Members of the North West’s Advancing Quality Alliance want to ensure innovation flows through NHS services. David Fillingham explains why, and how it could be done.

It has often been said that the NHS is good at innovation but poor at its dissemination. As a result the service has many islands of excellence which have made impressive improvements, but these rarely spread to neighbouring communities.

This leads to the quality of care for patients being variable, and time and again we miss out on the opportunity to provide better quality care at a lower cost. The risk is that the need for financial savings in an increasingly competitive NHS may make this situation even worse.

A group of NHS organisations in the North West of England have responded to this by taking the initiative to set up their own improvement body – the Advancing Quality Alliance. AQuA is not a quango or management consultancy. It is a membership organisation funded by and responsive to 54 NHS organisations in the North West of England which are its subscribing members.

AQuA was formed in April 2010 with a remit to streamline and consolidate a range of existing regional quality programmes. Since then it has established the Quality Observatory for the North West, developed the AQuA Academy to give staff the skills and experience in improvement that they so badly need and forged a range of strategic partnerships with organisations such as the King’s Fund, the Nuffield Trust and the Health Foundation.

Most importantly, it has engaged directly with its members to help them bring about improvements in outcomes, safety, patient experience and value.

The vision of AQuA members is an ambitious one. They want to work together to radically transform the care they provide for patients and the health of their communities.

Enlightened self-interest

The organisation is driven by the belief that we can move faster by working in cooperation than by acting in isolation from each other. This is not simple altruism – more a case of enlightened self interest.

Members are drawn from all sectors of service delivery – primary and community services, mental health, ambulance services and acute hospitals. They include commissioners as well as providers and are engaging with a range of important partners, including local authorities and patients’ groups.

The Advancing Quality programme is the flagship initiative. Based on pay for performance programmes in the US, the programme became fully operational in 2008. It has used a care bundle approach to drive up the quality of care in five clinical conditions: acute myocardial infarction; coronary artery bypass graft; congestive heart failure; community acquired pneumonia; and hip and knee replacements.

The project has been able to triangulate improvements in clinical processes and outcomes with patient reported outcome measures and measures of patient experience.

The results have been impressive, with quarter on quarter improvements in the quality of care.

AQuA is now working to extend the Advancing Quality programme beyond its original acute sector focus. Its aim is to work with clinical commissioning groups and others to develop suitable Advancing Quality metrics for patients with long term conditions, which will incentivise improvement across whole care pathways.

In its first year AQuA has had a major focus on improving the safety of patient care and reducing avoidable mortality. AQuA’s reducing mortality collaborative worked with nine of its member organisations, with the support of information consultancies Dr Foster and CHKS. The aim was to better understand the causes of avoidable mortality and to tackle these through improvements in clinical practice and better coding and recording of data.

Improving the quality of end of life care emerged as a major theme on which all organisations recognised that they needed to improve. Again, the results have been impressive, with nine organisations recording a 13.5 per cent reduction in their hospital standardised mortality rates during 2010-11, almost double the regional and national average rate of reduction.

AQuA’s developing safety networks programme has built improvement capability in a group of organisations which went on to run three safety improvement collaboratives of their own. The work was sponsored by the Health Foundation and brought about improvements in pressure ulcer care, venous thromboembolism and the management of head injuries. It formed the platform for the delivery of the much wider safety express programme which AQuA has led in the North West on a greater scale than in most other parts of the NHS.

Similarly, the Stroke 90:10 programme saw significant improvements in the quality of care for stroke patients across the region against the stroke sentinel audit metrics.

AQuA’s way of working is to help organisations move through accelerated cycles of improvement:

  • knowledge (what does best look like?);
  • intelligence (where are we now?);
  • improvement (how do we get there?).

The AQuA Observatory tackles the first two steps in this cycle by providing members with the knowledge and intelligence they need to bring about effective improvement. A regular observatory bulletin disseminates the latest news about evidence based practice and matches this with local data on members’ performance.

The observatory has also developed a series of safety workbooks and care domain workbooks which drill down into greater detail to provide both evidence and intelligence in relation to key topics such as venous thromboembolism, falls and pressure ulcers, and clinical care areas such as chronic obstructive pulmonary disease, diabetes, stroke and chronic kidney disease.

The observatory is also working with quality observatories in other parts of the NHS to develop and disseminate a series of regularly updated dashboards to help Monitor the performance of the alliance’s membership in relation to the outcomes framework as it is developed.

A firm foundation

AQuA believes improvement is more likely if it is underpinned by robust methods grounded in sound improvement science. A significant element of this is having the skills and capability to manage change effectively.

The AQuA Academy provides training and development for staff at all levels through a series of interventions, both face to face and virtual. These are geared to the different target audiences of improvement experts, boards, operational leaders and frontline staff.

For example, this September, AQuA will run a development programme for eight of its member boards, in conjunction with the Institute for Health Improvement and the North West Leadership Academy, to improve board level focus on quality and safety issues.

The AQuA Academy also oversees the development of the AQuA Associates scheme, which provides personal development for improvement enthusiasts, while using their talents on behalf of the wider membership.

These various elements – collaborative learning approaches, sound training and development through the AQuA Academy, and an emphasis on a strong evidence base and good intelligence through the observatory, are brought together in AQuA’s model of spread (see diagram, above).

AQuA’s experience is that it is only when all of these elements are present that we can achieve that rapid spread of best practice which is so rarely found in the NHS. In this way AQuA is striving to raise the quality and safety of care right across its membership to the standards of the best.

The 2011-12 work programme covers all healthcare sectors and fully engages commissioners as well as providers.

The most important priority remains patient safety. We need to ensure that the imperative of finding savings does not lead to harm to patients or worsen outcomes and experience. AQuA’s long term conditions programme is a decade-long vision to transform the quality of care for this important group of the population.

It is being strongly supported in this by its partner the King’s Fund, which is also working with AQuA to run a discovery community on integrated care to reinforce this approach.

Shared decision making with patients is another topic which members are keen to pursue vigorously and one that is firmly in tune with the main principles of the government’s reforms. AQuA’s partnership with the Health Foundation is providing them with rapid access to leading edge practice.

AQuA understands the immense financial pressures facing its membership and its lean network and enhanced recovery programme is helping members to raise quality while also lowering costs.

There will be many future challenges for AQuA, not least how we engage with the new commissioning landscape of GP groups, clusters, support agencies and local authorities. However, AQuA is determined to add value for its membership by focusing on a small number of big priorities and helping move good ideas out of the realm of wishful thinking and into the day to day reality of delivering better care for patients.

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Advancing Quality Alliance