James Innes is head of quality improvement at East London NHS Foundation Trust. A hospital pharmacist and IHI trained improvement advisor, he has specialist skills in patient safety and leading system wide improvement initiatives. James also acts as an editor for the Journal of Psychiatric Intensive Care.
When I think back to my time as a ward-based pharmacist, I still remember the first time that I saw how commissioning arrangements could directly impact front line clinical work. The year was 2011 and I was about to get my first taste of commissioning for quality and innovation, better known as CQUIN payments. Our Trust had been set a target to ensure that 90% of inpatients benefited from medicines reconciliation (MR) within 72 hours. Success was to be determined by an aggregate measure of our performance over a year’s period.
Designed to allow commissioners to reward excellence, CQUINs link the achievement of local quality improvement goals with payment. In recent years the size of the payments linked to these goals has increased and has sometimes resulted in an uncomfortable tension. On the one hand, Trusts want to innovate and improve quality, but on the other the financial repercussions of not meeting these could be significant. This can have a massive impact on how Trusts choose to achieve these targets and consequently the behaviour their approach motivates.
In the case of our MR target, the focus quickly turned to achieving minimum standards (working towards the minimum percentage required and the maximum permitted period of time), we only looked at data as an aggregate (how we rated versus our overall target) and we only took action on the cases where a MR wasn’t completed. These actions display all the hallmarks of a quality assurance approach.
This style of using data for assurance is not new in the NHS. Moreover, it is not new in healthcare across the world. Using data for assurance is one of the favoured mechanisms for ensuring quality. But is it the right or only one? Serious questions have been asked, particularly in light of the Francis, Berwick, and Keogh reports, questions such as, “how could organisations that satisfied rigorous external assurance checks go on to provide care that was so sub-standard?” Even within our own organisation we recognise that variation in quality exists between different services in the Trust, or even in the same services over the time. While assurance alone has got us so far, the only way we will begin to solve this problem is with a new approach to quality.
As an organisation we are changing the way we approach quality. Our Quality Improvement (QI) programme is unique for the Trust in its breadth, depth, and timescale. At its centre is a mission: to provide the highest quality mental health and community care in England. Underpinning this mission are two initial stretch aims: to reduce harm by 30% every year and to ensure that every patient receives the right care, in the right place at the right time. Our mission will be delivered by transforming the culture of the organisation to one of continuous improvement, where staff in collaboration with patients and carers, are able to improve the quality of services we provide.
So how might this new approach have affected the way we targeted our MR CQUIN? Well, for a start we would have looked at data over time rather than as an aggregate over many months. By looking at data over time you can really start to understand variation in your processes and truly understand whether the changes you are making generate a sustained effect. Secondly, we wouldn’t have just have taken action on the defects, but looked at improving the process as a whole by testing a number of change ideas iteratively. Thirdly, we could have involved all types of front line staff who play a role in MR from the start. They really are best placed to understand what changes would need to be made to improve MR overall. But clearly when you are being motivated by financial pressures, this will still nurture a certain type of behaviour.
And this brings us full circle to the subject of commissioning. To realise the maximum potential of this new approach to quality will require collaboration with our commissioners, regulators, and external partners. That is why we are using every opportunity available to engage them; so that funding is aligned with outcomes that patients think are important and that resultant CQUINs or KPIs support iterative learning, improvement, and expansion. We have already taken some key steps to start this happening. We now have representation from this group on our QI programme steering group, to help provide high level alignment with our organisational QI strategy. We have and continue to run numerous bespoke events to build will around QI and our organisational approach. And we have even built capability in a few commissioners and external partners through our ‘Improvement Science in Action’ training, run in conjunction with the Institute for Healthcare Improvement.
We recognise that it will take many years of work on both sides to achieve the Trust’s ambitious mission, but there are already small signs that our engagement may be starting to pay off. We recently celebrated our very first CQUIN that incentivised using a QI method to improve a quality problem, rather than setting a traditional target.