Q3 2011-12: Report on the activity of HQIP

Report on the activity of HQIP, September to December 2011

Headlines:

1.      National Clinical Audit

This work involves commissioning and contract managing large programmes of national audit and confidential enquiries, known as CORP (clinical outcomes review programme). Work described applies to England and Wales except where mentioned.

1.1   We monitor the progress of all the audits we commission as part of their contract management. This includes reviewing audits coming up to the end of their funding and where an agreed plan is in place to change the contract in some way. We are currently reviewing proposals to streamline four specific projects, two on stroke and those about falls and hip fracture, into two combined audits. We are also reviewing the four audits coming to the end of their first period of funding - Schizophrenia, Epilepsy 12, Pain and Inflammatory Bowel Disease - according to an agreed new format. Next year we will be further enhancing this review process with some external support, and it will be informed by feedback received from local clinicians, auditors and trusts - see 1.4.

1.2   We are carrying forward the commissioning process for the first four new national audits and extensively supported the press work for the 11 topics announced in September. The specification writing process, which we, and specialists concerned regard as essential and invaluable - is progressing for the first 2 with Pre-qualification Questionnaire (PQQ) pack development in train for the next 2. We have agreed a tender appraisal format, with scoring, for the new proposals for use by The National Clinical Audit Advisory Group -NCAAG.

1.3   We have been given final Departmental go-ahead re subscription by trusts to provide payment for national audit. The Department will write to all Trusts concerned in January 2012. HQIP will approach Trusts to recover their funding later 2012 but will arrange payment systems in advance of this (does not apply in Wales).

1.4   We have instigated a programme of action to address weaknesses in the national programme in regard to the concerns of local audit staff and clinicians. Their concerns are focused on the burden of participation in national audit, arising especially from their concerns about the quality of some audits. The actions to respond to these are contained as annex 1 below. The main aspects are: establishing a feedback channel from local people to national audits, via HQIP; a requirement on each funded audit to obtain feedback from its own identified stakeholders, as many do already; the Quality Accounts work given at 1.5 below; and an attempt to agree a consensus on quality principles for national audits, from an adapted version of the Australian Operating principles, consultation on which will start just after Christmas.

1.5   One of these improvement areas specifically relates to the selection of audits for inclusion with Quality Accounts. At high speed HQIP have instituted a stage of review against criteria of alignment to government policy and obtaining feedback from local people and professional groups. This completed on the 9th of December and is being considered by NCAAG, then approved by the Department of Health and then issued in January to local Trusts. This process has ensured openness and transparency for the QA audit selection process for the first time and given the opportunity for local people to feel involved (does not apply in Wales).

1.6   The index of participation by local trusts in national audits (PAR-CAR) has been renewed in a fully searchable form for January 2012, enabling greater functionality.

1.7   The National Joint Registry has published its first patient annual report, a really ground breaking patient specific version of the main annual reporting which will also help patients understand the process of joint replacement. This is available at: http://www.njrcentre.org.uk/NjrCentre/LinkClick.aspx?fileticket=27UDBe%2bCnwQ%3d&tabid=232&mid=902

The NJR is conducting a range of programmes to improve its data quality, expand to cover Ireland, explore alternatives to its funding model, and improve linkage and communication with other joint registries worldwide. These activities complement other work on supporting research in partnership with other organisations, and in review of internal governance.

1.8    We have recruited a consultant, Linda Haines, to lead our work on two areas of quality in national audit: Transparency (making publicly funded data more widely and openly available) and helping projects to achieve compliance with best practice in information governance.  On transparency she is working with each national audit contractor to ensure they are compliant with governmental requirements re transparency of data. This will involve developing a statement, completed by April 2012, of by when each audit will report results down to local trust or unit level, and in the case of surgical audits, potentially below this to individual surgeon level where the data quality allows. This work also involves establishing a timetable for reporting in different audiences and formats and making data available via various public channels. The first set of data went live on data.gov on 23 December 2011, for Lung Cancer: http://data.gov.uk/dataset/national-lung-cancer-audit-2011-annual-report (does not apply in Wales).

1.9    On Information Governance we are working with the national body, the ECC committee of the National Information Governance Board to review the compliance of the whole programme with NIGB expectations, partly as a result of their intent that wherever possible national audits should obtain patient consent, or use pseudonymised data, rather than securing exemptions under Section 251 of the relevant NHS Act. This work will be complete by April 2012.

