Quality accounts: pressure on to pick a winning combination

Of the 400-odd indicators of quality put online for consultation last week, none are intended to measure management.

But, although the tone of much of the new work on quality is clinical, it has thrown up a number of sizeable tests managers will have to meet, and to a tight timetable.

Legislation will dictate that all providers produce their first quality account - carrying a pre-selected set of measures for public consumption - at the end of 2009-10. This means deciding which measures will be included, and making sure solid data collection is in place to report them, before the end of next March.

Meaningful interpretation

While all trusts are awash with data, many lack the capacity to decipher it into meaningful indicators and are far from settling on a preferred set.

Even for providers that have already made an issue of reporting on quality and safety, there is work to be done quickly.

Rotherham foundation trust director of quality Jackie Bird sat down with clinicians and other staff and asked them to look at preferred measures two weeks ago, just before the Department of Health sent out Measuring for Quality Improvement.

“That was the culmination of 18 months’ work for me. It has taken that time to get everyone to this point,” she says.

The measures will be finalised in the next two months and managers will pick a handful as corporate priorities likely to feature in the trust’s first quality account.

Ms Bird recommends trusts wondering where to start should look at existing literature, campaigns such as the Institute for Healthcare Improvement’s safety and harm work, and trusts that are ahead of the game.

The freedom of choice on measures has been keenly welcomed by clinicians and providers but could leave advocates of patient involvement - and commissioners - a little concerned about accountability. Will a trust highlight its hospital standardised mortality ratio if it knows its performance is poor?

Primary care trusts might be expected to take a lead but, as well as sometimes appearing to lack the expertise, they have appeared sidelined in the improving quality debate.

Commissioning for quality

Doncaster PCT director of quality and assurance Julie Bolus, who has been developing a quality assurance framework for NHS Yorkshire and the Humber, believes the latest guidance strikes a balance.

“What we were feeding back was that originally it did not have much role for commissioners. We felt there needed to be an emphasis on commissioning for quality.”

Ms Bolus says PCTs must ensure their priorities are being measured on top: “Things that are very specific are for the clinical teams and perhaps the trust board - commissioners are not going to get to that detail. But we need to put some measures across the bow that matter to us.”

NHS Yorkshire and the Humber and the PCTs in the region are in the final stages of designing contracts that will be applied across the region.

As it stands, there will be three indicators in its ambulance service contract, three for mental health trusts, three for PCT provider arms and 10 for acute services, measuring performance against the regional Darzi vision, Healthy Ambitions.

“The North West approach was a little narrow to include all of our [regional] ambitions around children, mental health and crisis resolution,” Ms Bolus says.

Responding to data

Another question soon to face managers - particularly those not already on top of their measurement - will be how to respond when a service is found to be significantly below par.

Government guidance so far remains focused on the task of measurement, but being able to respond to the data is vital, says Royal Salford foundation trust chief executive David Dalton.

The trust is investing£1m in a quality improvement strategy for staff. Directors also have to equip themselves. “Much work needs to be done so that boards are as comfortable in effecting change in quality and safety as they have become in improving waiting times and financial performance,” Mr Dalton says.

British Association of Medical Managers chief executive Jenny Simpson agrees investment is needed: “You have got to have investment in clinical leadership development. Historically that has not been the case.

“It is starting but it needs to move up a gear. This will require performance management of quality rather than finance, and that will need new sets of skills.”

Mid Cheshire Hospitals foundation trust, which was a pilot for the North West Advancing Quality scheme, is also developing additional quality indicators. Chief executive Phil Morley says results can highlight a need to invest in services: “We realised we needed to do more with cardiac recovery nurses, increasing numbers and looking at their role.

“You also have to focus on getting the process better, for example making sure the right equipment is in the right place.”

The wheat from the chaff

Poor performing teams and staff must be approached with a “coaching ethos”, he says, but the spotlight will occasionally fall on staff who are failing to improve.

“There are always going to be one or two individuals who don’t have that ethos, who seriously have a problem. We have had to sack two consultants this past year, which is rare. It sends a strong message about how we should behave.”

British Medical Association consultants committee chair Jonathan Fielden believes trusts need to invest in engaging doctors rather than seeing the exercise as performance management.

“The most successful trusts are already strongly engaging their clinicians and getting them leading this agenda. There are those that are well behind that, and this is their opportunity.

“It is difficult to hold someone to account if you are not creating the right culture and engaging them.”

Poor performers

Trusts, and perhaps more importantly PCTs, will be faced with entire services, as well as individuals, that are below par and failing to improve. Will there be increased pressure for them to close? Jackie Bird answers: “As long as the metrics are transparent, it may be that people say, ‘That is not the business we want to be in any more.’”

But where teams and entire trusts fail to engage and improve, it may fall to PCTs to make tough changes.

Julie Bolus says it is important that PCTs have “conversations” with trusts based on the information.

It is unclear whether this will lead to decommissioning, she says: “There will be a number of opportunities [when taking commissioning decisions]. The honest answer is we don’t know.”

But she says there should be no doubt the regime will mean standards being taken more seriously on both sides of the commissioning equation. “Quality is starting to infiltrate director of finance conversations and that can only be a good thing.”

HSJ’s Delivering NHS Quality Improvement is on 31 March.