The Head of Quality and Nursing at Fareham and Gosport and South-Eastern Hampshire Clinical Commissioning Groups (CCGs) with support from the Quality Team led the development and implementation of a quality surveillance system. This has led to local improvements of patient outcomes and safety, patient and staff experience, and use of resources.
Where to look
Clinical Commissioning Groups (CCGs) were created following the Health and Social Care Act in 2012, and replaced Primary Care Trusts on 1 April 2013. They are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. Commissioning focuses on getting the best possible health outcomes for the local population. This involves assessing local needs, deciding priorities and strategies, and then buying services on behalf of the population from providers such as hospitals, clinics, community health bodies, etc. It is an ongoing process. CCGs must constantly respond and adapt to changing local circumstances as they are responsible for the health of their entire population, and measured by how much they improve outcomes.
Following the formation of Fareham and Gosport and South-Eastern Hampshire CCGs, it was recognised that there was a need to monitor local safety information ensuring this data supports commissioner oversight of service providers. Although there were areas of good practice locally, there was no single consistent system of identifying and learning from incidents across providers and systems, which was resulting in unwarranted variation in practice.
What to change
NHS England (2015) describe how responding appropriately when things go wrong in healthcare is a key part of the way that the NHS can continue to improve the safety of the services we provide for our patients. Healthcare systems and processes like any other systems and processes can have weaknesses that can lead to errors occurring and, tragically, these errors sometimes have serious consequences for patients, staff, services users and/or the reputation of the organisations involved themselves. It is therefore incumbent on us all to continually strive to reduce the occurrence of avoidable harm.
Over the last decade the NHS has made significant progress in developing a standardised way of recognising, reporting and investigating when things go wrong and a key part of this is the way the system responds to serious incidents.
The CCG nursing and quality leads noted that service and care quality concerns whilst being reported and dealt with appropriately by teams, they were often reported and viewed in isolation and on an ad hoc basis, which meant the leads couldn’t triangulate data. This meant that themes and trends which were useful to commissioners and providers alike could lead to unwarranted variation in practice.
How to change
The Head of Quality and Nursing, with support from the Quality Team within the CCG, led the search for a digital surveillance system that would help support longer-term multi-organisational learning and sustainable improvements, including sharing information and intelligence, early warning mechanism of risk about poor quality, and opportunities to coordinate actions across organisations to drive improvement. The Quality Team consists of a system administrator, project manager, system architect, senior analyst and clinical quality lead, with strategic direction from the CCG Chief Nurse. This mixture of capabilities provides wide and in-depth experience in clinical, primary care and technical knowledge. The Head of Quality and Nursing and the Quality Team worked in partnership with a media and technology company to develop a system called ‘Quasar’ to support safe and effective provision of healthcare services.
Quasar is a quality surveillance system underpinned by CCG safety incident policies that can help facilitate change, allowing healthcare professionals (HCPs) to report any concerns they have with the quality of care and services provided by healthcare providers. All feedback submitted is reviewed by registered nurses and midwives on a rota basis, applying their clinical judgement to determine how this is managed. The feedback is categorised for themes and trends and shared with the provider if there are any safety concerns where learning or change is necessary. The themes and trends are analysed down to department level to help identify services within providers that may be facing challenges in providing a quality service. This allows the CCG Quality Team, renamed the Quasar team, to work with the providers to support the relevant team/s with improvement.
The Quasar team contacted primary care practices and planned face-to-face visits to provide training on the system. A training resource pack was developed with slides, screen shots and reference documents. Training sessions included examples of incidents that practices would find familiar and the team mix provided clinical, primary care experience and technical support. Logins to the system were provided ahead of visits to enable practical set up during the training. Quasar supports primary care by:
- Practices having a system to record complaints and incidents;
- A clear audit trail of complaints and incident management;
- Supports nurse and GP appraisal;
- Evidence of contract and CQC compliance;
- Practices able to view HCP feedback; and,
- Standardises incident and complaint investigation to support cross practice working.
Fareham & Gosport and South-Eastern Hampshire CCG offer ongoing support to the CCG Practice Managers Forum, Clinical Assembly, and individually organised training sessions based on the ongoing needs. As a support resource, the Chief Nurse also led the Wessex Quality hub to develop ‘Managing Incidents in Primary Care’, which has now been adopted across Wessex and given to every practice as a reference guide. In 2018, acute and community providers also started to use Quasar.
Better outcomes – Since the implementation of Quasar, the CCG has significantly reduced unwarranted variation in safety practice. A single incident policy is now in place across the two localities and Quasar HCP reporting is continuing to increase, suggesting an evolving safety culture and awareness. Quasar provides functionality for a CCG to work with a provider to support improvement. The changes and improvements resulting from HCP feedback has put patient safety at the forefront of everyday practice. All primary care practices are now using Quasar and between April 2016 and March 2018 there were 2,266 pieces of feedback logged.
Better experience – Positive feedback has been received from system users, including:
“Thank you to the X department. All my recent contact with both registrars and consultants has been very positive. Also thank you to Mr X for providing medical statements to patients at clinics. This makes a big difference in reducing workload for primary care (X Medical Centre).”
“I would like to compliment the team on the development of the written complaints report. I used the Quasar report for my 2017-18 submission to NHS England and it matched exactly with the requirements. Thank you. (Y Medical Centre)”
Changes made following feedback has improved patient experience. Examples of this include: the hearing aid service reversed a change in hearing aid battery provision that was leading to poor patient experience, and the phlebotomy service has extended its hours and voluntary sector support has been obtained to meet patient needs.
Better use of resources – By measuring performance over time, trends can be identified and better forward planning can take place. Feedback has led to an improved use of resources locally, for example the blood service changed the blood courier schedule, reducing rejected potassium samples from 1700 to 263. With a local acute Trust, handwritten discharge summaries were causing delays in patient care and significant time was spent calling the relevant department to obtain necessary information – an electronic system has now been implemented to address these issues.
Challenges and lessons learnt for implementation
Safety culture needs to be considered as themed data is only as good as the information initially recorded in the system at the point of incident.
Reluctance to change is always a challenge – this was overcome through professional discussion, appreciative enquiry, all including the concept of ‘a just culture’, with a poster included in the resource pack. Peer influence and “train the trainer” also appeared to be effective approaches and the lived benefits of using Quasar were highlighted at every training opportunity.
For more information contact
Quality Systems Administrator
Fareham & Gosport and South-Eastern Hampshire Clinical Commissioning Groups