and confusion over which service to use and service names; telephone access not easy/not preferred by some groups; information continuity is important.

Dignity and respect: Patients want to receive personalised care and be treated with dignity and respect; also linked to equality issues.

Equality: Patients want to be treated equally and without discrimination; having equal access to services including access for vulnerable groups is important (e.g. homeless, people with disability including learning disabled, older people, people with mental health or alcohol and substance misuse problems, people with HIV, people whose first language is not English).

GP Access: People report difficulty (real or perceived) in obtaining appointments at short notice and want more convenient opening hours. Other issues include registration difficulties for homeless people and new migrants, difficulty in contacting services e.g. out of hours or negotiating the system and defaulting to emergency departments; also linked to equality issues.

Transport: Convenience and accessibility of location (including availability of public transport and parking – and cost of parking); mobility issues are also identified as a consideration.

Waiting times: Speed of response is important; waiting times to see a GP can be too long (general point of access ); waiting times to be seen following arrival at services can be an issue – more communication to keep people informed is required.

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Not just a matter of time: A review of urgent and emergency services in England (September 2008, Healthcare Commission)

This review highlights the importance of good information on the performance and use of services for commissioning and as an enabler to effective relationships within networks.

The review found that all PCTs monitor performance against national standards (e.g. response and waiting times) and look at trends in use of the main urgent and emergency care services. Other ways to measure the quality and outcomes of care were observed to be more limited. The report draws attention to the opportunity for commissioners and service providers to make better use of data both on the performance of individual services and on how well services are working together. This includes data on the quality of local services and comparative benchmarking data looking across services in different areas.

The review reported finding limited data on how well resources are used by urgent and emergency care services. Where it does exist, this data shows significant variations. The review highlighted a requirement for better data on the cost, capacity, use and outcomes of services.

While all PCTs have taken some action to try to build people’s understanding of services, opportunities to identify when this work makes a real difference are often lost, as its impact is not evaluated. This reinforces the importance of ensuring an evaluative approach is built into commissioning processes.

The review placed significant emphasis on integration. Four of the seven recommendations refer specifically to improving information collection and reporting and outcomes. The report identifies various aspects of care that require better data to support integrated working (see opposite)

8http://www.healthcarecommission.org.uk/_db/_documents/Not_just_a_matter_of_time_A_review_of_urgent_and_emergency_care_services_in_England_200810155901.pdf

Aspects of care that require better data to support integrated working:

Care pathways • Time taken to see a clinician/deliver pain medication/undertake a diagnostic test/start treatment • Handover of patients between services (for example, time taken to hand over patients arriving at A&E by ambulance) • Total use of services for different reasons (for example alcohol-related demand, use related to mental health issues) • ‘Whole pathway’ time to deal with urgent needs (from time of initial contact to time urgent need is resolved) • Access to medication • Number of patients referred/redirected between services • Time to reach a specialist centre • Sharing data electronically within and between services

Quality of care• Results of clinical audits • Patient safety incidents • Unplanned repeat attendances within a short timescale (for example, one week)

Outcomes• Patients treated at home/dealt with by telephone advice • Patients who do not complete their care (for example, who do not wait for care in A&E or do not attend appointments at out-of-hours GP centres) • Emergency attendances and admissions • Patients’ views• Mortality/survival rates (adjusted to take account of differences in risk and case mix)

Use of resources• Activity/demand for services• Deployment/configuration of services• Spend

Key findings from this work – a variety of measures are needed to gauge quality improvements in unscheduled care; potential indicators exist

A range of measures are needed to understand the impact of commissioning decisions in improving the quality of unscheduled care. To be comprehensive this needs to include measures which demonstrate how services work together within a whole system to provide consistent, coordinated and high quality care to patients as well as indicators applicable to individual services. Increasingly, there should be consistency in measures used across the system to enable this.

This work suggests that what is important to patients in the way they experience unscheduled care is not significantly different from people’s expectations of other health services. Better navigation and speed of access tend to be more important in accessing unscheduled care and situations requiring emergency and urgent care can be anxious and stressful times for patients and carers.

Whilst there is a need for better data on the cost, capacity, use and outcomes of services, a significant amount of data is already available that could be used to measure improvements in unscheduled care and indicate performance of the unscheduled care system (see box opposite); most of the existing data focuses on specific clinical or service areas, rather than the whole system, although some proxy indicators for the latter are available.

