Commissioning For Quality And Innovation Research Articles

P26 User experience of a clinical decision support system in the form of a mobile app in supporting antimicrobial stewardship

Abstract Background There are advancements in the use of technology in modern healthcare. Healthcare professionals use various digital platforms such as electronic medical records, e- prescriptions, websites and smartphone apps to enable prompt access to clinical information. Healthcare professionals are likely to refer to their smartphones for prompt clinical information or guidance that are easily accessible in contrast to paper guides, handbooks and desktop computers. Some studies have shown that mobile application guidelines within a smart phone app increase adherence to prescribing guidelines by clinicians. Furthermore, benefits of a smart phone app are the ability to update them more quickly than paper-based information and the ability to improve clinical decision-making within the form of an electronic clinical decision support system (CDSS). Despite the increased use of digital information there are limited studies in this area on the use of CDSS within smart phone antimicrobial apps. More evidence is needed to better understand healthcare usage of such apps in the area of antimicrobial stewardship. Microguide V1 (M1) is a smartphone antimicrobial app currently in widespread use in UK hospitals designed to provide access to local prescribing guidelines. However, M1 does not have a support tool to ‘direct’ or map prescribers to a specific treatment plan for their patients based on symptoms or suspected diagnosis. Microguide V2 (M2) is an updated version that includes an additional decision support tool that helps to identify the correct antibiotic to prescribe based on patient’s clinical symptoms. Objectives To evaluate clinician experiences with both versions of the app within Mid and South Essex University Hospitals (MSE) Trust. In MSE, the M1 is currently in use but M2 is being adopted from November 2023 onwards as part of strategies to improve antimicrobial stewardship, and to help with meeting Commissioning for Quality and Innovation (CQUIN) targets for IV to oral switching of antibiotics). Methods A mixed methods approach was devised utilizing an online survey and interviews pre- and post-introduction of M2. Questions were aligned to the COMB-B behaviour model approach influencing change. Topics covered were awareness, experience, barriers, concerns and prescribing behaviour. All prescribers within the Trust working on adult inpatient wards were eligible for participation. Results A pre-implementation survey of M2 was conducted between January and October 2023. A total of 473 people accessed the online survey, with 24 responses, but only a total of 15 participants fully completed the survey. The roles of the participants were 6 pharmacists, 3 nurses and 6 doctors. In terms of awareness of the app, 87% stated yes and 38% agreed that the app increased their awareness of antimicrobial stewardship. Two-thirds (67%) of participants used the app in supporting prescribing decisions, whilst a third had never used it. Nearly 40% of participants agreed that the app encouraged them to challenge inappropriate prescribing and almost half (46%) agreed that that they felt comfortable accessing the app at patient’s bedside. The interview analysis is still ongoing. Conclusions The results so far provide evidence that M1 is being accessed by prescribers in making clinical decisions and they find it useful. The obvious and major limitation of this study was the small number of responses, and this is partially explained by winter pressures and industrial action by nurses and doctors. This led to reduced availability of participants.

P01 Who’s counting? How many IV antibiotic administrations are given daily at four Midlands trusts

Abstract Background Up to 80% of patients admitted to hospital receive IV therapy during their stay.1 In the UK, the NHS England Commissioning for Quality and Innovation (CQUIN) audit for quarter 1 of 2023–24 in the Midlands shows that 9.1%–35.0% of patients prescribed IV antibiotics are appropriate for a switch to oral therapy. A recent time and motion study demonstrated that IV medicine administration takes 20 min longer to give than an oral preparation.2 Consequently, an appropriate IV to oral switch releases 20 min of nurse time per dose administered. The unknown parameter is ‘how many antibiotic injections are given daily in hospitals’. Quantifying this parameter would enable Trusts to calculate the workforce capacity that could be realized on implementing an effective IVOS pathway. Methods The number of IV antibiotics administered to inpatients was determined on one day for seven consecutive weeks at four Midlands trusts. In Week 1, data were collected on Sunday, Week 2 on Monday and so on until Week 7 on Saturday. Finally, the ratio of number of IV antibiotics doses per number of occupied beds was determined. Results The range of the number of doses administered per occupied beds was between 0.92 and 1.18; it would be reasonable therefore to use the approximation of the number of antibiotic injections given daily at the four trusts as one injection per occupied bed. Taking a pragmatic approach that 20% of IV doses could be given orally with each change to oral releasing 20 min per administration we are proposing a calculation for the potential workforce released if an effective IVOS pathway is implemented: number of workforce hours released/day=number of trust beds/15. Conclusions Implementation of an effective IVOS pathway has the potential to release a significant number of hours each day to nurses to undertake other tasks.

