Contents



Commissioning for Quality and Innovation (CQUIN)

payment framework

A set of exemplar CQUIN goals

Contents

Press CTRL and click on the relevant exemplar goal to go directly to the section.

Introduction to Exemplar CQUIN Goals 2

Ambulance – Care Planning 3

Ambulance – Clinical hub system 4

Ambulance – Rapid assessment & diagnosis (STEMI, stroke, TIA) 5

Ambulance – Rapid transfer (STEMI, stroke, TIA) 6

Ambulance – Service user feedback 7

Ambulance – Treatment outside A&E 8

Breast surgery 9

Cancer – Managing complications of chemotherapy (1 of 2) 10

Cancer – Managing complications of chemotherapy (2 of 2) 11

Cancer – Intensity Modulated Radiotherapy 12

Cancer – Patient experience survey 13

End of life – Death in place of choice 14

Falls 15

Fragility fractures – Fracture Prevention Service 16

Health care associated infection – Urinary catheters 17

Long term conditions 18

Long term conditions – care planning 20

Maternity – Home birth 21

Maternity – Normal birth 22

Maternity – Postnatal morbidity 23

Maternity – Prophylactic antibiotics 24

Nutrition (1 of 2) 25

Nutrition (2 of 2) 26

Patient experience – Ambulance 27

Patient experience – Community mental health 28

Patient experience – Community hospital 29

Patient experience - Community 30

Patient experience – Inpatient mental health 31

Patient Reported Outcome Measures (PROMS) – Groin hernia/varicose vein 32

Productive community services 33

Productive mental health ward 34

Productive operating theatre 35

Productive ward 36

Renal care – Acute kidney injury (1 of 2) 37

Renal care – Acute kidney injury (2 of 2) 38

Renal care – Home dialysis 39

Stroke unit care 40

Surgery – Enhanced recovery (1 of 3) 41

Surgery – Enhanced recovery (2 of 3) 42

Surgery – Enhanced recovery (3 of 3) 43

Surgery - Oesophageal Dopplar Monitoring 44

Tissue viability 45

Venous Thromboembolism (VTE) – Appropriate prophylaxis 46

Venous Thromboembolism (VTE) – Patient information 47

Introduction to Exemplar CQUIN Goals

In July 2010, the Government committed to continuation of the Commissioning for Quality and Innovation (CQUIN) payment framework, to support local quality improvement goals.[1]

The following CQUIN exemplar goals have been developed by the Department of Health and the NHS and broadly align with the White Paper “Liberating the NHS” as well as with national QIPP workstreams and the Nursing High Impact Actions. They are intended to exemplify well-defined evidence-based quality improvement goals that could be linked to provider payment through the CQUIN framework. Exemplar goals are a resource which local commissioners, providers and clinicians can draw on when agreeing local CQUIN schemes. There is no requirement to include these goals in schemes, nor is the list comprehensive or representative of a single CQUIN scheme. Other ideas and resources are available at:



Each goal is linked to one or more indicators which are formatted on one side and can be accessed via the electronic links on the alphabetically listed Contents page. Information for each indicator is provided in two distinct sections:

Provider sector: Acute / Ambulance / Community / Mental health

|Description of goal |[What you want to achieve] |

|Description of indicator |[How you will measure achievement] |

|Numerator | |

|Denominator | |

|Rationale for inclusion | |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

| |

|Suggested approach to measurement: |

| |

|What does “good” look like against this indicator? |

| |

|What perverse incentives or unintended consequences should be guarded against |

|locally? |

| |

|What resources are available to help providers meet this goal? |

| |

Ambulance – Care Planning

Provider sector: Ambulance

|Description of goal |To improve care planning for frequent callers – a frequent caller is defined as a person who has called the service |

| |3 or more times in a 12 month period, or 3 or more times in a rolling 12 week period, whichever is greater. |

|Description of indicator |Percentage of frequent users who have a care management plan agreed between ambulance service and primary care. |

|Numerator |The number of frequent callers who have a care management plan agreed. |

|Denominator |Total number of frequent callers. |

|Rationale for inclusion |The ambulance service is intended to be for emergency and urgent care. Where people are using the service |

| |frequently this could indicate that they do not have sufficiently robust care plans that allow them to pro-actively |

| |manage their condition. WAMS have a responsibility to work with other primary care providers to pro-actively manage|

| |the care needs of these people. |

| |There are a small number of people who use the service very frequently (up to 3 times a day). Many of these people |

| |have underlying problems (e.g. mental health) that need addressing. By identifying these people and working |

| |pro-actively with them to find suitable services for their needs, the demand from this group can be reduced, whilst |

| |delivering more appropriate care. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|This ensures that healthcare incidents that raise Safeguarding concerns are considered in the wider Safeguarding arena. |

|Safeguarding becomes integrated into NHS ambulance service systems, with greater transparency, learning from Safeguarding concerns, a clarity of reporting and |

|improved positive partnership working. |

|Suggested approach to measurement: |

|Local Computer Aided Despatch systems can be used to identify frequent callers. |

|What does “good” look like against this indicator? |

|More than 30% of people who are defined as a Frequent Caller have in place a clinical management plan. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Needs a clear definition of what constitutes a frequent user, and that some people’s frequent use is appropriate. |

|What resources are available to help providers meet this goal? |

|Clinical Governance & Adult Safeguarding – An Integrated Process – DH |

| |

|Letter From Sir David Nicholson to Chief Executives |

| |

Ambulance – Clinical hub system

Provider sector: Ambulance

|Description of goal |To increase staff usage of the clinical hub system |

|Description of indicator |This is a 2 part indicator: |

| |% incidents where vehicle based clinical staff access the clinical hub |

| |% incidents where staff report a high level of satisfaction with the speed and accuracy of the |

