Performance management of contracts and contractors

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Performance management ofcontracts and
contractors
Bev Norton
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Why performance manage?

• Public and patient safety
• Advance learning

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What we believe

• the vast majority of healthcare professionals are
  already seeking to give high-quality care to
  their patients for them, clinical governance
  arrangements are intended to provide support,
  encouragement and time for reflection on their
  clinical practice
• the best way of protecting patients is to build
  on and strengthen the existing arrangements for
  promoting the quality of clinical care,
  collectively known as clinical governance

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But..

• a small minority exhibit behaviour or clinical
  performance which puts patients at risk.
  Clinical governance needs to be sufficiently
  robust to maximise the chance of identifying
  these clinicians so that prompt action can be
  taken to protect patients. But no system can
  give an absolute guarantee of safety, especially
  (as the Shipman Inquiry fully recognised) when
  faced with an individual as devious and malign as
  Shipman.

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Performers List Management

• How robust is your system?
• Who monitors the inclusions?

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The National Health Service (General Medical
Services) Amendment (No. 4) Regulations 2001 (the
2001 Amendment Regulations) (1)

• obligatory for a PCO (then the HA) to carry out
  certain checks before admitting a doctor to its
  list. HAs were required to check, as far as
  practicable
• references provided by the applicant
• information given by the applicant relating to
  his/her medical qualifications and his/her
  registration

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The National Health Service (General Medical
Services) Amendment (No. 4) Regulations 2001 (the
2001 Amendment Regulations) (2)

• contents of his/her declaration about any past
  criminal or disciplinary record.
• This declaration was now required to be
  significantly fuller than previously whether
  there was any past or ongoing fraud investigation
  involving the doctor.

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The Health and Social Care Act 2001 powers (and
obligations) on HAs to remove a doctor from their
list on the grounds that

• the doctors continued presence on the list would
  be prejudicial to the efficiency of the medical
  services which doctors on the list undertook to
  provide (an efficiency case)
• the doctor had been involved in an incident of
  fraud or attempted fraud (a fraud case)
• the doctor was unsuitable to remain on the list
  (an unsuitability case).

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National Clinical Assessment Service

• the model recommended by NCAS involves
  investigation by a multi-PCT resource (the
  Performance Advisory Group) to establish the
  facts and decision by a senior PCT committee (the
  Decision Making Group) typically chaired by the
  medical director. Options include imposing
  restrictions on the practice, removal from the
  PCT list, application to the FHSAA for national
  disqualification as a GP, and referral to the
  GMC for possible erasure from the register.
• Shipman 5 has also recommended giving PCTs powers
  for some lesser actions e.g. warnings and
  requiring remedial action

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PCTs do have a range of mechanisms

• for identifying individual GPs whose performance
  is of concern. These include
• Monitoring of routine data including QOF scores
• Annual clinical governance reviews
• Analysis of complaints
• Concerns from other professionals
• Patient surveys
• Appraisal ? Revalidation?

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Where are the measures?

• It is possible to construct objective measures,
  with indicators that cover
• Clinical quality
• Organisational performance
• Patient experience
• Compliance with regulatory requirements
• Resource utilisation

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Clinical Governance reviews

• How do the practice approach their own clinical
  ?
• Protected time for regular team meetings
• Learning from significant events
• eg premature deaths, cancer cases, patient
  complaints
• Clinical audit
• Practice protocols
• What does the Clinical Governance Team do with
  the reports?

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Significant events learning

• Focus on the facts
• No blame
• Look at the system v individual
• What went well
• What was OK
• What could have gone better
• What should we do next time?