Adherence to vascular care guidelines for emergency revascularization of chronic limb-threatening ischemia

ObjectiveIn 2022, the National Health Service Commissioning for Quality and Innovation (CQUIN) indicator for vascular surgery, with its pay-for-performance incentive for timely (5-day) revascularization of chronic limb-threatening ischemia (CLTI), was introduced. We sought to assess its effects in terms of (1) changes in the care pathway process measures relating to timing and patient outcomes; and (2) adherence to the Peripheral Arterial Disease Quality Improvement Framework (PAD-QIF) guidelines for patients admitted with CLTI. MethodsA retrospective before-and-after cohort study was performed from January to June 2022 of nonelective admissions for CLTI who underwent revascularization (open, endovascular, or hybrid) at Cambridge University Hospitals National Health Service Foundation Trust, a regional vascular “hub.” The diagnostic and treatment pathway timing-related process measures recommended in the PAD-QIF were compared between two 3-month cohorts—before vs after introduction of the CQUIN. ResultsFor the two cohorts (before vs after CQUIN), 17 of 223 and 17 of 219 total admissions met the inclusion criteria, respectively. After introduction of financial incentives, the percentage of patients meeting the 5-day targets for revascularization increased from 41.2% to 58.8% (P = .049). Improvements were also realized in the attainment of PAD-QIF targets for a referral-to-admission time of ≤2 days (from 82.4% to 88.8%; P = .525) and admission-to-specialist-review time of ≤14 hours (from 58.8% to 76.5%; P = .139). An increase also occurred in the percentage of patients receiving imaging studies within 2 days of referral (from 58.8% to 70.6%; P = .324). The reasons for delay included operating list pressures and unsuitability for intervention (eg, active COVID-19 [coronavirus disease 2019] infection). No statistically significant changes to patient outcomes were observed between the two cohorts in terms of complications (pre-CQUIN, 23.5%; post-CQUIN, 41.2%; P = .086), length of stay (pre-QUIN, 12.0 ± 12.0 days; post-QUIN, 15.0 ± 21.0 days; P = .178), and in-hospital mortality (pre-QUIN, 0%; post-QUIN, 5.9%). Other PAD-QIF targets relating to delivery of care were poorly documented for both cohorts. These included documented staging of limb threat severity with the WIfI (wound, ischemia, foot infection) score (2.9% of patients; target >80%), documented shared decision-making (47.1%; target >80%), documented issuance of written information to patient (5.9%; target 100%), and geriatric assessment (6.3%; target >80%). ConclusionsThe pay-for-performance incentive CQUIN indicators appear to have raised the profile for the need for early revascularization to treat CLTI, engaging senior hospital management, and reducing the time to revascularization in our cohort. Further data collection is required to detect any resultant changes in patient outcomes. Documentation of guideline targets for delivery of care was often poor and should be improved.

P12 Commissioning for Quality and Innovation (CQUIN) schemes—revisiting urinary tract infection (UTI) management. What worked? What lasted? What next?

