HULL CCG BUSINESS INTELLIGENCE FRAMEWORK
1. INTRODUCTION
As NHS Hull CCG is now a statutory organisation it needs to have robust business intelligence (BI) arrangements in relation to both its statutory responsibility as a commissioner and as a membership organisation. The CCG will be held accountable by the Area Team of NHS England for delivery of key national requirements and it will need to demonstrate that its commissioning decisions are making a difference. In addition, it will need to ensure its members are receiving timely information to support decision making and facilitate clinical involvement and leadership.
A BI framework is important as it not only enables the CCG to receive up to date performance on the national and local indicators but also ensures there is clear reporting mechanism in place with clear accountability and ownership between groups and individuals. This BI framework identifies leads for each of the indicators covering both the national and local requirements. The lead is responsible for the performance either through their role as a programme area lead or contract lead. They will be responsible for managing any underperformance either through development and monitoring of recovery plans and/or implementation of contractual arrangements.
The framework also clarifies the relationship between the forums within the CCG. This enables the CCG to focus on not only reporting and monitoring but the active management of performance, through internal and external assurances on delivery and improvement. The BI framework identifies two sources for assurance: programme areas and contractual management boards. For any underperformance assurances will be provided to the Quality and Performance Committee on improvements. The Quality and Performance Committee will in turn provide assurances to the Governing Body that they are satisfied with the systems in place to improve performance.
Establishingthese arrangements within the BI framework shouldensure the Governing Body when presented with a performance issue has a clear reason for underperformance, along with a robust recovery plan that has assurances that the plan will be delivered and that improvements in performance will be made.
2. NATIONAL REPORTING REQUIREMENTS
The CCG will be held accountable by NHS England for the delivery of key national requirements and the various national frameworks that are relevant to the CCG are described below:
NHS Outcomes Framework
The NHS Outcomes Framework 2013-14 sets out the outcomes and corresponding indicators that will be used to hold the NHS England to account for improvements in health outcomes, as part of the government’s mandate.
Indicators in the NHS Outcomes Framework are grouped around five domains, which set out the high-level national outcomes that the NHS should be aiming to improve. For each domain, there are a small number of overarching indicators followed by a number of improvement areas. They focus on improving health and reducing health inequalities:
Preventing people from dying prematurely;
Enhancing quality of life for people with long-term conditions;
Helping people to recover from episodes of ill health or following injury; Ensuring that people have a positive experience of care; and
Treating and caring for people in a safe environment and protecting them from avoidable harm.
The five domains were derived from the three part definition of quality first set out by Lord Darzi as part of the NHS Next Stage Review. In addition, the Secretary of State, NHS England and Clinical Commissioning Groups have a duty, for the first time, to have regard to the need to reduce inequalities between the people of England. The NHS Outcomes Framework sits alongside similar frameworks for public health and adult social care.
CCG Indicator set
The CCG indicator set (CCG IS) includes NHS outcome indicators that can be measured at CCG level and additional indicators developed by NICE and the Health and Social Care Information centre. The aim of CCG IS is to support CCG and Health and Well-being Board (HWB) partners improve health outcomes by providing comparative information on the quality of health services commissioned by CCG and the associated health outcomes. It is intended to support CCGs in determining local priorities and levels of ambition with HWB. The NCB will monitor the CCG on the CCG IS although it will not set thresholds or levels of ambition for CCGs, although the “Everyone Counts” planning guidance states that CCG plans should be built on the assumption that no indicator contained within the national NHS outcomes framework or CCG outcomes indicator set deteriorates. Therefore, it is important to monitor the CCG IS in year to ensure no indicators are deteriorating and if required implement recovery plans.
Many of the indicators have not been reported by the CCG or previous PCT and some are still in development. Work is ongoing to baseline indicators and compare with peers to identity where the CCG is an outliner. In addition, for those indicators that can be measured in year these will need to be reported on quarterly to the Quality and Performance Committee (In full) and Governing Body by exception.
All the CCG IS have been aligned to one of the programme areas and/ or one or more providers. For each indicator there is also a CCG lead identified as shown in appendix 2. Where a CCG IS is aligned to a programme area these will form part of the programme area report.
The NHS mandate confirmed the commitment to the NHS constitutional requirements and as a result CCGs were required to self-certify that plans ensured that the performance standards in the NHS Constitution will be delivered throughout 2013/14. The existing commitments include:
18 week Referral to treatment
Cancer waits for 2 weeks, 1 month and 2 months Ambulance response times
A&E four hour wait
Cancelled operations offered a new appointment within 28 days and; Care Programme Approach (CPA) for mental health patients.