| |service provided by the clinical hub |

|Numerator |The number of incidents where vehicle based clinical staff access the clinical Hub for at least one |

| |of: |

| |Clinical advice |

| |Additional patient information to assist patient assessment |

| |Guidance on patient referral |

| |The number of incidents where staff report a high level of satisfaction with the speed and accuracy |

| |of the service provided by the clinical hub for at least one of: |

| |Clinical advice |

| |Additional patient information to assist patient assessment |

| |Guidance on patient referral |

|Denominator |Total number of incidents |

| |Number of incidents where a vehicle based clinical staff member has accessed the clinical hub for at |

| |least one of: |

| |Clinical advice |

| |Additional patient information to assist patient assessment |

| |Guidance on patient referral |

|Rationale for Inclusion |The Clinical Hub is a key part of the future operation of the ambulance service. New ambulance |

| |performance measures, operational regimes and PbR are all predicated on the efficient and effective |

| |operation of a clinical hub to assess and refer callers already triaged away from an immediate |

| |vehicular response. |

| | |

| |This indicator supports and strengthens the confidence and capabilities of vehicle based staff to |

| |make good and appropriate decisions about patient treatment and referral. This will increase the use |

| |of ‘alternative’ care pathways and reduce conveyance and admission rates to Emergency Departments |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|The ambulance service nationally is expected by commissioners to change its operational regimes to enable the increasing utilisation of ‘alternative’ care |

|pathways and reduce conveyance to Emergency Departments. |

|Fits well with the care closer to home agendas |

|Suggested approach to measurement: |

|Existing activity data via KA34 and Minimum Data Sets, supplemented by local Clinical Aided Despatch systems. |

|Patient Record Forms (PRF) |

|What does “good” look like against this indicator? |

|More patient care is triaged and directed by the clinical hub. |

|Staff are supported in clinical decision making. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|As the vehicle based staff will be reporting back on clinical hub staff there may be a tendency for the clinical hub staff to be more solicitous or take make |

|time on staff calls than necessary. This risk can be mitigated by random sampling of call recordings and by addressing this in the feedback mechanism for |

|vehicle based staff. |

|What resources are available to help providers meet this goal? |

|Availability of a clinical hub team. |

|A relevant range of available alternative care pathways. |

Ambulance – Rapid assessment & diagnosis (STEMI, stroke, TIA)

Provider sector: Ambulance

|Description of goal |To ensure rapid assessment and diagnosis of people suspected of having STEMI, Stroke or TIA. |

|Description of indicator |Percentage of people attended with potential diagnosis of STEMI, Stroke or TIA for whom appropriate |

| |physiological measurements have been undertaken and recorded with an accurate working diagnosis |

| |arrived at. |

|Numerator |Number of people attended with a potential diagnosis of TIA. Stroke, STEMI, for whom appropriate |

| |physical measurements have been undertaken and recorded, and an accurate working diagnosis arrived |

| |at. |

|Denominator |Number of patients attended with potential diagnosis of STEMI, Stroke or TIA. |

|Rationale for Inclusion |For people with STEMI, Stroke, and TIA there is evidence that clinical outcomes are better with early|

| |diagnosis, rapid and specialist treatment when appropriate. This reduces death rates and morbidity |

| |and dependency figures. |

| |Traditionally, an ambulance service identified people that needed health care interventions and |

| |transported them to the nearest acute hospital. |

| | |

| |This indicator incentivises Ambulance Services to accurately assess a patient, and make a working |

| |diagnosis, to identify those patients that will benefit from going to a specialist centre. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Improved clinical outcomes. |

| |

|Getting patients to the right place first time – Right Care, Right Place, Right Time. |

|Suggested approach to measurement: |

|Existing activity data via KA34 and Minimum Data Sets, supplemented by local Clinical Aided Despatch systems. |

|Patient Record Forms (PRF) |

|What does “good” look like against this indicator? |

|100% of patients are appropriately assessed and people suitable for transfer to a specialist centre are identified in a timely way. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Need to ensure that people are not over-triaged, and only patients suitable for transfer are taken to a specialist unit. |

|What resources are available to help providers meet this goal? |

|Staff trained in assessment of STEMI, Stroke and TIA |

| |

|National Strategies |

|National Stroke Strategy |

|Treatment of Heart Attack – National Guidance |

| |

| |

| |

| |

Ambulance – Rapid transfer (STEMI, stroke, TIA)

Provider sector: Ambulance

|Description of goal |To ensure rapid transfer to appropriate care setting of people with STEMI, Stroke or TIA. |

|Description of indicator |Percentage of people attended with potential diagnosis of STEMI, Stroke or TIA who arrive at an |

| |appropriate acute centre in under 60 mins from time of call. |

|Numerator |Number of people attended with a potential diagnosis of TIA. Stroke, STEMI, for whom arrival at an |

| |appropriate specialist unit occurs in under 60 minutes from time of call. |

|Denominator |Number of patients attended with potential diagnosis of STEMI, Stroke or TIA. |

|Rationale for Inclusion |For people with STEMI, Stroke, and TIA there is evidence that clinical outcomes are better with early|

| |diagnosis, rapid and specialist treatment when appropriate. This reduces death rates and morbidity |

| |and dependency figures. |

| |Traditionally, an ambulance service identified people that needed health care interventions and |