Abstract Background UK CQUIN schemes encourage an improvement focus on a specific area of care. In 2019, CQUIN CCG1a: Improving the management of lower UTI in older people1 was adopted at the RUH resulting in increased alignment with UK guidance on diagnosis and treatment.2 Our aim was to investigate whether this improvement was sustained two years later. This would help inform quality improvement interventions prior to adoption of the 2022 CQUIN, CCG2: Appropriate antibiotic prescribing for UTI in adults aged 16+.3 Objectives Service evaluation of the UTI pathway including compliance with two of the CQUIN care processes for UTI diagnosis in patients age 65+ presenting to ED (not admitted): (i) diagnosis excludes use of urine dipstick in people aged 65+; and (ii) urine sample sent to microbiology as per UK guidance.2 Methods A search of the electronic patient record for key terms (Table 1) identified 6076 ED attendances for patients age 65+ between 1 August and 31 October 2021 of which 40 were identified with a primary diagnosis of UTI not requiring hospital admission. Paramedic, ED and Urgent Treatment Centre notes (paper and electronic) were reviewed in detail and information gathered regarding presence/absence of UTI symptoms aligned to diagnostic guidelines;2 presence/absence of urine dipstick test; and presence/absence of urine sample for culture and susceptibility testing. Findings were compared with identical trust data for patients (admitted and non-admitted) obtained during the 2019 CQUIN: Q1 April–June; Q2 July–September; Q3 October–December. During this period improvement interventions were implemented. Results See Table 2. Conclusions Following intensive staff education improved practice regarding urine dipstick testing and appropriate urine sampling in elderly patients with possible UTI was observed during the 2019 CQUIN period. Two years later this improvement had not been sustained. When planning interventions during the 2022 CQUIN,3 consideration should be given to a bundle of interventions including education, data feedback and systems improvement, for example, computerized decision support systems (CDSS) to embed sustained change.

The Vascular PAD-QIF CQUIN: what is it, why is it important, what does it mean for vascular units?

The Commissioning for Quality and Innovation (CQUIN) indicators for 2022/23 were recently published by NHS England and for the first time include a vascular indicator, the “Achievement of revascularisation standards for lower limb ischaemia”.1 This is great news and will drive quality improvement for patients with chronic limb-threatening ischaemia (CLTI). In this editorial we describe what this means for English NHS organisations providing vascular services, vascular clinicians and patients.

Service evaluation project: the effects of healthy weight commissioning for quality and innovation (CQUIN) interventions on metabolic parametrs of service users in a medium secure forensic ward

AimsService users of secure forensic units can be prone to weight gain due to various reasons including medications, physical illnesses, sedentary habits and mental health difficulties. They in turn are at greater risk of obesity related health problems like Diabetes, Hypercholesterolaemia, Ischaemic Heart Disease, Depression among others.Our project was aligned with government's plan to improve prevention and screening for the obesity and metabolic syndrome among the patients of medium secure facilities by 2020.Our primary objective was to gather and analyse the data on current metabolic parameters such as weight, body mass index (BMI), blood pressure (BP) and biochemistry markers of the service users on a 18 bedded Male medium secure long term rehabilitation ward.Our secondary objective was to suggest healthy weight interventions that would help patients to loose weight and to explore the effects of these interventions on biochemistry markers and vital signs parameters.MethodWe collected cross sectional data in given period of time (mid-March 2020). Seventeen service users were included in the final sample. Following initial data collection, we suggested various healthy weight interventions for the patients and repeated data collection after four months (July 2020).Interventions offered:Healthy eating group1:1 sessions with doctors and pharmacistsGym referralsDietician referralsRelaxation groupResultBaselineFourteen patients on the ward (n = 14) were found to be either overweight or obese. Two patients (n = 2) had high BP, twelve patients (n = 12) had deranged lipid profile, six (n = 6) had high blood glucose (existing Diabetes).Following interventionFourteen patients (n = 14) remained either overweight or obese. Nine patients (n = 9) lost weight following the intervention. Eight patients (n = 8) gained weight over 4 months. In both of the patients (n = 2) with raised BP the readings came back to normal after the intervention. One (n = 1) patient with normal BP at the baseline had high blood pressure following intervention.ConclusionOur service evaluation projects revealed that majority of the patients on the ward had deranged metabolic parameters such as increased BMI, abnormal blood tests and high BP.Following our intervention more than a half of the patients lost weight whilst other half gained weight during the period of observation, which we suspect is associated with significant physical activity restrictions during the coronavirus pandemic. In both patients with high BP at the baseline it has improved following the intervention.We would continue implementing healthy weight interventions on the ward and across the unit.

A student and staff collaborative audit exploring the food and drinks available from a dental teaching hospital outlet.

