David Prior: driving improvements in the quality of care across the system
David Prior, Chair, Care Quality Commission, explains how clinicians, providers, commissioners and service users all have a role in regulation. He highlights the new responsibilities of the CQC and how they can help to support integrated care in England.
David Prior: driving improvements in the quality of care across the system
1Drivingimprovementsin qualityacross thesystem?David PriorChairman, CQC The King’s Fund Integrated CareSummit8 May 2013
2Role of regulation in ensuring qualitycare• Professionals know more than system users• Difficult to measure quality of care• Difficult to assess relative quality acrossproviders - system is complexInformationasymmetryMarketstructure• Natural monopolies limit choice and competition• Significant barriers to market entry and need tomanage market exits• Healthcare not a normal good - consequencesof poor care more serious than monetary loss• Given potential to cause serious harm, injury, ordeath, there is little tolerance for varyingoutcomesNature ofgood• Regulation ensuresand enforces minimumstandards of care, andacts swiftly wherebreached• Regulation canaddress informationasymmetries byassessing standardsand communicatingthem objectively anddispassionately (e.g.,through ratings)• Regulation is one ofmany routes to higherquality – providers,professionals, patients,and commissioners allplay roles
Distribution of acute hospital performanceProportion of acute hospitalsQuality40% 60%20% 80%ILLUSTRATIVEFocus forinterventionThe CQC will intervene, address risks,and publish holistic ratingsDanger Acceptable to good Outstanding• Highest volume ofproviders• Consequences ofslippage relatively low• Cannot regulate breakthroughs in technologythat push up quality• Avoid stifling innovationRationale • Consequences aresevere• Action required toprevent quality issuesfrom emerging• Consequences aresevere• Enforceable – the CQCcan define minimumstandards• Prevent deteriorationof care to unacceptablelevels• Empower providers,commissioners andpatientsObjective • Support leaders inpushing boundaries ofcare quality• Avoid unacceptablefailure of patient care• Address risks to qualityto ensure positivetrajectory• Publish holistic performance assessments to informpatients, providers and commissionersCQC role • Intervene swiftly anddecisivelyFailure
4Our purpose and roleOur purposeWe make sure health and social care services providepeople with safe, effective, compassionate, high-qualitycare and we encourage care services to improveOur roleWe monitor, inspect and regulate services to make surethey meet fundamental standards of quality and safetyand we publish what we find, including performanceratings to help people choose care
5We will tackle the following five questionsabout each providerAre they safe?Are they effective?Are they caring?Are they well led?Are they responsive to people’s needs?Five things we will look at
Are they safe?Dimension IndicatorsDeaths from low risk conditions that generally donot result in mortalityNever eventsNever EventsUnder-reportingUnder-reporting of safety incidents for which reportinglegally requiredAvoidableinfections MRSA IncidenceMSSA IncidenceC.Diff IncidenceDeaths from lowrisk conditionsPatient safetythermometerFalls with harmNew VTEsUTIs with cathetersPressure ulcers
77Mortality – 20% of diagnosiscodes (64) equal to 70% ofmortalityComplicationsSub-optimal outcomesAvoidable morbidityAre they effective?
SOURCE: Dr Foster Hospital Guide 2012. East Midlands Quality Observatory, 2012Trust 3Trust 2Trust 1 Trust 41 SHMI measures the degree to which actual deaths compare to expected mortality rates given hospital admission profile . RR= 100 meansthat actual levels mortality is equal to expectations.Standardised Hospital Mortality by Primary DiagnosisStandardised Hospital Mortality Index90 100 110 120HeartFailure78 92 9785Pneumonia 92 1009794Stroke 11589 10694Overall100100100 100RR= 80FracturedHip70 115 135100Overall performance can obscurevariation in services
9Overall experienceCompassionate careDignity and respectPhysical needs eg. pain relief,hydration and nutritionIssue resolutionSources:Patient surveyInspectionsAre they caring?
10Board to ward relationshipOpen cultureSources:GMC surveyStaff surveyMonitor ratingsAre they well-led?
11Involved in their careListened toWaiting timesComplaintsAre they responsive to people’s needs?
Monitor ratings, staff survey results, andParliamentary Ombudsman complaints - strongestcorrelations with the raised profile listCategory Example indicatorsPercentage of identified Trustson raised profile listInternalindicatorsof stressSources ofstressExternalindicatorsof stress36492938274758243136246725202927• Financial risk rating of 1or 2• % annual change in non-elective admissions• Bank and agency ratio to total nursing staff• Governance risk “red”• Complaint investigated by parliamentary Ombudsman2• Average compliance with 4hr A&E waiting time targets• Complaint numbers• NHS Choices negative comments2• Bed occupancy % of total• GMC junior doctor survey “overall satisfaction”• NHS staff survey: “care of patients is top priority”• Proportion of vacant positions• Staff sickness rates• Staff turnover• Locum ratio to total clinical staff• Changes in control• % of site non-functionally suitable• Changes in leadership• 1 year % CIP plan opexGovernanceFinancialActivityAccessUser opinionStaff surveyStaffingOperational“Monitor” ratingsN/A1N/A1SOURCE: Various NHS data sources (2011 or 2012 data)# of Trustsanalysed2245454945454545454545455 indicators with greatest apparent correlation toraised profile Trusts that will be analysed in further detailData not easily accessible45# of raisedprofile Trustspicked up61391611161411262112171345 2245 161 Not possible to evaluate historically, but intuitive leading indicator; 2 Per 1,000 admissionsWould expect ~27% of raised profile trusts to be caught if evenly distributedWORK IN PROGRESS
1313Generic to specialist inspectorsUniversal to risk-basedinspectionsSurface to in-depth inspectionsEssential standards tofundamental standardsCompliance to judgement basedratingsWhat is changing?
14Appoint a Chief Inspector of Hospitals,and a Chief Inspector of Adult SocialCare and Support, and consider theappointment of a Chief Inspector forPrimary and Integrated CareDevelop fundamental standardsSpecialist inspectors leading expertteams, including clinical and otherexperts, and experts by experienceRefined surveillance ‘smoke alarm’ metricsWhat is changing?
15NHS hospitals: national teams withexpertise to carry out in-depth reviewsof hospitals with significant problemsNHS hospitals: a clear programme forfailing trusts that makes sureimmediate action is taken to protectpeople and deal with failureWhat is changing?
16Publish better information for the public,including ratings of servicesA more thorough test for organisationsapplying to provide care services, makingsure named directors, managers andleaders commit to meeting standardsStrengthen the protection of peoplewhose rights are restricted under theMental Health ActWhat is changing?
1717Our judgements will be independent ofthe health and social care system; andpoliticsWe will always be on the side of peoplewho use servicesOur relationship with providers will beconstructive not adversarialPatients and other users will be at theheart of the regulatory processProviders, commissioners and clinicianshave prime responsibility for safety andqualityNo 100% guaranteesUnderpinning our approach