1.10   As previously announced we will be providing a programme of advice and information about data governance, based on NIGB requirements for providers. We are developing new guidance to providers on information governance, including release, and to local providers who supply data, to improve understanding of how data will be shared and used. This will include an update of our template for national audit reports.

1.11   Our seminar programme to support best practice restarts in 2012 with a seminar on Information Governance issues on 20^th February at the Welcome institute; this will be followed by seminars on PROMS/PREMS and ethical considerations (April 2012); Outliers - making guidance a reality (Oct 2012); Contracting and procurement for beginners - financial governance and reporting (Dec 2012) and our annual conference in May.

1.12   We will be inviting proposals for a new round of multisite audits in January 2012 (does not apply in Wales).

1.13   We are working on a guide to setting up registers and national audits, which is aimed to be ready in March 2012.

1.14   We of course manage on a routine basis the issue of reports from national audits, assisting with press handling and approval prior to issue. Recent reports, such as for dementia, have received wide attention. We have reviewed the system used and the guidance to audits in preparing their reports to streamline this and improve the quality of the reports.

1.15   We have invited bids for a new round of funding for clinical registers. We continue to expand and improve the existing mapping of registers and databases launched late in the summer.

1.16   We regularly meet with teams considering developing new audits or looking for future funding. We advise them on the steps they need to take and what they need to have in place, whether applying for funding from HQIP in the future or seeking funding elsewhere. This includes advice on methodology, governance, information governance, clinical and patient engagement, and reporting findings and helping steer change at the local level.

1.17 We are looking to strengthen our advice on methodology, either from direct recruitment or the identification of suitable consultancy from academic centres.

1.18  On the CORP programme we are working through the commissioning of the new provider of the Maternal infant and perinatal study. Whilst the formalities of this are completed we continue to operate the interim data collection devised by Departmental leads with the previous provider, the NPSA. Data on deaths in this category is being collected for 2011-12.

1.19  We are working with the Specialist and specialised commissioning teams to advise on commissioning of registers that support their commissioning of specialist and specialised services.

2.  Cross cutting work on clinical audit

2.1   Clinicians: We have placed a detailed mapping of specialist bodies, from colleges down to faculties and societies with their interests in audit and registers, on our website, and this is being updated constantly. (see: http://www.hqip.org.uk/assets/National-Team-Uploads/Specialist-societies-and-their-role-in-audit-Website-12-11.pdf ). We are engaging with some of these bodies to promote their greater involvement in audit. This includes advising them how to develop national audits with a view to improving the size and quality of the UK market of providers in audit.

We are currently recruiting two clinical fellows, jointly with the RCGP, to promote audit in general practice.

2.2   Education: We plan to issue the new version of the training standards and curricula guidance for audit in late January 2012, following analysis of the responses to consultation. The comments were generally very supportive.

2.3   Our educational resources continue to come on line in sequence - Non-Executive Directors (NEDs) and Internal Audit guidance contracts are let and will be delivered in the new year; with GPs and Medical Directors on boards guidance to follow.

2.4   We will be hosting a conference on clinical audit in Europe, in London, on behalf of the European Society for Quality in Healthcare (ESQH) in 2012.

2.5  Governance: Work continues on finishing the integrated governance handbook through The Good Governance Institute  - GGI - whose partners wrote the original integrated governance handbook whilst at DH; this has been delayed but will be put on line in January.

2.6   Audit as part of Information strategy:  This autumn we have been required to promote the importance of audit data as part of the information needs of the NHS. This has involved submission to various consultations, presenting to the Francis Enquiry, chairing events and speaking at conferences.

2.7 We have created a consultancy marketplace to enable consultants who specialise in specific areas of support for national and local audit to advertise themselves via the website.                                                                  

3. Supporting Local Audit practice

3.1       Much of 2 above, relates to local audit staff, and in this report, under 1 also as we are trying to ensure our work is more integrated across both sectors with increasing use of our development team to communicate to national audit and channel issues to or national audit team. We continue, as ever, to support local teams through advice, information, local networks and events. We support the national audit practitioners group. NAGG, the regional groups, and a new pilot regional clinicians group in the North East. We have refreshed our website section for this team and during 2012 will be exploring differences in views about support for national audits at local level given the different views local audit staff have about national audits from the Department of Health, NCAAG, and those who run national audits.