The Everyone Counts planning guidance included further commitments in relation to the constitutional indicators including:
Zero tolerance to 52 week waits
All handovers between an ambulance and an A&E department to take place within 15 minutes and crews ready to accept new calls within further 15 minutes
Implementation of contractual fine for all delays over 30 minutes for both of the above situations and a further fine for delays of over an hour for both situations
No patient to tolerate an urgent operation being cancelled for the second time Zero tolerance to MRSA
No waits from decision to admit to admission (trolley waits) over 12 hours
The NHS mandate also includes the commitment for the full roll out of the Improved Access to Psychological Therapies (IAPT) programme by 2014/15 with the expectation that 15% of eligible patients will receive IAPT services with a 50% recovery rate.
Everyone Counts planning for patients 2013/14 requirements
As part of the “The everyone counts planning for patients 2013/14” CCG can now receive a Quality Premium. This will be paid to the CCG in 2014/15 based on 2013/14 performance for achieving improved or high standards of quality in the following four measures:
1. Potential years of life lost from causes considered amenable to healthcare 2. Avoidable emergency admissions
3. Friends and family test
4. Incidence of C. Difficile (include a zero tolerance for MRSA)
In addition, the CCG isexpected to deliver on three locally selected indicators and a locally set ambitious dementia diagnosis target.
3. CCG RELATIONSHIPS
As covered above It is important to clarify the reporting arrangements between the various groups within the CCG and externally. The diagram below illustrates these relationships and how assurances are reported. At the core of the diagram is the Quality and Performance Committee, which will receive reports, recovery plans and/or assurances from the contact
management boards (CMB) and the transformational programme areas. It will also triangulate BI with Quality and Safety and Patient Engagement reporting which are detailed below.
In Appendix 1 and 2 all National requirements have been aligned to either a programme area and/or contract. This ensures each is reviewed and discussed prior to it being presented to the Quality and Performance Committee. If an indicator’s performance is dependent on a provider and this is detailed within the relevant contract, this is classified as a contractual indicator and will not be required to be reported on by one of the transformational programmes. The transformational programme areas will only focus on indicators that they have a level of direct control over.
The Quality and Performance Committee will need to have an overview of all key performance indicators to assure itself and the Governing Body that the CCG is meeting its statutory responsibilities. In addition, the Quality and Performance Committee will be required to challenge any underperformance and scrutinise recovery plans for improvement and once satisfied, provide assurances to the governing body that improvements in performance will be made.
The mechanism for how Peer groups will feed into the framework and how and who they assure is still being developed.
To facilitate the relationships described above and decision making within the organisation a suite of BI reports are required. A report is required for each of the CCG groups described in the diagram of varying detail, content and style of presentation.
Sections Group NHS constitution requirement Quality premium (4 indicators) (Graph) 3 local priority indicators. (Graph) Dementia and IAPT. (Graph) CCG Indicators Programme area key outcome measures Programme productivity measures Finance (Graph). Governing
Body exception By Yes Yes Yes exception By Exception By No Yes Quality &
Performance Yes Yes Yes Yes Yes Yes No
Yes Senior
Leadership
Team Yes Yes Yes Yes
By exception By Exception No Yes Programme
areas No measures Proxy aligned to Yes – if area Yes- if aligned to area Yes – if aligned to area Yes Yes No
HWB No Yes Yes Yes By
exception No No No Peer Groups No No No Integrated Audit and Governance Committee
Exception Exception Exception Exception Exception Exception No Exception
Public Yes N/A Yes Yes Yes N/A N/A N/A For example the governing body report will be made up of sections covering: NHS
constitution requirements (by exception), Quality premium, local priorities, dementia/ IAPT, CCG IS (by exception), key outcome measures (by exception).
Practice and Peer Groups
It is proposed that in the short term the current practice level report continues with a CCG commitment to review during 2013/14 through consultation with practices and peer groups. Transformational programme areas
Each of the four programme areas will receive a BI report that will contain any CCG IS, NHS constitutional and NHS Mandate requirements that they have an impact on. In addition, each programme area will need to pick 2-5 key outcome measures which will be used to demonstrate overall performance of the programme to the Quality and Performance Committee and Governing Body. The reports will contain a number process measures to be used by the programme board to monitor and assure of the progress and impact of delivery plans. Each programme area has identified the measures it will use and these are demonstrated in appendix 3 to 7.
Quality and Performance to Governing Body
The Quality and Performance Committee will receive reports covering all the constitution and mandate commitments, indicators linked to the Quality Premium, CCG IS and the key outcome measures from each of the programme areas. In addition, it will receive any associated recovery plans and assurances.
Governing Body
The Governing Body will receive reports covering all the constitution and mandate commitments, indicators linked to the Quality Premium, CCG IS by exception and key outcome measures for the programme areas by exception. Rather than receiving detailed recovery plans it will receive narrative for each of the underperforming indicators. The narrative will cover reasons for underperformance, actions to improve performance and expected timescales when performance is expected to improve by.
Integrated Audit and Governance Committee
The Integrated Audit and Integrated Governance Committee will receive reports covering by exception the constitutional, CCG indicators set and Key outcome measures (as detailed above) on a timeframe to be agreed.