| |transported them to the nearest acute hospital. Increasingly. Commissioners are asking paramedics to|

| |make a diagnosis, and take people to an appropriate centre for treatment, often bypassing a local |

| |hospital. |

| | |

| |This indicator incentivises Ambulance Services after making a working diagnosis, to take the patient |

| |to the most appropriate unit to deal with their condition. This will require significantly higher |

| |levels of decision-making and accountability. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Improved clinical outcomes. |

| |

|Getting patients to the right place first time – Right Care, Right Place, Right Time. |

|Suggested approach to measurement: |

|Existing activity data via KA34 and Minimum Data Sets, supplemented by local Clinical Aided Despatch systems. |

|Patient Record Forms (PRF) |

|What does “good” look like against this indicator? |

|100% patients that are assessed as needing to go to a specialist centre, and are able to get there in the required timeframe, are taken direct to a specialist |

|unit. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Need to ensure that people are not over-triaged, and only patients suitable for transfer are taken to a specialist unit. |

|What resources are available to help providers meet this goal? |

|High skill mix, and Staff trained in assessment of STEMI, Stroke and TIA |

| |

|National Strategies |

|National Stroke Strategy |

|Treatment of Heart Attack – National Guidance |

| |

| |

| |

Ambulance – Service user feedback

Provider sector: Ambulance

|Description of goal |To pro-actively seek feedback from all service users, and increase the overall level of feedback that is|

| |given |

|Description of indicator |The percentage of service users who have had opportunity to give feedback on the service provided. |

| |The percentage of service users who have given feedback on the service provided, relative to the |

| |diversity of the service users. |

| |Evidence that service user feedback has resulted in changes to service delivery. |

|Numerator |The number of service users who are offered the opportunity of giving feedback on the service received. |

| |The number of service users giving feedback, broken down by diversity indicators – age, sex, ethnicity. |

| |N/A |

|Denominator |Total number of incidents. |

| |Total number of incidents, broken down by diversity indicators – age, sex, ethnicity. |

| |N/A |

|Rationale for Inclusion |The feedback of service users is an integral part of assuring a safe and effective service. Whilst |

| |service users in other parts of the healthcare system are offered the opportunity to provide formal |

| |feedback via patient surveys, it is equally important that we ascertain satisfaction with the emergency |

| |ambulance aspect of the service. |

| |Service user feedback provides a rich source of data on areas of potential improvement, different from |

| |information received purely from complaints. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Service user feedback is seen as a critical way of getting accurate information to assure commissioners of quality and appropriateness of services. |

|Suggested approach to measurement: |

|Existing activity data via KA34 and Minimum Data Sets, supplemented by local Clinical Aided Despatch systems. |

|Local recording of feedback received. |

|Web based data collection from service users (with consideration for users with other needs). |

|Local organisations may wish to agree specific CQUIN payment thresholds for particular demographic groups within this indicator, reflecting any local focus to |

|improvement priorities |

|What does “good” look like against this indicator? |

|95% of service users are given the opportunity to give feedback on their experience via a web based survey. |

|People giving feedback are representative of the population using the service e.g. age, sex, ethnicity. |

|The service is able to demonstrate improvements made as a result of service user feedback by demonstrable examples in quarterly reports. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Service user feedback could be seen as the alternative to a complaints route. |

|Methods of obtaining service user feedback could under-represent certain population groups; they therefore need to take account of different needs |

|What resources are available to help providers meet this goal? |

|Availability of a web based feedback methodology. |

| |

|Examples of Best Practice e.g. Service User Involvement in Cancer Care: |

| |

|Rights enshrined in the NHS Constitution: |

| |

Ambulance – Treatment outside A&E

Provider sector: Ambulance

|Description of goal | |

| |To increase treatment of patients outside of A&E |

|Description of indicator | |

| |Percentage of patients attended by the ambulance service who are treated outside of an A&E |

| |environment. |

|Numerator | |

| |Number of patients who are attended by Ambulance Service, and treated outside of an A&E environment |

| |(includes walk in centres, and minor injury units). |

|Denominator | |

| |Total number of patients attended |

|Rationale for Inclusion | |

| |The emergency and urgent ambulance service deal with increasing numbers of requests for assistance. |

| |The rise in demand is not explained by need, so a proportion of calls can be managed in different |

| |ways. |

| | |

| |Many requests for assistance received via a 999 route can be more suitable dealt with outside of a |

| |traditional acute A&E environment. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Care closer to home agenda. |

| |

|Managing urgent and emergency care demands, and releasing acute care capacity. |

|Suggested approach to measurement: |

|Existing activity data via KA34 and local CAD systems |

|What does “good” look like against this indicator? |

|More appropriate intervention outside of an acute environment can lead to quicker and more appropriate care. |

| |

|All people are treated at scene, or taken to an appropriate centre for treatment. For a large proportion of people (35%) this will mean they are not taken in |

|the first instance to an acute A&E department. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Where a person’s expectation is that they want to go to A&E, they may still self present after treatment outside of an A&E setting. |

|What resources are available to help providers meet this goal? |

|Availability of alternative care pathways e.g. Walk in Centres, Minor Injury Units. |

| |

|Best Practice Guidance e.g. Shifting Care Closer to Home; Taking Healthcare to the Patient; Tackling Demand Together: |

| |

| |

Breast surgery

Provider sector: Acute

|Description of goal |To improve the quality, safety, outcomes and productivity of breast surgery |