The aim should clearly be to measure what is important and not just what can be measured. Some outcome measures will require new data collection processes to be put in place; the practicalities and any added burden of data collection needs to be weighed against the benefit anticipated; however if the outcome and associated measure is considered an important one then the commissioning process should seek to ensure that mechanisms and, where necessary incentives, are put in place.

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Many indicators of unscheduled care quality and performance already exist

Around 130 different metrics, in use or in development, can be immediately located which relate to unscheduled care, drawing from the following sources:

• NHS Institute Innovation & Improvement (Better care, better value metrics)• NHS Improvement Agency• Healthcare Commission (Annual Health check, Better Metrics, service reviews)• DH existing national targets (inc. 4 hr A&E target)• DH Vital Signs• National indicator set for local authorities and local authority partnerships • Local Area Agreements• World Class Commissioning Outcomes• Quality Outcomes Framework• National Audit Office• Primary Care Foundation GP OOHs benchmarks• PCT/Acute specific data measured e.g. HES

Relevant work in this area is in development e.g. the Medical Care Research Unit, University of Sheffield, is examining indicators to measure the performance of emergency and urgent care systems as part of a Department of Health funded research programme. The Unscheduled Care Project Commissioning Group has expressed particular interest in this work.

http://www.shef.ac.uk/content/1/c6/05/91/14/Performance%20Indicators.pdf

Recommendations – take a pragmatic approach using data already available whilst developing a more robust way forward

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Proposed approachTaking account of the findings from this work the unscheduled care project recommends a pragmatic approach initially, focusing on a relatively small number of outcome measures and indicators that:

Include aspects of care important to patients and the public Include quality markers of clinical care and patient outcomes Show how the delivery model is being implemented e.g. shifts in care to new settings, access to new pathways Have potential to signal improvements in the unscheduled care system i.e. integration, consistency Could be implemented relatively easily and therefore could start to be used quickly e.g. do not require significant new data collection

What should be measured?14 measures are proposed as initial indicators of progress towards implementation of the unscheduled care delivery model. These are described in pages 11-14 and mapped against the delivery model on page 16. Potential developmental measures are shown on page 17.

These measures are recommended alongside the following (and there may be some overlap):• National priorities and existing commitments, including vital signs, set out in the operating framework for 2009/10 •The target agreed for 2009/10 with the LAS for ambulance turnaround times under the Commissioning for Quality and Innovation (CQUIN) payment framework• Any other relevant measures being developed locally by PCTs

Involving patients and the publicThe proposed measures encompass some but not all of the areas that have been identified as particularly important by patients and the public for unscheduled care. These should be viewed as a starting point, to be developed and built on.

Patient reported outcomes measures (PROMs)For unscheduled care, methods established by commissioners and service providers should embrace a whole system perspective as well as specific services and/or settings of care. Patients’ and the publics’ use of different services and referrals between services mean that they are likely to have the greatest insight into how well the unscheduled care system works as a whole – this is highlighted as an important consideration. Ways of receiving feedback on patient experience and effectiveness of care from a patient's perspective will need to be determined locally e.g. measured through patient reported outcome measures (PROMs).

A variety of techniques can be used to explore patients’ and the publics’ views and experiences, however. Commissioners and providers are encouraged to examine and utilise different methods and to share and disseminate local work, particularly where the impact has been evaluated, to promote findings and to help raise the profile of involvement. A ‘Guide to Patient and Public Involvement in Urgent Care‘ (link below) http://www.nhscentreforinvolvement.nhs.uk/index.cfm?Content=220 explores the range of techniques that are available. A further example of a tool is available at http://www.shef.ac.uk/content/1/c6/05/91/04/final%20report.pdf (section

4). A pan-London tool to assist in identifying key systems issues to focus on could be developed for local adaptation. Pan-London work to support development of PROMs may also be helpful.

14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome

The table below summarises each proposed quality indicator, the rationale for proposing it, comments on a potential metric and notes other relevant information. The indicators are categorised into three groups: outcome based indicators, process based indicators and system based indicators. They are mapped against the delivery model on page 16 to show where they apply in the overall system.