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One approach
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Essential Ingredients

• Clear evidence and clear focus
• Examples From the field
• Time to consider solutions
• Reality of working at street level
• Systematic recording of information
• Rapid feedback
• Appropriate resources
• Skilled management

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Data Used For Prescribing Analysis

• Name of prescriber
• Drug name, formulation and strength
• Quantity prescribed
• Number of items prescribed
• Cost of prescribing

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Method

• Analyse prescribing by practice for Morphine,
  Diamorphine and Pethidine injections only.
• Compare Cost and Items per 1000 Patient unit
  between practices and the PCT average.
• Identify practices above the norm (PCT average).
• For these practices identify the injections that
  are above average.
• Produce a detailed report itemising all
  prescriptions prescribed.
• Produce a trend graph for the injection(s)
  detailing the number of ampoules prescribed in
  the past 24 months.

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QOF and Assessment
Match indicators against other hard data
sources, such as PACT. Eg. Do cholesterol
indicator reports from QMAS match the extent of
prescribing for cholesterol lowering
drugs? diabetes matching appropriateness of
diagnosis against date of diagnosis, laboratory
test results looking at glycosylated Hb and
blood glucose results.
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Practice List Size
Spearmans Rho 0.33 Sig at 99
level Association particularly strong with
Organisational Achievement Confounding variables?
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Prevalence by Condition
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Prevalence Map Diabetes Mellitus

• Deprivation
• Ethnicity
• Age profiles
• Identification

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Indicator DM7

• Indicator DM7 - The percentage of patients with
  diabetes in whom the last HbA1C is 10 or less (or
  equivalent test/reference range depending
  on local laboratory) in last 15 months. 

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Indicator - DM7
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Potential to develop hypertension
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Areas to develop hypertension

• More blood pressure recording
• ?staffing, ?coding
• Increased use of guidelines and protocols for BP
  control
• Primary prevention strategy
• Diet, exercise, smoking cessation

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Contract monitoring An approach form some BBC
PCTs

• Review of NSF work
• QOF
• Contractual obligations framework
• Practice specific information
• Previous reports

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15 target areas

• A full review of all the contract clauses with
  details and evidence

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Issues for the future

• To some extent, the provider is also an
  individual, the GP. Clearly this is the case for
  all single-handed GPs but more generally reflects
  the fact that most providers in primary care
  are small independent partnerships.
• determining a practice is failing will
  sometimes be equivalent to asserting the
  clinician is failing as well (with the
  implications this has for their employment in the
  NHS).

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The old story, new twists

• variations in the quality of primary care
  providers.
• introduction of a wider set of providers
  competing for patients (along with increased
  incentives on existing providers) increases the
  need to provide assurance that performance
  standards are high.
• market led approaches to primary care are also
  likely to increase the number of business
  failures and voluntary exits (e.g. retirement)
  that will require handling.

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strong need for a clear accreditation process

• These could include
• A new peer review process building on the RCGPs
  existing practice accreditation scheme
• Assessment by PCTs operating under license from
  the RCGP or Healthcare Commission
• More robust quality measures added to APMS
  contracts

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Subtle ways patient empowerment

• the importance of information to enable patients
  to make informed choices in dialogue with
  clinicians and to take better control of their
  own health - Better information, better choices,
  better health
• Expert patient programmes for patients with
  longer-term conditions
• use of information from patient satisfaction
  surveys, involving all hospital trusts and
  administered by the Healthcare Commission, to
  assess and improve services
• use of patient surveys to assess DES for Choice
  and Access
• a specific duty on all organisations to involve
  patients and the general public in the planning
  and development of services

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Subtle ways patient empowerment

• Patient Liaison Services (PALS) and the
  Independent Complaints Advocacy Service (ICAS).
  Both these services act as a powerful lever for
  change by providing feedback and highlighting
  best practice
• the provision of direct mechanisms to enable
  patients to report patient safety episodes
  directly to the NPSA and adverse drug reactions
  to the Medicines and Healthcare Products
  Regulatory Agency (MHRA)
• the proposed provisions in the NHS Redress Bill
  for financial recompense to those who suffer as a
  result of avoidable errors in the NHSiv. This
  places the emphasis on putting things right for
  patients as a matter of course, provides an
  alternative to litigation, and will contribute to
  the culture of learning in the NHS.

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Performance management ofcontracts and
contractors
Bev Norton