|Description of indicator | |

| |Number of patients having breast surgery as a day case or 23 hour stay |

|Numerator |Number of patients having breast surgery as day case or 23 hour stay in the trust |

|Denominator |Total number of patients having breast surgery in the Trust |

|Rationale for inclusion |The Breast Day Case/23 hour Surgical Model has been developed as a good practice model by clinicians and |

| |endorsed by the British Association for Day Surgery. The new pathway has been widely welcomed by cancer and |

| |non-cancer patients. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|NHS Evidence; The Breast Model submitted to NHS Evidence as good practice. |

|British Association Day Surgery inclusions in “basket of procedures” |

|Suggested approach to measurement: |

|HES data |

|Local organisations may wish to exclude from this indicator those procedures falling within the scope of the planned Best Practice Tariff on breast surgery from|

|April 2011 to avoid duplication of financial incentives |

|What does “good” look like against this indicator? |

|Around 80% of all breast patients (non-cancer and cancer without reconstruction) should benefit from the Breast Day case/ 23 hour surgical model, although there|

|will be some local casemix variation. |

|Commissioners may wish to reward providers through the CQUIN framework for ambitious improvements above local baseline even if 80% is not reached. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|The drive to deliver reducing length of stay “to get paid” to the detriment of the quality elements. |

|The model has been tested in a variety of settings Day Case, Inpatient wards and inpatient theatres, treatment centres. The principles of short-stay surgery can|

|be delivered successfully in all settings by changing the purpose rather than investing in new. |

|What resources are available to help providers meet this goal? |

|NHS Improvement and Cancer Network Service Improvement teams are supporting local Clinical teams in the delivery of the Breast model and building local |

|capability and capacity. |

|The Cancer Transforming Inpatient Programme partners (Cancer Policy, NHS Improvement, National Cancer Action Team NATCANSAT) are raising awareness of the |

|principles and benefits of the model through sharing learning and disseminating good practice across the NHS. |

|NHS Improvement and NATCANSAT website, provides access to information and resources. |

| |

|Models of exemplar practice for breast day case/23 hour model exist at King’s College Hospital NHS Foundation Trust, Sandwell and West Birmingham Hospitals NHS |

|Trust and the Pan Birmingham Cancer Network |

| |

Cancer – Managing complications of chemotherapy (1 of 2)

Provider sector: Acute

|Description of goal |To improve the management of cancer patients admitted via A&E with complications following chemotherapy |

| |treatment |

|Description of indicator |% cancer patients admitted via A&E due to complications of chemotherapy who are reviewed by a member of the |

| |acute oncology team within 24 hours of admission |

|Numerator |Number of cancer patients admitted via A&E due to complications of chemotherapy who are reviewed by a member of |

| |the acute oncology team within 24 hours of admission. |

|Denominator |Number of cancer patients admitted to hospital via A&E due to complications following chemotherapy |

|Rationale for inclusion |The NCAG report (2009) recommended that all hospitals with an A&E department should establish an Acute Oncology |

| |Service but little progress has been made. There would be a reduced inpatient stay inpatient stay in patients |

| |suffering complications of treatment if there is an inpatient review available by a member of the AOS during the|

| |working week, or 7 days a week. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Reducing bed days shown in the Cancer Reform Strategy |

|Implementation of NCAG recommendations (Chemotherapy Services in England: Ensuring Quality and Safety, 2009) |

|Reduced length of stay. |

|Improved patient experience |

|Suggested approach to measurement: |

|Audit case notes to check when patient first seen by member of the team. |

|Suggest including only those patients who are currently being actively treated for cancer. |

|What does “good” look like against this indicator? |

|Local organisations may wish to take a flexible approach with this and phase implementation by providing the service during the working week and then extending |

|to the full week. |

|As the baseline is very low the acute oncology team may only comprise a nurse rather than an oncologist and the full team outlined in the NCAG report. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|This might lead to patients being admitted inappropriately, when the admission might be avoided. |

|What resources are available to help providers meet this goal? |

|Models of exemplar practice for an Acute Oncology service exist in St Helen’s and Knowsley Trust, and also the Whittington Hospital. Clinicians in Dorset are |

|working within current resources to establish what model might best suit their practice. |

|Draft Peer review measures |

|Emergency pathway development work from NHS Improvement (Cancer) |

Cancer – Managing complications of chemotherapy (2 of 2)

Provider sector: Acute

|Description of goal |Reduced mortality within 30 days of chemotherapy due to febrile neutropenia. |

|Description of indicator |Mortality within 30 days of chemotherapy due to Febrile Neutropenia |

| |Door to needle times for intravenous antibiotics or door to swallow times for oral antibiotics in the management|

| |of febrile neutropenia. |

|Numerator |Number of deaths due to FN within 30 days of chemotherapy |

| |Number of patients receiving treatment within an hour. |

|Denominator |Number of episodes of patients with febrile neutropenia |

| |Number of episodes of patients with febrile neutropenia |

|Rationale for inclusion |Most deaths within 30 days of chemotherapy are due to cancer progression but some are due to complications of |

| |chemotherapy. A number of recommendations in the NCAG report (2009) addressed the safety of chemotherapy, this |

| |was published as best practice guidance. Need to ensure that Trusts have a pathway of care for the rapid |

| |assessment and treatment of chemotherapy patients presenting with potential neutropenic sepsis. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Cancer Reform Strategy and Chemotherapy Services in England: Ensuring Quality and Safety. |

|1. Local service response to the NCEPOD report which highlighted concerns around a lack of appropriate care pathways for the care of patients with febrile |