5. ROLE OF THE HULL CCG BI TEAM
The CCG has an internal Business Intelligence team within the Resources Directorate. The BI team is responsible for the development and implementation of this BI framework and will be responsible for ensuring the BI framework is delivering all the responsibilities. This will include ensuring the quality of BI reports produced by the CSU, the co-ordination of recovery plans and the quality of narratives. In addition, members of the Hull CCG BI team are aligned to the programme areas and healthcare contracts.
6. ROLE OF THE CSU BI TEAM
The implementation and ongoing servicing of the BI framework is dependent on a fully staffed embedded BI team which will be in place from April 2013. The embedded team will be responsible for developing the reports, baselining the indicators and then ensuring all reports are fully populated to agreed timescales. A development plan is in place for the development of the various sections and reports.
7.EXTERNAL REPORTING
To meet NHS constitutional requirements the national reporting requirements need to be published on the website and be publically available. The NHS constitutional indicators, CCG outcome measures, and national reporting requirements will be published monthly on the Hull CCG website. It will be the responsibility of the CSU BI team to ensure that the internet and intranet have up to date BI reports.
Ultimately the BI framework will be aligned to the CCG BAF and risk register. This is currently being scoped and is captured in the development plan (appendix 9).
9. QUALITY AND SAFETY FRAMEWORK Patient Experience
Alongside this BI framework the CCG has in place a Quality and Safety Framework and Patient Experience framework. Each will report to the Quality and Performance Committee to give a balanced picture of the local health community. There are overlaps and in relation to the BI framework as there are some indicators included in this framework that appear in the other two frameworks as listed below. The performance of these indicators will be reported through the BI framework with qualitative information associated with the indicators included within the quality and safety report and patient experience report.
BI link to Quality and Safety
Mixed Sexed Accommodation breaches C4.4 Friends and Family test
C5.1 Patient safety incident reporting
C5.2 Incidence of hospital-related venous thromboembolism (VTE) C5.3 Incidence of healthcare associated infection MRSA
C5.4 Incidence of healthcare associated infection C.Difficile BI link to Patient Experience
C3.3a Total health gain as assessed by patients for elective procedures – Hip C3.3b Total health gain as assessed by patients for elective procedures - Knee
replacement
C3.3c Total health gain as assessed by patients for elective procedures - Groin hernia
C3.3d Total health gain as assessed by patients for elective procedures – Varicose veins
C4.1 Patient experience of primary care - GP out-of-hours services C4.2 Patient experience of hospital care
C4.4 Friends and Family test
C4.4 Patient experience of outpatient services C4.5 Responsiveness to in-patients’ personal needs C4.6 Patient experience of A&E services
C4.7 Women’s experience of maternity services
C4.8 Patient experience of community mental health services
10. FINANCE AND CONTRACTING UPDATE
A further section will focus on the financial reporting for the CCG, the measures are listed in appendix 8, as well as a contract update. The contract update which will be mostly narrative will cover the following points for the main providers Financial position
CQUIN – proportion of total indicator delivering.
Outstanding issues.Appendix 1 - Constitutional indicators and Everyone counts additional planning requirements Indicator Contract Transformational programme area CCG responsible Owner Waiting times
RTT waiting times - 90% of admitted patients to start treatment within a max of 18 weeks from referral (to include number of specialty level breaches)
HEYHT, CHCP & Other acute and community providers
N/A Head of BI / BI Manager RTT waiting times - 95% of non-admitted patients to start treatment
within a max of 18 weeks from referral (to include the number of speciality level breaches)
HEYHT, CHCP & Other acute and community providers
N/A Head of BI / BI Manager RTT - 92% of patients on an incomplete non-emergency pathway (yet
to start treatment) should have been waiting no more than 18 weeks from referral
HEYHT, CHCP & Other acute and community providers
N/A Head of BI / BI Manager Zero tolerance for all patients for any referral to treatment waits of more
than 52 weeks.