Introduction NHS England's Commissioning for Quality and Innovation (CQUIN) standard 1b sets targets for food and drinks high in fat, sugar or salt (HFSS) that should be sold in hospitals.Aims To assess the products that were available in a dental hospital food outlet and to explore the cost and placement of HFSS products.Design and setting A prospective audit of the food outlet in a dental hospital in London, UK carried out by staff and students in May 2018 benchmarked against CQUIN 1b.Materials and methods Staff and students collected data on food and drinks that were available over a two-week period.Results Only cold and hot drinks met the CQUIN target that 80% of drinks should contain less than five grams of sugar/100 ml. A third of packaged biscuits and 50% of cakes and pastries contained more than 250 kcal per portion. HFSS products were visible in front of customers at the checkout till. Packaged fruits were more expensive than packaged biscuits.Discussion and conclusion This audit showed inconsistencies between the food and drinks available for staff, students and patients at a dental hospital and the healthy eating messages that staff and students relay to support patients' oral health.

CQUIN for lower limb wounds

Journal of Prescribing PracticeVol. 2, No. Sup8 Management of Leg UlcersCQUIN for lower limb woundsKaren StainesKaren StainesE-mail Address: [email protected]Director of Education and Research/Clinical Lead: Wound Care, Accelerate CICSearch for more papers by this authorKaren StainesPublished Online:18 Aug 2020https://doi.org/10.12968/jprp.2020.2.Sup8.3AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article References Academic Health Science Network (AHSN). National Wound Care Strategy Programme. 2019. https://www.ahsnnetwork.com/about-academic-health-science-networks/national-programmes-priorities/national-wound-care-strategy-programme (accessed 5 June 2020) Google ScholarBritish Lymphology Society. Position paper for ankle brachial pressure index. 2018. https://lymphoedemaeducation.com.au/wp-content/uploads/2018/10/BLS-ABPI-A4.pdf (accessed July 19 2020) Google ScholarColeman S, Nelson EA, Vowden P et al.. Development of a generic wound care assessment minimum data set. J Tissue Viability. 2017;26(4):226–240. https://doi.org/10.1016/j.jtv.2017.09.007 Google ScholarDepartment of Health. Using the Commissioning for Quality and Innovation (CQUIN) payment framework - a summary guide. Department of Health, London; 2010 Google ScholarFranks PJ, Barker J, Collier M et al.. Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice. Journal of Wound Care. 2016;25(Sup6):S1–S67. https://doi.org/10.12968/jowc.2016.25.sup6.s1 Abstract, Google ScholarGohel MS, Heatley F, Liu X et al.. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. New England Journal of Medicine. 2018;378(22):2105–2114. https://doi.org/10.1056/nejmoa1801214 Google ScholarGuest JF, Ayoub N, McIlwraith T et al.. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open. 2015;5(12):e009283. https://doi.org/10.1136/bmjopen-2015-009283 Google ScholarGuest J. Wound care delivers: quo vadis? Wounds UK. 2017;13(4) Google ScholarHopkins A, Bull R, Worboys F. Needing more: the case for extra high compression for tall men in UK leg ulcer management. Veins and Lymphatics. 2017;6(1). https://doi.org/10.4081/vl.2017.6630 Google ScholarHopkins A. The Legs Matter campaign: we need to optimise compression therapy more than ever. Wounds UK. 2020;16(2) Google ScholarJones D. Emotional and financial costs associated with stress and pain in two chronic leg ulcer patients. Wounds UK. 2013;2:83–85 Google ScholarKantor J, Margolis DJ. A multicentre study of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks. Br J Dermatol. 2000;142(5):960–964. https://doi.org/10.1046/j.1365-2133.2000.03478.x Google ScholarMoffatt CJ, Franks PJ, Doherty DC et al.. Psychological factors in leg ulceration: a case-control study. British Journal of Dermatology. 2009;161(4):750–756. https://doi.org/10.1111/j.1365-2133.2009.09211.x Google ScholarNational Institute for Health and Care Excellence. Varicose veins in the legs. The diagnosis and management of varicose veins (NICE guideline). Clinical guideline 168. 2013. https://www.nice.org.uk/guidance/cg168 (accessed 15 July 2020) Google ScholarNational Wound Care Strategy Programme. Lower Limb Assessment Essential Criteria. 2020. https://www.ahsnnetwork.com/wp-content/uploads/2019/11/V2-Draft-Lower-Limb-Assessment-Essential-Criteria-25.11.19.pdf (accessed 22 July 2020) Google ScholarNHS England. Leading Change, Adding Value: A framework for nursing, midwifery and care staff. 2016. https://www.england.nhs.uk/publication/leading-change-adding-value-a-framework-for-nursing-midwifery-and-care-staff/ (accessed 7 June 2020) Google ScholarNHS England and NHS Improvement. Commissioning for Quality and Innovation. Guidance for 2019-2020. 2019. https://www.england.nhs.uk/wp-content/uploads/2019/03/CQUIN-Guidance-1920-080319.pdf (accessed 15 July 2020)] Google ScholarPhillips CJ, Humphreys I, Thayer D et al.. Cost of managing patients with venous leg ulcers. International Wound Journal. 2020;17(4):1074–1082. https://doi.org/10.1111/iwj.13366 Google ScholarPosnett J, Franks PJ. The burden of chronic wounds in the UK. Nurs Times. 2008;104(3):44–45 Google ScholarScottish Intercollegiate Guidelines Network. Management of chronic venous leg ulcers. 2010. https://www.sign.ac.uk/sign-120-management-of-chronic-venous-leg-ulcers (accessed 15 July 2020) Google ScholarWounds UK. Best Practice Statement: Holistic management of venous leg ulceration. London: Wounds UK; 2016 Google ScholarSIGN. Management of chronic venous leg ulcers - a national clinical guideline. 2010. https://www.sign.ac.uk/sign-120-management-of-chronic-venous-leg-ulcers.html (accessed 22 July 2020) Google ScholarWounds UK. Best Practice Statement: Addressing complexities in the management of venous leg ulcers. London: Wounds UK; 2019. Google Scholar FiguresReferencesRelatedDetails 1 August 2020Volume 2Issue Sup8ISSN (print): 2631-8385ISSN (online): 2631-8393 Metrics History Published online 18 August 2020 Published in print 1 August 2020 Information© MA Healthcare LimitedPDF download