|neutropenia as well as a lack of policies or unawareness of such policies by some staff in emergency departments and in acute medicine. |

|2. The goal should support the better management of patients with severe complications following chemotherapy with integration of assessment & decision to |

|treat, the rapid prescription, dispensing and administration of antibiotics and subsequent triage to the acute oncology team . |

|3. Patient information systems that flag up attendance, admission and triage to the acute oncology team. |

|4. Supports regular mortality/ morbidity meetings to review practice, policies and procedures in relation to FN. |

|Suggested approach to measurement: |

|1. HES data should identify patients being treated with chemotherapy and deaths within 30 days of treatment |

|2. Audit programme to ensure compliance with protocol. |

|NB. Treatment is taken as each attendance for chemotherapy and may be part of a cycle |

|What does “good” look like against this indicator? |

|Reduction in numbers of deaths relating to febrile neutropenia within 30 days of treatment. For solid tumours, the death rate from FN should be less than 2%. |

|100% compliance against the protocol. |

|What perverse incentives or unintended consequences should be guarded against locally? |

| |

|What resources are available to help providers meet this goal? |

|Cancer networks are working with Trusts to implement the recommendations in the NCAG report. A requirement of Cancer Peer Review is that there should be Network|

|agreed protocols and polices for the management of Febrile Neutropenia. These should be available in every setting including A&E departments. |

|A good example of an audit programme is to be found at the Royal Berkshire NHS Trust. Clatterbridge Centre for Oncology has a robust process for alerting |

|clinicians to ‘unexpected’ deaths and mortality/morbidity review meetings. |

Cancer – Intensity Modulated Radiotherapy

Provider sector: Acute

|Description of goal |Increased access to modern radiotherapy techniques |

|Description of indicator | |

| |Increase in radical radiotherapy fractions delivered by Intensity Modulated Radiotherapy (IMRT) |

|Numerator | |

| |Number of radical fractions delivered with IMRT |

|Denominator | |

| |Total number of radical fractions delivered in a radiotherapy centre. |

|Rationale for inclusion |The National Radiotherapy Advisory Group report published in 2007 said that 4D adaptive radiotherapy should be |

| |the norm (IGRT & IMRT). Reasons given for not using the technique have been the need to train staff and alter |

| |protocols locally with the associated upfront cost. A financial incentive might enable this initial investment |

| |to be made and ensure that more patients have access to this technique more quickly. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Advanced radiotherapy techniques such as Intensity Modulated Radiotherapy (IMRT) and Image Guided Radiotherapy (IGRT) improve outcomes and provide better |

|experience for patients. |

|Suggested approach to measurement: |

|The Radiotherapy Dataset (RTDS) should provide this information, this is maintained by the National Cancer Statistics and Analysis Team - NATCANSAT |

|What does “good” look like against this indicator? |

|Commissioning guidance produced by the National Radiotherapy Implementation Group is available at |

|The guidance states that over 30% of all radical fractions should be delivered using planned IMRT, although there will be some local casemix variation. |

|Tumour site |

|% of all RT fractions |

|% pts who benefit |

|% all fractions as IMRT |

| |

|Forward Planned Inverse Planned |

| |

|Breast |

|30% |

|30% |

|9% |

|- |

| |

|Prostate |

|16% |

|80% |

| |

|13% |

| |

|Gynaecological |

|5% |

|20% |

| |

|1% |

| |

|H + N |

|8% |

|80% |

| |

|6% |

| |

|CNS |

|3% |

|60% |

| |

|2% |

| |

|Other sites |

|10% |

|20% |

| |

|2% |

| |

| |

| |

|Total |

|9% |

|24% |

| |

| |

| |

|Grand Total |

|33% |

| |

| |

| |

|A CRUK survey has recently reported access to IMRT in the UK at 7% while other European countries report rates of 20%. Providers should aim for an increase in |

|IMRT fractions to match delivery in other countries |

|What perverse incentives or unintended consequences should be guarded against locally? |

|There is potential that patients might be treated inappropriately with IMRT. The technique should be used for indications recommended by published guidance. |

|What resources are available to help providers meet this goal? |

|Equipment to support IMRT has been available for some time (97% of all Linacs are IMRT enabled.) The National Cancer Action Team has developed a training |

|programme to support the wider roll out of the technique. |

Cancer – Patient experience survey

Provider sector: Acute

|Description of goal |To improve the experience of in-patient and day case cancer patients and reduce inequalities in the experience |

| |of different groups in society. |

|Description of indicator |The indicator will be a composite based on casemix-adjusted responses to the 72 questions in the survey, with a |

| |breakdown for different multi-disciplinary teams (MDTs) within a Trust where numbers allow. |

|Numerator |Single composite score |

|Denominator |N/A |

|Rationale for inclusion |To measure and drive improvements in cancer patient experience, specifically: information and communication, |

| |co-ordination of care, supportive care, shared decision making (“no decision about me without me”), hospital |

| |care and treatment, and staff, particularly doctors and clinical nurse specialists. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|The Cancer Reform Strategy (CRS – 2007) set out a commitment to establish a new NHS Cancer Patient Experience Survey programme to monitor national progress and |

|to use the findings to drive quality improvements in patients experience locally. Government has asked for a refresh of the CRS to be published in winter |

|2010-11. |

| |

|Patient experience one of three domains of quality, and results of survey will be fed into CQC assessments and Cancer Peer Review programme |

|Suggested approach to measurement: |

|This indicator is based on the national Cancer Patient Experience Survey which, in 2010, involved postal questionnaires being sent to 110,000 cancer patients |