HEYHT, CHCP & Other acute and community providers
N/A Head of BI / BI Manager Patients waiting for a diagnostic test should have been waiting no more
than 6 weeks from referral – 99%
HEYHT, CHCP & Other acute and community providers
N/A Head of BI / BI Manager
Emergency department
95% of patients should be admitted, transferred or discharged within 4
hours of their arrival at an A&E department? HEYHT & CHCP Unplanned care Head of BI / BI Manager No waits from decision to admit to admission (trolley waits) over 12
hours HEYHT & CHCP N/A Head of BI / BI Manager
All handovers between an ambulance and an A&E department to take place within 15 minutes and crews ready to accept new calls within
further 15 minutes YAS & HEYHT N/A
Head of BI / BI Manager Ambulance
response times
75% Cat A calls resulting in an emergency response arrive within 8
minutes (met for red 1 and red 2 calls separately) YAS N/A Head of BI / BI Manager
95% cat A calls resulting in an ambulance arriving at the scene within
19 minutes YAS N/A
Head of BI / BI Manager
Cancer waiting times
93% max 2 week wait for first appointment for patients referred
urgently with suspected cancer by a GP HEYHT N/A Head of BI / BI Manager
93% max 2 week wait for first appointment for patients referred urgently with breast symptoms (where cancer was not initially
suspected) HEYHT N/A
Head of BI / BI Manager 96% max one month (31-day) wait from diagnosis to FDT for all
cancers HEYHT N/A Head of BI / BI Manager
94% max 31 day wait for subsequent treatment where that treatment is
surgery HEYHT N/A Head of BI / BI Manager
98% 31 day wait for subsequent treatment where that treatment is an
anti-cancer drug regime HEYHT N/A
Head of BI / BI Manager 94% max 31 day wait for subsequent treatment where that treatment is
a course of radiotherapy HEYHT N/A Head of BI / BI Manager
85% max 2 month (62-day)wait from urgent GP referral for FDT for
cancer HEYHT N/A Head of BI / BI Manager
95% max 62 day wait from referral from an NHS Screening service for
FDT for all cancers HEYHT N/A Head of BI / BI Manager
Max 62 day wait for FDT following a consultant's decision to upgrade
the priority of the patient (all cancers) - no operational standard. HEYHT N/A
Head of BI / BI Manager
Dignity Mixed sexed breaches HEYHT & other acute
providers Quality and safety Head of BI / BI Manager Cancelled
operations.
All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patients treatment to be funded at the time and hospital of the patients choice.
HEYHT & other acute
providers N/A
Head of BI / BI Manager No patient to tolerate an urgent operation being cancelled for the
second time HEYHT & other acute providers N/A Head of BI / BI Manager
Mental Health
Care Programme Approach (CPA): 95% of the proportion of people under adult mental health specialities of CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period
Humber FT N/A
Head of BI / BI Manager
IAPT Humber FT & AQPs Mental Health Head of BI / BI
Manager Hospital
infections
C. Difficile infections HEYHT Quality and safety Director of Quality and
Clinical Governance
Zero tolerance on MRSA breaches HEYHT Quality and safety Director of Quality and
Appendix 2 CCG indicator set
Domain Indicator Contract Frequency Programme
area CCG responsible Owner Preventing people from dying prematurely
C1.1 Potential Years of Life Lost (PYLL) from causes considered amenable to health care – Adults and Children and YP (OF A1i and ii)
N/A Annual (ONS)
HWB Director of Commissioning & Partnerships
C1.2 Under 75 mortality rate from cardiovascular disease N/A Annual
(PCMD)l HWB Director of Commissioning & Partnerships C1.3 Cardiac rehabilitation completion CHCP Quarterly Planned Care Head of BI / BI Manager C1.4 Myocardial infarction, stroke, stage 5 kidney disease in
people in diabetes N/A SSNAP Primary Care Manager (Primary Care) Senior Commissioning
C1.5 Mortality within 30 days of hospital admission for stroke HEYHT Monthly
(SUS) Unplanned care/ Primary care
Head of BI / BI Manager) C1.6 Under 75 mortality rate from respiratory disease N/A Annual HWB Director of Commissioning &
Partnerships
C1.7 Under 75 mortality rate from liver disease N/A Annual HWB Director of Commissioning & Partnerships
C1.8 Emergency admissions for alcohol related liver disease N/A Monthly
(SUS) Primary Care Manager (Primary Care) Senior Commissioning
C1.9 Under 75 mortality rate from cancer N/A Annual HWB Director of Commissioning &
Partnerships C1.10a Under 75 mortality from cancer - 1 year survival from all
cancers
N/A Annual HWB Director of Commissioning &
Partnerships C1.10b Under 75 mortality from cancer - 5 year survival from all
cancers N/A Annual HWB Director of Commissioning & Partnerships
C1.11a Under 75 mortality from cancer - 1 year survival from
breast, lung and colorectal cancer N/A Annual HWB Director of Commissioning & Partnerships
C1.11b Under 75 mortality from cancer - 5 year survival from
breast, lung and colorectal cancer N/A Annual HWB Director of Commissioning & Partnerships
C1.12 People with severe mental illness who have received a list of physical checks
Humber Monthly (Practice Lists)
Partnerships Senior Commissioning Manager Partnerships C1.13 Antenatal assessment <13 weeks HEYHT Quarterly
(UNIFY) Partnerships Senior Manager Partnerships Commissioning
Domain Indicator Contract Frequency Programme area
CCG responsible Owner
(OMNIBUS) Manager Partnerships
C1.15 Breastfeeding prevalence at 6-8 weeks N/A Quarterly (UNIFY)
Partnerships Senior Commissioning Manager Partnerships
C2.1 Health related quality of life for people with long-term
conditions N/A Annual Primary Care Manager (Primary Care)Senior Commissioning
Enhancing quality of life for people with long term conditions
C2.2 Proportion of people feeling supported to manage their