An audit tool for assessing electronic discharge summaries of head and neck oncology patients

Supporting proactive and safe discharge is one of the national clinical indicators for Commissioning for Quality and Innovation (CQUIN) 2017/2019. Head and neck (HNC) oncology patients after major ablative and reconstructive surgery require comprehensive discharge summaries for GPs, their care workers and members of the HNC multidisciplinary team. We aimed to assess the quality of our unit's electronic discharge summaries (EDN) and developed a tool for this purpose.

Pay for performance for specialised care in England: Strengths and weaknesses

Pay-for-Performance (P4P) schemes have become increasingly common internationally, yet evidence of their effectiveness remains ambiguous. P4P has been widely used in England for over a decade both in primary and secondary care. A prominent P4P programme in secondary care is the Commissioning for Quality and Innovation (CQUIN) framework. The most recent addition to this framework is Prescribed Specialised Services (PSS) CQUIN, introduced into the NHS in England in 2013. This study offers a review and critique of the PSS CQUIN scheme for specialised care. A key feature of PSS CQUIN is that whilst it is centrally developed, performance targets are agreed locally. This means that there is variation across providers in the schemes selected from the national menu, the achievement level needed to earn payment, and the proportion of the overall payment attached to each scheme. Specific schemes vary in terms of what is incentivised – structure, process and/or outcome – and how they are incentivised. Centralised versus decentralised decision making, the nature of the performance measures, the tiered payment structure and the dynamic nature of the schemes have created a sophisticated but complex P4P programme which requires evaluation to understand the effect of such incentives on specialised care.

To accept, or not to accept? A service evaluation to appraise complexity assessment of orthodontic patients referred into a secondary care setting.