|from all 158 Trusts providing major cancer care in England. Response rate was over 66%. |

|Baseline scores will be available in benchmarked Trust level reports, issued by end December 2010. |

|Trusts may wish to focus improvements on particular MDTs or on particular groups of patients based on age, gender, ethnicity, disability, sexual orientation or |

|deprivation. |

| |

|If the national survey is repeated, it will enable the measurement of improvement against baseline for each Trust. If it is not repeated, Trusts can choose to |

|replicate the survey locally and/or contract with Quality Health to support this work. |

|What does “good” look like against this indicator? |

|Will be informed by benchmarked data from 2010 survey, due for publication by end 2010. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Trusts would need to consider full 2010 Trust level report from survey, not just single measure, to ensure appropriate improvements are made |

|What resources are available to help providers meet this goal? |

|Quality Health is contracted as the survey supplier for this survey in 2010 |

End of life – Death in place of choice

Provider sector: Acute / Community /Mental Health

|Description of goal |Increase number of people who are able to die in the place of their choice. |

|Description of indicator |Percentage of people who die in their place of choice |

|Numerator |Number of people who died in their place of choice |

|Denominator |Number of people who have died |

| |(May agree locally to exclude those who have been offered the opportunity to advance care plan but have chosen |

| |not to) |

|Rationale for inclusion |Evidence shows that around half the annual 500,000 deaths in England currently occur in acute hospitals, with |

| |people spending an average of 18 days as in-patients during the last year of their life, often spread over |

| |several admissions. Research shows (NAO) that 40% of those who die in hospital have no medical need to be there.|

| |Whilst a significant proportion of people die in hospital, there is evidence to suggest this is not the place |

| |where most would choose to die. Enabling people to die in a place of their choosing requires individuals and |

| |their families to be involved in decision making and planning for the end of life, and for appropriate community|

| |based support and care to be put in place. Achieving this goal will support a reduction in inappropriate |

| |hospital admissions. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|This goal supports the High Impact Actions and the wider QIPP agenda (End of Life Care - EOLC) |

|Suggested approach to measurement: |

|Suggested data collection: Data is determined from local documented decision and actual place of death, with the data collection method agreed locally. It may |

|be appropriate to consider sampling. |

|Other related data (in addition to HES data) includes for example: |

|End of life care locality register pilot sites can provide information from November 2010. In the interim the QOF EOLC registers can be used to determine % of |

|deaths on an EOLC register, numbers on the registers and whether ACPs are in place |

|The National end of life care intelligence network, which will include HES and ONS data |

|Public Health Observatories |

|Locally implemented advance care planning documents |

|The indicator is calculated as Numerator / denominator x 100 |

|What does “good” look like against this indicator? |

|Commissioners should ensure they understand local baselines before agreeing payment thresholds for this indicator, to ensure that the goal is ambitious but also|

|realistic. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Death in preferred place pre-supposes a process whereby choice is ascertained, that informal carers are in agreement with the choice, this choice is |

|communicated to all relevant health and social care professionals, the choice is reviewed as a person’s wishes or circumstances change and that the services are|

|in place to meet this choice. This is a complex process that crosses organisational boundaries. This goal therefore incurs shared responsibility and risk across|

|providers, which should be agreed through local negotiation. |

|What resources are available to help providers meet this goal? |

|The Essential Collection institute.nhs.uk/hia. |

|Marie Curie Delivering Choice Programme deliveringchoice..uk |

|NHS End of Life Care Programme endoflifecare.nhs.uk |

|The National Council for Palliative Care .uk |

|Nurse sensitive indicator for important choices: |

| |

|QIPP workstream: |

Falls

Provider sector: Acute / Community / Mental health

|Description of goal |Reduction in the number of falls sustained by older people receiving inpatient care |

|Description of indicator |Falls in which physical injury occurs by age band per 1000 occupied bed days |

|Numerator |Number of incidents where people have been physically harmed or injured by a fall |

|Denominator |Inpatient only: total occupied bed days/1000 |

|Rationale for inclusion |The NHS National Patient Safety Agency (NPSA) has identified that there were 257,679 falls reported in the year |

| |ending March 2009 and estimates that about 1000 patient falls a year result in fractures. In 2005/6, it was |

| |estimated that 26 falls resulted in patient deaths. In an 800-bed acute organisation, there are an estimated 24 |

| |falls each week, costing on average about £92,000 per year per NHS Trust. A significant number of falls result |

| |in death or severe or moderate injury, at an estimated national cost of £15m per annum for immediate healthcare |

| |treatment alone. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Reducing falls is one of the High Impact Nursing Actions (HIA) and is fundamental to the successful delivery of Safety Express and the QIPP Safe Care |

|workstream. There are also links to other QIPP programmes such Long Term Care and the Productives. |

|Suggested approach to measurement: |

|Use incident reporting systems already in place. Trusts may also be participating in the Safety Express “Safety Thermometer” quarterly. |

|Number of incidents should include any repeated falls by same patient over a time period. |

|What does “good” look like against this indicator? |

|Commissioners should ensure they understand local baselines before agreeing payment thresholds for this indicator, to ensure that the goal is ambitious but also|

|realistic. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Need to ensure patient dignity maintained appropriately whilst also reducing frequency and severity of in patient falls. If reporting of falls is poor locally |