condition N/A Annual Primary Care Manager (Primary Care)Senior Commissioning
C2.3 People with COPD and Medical Research Council dyspnoea scale ≤3 referred to a pulmonary rehabilitation programme
CHCP Annual
(GPES) Primary Care Manager (Primary Care) Senior Commissioning C2.4 People with diabetes who have received nine care
processes N/A Annual Quarterly? Primary Care Manager (Primary Care) Senior Commissioning C2.5 People with diabetes diagnosed less than one year
referred to structured education HEYHT? Annual/ Quarterly Primary Care Manager (Primary Care) Senior Commissioning C2.6 Unplanned hospitalisation for chronic ambulatory care
sensitive conditions (adults)
N/A Monthly (SUS)
Unplanned Care
Senior Commissioning Manager (Unplanned Care) C2.7 Unplanned hospitalisation for asthma, diabetes and
epilepsy in under 19s N/A Monthly (SUS) Unplanned Care/ Partnerships/ Primary Care Senior Commissioning Manager (Primary Care) C2.8 Complication associated with diabetes including
emergency admissions for diabetic ketoacidosis and lower limb amputation
N/A Annual (National
Diabetes audit)
Primary Care Senior Commissioning Manager (Primary Care) C2.9 Access to community mental health services by people
from BME groups Humber Quarterly Partnerships Senior Manager Partnerships Commissioning
C2.10 Access to psychological therapy services by people from
BME groups Humber Quarterly Partnerships Senior Manager Partnerships Commissioning
C2.11 and C2.12 Recovery following talking therapies Humber Quarterly Partnerships Senior Commissioning
Manager Partnerships C2.13 Estimated diagnosis rate for people with dementia Humber Monthly Primary Care
& Partnerships Senior Manager Partnerships & CSU Commissioning Lead
C2.14 People with dementia prescribed anti-psychotic
Domain Indicator Contract Frequency Programme area
CCG responsible Owner audit) Care
C3.1 Emergency admissions for acute conditions that should not usually require hospital admission
N/A Monthly (SUS) Unplanned Care & Primary care Senior Commissioning Manager (Primary Care)
Helping people to recover from episodes of ill
health or following injury
C3.2 Emergency readmissions within 30 days of discharge from
hospital HEYHT all acute
providers
Monthly
(SUS) Unplanned Care and Primary care
Senior Commissioning Manager Unplanned Care C3.3a Total health gain as assessed by patients for elective
procedures - Hip HEYHT all acute providers Quarterly (PROMS)
N/A Head of BI / BI Manager C3.3b Total health gain as assessed by patients for elective
procedures - Knee replacement HEYHT all acute
providers
Quarterly
(PROMS) N/A Head of BI / BI Manager
C3.3c Total health gain as assessed by patients for elective procedures - Groin hernia
HEYHT all acute providers
Quarterly (PROMS)
N/A Head of BI / BI Manager C3.3d Total health gain as assessed by patients fro elective
procedures – Varicose veins HEYHT all acute
providers
Quarterly
(PROMS) N/A Head of BI / BI Manager
C3.4 Emergency admissions for children with lower respiratory tract infections (LRTI)
N/A Monthly Partnerships & Planned Care
Senior Commissioning Manager Partnerships C3.5 People who have had a stroke who are admitted to an
acute stroke unit within four hours of arrival to hospital HEYHT Quarterly? SSNAP N/A Head of BI / BI Manager C3.6 People who have had a stroke who receive thrombolysis
following an acute stroke HEYHT Quarterly SSNAP N/A Head of BI / BI Manager
C3.7 People who have had a stroke who are discharged from
hospital with a joint health and social care plan HEYHT/ Humber Quarterly SSNAP Partnerships Head of BI / BI Manager BI C3.8 People who have had a stroke who receive a follow up
assessment between 4-8 months after initial admission
Humber Quarterly SSNAP
N/A Head of BI / BI Manager C4.1 Patient experience of primary care - GP out-of-hours
services N/A Quarterly (GP Patient
Survey) Primary Care Query unplanned care Senior Commissioning Manager (Primary Care) Ensuring that
people have a
C4.2 Patient experience of hospital care HEYHT all
acute
Domain Indicator Contract Frequency Programme area CCG responsible Owner positive experience of care providers
C4.4 Friends and Family test HEYHT all
acute providers
Quarterly (UNIFY)
N/A Head of BI / BI Manager
C4.4 Patient experience of outpatient services HEYHT Annual Quality and
Safety Head of BI / BI Manager
C4.5 Responsiveness to in-patients’ personal needs HEYHT Annual N/A Head of BI / BI Manager
C4.6 Patient experience of A&E services HEYHT Annual N/A Head of BI / BI Manager
C4.7 Women’s experience of maternity services HEYHT Annual N/A Head of BI / BI Manager
C4.8 Patient experience of community mental health services Humber Annual N/A Head of BI / BI Manager
Treating and caring for people in a safe environment and protecting them from avoidable harm
C5.1 Patient safety incident reporting All
providers Monthly NRLS? Quality and Safety Quality Facilitator C5.2 Incidence of hospital-related venous thromboembolism
(VTE) HEYHT Monthly Quality Safety and Head of BI / BI Manager
C5.3 Incidence of healthcare associated infection MRSA HEYHT Monthly Quality and Safety
Director of Quality and Clinical Governance C5.4 Incidence of healthcare associated infection C.Difficile HEYHT Monthly Quality and
APPENDIX 3 UNPLANNED CARE FRAMEWORK
Key Outcome Measures Source Freq Target
Attendance at AE (type 1 and 2) TBC TBC TBC
Attendance at MIU (numbers) TBC TBC TBC
Non elective admission over 65 SUS M Note a
Non elective admissions from care homes SUS M Note a
Delayed transfer of care TBC TBC TBC
Excess bed days TBC TBC TBC
C2.6 Unplanned hospitalisation for chronic ambulatory care sensitive
conditions (adults) SUS M TBC
NHS Constitutional Indicators Source Freq Target
95% of patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department?