No. What would be included

Rationale Proposedmetric(s)

NOTES

Outcome based indicators (indicators/proxy indicators of practice likely to improve outcomes)

1 Improvement in patient experience of the unscheduled care system

Patients report aspects of their experience in using unscheduled care services that fall short of their expectations and/or do not meet their needs

Improvements reported through PROMs, patient surveys or other technique applied

Patterns of complaint and related processes

This could focus on specific issues (e.g. speed of access, receipt of information, interactions with staff) or on overall experience or focus on specific communities etc; the extent to which patients and the public are involved at all (this could be a bespoke metric)

2 Effective management of acute asthma

Asthma is still a significant cause of death in young adults. Its effective management reduces morbidity and the need for hospital admission. 

% of patients with this condition whose oxygen saturation level was assessed on arrival (i.e. %yes/%no)

% of staff trained in British Thoracic Society guidelines

See note on p14

Many possible metrics exist. The two proposed in combination are suggested as key measures of good care.

Time to first O2 measurement was considered but considered onerous.

Some stakeholders flagged assessment on arrival of O2 saturation together with respiratory rate and peak flow as a more comprehensive indicator. This could be considered further following testing.

3 Effective management of fractured neck of femur

Indicator of process and quality of care for older people.

Prompt treatment in the ED followed by early access to theatre followed by rehabilitation increases likelihood of older people maintaining independence, reduces discomfort and reduces risk of complications.

High volume HRG.

Time to pain management

Time to operation

Time to home

See note on p14

Expectations about use of pain management guidelines need to be considered.Submission of data to/use of the National Hip Fracture Database would provide comparative dataThe NHS Institute of Improvement and Innovation has useful resources at http://www.institute.nhs.uk/quality_and_value/high_volume_care/fractured_neck_of_femur_facts.html

Indicators 1-3

11

No. What would be included

Rationale Proposedmetric(s)

NOTES

Outcome based indicators (cont’d)

4 Effective management of pain Reducing pain promptly and effectively, reduces adverse physiological responses and improves patient experience.

Availability and adherence to guidelines on assessment of pain and receipt of appropriate analgesia.

See note on p14

Link to indicator 1– explore whether any related work is taking place as part of wider PROMs development.

Various tools and clinical practice guidelines are available. Further work should determine if use of particular guidelines should be advocated.

5 Effectiveness of falls assessment and prevention

This is a good indicator of the interface and communications between hospital and community services; focusing on people who have already been assessed has the potential to highlight issues relevant to preventative intervention.

% of people attending unscheduled care services following a fall who are appropriately assessed

% who have previously been referred to a falls service.See note on p14

Should be applied to all unscheduled care access points.

Need to establish what good practice in assessment looks like.

Process indicators (indicators of improvement in unscheduled care processes)

6 Participation in audit (e.g. by professional bodies College of Emergency Medicine, RCGP clinical audit toolkit for OOH services and local audit processes)

Routine participation in audit is a good indicator of quality

Annual review of audits carried out, key findings and action taken.

Could form part of commissioners and provider review process.Joint audits (e.g. hospital and community based UCCs audits with ED) potential indicator of collaboration/enabler to improve care pathways

7 Time to clinical assessment by an appropriately skilled professional in an urgent care setting.

Indicator of:• Speed of response • Effectiveness of risk management• Consistency of response in different settings IF the same measure is applied

% of walk-in attendances who receive a clinical assessment within 20 minutes of arrival (15 minutes for children)

Aim is 100% - benchmark initially rather than set as a standard

20 minutes proposed to be consistent with OOH service standard. Should apply to all direct access urgent care services i.e. hospital and community based urgent care centres (including WiCs and MIUs) and urgent care services in polyclinics. Standard for children consistent with intercollegiate guidance applied to UCCs www.rcpch.ac.uk/doc.aspx?id_Resource=2621

Not proposed for GP practices.

14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome

Indicators 4-7

12

No. What would be included

Rationale Proposedmetric(s)

NOTES

Process indicators (cont’d)

8 How promptly definitive care (patient assessed, treated and discharged) is received in an urgent care setting.

Indicator of speed of access and consistency of access across the unscheduled care system IF applied to all walk-in urgent care services.

% of walk-in attendances who are seen (assessed, treated and discharged) within 60 minutes of arrival

This would apply to all direct access urgent care services i.e. hospital and community based urgent care centres (including polyclinics, WiCs and MIUs).Not proposed for GP practices.

