© Nuffield TrustMarch 2013 Twitter: #NTSummit

Quality In Austerity - Indicators of Quality

Martin BardsleyDirector of Research, Nuffield Trust

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Why is HF/NT investing in work on quality?

There is no inevitable inverse relationship between finance and quality but....

•Financial pressure may divert attention from quality

•Search for transformational changes in delivery may have unintended consequences (good/bad) on quality

•Historically success in areas like waiting times and HAI linked with significant investment

•Efficiencies likely to be sought in staffing

•New organisational structures everywhere

•Implications of austerity on health needs

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There a whole lotta monitoring going on

User-generated content organisationsNHS Ombudsman

HealthWatch

ExperienceComplaints

Engagement

Professional regulators

Quality of educationIndividual competence

National Quality Dashboard

and corporate intelligenceNHS TDA CCGsContract management

Performance against plan

NHS CB

Provider

Patients

Continuous monitorin

g of quality

Dep

artm

ent

of H

eal

th

Information from people using services

third party information

support to the commissioners

Public Health England

Commercial analystsCare Quality Commission

Monitor

NHS Outcomes Framework.

Performance against objectives

Data (eg QRP s) and inspection / investigation

Data

CSUsData

Self monitoringContract monitoringData monitoringInspection monitoringExperience monitoring

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What can Health Foundation and Nuffield Trust add?

Provides an independent overview of how quality of care is changing over time.

Offers a view across different dimensions of quality that is not linked to any one provider or sectors.

Enable flexible analysis of important quality issues as they arise, and uses a range of methodologies.

Develops the methods used to measure quality, including innovative analyses across linked data sets at person-level.

Looks across the care system and where possible include international comparators.

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Quality in Austerity Programme

• 5 year, multi-stranded programme

• Compliment existing initiatives looking at quality

Developing sets of indicators…

…to measure changes in the quality of care over time across care settings.

 

Deeper analyses on ‘hot topics’…

…building on our capacity to use complex information to create new approaches and new perspectives on how the quality of care is changing within the NHS.

 

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Topic: Trends in Ambulatory Care Sensitive Admissions

Age-standardised rates of admission for ear, nose and throat infections, 2011/12

ACS admissions have increase by 40% in the last 10 years – will they continue to grow?

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Individual indicators

Effectiveness

Access and timeliness

Capacity

Safety

Patient centeredness

Equity

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147 274 26 13 82 542

46 75 41 13 9 184

35 47 24 30 1 137

66 160 82 11 7 326

27 159 77 18 5 286

7 10 10 0 1 28

328 725 260 85 105 1503

Primary and community provision

General and acute

Mental health

Social care provision

Population / commissioner

level

An explosion of indicators……but some areas better covered than others

Outcomes Frameworks, NICE, QRP, QIPP, QOF, Quality Accounts, Dashboards, Thermometers, Atlases…

Total

Total

Secondary / tertiary provision

Effectiveness

Access and timeliness

Capacity

Safety

Patient centeredness

Equity

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Some areas better populated than others

Hospital admin systems - strong on activity and coverage but limited detail

General Practice – massive data sets with untapped potential

Acute care specialist and clinical systems – hugely variable

Social Care – tend to be local, not shared. Major problem re self funders

Community Care – very variable

Independent Sector Care – very limited

Even more limited outside acute trusts

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And an external body can only see so much in a complex organisation

Community

Visibility of performance (quality)

Though good data exists in places we still rely too much on HES based

Corporate

Clinical

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Failures in quality: the holy histogram theory

Weak OK Good Excellent

Basket

Non compliant

REGULATOR or COMMISSIONING(enforcement) (contracting)

‘IMPROVEMENT’ BODIES

COMMISSIONING(contracting, choice, competition…)

‘IMPROVEMENT’ BODIES

Nu

mb

er

of

org

an

isa

tion

s

Quality

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In an ideal world, quality indicators would be built from…

1. The information we need to understand clinical quality at organisational level and above should flow from information collected in the course of people doing their jobs

Including... Patients views, PREMS and PROMS

2. Data linkage between these encounters / events / episodes at patient level is important:

a. To make the most of what data we have

b. To measure outcome

(“change in patient health status that can be attributed to

antecedent health care”)

GP Health status

Hospital Social care

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Some of the most critical areas are the most challenging eg Information from care users

Care Users – Surveys, F&F, Complaints, Individual reports/stories

Patient reported outcome measures

Staff perceptions

Quality of medical treatments – limited information

Patient outcomes – difficult to assign causality

Capturing qualitative intelligence

Improving these will help but no guarantee of predicting future

failure

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So what do we need to do…

A. Continue developing information from patients and staff

B. Fill the gaps for services that are lacunae – OOH, community, independent sectors...

C. Go beyond HES into the quality of services including clinical audits

D. Integrate the quantitative and qualitative

E. Link data to make the most of what there is and to assess consequences /outcome

F. Link the information to subsequent action....