|then this goal may disincentivise improvements in reporting. |

|What resources are available to help providers meet this goal? |

|The Essential Collection institute.nhs.uk/hia. |

|Essence of Care - |

|NICE |

|NPSA Slips, trips and falls in hospital guidelines |

|Prevention of Falls Network Europe profane. |

|Nurse sensitive indicator for falls: |

| |

|QIPP workstream: |

Fragility fractures – Fracture Prevention Service

Provider sector: Acute

|Description of goal – what do you |To improve the secondary prevention of fragility fractures. |

|want to achieve? | |

|Description of indicator – how will |% patients over 50 admitted to hospital or attending outpatient clinics or A&E due to a low impact fracture who are |

|achievement be measured? |screened by a Fracture Prevention Service. |

|Numerator |Patients over 50 who are admitted to hospital or who attend A&E/fracture clinic due to a low impact fracture who are |

| |screened by the Fracture Prevention Service. |

|Denominator |Patients over 50 who are admitted to hospital or who attend A&E/fracture clinic due to a low impact fracture. |

|Rationale for inclusion |Fracture Prevention Services are a well established, NICE-recommended and cost-effective service to reduce secondary |

| |fracture prevention, that offer an opportunity to successfully intervene in 50% of future hip fracture cases (as half|

| |of hip fracture patients suffer a prior fragility fracture). |

Context for local organisations seeking to use this goal

|Wider commissioning strategies that may be supported by this goal: |

|Falls and Bone Health, Osteoporosis, Frail Older People |

|Commissioners will need to agree this goal in the context of an agreed local service specification and business model for the Fracture Prevention Service. |

|Suggested approach to measurement: |

|Local HES data and local tracking systems |

|What does “good” look like against this indicator? |

|A high proportion of the target group screened ( 90%). However commissioners may wish to reward progressive improvements above local baseline levels. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|An agreed business model for the Fracture Prevention Service will help avoid any unexpected activity-related costs of this CQUIN goal. |

|What resources are available to help providers meet this goal? |

|DH Falls and Fractures Commissioning Toolkit materials (2009), including full cost-benefit case. |

| |

|In 2009, the Department of Health, the National Osteoporosis Society and relevant national professional associations advocated for universal adoption of |

|the FLS model across the NHS, via: |

|DH Prevention Package for Older People |

|National Osteoporosis Society Manifesto for England |

|British Orthopaedic Association/British Geriatric Society Blue Book on the Care of Patients with Fragility Fractures |

Health care associated infection – Urinary catheters

Provider sector: Acute / Community / Mental health

|Description of goal |To reduce the number of indwelling urinary catheters |

|Description of indicator |Incidence of patients with an indwelling urinary catheter |

|Numerator |Number of patients with an indwelling catheter: |

| |for less than or equal to 28 days |

| |for more than 28 days |

|Denominator |Inpatient denominator: total bed days/1000 |

| |Community care denominator (non in-patient) : PCO population estimate/ 10000 |

|Rationale for inclusion |Urinary tract infections (UTIs) are the second largest single group of healthcare-associated infection in the UK|

| |amounting to 19.7% of all hospital infections. Evidence suggests that 60% of all UTI’s are related to urinary |

| |catheter insertion. The estimated cost for each Catheter Associated Urinary Tract Infection (CAUTI) is in excess|

| |of £1000 per patient. |

| |The Department of Health’s Infectious diseases and blood borne policy area has advised via the Advisory |

| |Committee on Antimicrobial Resistance and Healthcare Infection Advisory Committee “….It is recommended that |

| |organisations undertake ongoing assessment of the use of urinary catheters with a view to minimising usage, |

| |appropriate care and removal at the earliest opportunity.” |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Reducing health care associated infections is one of the High Impact Nursing Actions. Reducing the use of indwelling urinary catheters and CAUTIs is fundamental|

|to the successful delivery of Safety Express and the QIPP Safe Care workstream. |

|Suggested approach to measurement: |

|Trusts may also be participating in the Safety Express “Safety Thermometer” quarterly. |

|What does “good” look like against this indicator? |

|Commissioners should ensure they understand local baselines before agreeing payment thresholds for this indicator, to ensure that the goal is ambitious but also|

|realistic. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Necessary catheterisation may be avoided to the detriment of patient care |

|What resources are available to help providers meet this goal? |

|The Essential Collection institute.nhs.uk/hia. |

|DH Saving Lives clean-safe-care.nhs.uk |

|High Impact Intervention No 6 urinary catheter bundle |

|Nurse sensitive indicator for CAUTIs: |

| |

|QIPP workstream: |

Long term conditions

Provider sector: Acute / Ambulance / Community

NB. The indicators within this exemplar goal require further definition at local level in order to be suitable for inclusion within a CQUIN scheme

|Description of goal – what do you |To personalise and improve community based care for patients with long term conditions through joint working across health|

|want to achieve? |and social care using a generic LTC model. |

|Description of indicator – how will |Number of acute admissions for patients with a long term condition |

|achievement be measured? |Number of acute admissions for patients with a long term condition-related ambulatory care sensitive condition |

| |Number of occupied bed days for acute admissions of patients with a long term condition |

| |Number of patients with a long term condition who were transferred to hospital after being attended by the ambulance |

| |service |

| |% of patients with a long term condition who are discharged to a care home (residential or nursing) with a full social |

| |care assessment |

| | |

| |NB. The definition of a “long term condition” for the purpose of these CQUIN indicators should be as per local agreement |

| |and in line with internationally evaluated definitions (see ) |

|Numerator |TBC (based on local definitions as per note above) |

|Denominator |TBC (based on local definitions as per note above) |

|Rationale for inclusion |It is estimated that the treatment and care of those with long term conditions accounts for 70 percent of the primary and |