9 Time taken to transfer patients from an Urgent Care Centre to an adjoining ED when treatment in the ED is assessed to be required.

For UCCs at the front of EDs measurement of the 4-hour wait starts from the point of arrival at the UCC. Any referral to the ED must be made early enough to ensure timely access to appropriate care and case completion w/o breaching the standard.

Number and % of UCC attendances referred to the ED more than 60 minutes after arrival.

All UCC referrals to the ED that breach the 4 hour standard.

This measure is included in the UCC commissioning guidance and endorsed by the clinical reference group that advised on development of that guidance. We expect a clinical decision about treatment required to have been taken within a maximum of 60 minutes.

10 Time taken for a patient with an acute mental health problem attending an UCC/ED to be seen by a psychiatric liaison team/ CRHT.

The current response for patients attending UCCs/emergency departments with mental health problems is acknowledged to be poor and services are patchy. A short wait would indicate both availability of services and services working well together.

Access to assessment with 60 minutes.

Assessment of equality of access to services.

RCPsych standard is 30 minutes to assessment and 60 minutes for Section 12 assessment. MH project flags move towards integration of psychiatric liaison and crisis teams and geographical variation, hence suggestion of focus on equality of access. Project Commissioning Group suggested 60 minutes overall standard. This needs to be benchmarked rather than being a target initially.

11 The extent to which relevant information is shared and how quickly this occurs.

Information sharing is important for care continuity .

Data collection and sharing processes across the unscheduled care system are acknowledged to be poor.

% of attendances with a summary of the care episode communicated to:• a patients GP by 8.00am on the next working day • Health visitor or school nurse within 2 working days • a CMHTs within 2 working days (for relevant patients) % of MDS sent in electronic formSee note on p14

Should apply to all unscheduled care services. UCC guidance includes proposed standard for communication with GPs, also consistent with OOH standards.Health visitor/school nurse standard included in UCC guidance.CMHT standard advised by HfL Mental Health projectMay need to adopt a benchmarking approach rather than set a standard initially.Could develop a minimum data set/content for summary information.

14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome

Indicators 8-11

13

14

No. What would be included

Rationale Proposedmetric(s)

NOTES

System indicators (indicators of development and greater integration across the unscheduled care system)

12 999 callers conveyed to alternative (than ED) pathways (i.e. treated at scene, conveyed to community settings)

Indicator of:• Whole system working• Availability/shortage of alternative pathways• Shift in care setting/ development of new pathways• Enhanced skills in LAS workforce and staff empowerment

% of all 999 calls not conveyed to an ED

Increase in ambulance responses that result in treat at scene

Number of alternative pathways available to each LAS complex

See note below

Could be linked to initiatives to incentivise new pathway development

Would need to be recorded and reported by LAS (already being considered)

The expectation is that the % conveyed to settings other that an emergency department (ED) would increase over time.

13 Emergency admissions for ambulatory care sensitive conditions (ASCs)

Indicator of :• Adherence to good practice• Potential to use resources more effectively• Development of care closer to home/ new pathways• How well the system works as a whole

% of patients admitted with ambulatory care sensitive conditions

Data already availableIncluded within Better Care Better Value work of NH Institute – can be readily benchmarked. NHS Information Centre ASC set proposed) – could measure some/all of 19 ASCs in this set

14 Patients re-admitted as emergencies within a short period following discharge

Indicator of :• How well the system works as a whole• Potential to use resources more effectively• Community services/home support working /not working well• Discharge arrangements working / not working well

% of emergency re-admissions within 14 days of discharge

% of emergency re-admissions within 28 days (for mental health admissions)

Data already availableIncluded within Better Care Better Value work of NH Institute – can be readily benchmarked.

Note• Method of extracting and reporting the metric and frequency not yet established• Need to determine whether this should be a specific standard or a benchmark?

14 indicators of quality in unscheduled care are proposed as an initial set; these include some measures of outcome

Indicators 12-14

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Some of the indicators proposed need further refinement – e.g. in the form developed by the London Commissioning for Quality Network

1. Patient experience of care when admitted to hospital Aspects of quality addressed by indicator

Patient experience – focusing on patients interactions with professionals and on their experience of cleanliness of the health care settings they are admitted to.