3.2    We ran our national conference for local audit staff in October in Manchester at which Sir Bruce Keogh spoke. Evaluations were very positive and the annual awards winners are on our website.

3.3    We are soon to complete the consultation, via our consultants the Social Care Association, on the formation of a possible professional body for those who work in audit/and or QI generally. This will report in January.

3.4    Work continues to plan the annual two day Healthcare Conferences event in February 2012, which we jointly run and which has been publicised. HQIP subsidises places.

3.5   We continue to undertake extensive work on promoting and developing audit practice adapted to a social care environment. As well as recently meeting with key social care researchers and more extensively with DH social care staff, this has included practitioner workshops over the autumn and commencement of writing a handbook, which is planned to be ready in April. SCIE are assisting us with this. We are helping the nutrition audit to develop to be suitable for a social care audience and are exploring with Departmental officials, potential topics for audits in social care settings which will meet their policy needs and how audit in the sector can be supported.

4. Other work

4.1  We are engaging with colleges about their interests in accreditation of accreditation systems for clinical services.

4.2  We continue to host the UKQC advisory group on quality.

4.3 HQIP has recently conducted a review of its internal governance and is exploring how we can recruit a new advisory group, made up of a wider range of interested organisations.

4.4  We are currently in discussion with the NHSIII about how we might work together more closely - a very welcome step.

Annex 1

1.         Improving the national audit programme

Starting this month (November 2011), with support from the Department of Health, HQIP is starting a rolling programme of improvement of aspects of the national audit programme.

The purpose of this work is to act on some areas of key government policy, such as in relation to transparency of data and openness of dissemination of findings; but also to improve the functionality of the programme and related activity like Quality Accounts, and to address some issues with the effectiveness of some of the audits and act on feedback received from local stakeholders. This has been under discussion for some months, and our recent conference for local audit staff was useful in confirming some of the detail of what we needed to do.

The key elements are:

Agreeing consensus in key principles in national audit

The creation of a document which sets out essential criteria and principles for national audits. This will have multiple purposes but it will help inform commissioning decisions, help those designing audits, and set out key aspects we expect to see in any audit project, including governance, purpose, methodology, relationship to other data, transparency, action to drive change, and measurement of outcomes. It will resemble, and draw from but extend beyond, a similar document produced in Australia and available here. 

HQIP will consult extensively on the draft document with a wide range of stakeholders, both at national and local level. The new document will be complete by April.

A new process for agreeing inclusion of national audits in the Quality Accounts list

HQIP will supervise a new consultative process to agree a final list of audits to be included in the quality accounts reporting. This will involve obtaining the views of local and national stakeholders and be completed in adequate time for preparation at local level. This will start very soon.

The department listened to some concerns that have been raised about the QA list, and emphasise that Quality Accounts don't mandate participation in particular clinical audits only that providers describe which audits they have participated in.  In order to 1. alert providers to NCAs that they can participate in, 2. support the description of which audits providers have participated in and 3. provide comparability between each provider's Quality Account -  the Department provides an annual list.  Overall this approach has worked very well. HQIP will be consulting with stakeholders with the aim of producing a list of NCAs whose quality/usefulness has been assessed to aid providers in deciding which NCAs to participate in.

Transparency and Reporting

HQIP will agree with every funded audit a plan for when they will publish their data at the appropriate level of granularity for their audit. This will be complete by April 2012. In nearly all cases this will be at a default level of the trust as soon as possible, and for audits which can work towards an even more detailed level of reporting, where this is appropriate, protects patient confidentiality and is supported by the data.

We will also increasingly expect to see the production of audit findings in a manner easily understood by the general public, with an expectation of a patient appropriate version of their annual reporting, with guidance on how to do this.

Review of quality of existing funded audits

We will be commencing a more detailed ongoing process of independent review of audits before they are renewed. We will also be reviewing each audit with the IGB to ensure there is full compliance with their expectations and making changes as necessary.

A feedback system for national audits

HQIP will shortly (before Christmas) be rolling out a new system for obtaining feedback on existing national audits, which will involve gathering stakeholder views on a regular basis. This is will incorporate findings from work being led by NAGG. We will also expect all national audits to carry out request for feedback from key stakeholders as part of their work, and report to HQIP on how they have addressed the findings. All feedback will be used to help improve the functionality and output of these projects.

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