Unify D 95%
CCG Indicator Set Source Freq Target
C1.5 Mortality within 30 days of hospital admission for stroke *** SUS M Note c C2.6 Unplanned hospitalisation for chronic ambulatory care sensitive
conditions (adults)
SUS M TBC C2.7 Unplanned hospitalisation for asthma, diabetes and epilepsy in under
19s *&*** SUS M Note c
C3.1 Emergency admissions for acute conditions that should not usually
require hospital admission *** SUS M Note c
C3.2 Emergency readmissions within 30 days of discharge from hospital *** SUS M Note c
Process measures Source Freq Target
Primary care activity in AE. TBC M TBC
Reduced length of stay for patients admitted with a mild to moderate stroke. TBC M TBC Fractured neck of femur (previous VS3) (HRG) SUS M TBC Total number of non-elective admissions (HRG) SUS M TBC Total number of non- elective admissions for over 65s (HRG) SUS M TBC Total number of non- elective admissions for over 65s (excluding LTC)
(HRG) SUS M TBC
Total number of non-elective admissions from care homes SUS M TBC Care Home Emergency Non-elective spells by Length of Stay SUS M TBC
Care Home Emergency PbR Excess Bed days SUS M TBC
Care Home Accident and Emergency Attendances by Time Status (HRG) SUS M TBC Care Home Emergency Non-Elective Spells Top 10 Primary Diagnosis
(HRG) SUS M TBC
Total number of non-elective admissions with COPD (HRG) SUS M TBC Total number of non-elective admissions with CHD-(HRG) SUS M TBC
All LTC Only Excess Bed Days - SUS M TBC
Total number of emergency re-admissions for CHD patients (HRG) SUS M TBC Total number of emergency re-admissions for COPD patients (HRG) SUS M TBC Delayed Transfers of Care – Numerator (acute 8119) TBC TBC TBC NB unplanned care board (Hull and East Riding – Headline measures) and programme report all key outcome measures
APPENDIX 4 PARTNERSHIPS FRAMEWORK
Key Outcome Measure Source Freq Target
Children experience of healthcare (composite measure from service specifications) Query CQUIN IN DEVELOPMENT
TBC TBC TBC
C1.13 Antenatal assessment <13 weeks Unify 2 Q TBC
C4.7 Women’s experience of maternity services CQC A TBC
Number of non-elective emergency admissions for those aged under 19s (HRG)
SUS Q TBC
Reduction in assisted deliveries (births by intervention i.e. C-section,
forceps and ventouse) TBC Q TBC
CCG Indicator Set Source Freq Target
C1.1 Potential Years of Life Lost (PYLL) from causes considered amenable
to health care – Children and YP (OF A1i) ONS A Note c
C1.13 Antenatal assessment <13 weeks Unify 2 Q TBC
C1.14 Maternal smoking at delivery + Unify 2 Q TBC
C1.15 Breastfeeding prevalence at 6-8 weeks + OMNIBUS Q TBC C2.7 Unplanned hospitalisation for asthma, diabetes and epilepsy in under
19s ****
SUS M TBC
C3.4 Emergency admissions for children with lower respiratory tract
infections (LRTI) ** (UNIFY) Q TBC
C3.7 People who have had a stroke who are discharged from hospital with
a joint health and social care plan. SUS M TBC
C4.7 Women’s experience of maternity services CQC A TBC
Process measures Source Freq Target
Infant mortality ONS A TBC
Maternal mortality ONS A TBC
Children experience of healthcare (composite measure from service specifications) Query CQUIN IN DEVELOPMENT
TBC TBC TBC
Low birth weight babies – 10% of live births at term >38 weeks with LBW <2500g +
Provider Q TBC VSC29 Unintentional and deliberate injuries to
children aged under 18 +
SUS M TBC
Immunisation rates (all) + PC M TBC
Number of non elective emergency admissions for those aged under 19s (HRG)
SUS Q TBC Number of non elective emergency admissions for those aged under 19s
(excluding LTC) (HRG)
SUS Q TBC Number of non- elective emergency admissions for those aged under 19s
(for LTC) (HRG)
SUS Q TBC Number of and percentage BMI over 30 at 12 weeks and 6 days of
maternity
Provider Q TBC Proportion of women with a BMI recorded over 30 referred to healthy
lifestyle midwife.