Purpose of Indicator

To improve the components of the patient experience that patients rate weakest and improve the areas of care that get the lowest patient experience ratings

Description of the Indicator

The improve the current patient experience scores for the areas of:treating patients with dignity and respect involvement in decisions about carecleanlinessfor patients admitted to hospital as:impatient general admissions emergency psychiatric admissions (MH Trusts)maternity cases

Nature of indicator

Quality indicator

Focus of Indicator

Secondary care Acute and Mental Health Trusts

The Commissioning for Quality Network has considered the potential for using quality indicators at a strategic level across London. These indicators are not meant to replace the quality indicators that PCTs have been developing as part of their commissioning process with providers. Instead they are meant to shine a spotlight on a small number of quality issues that are key priorities for London and where progress on the specific issues identified would act as a clear marker for wider changes in quality outcomes for patients across London. Ten indicators have been developed; two summary examples are shown below.

6. Improving the quality of the risk assessment and risk management of people with severe mental illness

Aspects of quality addressed by indicator

Safe care – by reducing the risk of patient safety incidents occurringEffective care – by improving the support of people with severe mental illness through effective risk assessment and risk management

Purpose of Indicator

To improve the quality and delivery of risk assessment procedures for people with severe mental illness so that the safety of patients, staff and the public is improved and the care of people with severe mental illness addresses their needs

Description of the Indicator 4

All Mental Health Trusts to use agreed risk assessment and risk management tools in the care of people with severe mental illness

Nature of indicator

Interim Quality indicator

Focus of Indicator

Mental Health Trusts and PCT Provider services

Potential quality outcome indicators

Reduction in patient safety incidents involving people with a severe mental illness including:FallsSelf-harmSuicideMedicines managementFailure to recognise physical health problemsSexual AssaultHomicide

States which major aspects of quality covered by the Next Stage Review – Safe, Effective, and Patient Experience - are addressed by the indicator

The ten quality indicators include interim quality indicators focussed on improvements to systems and process and data quality indicators developed to address areas where the quality of the data collected directly compromises the ability to assess the quality of care and outcomes for patients

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Proposed outcomes and indicators mapped to the unscheduled care delivery model

• Improvement in patient experience• Participation in audits (e.g. College of Emergency Medicine)• Effective management of acute asthma• Effective management of fractured neck of femur• Effectiveness of falls assessment and prevention • Effectiveness management of pain• Time for a mental health patient to be seen by a PLT/CRHT• Improvement in timely information sharing with GPs/others

• Improvement in patient experience• 999 calls conveyed to alternative pathways• Participation in audits (e.g. OOH Quality Requirement)• Effectiveness of falls assessment and prevention• Effectiveness management of pain • Time to clinical assessment in urgent care services• Time for referral from UCC to ED where ED treatment is required• Time to definitive care in an urgent care service • Time for a mental health patient to be seen by a PLT/CRHT • Improvement in timely information sharing with GPs/others

• Improvement in patient experience• Improvement in timely information sharing with GPs/others• Effectiveness of falls assessment and prevention• Effective management of pain• Participation in audit

System/system wide indicators

• Improvement in patient experience (across services)• Improvement in timely information sharing (with GPs, health visitors, school nurses and community mental health teams)• Variations in levels of emergency admissions for 19 ambulatory sensitive conditions (ASCs) • Patients re-admitted as emergencies following a previous admission

Other potential outcome measures and quality indicators have been identified and could be developed for future useIn considering outcome measures and quality indicators for unscheduled care, particularly for an unscheduled care system, a number of other areas have been identified as important however potential indicators and/or the means of collecting and reporting them need further consideration. These are identified below as “developmental” measures. Whilst they need further work, commissioners and providers may wish to explore their merit. The list includes aspects of care important to integrated working identified in the Healthcare Commission report Not just a matter of time: a review of urgent and emergency care services in England (see page 8).