| |acute care budget in England and rising demand and pressure on finances make reform urgent and essential. Demographic |

| |projections outline a 252% rise in the number of people over 65 nationally by 2050. More joined up care centred around |

| |people's individual needs will improve people's experiences, maintain their independence and make care more |

| |cost-effective. The CQC reported earlier in 2010 that up to £2.7 billion per year could be saved by enabling people with |

| |long-term conditions, such as diabetes, to manage their conditions better, treating them closer to home and avoiding |

| |unnecessary hospital visits. Achievement of this and the related indicators depend on a whole system approach to |

| |supporting patients with LTCs. |

Context for local organisations seeking to use these indicators

|Wider commissioning strategies that may be supported by this goal: |

|Specifically, local organisations will need to engage in: |

|risk profiling of the long term condition population |

|systematised self management and personalised care planning |

|proactive preventative community based care co-ordination through multi agency multidisciplinary local care teams |

|multidisciplinary discharge planning |

|Suggested approach to measurement |

|Depending on indicator definition, local organisations may make use of SUS data as well as social care data and KA34/local CAD systems |

|What does “good” look like against this indicator? |

|Commissioners will want to reward ambitious improvements in relation to baseline levels (a reduction on indicators 1-4, and an increase on indicator 5. |

|Case studies showing what is achieveable can be found at: |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Partnership working with other providers (primary, community, acute, ambulance, and social) needs agreeing up front to ensure all share both the responsibility |

|and risk. The goal will only be achieved by truly working together. |

|In order to ensure that achievement of this goal does not inadvertently cause any deterioration in, but rather improves patient experience, local organisations |

|may wish to consider use of a focussed patient experience indicator alongside the indicators on long term conditions suggested here |

|What resources are available to help providers meet this goal? |

|DH LTC QIPP workstream: |

|DH LTC webpage: |

|NHS Evidence: |

|Local LTC QIPP workstreams |

Long term conditions – care planning

Provider sector: Acute / Ambulance / Community

|Description of goal – what do you |To improve personalisation of care planning and self-management amongst patients with long term conditions |

|want to achieve? | |

|Description of indicator – how will |Achievement will be measured using responses to two questions from the LTC6 questionnaire for with patients on LTC |

|achievement be measured? |registers (Diabetes, COPD, CHD, HF, Hypertension, Stroke, TIA, Renal, Epilepsy, Asthma, Multiple Sclerosis, Parkinsons): |

| |Did you discuss what was most important for you in managing your own health? |

| |How confident are you that you can manage your own health? |

| |Respondents give a score on a scale of 0-3 for each question. |

|Numerator |Number of respondents scoring 3 on both the above questions |

|Denominator |Number of respondents to the LTC6 survey |

|Rationale for inclusion |The process of engaging people in their care, supporting them to take control and get the most out of life with a LTC is |

| |the central thread of the LTC strategy. Planning care in this way is more proactive and meets individuals’ full range of |

| |needs. Patients who are better able to self manage also have fewer contacts with health services. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Care planning is the central thread of LTC management. Personalisation is a key strand in current and emerging health and social care policy. The Department of |

|Health’s 2010 White Paper Equity and Excellence: Liberating the NHS continues to advocate person-centredness as a key priority. |

|Suggested approach to measurement: |

|Use of LTC6 questionnaire with patients on LTC registers. |

|Consideration should be given to appropriate sampling, i.e. at least 30% of patients on the LTC registers being sent the LTC6 questionnaire, and with a minimum |

|response rate of 50%. |

|Commissioners may choose to obtain baseline measurement at the outset, in order to agree an ambitious improvement goal |

|What does “good” look like against this indicator? |

|At least 75% of the population surveyed scoring 3 for both questions |

|What perverse incentives or unintended consequences should be guarded against locally? |

|To ensure results are truly representative, commissioners will want to ensure that all LTC patients are covered, rather than focussing disproportionately on one|

|or a few specific disease areas which are better managed in the locality. |

|What resources are available to help providers meet this goal? |

|- Supporting People with Long Term Conditions: Commissioning Personalised Care Planning: A guide for commissioners |

|- Improving the health and well-being of people with long term conditions: world class services for people with long term conditions – information tool for |

|commissioners |

|- Care planning e-learning tool for NHS and Social Care workforce |

Maternity – Home birth

Provider sector: Acute

|Description of goal |To extend maternity choice in the place of birth |

|Description of indicator |Percentage home births |

|Numerator |Number of women giving birth at home |

|Denominator |Total number of women giving birth |

|Rationale for inclusion |Women should be offered the choice of place of birth including home birth[2]. Planned home birth is associated |

| |with lower caesarean section and instrumental delivery rates, higher intact perineum rates (refs in Midwifery |

| |2020 Measuring Quality [3]) and lower rates of pharmacological pain relief[4]. |

Context for local organisations seeking to use this indicator

|Wider commissioning strategies that may be supported by this goal: |

|Home birth rates are considered a proxy measure for the offer of real choice[5]. Availability of choice in place of birth should be addressed in the |

|development of networks of care for maternity provision.[6] page 17 |

|Suggested approach to measurement: |

|The formula for calculating the indicator = (Numerator/Denominator) x 100 |

|What does “good” look like against this indicator? |

|In 2008, the proportion of home births in England was 2.8%. This is a nominal increase from the 2.1% of home births in 2000. |

|What perverse incentives or unintended consequences should be guarded against locally? |

|Home birth rates vary widely throughout England from 11% down to ................
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