Introduction Commissioners in England use the Commissioning for Quality and Innovation (CQUIN) payments mechanism to encourage the best provision of orthodontic treatment. However, CQUIN only use the patient's orthodontic need as a measure of complexity, rather than the levels outlined in the orthodontic commissioning guide published by NHS England. A service evaluation was designed to ascertain a secondary care setting's compliance with the commissioning complexity levels, as a new comparator for CQUIN case-mix assessment.Materials and methods A prospective evaluation was conducted for all new patients referred to the Mid Yorkshire NHS Trust orthodontic department in a 12-month period, using the levels categorised by the commissioning guide. A standard was set to accept no fewer than 80% level 3b patients.Results Of patients accepted for orthodontic treatment, 89.9% were of the highest level 3b complexity. This was compared to only 69.8% of patients having an Index of Orthodontic Treatment Need, Dental Health Component, 5.Conclusion The findings support a recommendation that commissioners should consider complexity based on the commissioning guidance, rather than orthodontic need alone; it is important that the economic drivers of commissioning implementation fairly reflect the specialist work being carried out by the workforce.

Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism in medical inpatients

Venous thromboembolism (VTE), consisting of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a common, potentially preventable and sometimes fatal illness complicating hospitalisation. Although the case incidence rate is higher in surgical patients, medical patients are probably responsible for up to 75% of hospital-acquired VTE defined as VTE occurring within 90 days of a period of hospitalisation. The Department of Health in 2010 mandated VTE risk assessment for all hospital admissions, and the implementation of this was initially assisted through a national CQUIN (Commissioning for Quality and Innovation). As a consequence, it is likely that many more medical admissions now receive prophylaxis than in the past, although data on the outcome of risk assessment and the use of chemical thromboprophylaxis in general medical inpatients in the NHS is not collected or published. The treatment of clinically diagnosed VTE is well established, with increasing use of outpatient management.1 By contrast, there is uncertainty around which medical patients should receive VTE prophylaxis, with which agent, at what dosage and for how long. The recent National Institute for Health and Care Excellence (NICE) guideline update NG892 reviewed the evidence and made recommendations for all inpatients over 16. This concise guideline focuses on recommendations relevant to medical inpatients.

A computerised system to evaluate patients with rheumatic diseases

Management decisions for complex cases should be made on the basis of multidisciplinary consensus in order to ensure that the optimal treatment decisions are made within a setting of increasing case complexity coupled with an expanding range of treatment options, many of which are very expensive. An NHS England commissioning for quality and innovation (CQUIN) was introduced for autoimmune rheumatic diseases in 2016. The aim of this proposal was to develop and implement an innovative software system to capture data on clinical caseload including complex disease status assessment using validated measures so that we could evaluate each patient and use a …

Using contractual incentives in district nursing in the English NHS: results from a qualitative study

Since 2008, health policy in England has been focusing increasingly on improving quality in healthcare services. To ensure quality improvements in community nursing, providers are required to meet several quality targets, including an incentive scheme known as Commissioning for Quality and Innovation (CQUIN). This paper reports on a study of how financial incentives are used in district nursing, an area of care which is particularly difficult to measure and monitor.

Healthcare professionals\u2019 views of the enhanced recovery after surgery programme: a qualitative investigation

BackgroundThe Enhanced Recovery After Surgery (ERAS) programme is an approach to the perioperative care of patients which aims to improve outcomes and speed up recovery after surgery. Although the evidence base appears strong for this programme, the implementation of ERAS has been slow. This study aimed to gain an understanding of the facilitating factors and challenges of implementing the programme with a view to providing additional contextual information to aid implementation. The study had a particular focus on the nutritional elements as these have been highlighted as important.MethodsThe study employed qualitative research methods, guided by the Normalisation Process Theory (NPT) to explore the experiences and opinions of 26 healthcare professionals from a range of disciplines implementing the programme.ResultsThis study identified facilitating factors to the implementation of ERAS: alignment with evidence based practice, standardising practice, drawing on the evidence base of other specialties, leadership, teamwork, ERAS meetings, patient involvement and education, a pre-operative assessment unit, staff education, resources attached to obtaining The Commissioning for Quality and Innovation (CQUIN) money, the ward layout, data collection and feedback, and adapting the care pathway.A number of implementation challenges were also identified: resistance to change, standardisation affecting personalised patient care, the buy-in of relevant stakeholders, keeping ERAS visible, information provision to patients, resources, palatability of nutritional drinks, aligning different ward cultures, patients going to non-ERAS departments, spreading the programme within the hospital, differences in health issue, and utilising a segmental approach. ConclusionsThe findings presented here provide useful contextual information from diverse surgical specialties to inform healthcare providers when implementing ERAS in practice. Addressing the challenges and utilising the facilitating factors identified in this study, could speed up the rate at which ERAS is adopted, implemented and embedded.