No. Potential outcome indicators

1 Outcome and impact of clinical audits, reviews of patient safety incidents etc.

2 Extension of monitoring the impact of different pathways of care, including on patient experience e.g. patients treated at home/dealt with by telephone advice

3 Development of more indicators of effective treatment for specific clinical scenarios (short-term focus or ongoing) e.g. management of the limping child

4 Mortality/survival rates (adjusted to take account of attribution: difference in risk and case mix)

5 Patients who do not complete their care (e.g. leave before treatment)

6 Equality of access to quality services e.g. people with disability, mental health problems, homeless, age, sexual orientation

7 Access to medication; compliance with national/local prescribing guidance

No. Potential process indicators

8 Improvement in access to same day primary care (e.g. urgent GP slots, unscheduled primary care mental health liaison)

9 Availability of information for patients, the public and staff (e.g. including streamlining processes/reducing complexity via single points of access/referral)

10 Number of patients referred/redirected between services and effectiveness of handoffs

No. Potential system indicators

11 Unplanned re-attendance/repeat attendance at unscheduled care access points within defined period (e.g. 3 or 7 days)

12 Access to specialist advice (e.g. access for primary care providers), access to specialist care (e.g. time to reach centre), access to specialist teams e.g. older people’s team/service

13 Access to care plans across the unscheduled care system (or across key access points)

14 Consistency of assessment across access points (health and social care)

15 Sharing data electronically (gradual extension of measure across access points) and consistent use of NHS number, including across social care.

16 Increase in availability of integrated out of hospital pathways/care packages (evidence of health and social care co-design/joint commissioning) and impact

17 ‘Whole pathway’ time to deal with urgent needs (from time of initial contact to time urgent need is resolved)

18 Total use of services for different reasons (for example alcohol-related demand, use related to mental health issues)

17

Where benchmarking is in use – potential resources (1)

NHS Benchmarking Club as at 2008 – website provides data analysis reports on various projectshttp://www.nhsbenchmarking.nhs.uk/projects.aspCompleted projects:PMSOlder peopleCommunity provisionAsthma, diabetes and CHD in primary careDental, Optometric, pharmaceuticalContribution to public healthHealth Improvement programmesHealth Authority costs/financePCG (primary care groups) Clinical GovernancePCG Public InvolvementPCG PerformanceHlmP performanceDemand Management

Current projects:PCT provider functionsShared servicesOlder people – non-acute10 High impact changesDiabetesMaternityPrimary care indicatorsPrescribingWorkforceOut of hours

Planned projects:Primary Care Contracting - Benchmarking Medical Services (2009)11 WCC competencies

This page summarises resources (and web-links where relevant) that could be used to support improvements in unscheduled care delivery and inform commissioning. It is not exhaustive.

DH Essence of Care Benchmarking categorieshttp://www.dh.gov.uk/en/Publichealth/Patientsafety/Clinicalgovernance/DH_082929• Communication• Privacy & Dignity• Records/ transfer of information• Safety of clients with mental health needs • Self-care and control of own health care • Everyone will be supported to make healthier choices for • themselves and others • People are confident that the care environment meets their individual needs and preferences

NHS Institute - Productivity Metricshttp://www.productivity.nhs.uk/Accessed on line per SHA broken down into AHTs or PCTs or per all Foundation trusts:Clinical categories – Acute Trusts/FTs:• Reducing length of stay• Increasing day case surgery rates• Reducing pre-operative bed days• Reducing DNA• New to follow up• Reducing emergency patient readmissions

Clinical categories PCTs:• Managing variation in surgical thresholds• Managing variation in emergency admissions• Managing variation in outpatient attendances• Managing variation in outpatient referrals

Where benchmarking is in use – potential resources (2)

Primary Care Foundation GP OOHs benchmarking standards projecthttp://www.primarycarefoundation.co.uk/(Reports back to PCTs and hospital trusts in March 2009)

Healthcare Commission

Annual Healthcheck 2008/09

Benchmarking data from the review of urgent and emergency care in

England (CD issued in February 2009 to all PCTs, NHS Trusts, NHS

Foundation Trusts and SHAs in England).

The Information Centre provides information on line for the following primary care categories which provide a benchmark:http://www.ic.nhs.uk/statistics-and-data-collections/primary-care

• Pharmacies• Prescriptions• General practice• Dentistry• Eye care

Examples of reports accessed from this site include:The Quality and Outcomes 2007/08 Exception Report A summary of public health indicators using electronic data from primary careQ research report on trends in consultation rates in General Practice 1995-2008The Quality and Outcomes Framework2007/08GP Practice Vacancies Survey 2008GP Survey 2007/08 http://www.gpps.ic.nhs.uk/results08/

College of Emergency Medicinehttp://www.collemergencymed.ac.uk/asp/subview2.asp?ID=196Clinical Standards for Emergency Departments (January 2008)