Provider Q TBC Proportion of women booked at 12 weeks 6 days with a BMI recorded Provider Q TBC Number of pregnant women accessing stop smoking services Provider Q TBC Number of pregnant women stopped smoking at 4 week follow up. Provider Q TBC
Number of pregnant women accessing peer support/ Doula support services
Provider Q TBC Percentage of neo natal babies having breast milk or donor milk Provider Q TBC Percentage of neo- natal babies having breast milk at discharge Provider Q TBC Number of mothers accessing birth preparation and parent education. Provider Q TBC
Reception year obesity levels PH A TBC
Year 6 obesity levels PH A TBC
Number of children receiving a wheel chair on day of assessment Provider Q TBC
APPENDIX 5 MENTAL HEALTH
Key Outcome Measure Source Freq Target
CAHMS user and carers satisfaction – to be developed within the
contract* Provider Q TBC
15% of eligible patients receive IAPT services Data set Q 13% C2.13 Estimated diagnosis rate for people with dementia Register Q 46% Early diagnosis – to be developed. Using 9 I statements National
dementia strategy. TBC TBC TBC
Friends and family approach to inpatient services (to be developed 13/14
and implemented 14/15 with all services). TBC TBC TBC
NHS Constitutional Indicators Source Freq Target
IAPT – proportion of eligible patients receiving IAPT services Data set Q 13%
IAPT – recovery rate Data set Q 50%
CCG Indicator Set Source Freq Target
C1.12 People with severe mental illness who have received a list of physical checks
GPES A Note c
C2.9 Access to community mental health services by people from BME groups
Data set Q Note c C2.10 Access to psychological therapy services by people from BME
groups Data set Q Note c
C2.11 and C2.12 Recovery following talking therapies all ages and over
65 Data set Q Note c
C2.13 Estimated diagnosis rate for people with dementia *** Registers Q 46% C2.14 People with dementia prescribed anti-psychotic medication *** Dementia
audit
A Note c
Process measures Source Freq Target
Number of people accessing MH services Provider Q TBC Number of people accessing LD services Provider Q TBC Number of people accessing services out of area Provider Q TBC
APPENDIX 6 PRIMARY CARE
Key Outcome Measures Source Freq Target
People supported by telehealth to manage a Long Term Condition (#) CHCP M 550 by 31/03/2014 900 by 31/03/2015 People taking up a Personal Health Budget (#) CHCP M 100 per
year in 2013/14 People with multiple Long Term Conditions comprehensively reviewed (#) Practices M 1,000 in 2013/13 2,000 in 2014/15 Reduction in non-elective admissions from care homes (#) SUS M Reduction
of 220 per year by 2014/15
CCG Indicator Set Source Freq Target
C1.4 Myocardial infarction, stroke, stage 5 kidney disease in people in diabetes
SUS M Note c
C1.5 Mortality within 30 days of hospital admission for stroke **** SUS M Note c C1.8 Emergency admissions for alcohol related liver disease SUS M Note c
C2.1 Health related quality of life for people with long-term conditions TBC A Note c
C2.2 Proportion of people feeling supported to manage their condition TBC A Note c C2.3 People with COPD and Medical Research Council dyspnoea scale
≤3 referred to a pulmonary rehabilitation programme
GPES Note c
C2.4 People with diabetes who have received nine care processes NDA A Note c C2.5 People with diabetes diagnosed less than one year referred to
structured education
NDA A Note c
C2.7 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s *&****
SUS M Note c
C2.8 Complication associated with diabetes including emergency admissions for diabetic ketoacidosis and lower limb amputation
NDA A Note c
C2.13 Estimated diagnosis rate for people with dementia ***** QMAS M 46% C2.14 People with dementia prescribed anti-psychotic medication ***** Dementia
audit
A Note c
C3.1 Emergency admissions for acute conditions that should not usually require hospital admission ****
SUS M TBC
C3.2 Emergency readmissions within 30 days of discharge from hospital ****
SUS M TBC
C4.1 Patient experience of primary care - GP out-of-hours services GP survey
Process measures Source Freq Target Non elective admission for under 19 for asthma SUS TBC TBC % of people with a long-term condition who are "supported by people
providing health and social care services to manage their condition"
TBC TBC TBC
Number of people diagnosed CHD, Heart Failure, AF, Stroke/ TIA, Hypertension, Asthma, COPD, Diabetes Mellitus, Dementia, Epilepsy.