Improving inpatient care for older adults: Implementing Dementia Commissioning for Quality and Innovation (CQUIN)

Dementia is a common condition, and people with dementia occupy around 25% of hospital beds. Commissioning for Quality and Innovation (CQUIN) is an NHS payment framework that links part of...

Systems for physical health care for mental health patients in the community: different approaches to improve patient care and safety in an Early Intervention in Psychosis Service

Patients with mental illnesses have a high rate of physical comorbidity, and specifically, those with psychosis are at an increased risk of cardiometabolic disease and shortened lifespans, due to medication,...

Venous thromboembolism capture on electronic systems in obstetrics patients at St Thomas' Hospital.

Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the UK. Therefore, timely VTE risk assessment is essential in all obstetrics patients. The Commissioning for Quality and Innovation (CQUIN) payment framework set a target for trusts to complete a VTE risk assessment within 24 hours of admission for 95% of patients. A combination of factors, including lack of integration between multiple IT systems, means that this CQUIN target is currently not being met for obstetric patients in the Hospital Birth Centre at Guys and St Thomas' NHS Trust.This project aims to increase staff awareness of this issue and educate them regarding the correct procedure for VTE assessment. Trialled methods included reminders at staff handovers, use of magnets on the patient whiteboard, posters and stickers displayed around the unit and a loyalty card scheme as incentive to complete assessments. Initial average completion rate was 20.7%, which increased to 67.5% after the first plan, do, study, act (PDSA) cycle with a slight drop to 65.7% after the second cycle. Completion rates increased to 92.3% on the last day of the third PDSA cycle. Although we did not reach the 95% target, we have raised awareness of the importance of recording VTE assessment on electronic systems, and hope we have created sustainable change.

Community nursing quality indicators for end-of-life care in England: identification, preparation, and coordination.

High-quality community nursing is essential to ensure that end-of-life care can be provided in community settings in line with patient preferences. This article examines the quality priorities commissioners sought to incentivise in end-of-life care, by reviewing a survey of Commissioning for Quality and Innovation (CQUIN) indicators for community nursing conducted in England in 2014-2015. Findings from the survey suggest that end-of-life care was not given a high priority with the CQUIN indicators for community nursing. Vigorous quality standards, including training and development, need to be in place to make sure that the potential of community nursing is being used to sensitively engage with people nearing the end of their lives and support them to plan their future care, if they so wish.

Paying for improvements in quality: recent experience in the NHS in England

There is a long-term international trend towards linking payments more closely to providers’ performance. The US and England have been at the forefront of the design and introduction of such pay-for-performance (P4P) schemes. England’s experience is, however, likely to have greater salience for the Nordic countries’ health care systems due to the publicly funded finance structure. We review the development of five of England’s major schemes and summarise the available evidence on their impacts. These schemes are: the Quality and Outcomes Framework (QOF); Advancing Quality; the Commissioning for Quality and Innovation (CQUIN) framework; Best Practice Tariffs; and the newest ‘non-payment’ policies. Much of the evidence is limited by the non-experimental way in which the schemes have been introduced, with limited data available prior to the introduction of the schemes and no experimentally unexposed providers to serve as controls. Nonetheless, the existing evidence suggests that P4P can result in modest short-term improvements in the incentivised aspects of performance. There is little evidence of effort diversion, yet some to suggest positive spillovers of these schemes onto non-incentivised aspects of performance. While there is some evidence of gaming and inequitable consequences, these do not appear to be widespread. The gains that can accrue across large patient populations as a result of relatively small financial incentives mean that P4P schemes can be cost-effective. P4P programmes are likely to be most effective when introduced as a supporting part to a wider quality improvement initiative, and when results are published to encourage a reputational as well as a financial incentive for improvement. Though the accumulation of evidence to support P4P has not been systematic or especially robust, it remains a popular policy tool with decision-makers in England, with its reach set to increase further in the future.