Practice lists
Q TBC
Number of NT-proBNP test administrated TBC TBC TBC
Number of patients who participate in a cardiac rehabilitation programme meeting NICE requirements duplicated by Cxxx
TBC TBC TBC
Number of patients completing pulmonary rehabilitation duplicated by Cxxx
TBC TBC TBC
Risk stratification usage in primary care (to developed) TBC TBC TBC
MDT usage (to be developed) TBC TBC TBC
% eligible people who have been offered an NHS Health Check TBC TBC TBC
APPENDIX 7 PLANNED CARE
Key Outcome Measure Source Freq Target
E consultation (to be developed) TBC TBC TBC
Advice and guidance -choose and book- (to be developed) TBC TBC TBC
CCG Indicator Set Source Freq Target
C1.3 Cardiac rehabilitation completion National audit
? Note c
C3.4 Emergency admissions for children and lower respiratory tract infections (LRTI) *
SUS M Note c
Process measures Source Freq Target
E consultation (to be developed) TBC TBC TBC
Advice and guidance -choose and book- (to be developed) TBC TBC TBC Procedures of limited clinical value – based on Capita work – (to be
developed)
TBC TBC TBC
Direct GP access to CT and Urology diagnostics (to be developed) TBC TBC Ophthalmology – 1st Appointment reduction SUS M 288
(13/14) Ophthalmology – Follow up activity reduction SUS M 672
(13/14) Ophthalmology – RRT Waiting times (to be base lined) Unify M TBC
ENT – 1st Appointment reduction SUS M 160
(13/14)
ENT – Follow up activity reduction SUS M 192
(13/14) ENT – RRT Waiting times (to be base lined) Unify M TBC
Dermatology – 1st Appointment reduction SUS M 140
(13/14)
Dermatology – Follow up activity reduction SUS M 230
(13/14) Dermatology – RRT Waiting times (to be base lined) Unify M TBC
Plastics – 1st Appointment reduction SUS M 84
(13/14)
Plastics – Follow up activity reduction SUS M 193
(13/14) Plastics – RRT Waiting times (to be base lined) Unify M TBC
Rheumatology – 1st Appointment reduction SUS M 56
(13/14) Rheumatology – Follow up activity reduction SUS M 230
(13/14) Rheumatology – RRT Waiting times (to be base lined) Unify M TBC
Urology – 1st Appointment reduction SUS M 100
(13/14)
Urology – Follow up activity reduction SUS M 158
Urology – RRT Waiting times (to be base lined) Unify M TBC
Neurology – 1st Appointment reduction SUS M 100
(13/14)
Neurology – Follow up activity reduction SUS M 125
(13/14) Neurology – RRT Waiting times (to be base lined) Unify M TBC Diabetic Medicine – 1st Appointment reduction SUS M 26
(13/14) Diabetic Medicine – Follow up activity reduction SUS M 137
(13/14) Diabetic Medicine – RRT Waiting times (to be base lined) Unify M TBC
Note a – target as of unify submission for activity lines Note b – no target just a comparison with the YTD last year Note c – no deterioration
* links to Partnership Programme area ** links to Planned Care Programme area *** links to Primary Care Programme area **** links to Unplanned Care Programme area ***** links to Mental Health Programme areas + links to public health
APPENDIX 8 FINANCIAL REPORTING
Key Outcome Measure Source Freq Target
Forecast out turn DS M As
plan Running costs DS M £25 ph Cash Limit DS M As plan Run rate DS M As plan BPP DS M 95%
Investment plan performance DS M As
plan
APPENDIX 9 DEVELOPMENT PLAN
Task Responsible Officer Date for completion
Develop CAMHS carers and user satisfaction indicator – along
with setting trajectory Keith Baulcombe and Joy Dodson TBC Develop early dementia diagnosis indicator - along with setting
trajectory
Keith Baulcombe and Joy Dodson
TBC Develop reporting arrangement for LD Keith Baulcombe
and Bernie Dawson
TBC E consultation (to be developed) Karen Bilany and
Senior BI lead TBC Advice and guidance -choose and book- (to be developed) Karen Bilany and
Senior BI lead TBC Procedures of limited clinical value – based on Capita work Karen Bilany and
Senior BI lead
TBC Planned care – baseline RTT waiting times for Ophthalmology,
ENT, Dermatology, Plastic, Rheumatology, Urology, Neurology, Diabetic Medicine
CSU BI team TBC Direct access to CT diagnostics CSU BI team and
James Dawson
TBC Children experience of healthcare (composite measure from
service specifications) Query CQUIN IN DEVELOPMENT Bernie Dawson and Joy Dodson TBC Risk stratification usage in primary care (to developed) Phil Davis and BI
lead TBC
MDT usage (to be developed) Phil Davis and BI
lead TBC
Review practice level report Hull CCG BI June 2013
Procedure for publishing report sections in the Hull CCG website
BI Lead April 2013
Alignment to the CAF/ BAF Mike Napier and
BI lead April 2013
Design Contracting update BI lead TBC
Clarify roles and responsibilities between the Hull CGC BI and