Scottish Government

5. The Way Ahead - The Quality Strategy

The Aim

The clear aim of our Quality Strategy will be the creation of a new era of health improving and healthcare services in Scotland where we listen to what staff, patients and carers tell us, and we all work together to provide person centred, safe and clinically effective care for everybody, every time, now and for the future. Achieving this will ensure that the quality of healthcare services delivered by NHSScotland is recognised as amongst the best in the world.

This high-level aim will be achieved by working from the bottom up, and will build on:

• Scotland's reputation for high-level clinical skills and leadership - for example, pioneering the use of quality guidelines through SIGN, best practice statements, knowledge exchange and leading in the development of the use of clinical data
• The early success of the Scottish Patient Safety Programme which has marked Scotland as a world leader in developing a national patient safety programme
• The opportunity for strong leadership and delivery which our integrated NHS system provides
• Professional Values
• Staff ownership and enthusiasm for improving quality and safety
• High quality partners in the contracting and voluntary sectors
• Patients' motivation to be partners in their own care
• Scotland's focus on collaboration and professional values
• The range of existing national and local initiative and programmes already in place.

We will need action at all levels if we are to succeed. We will need true alignment from national strategies through to individual behaviours. In order to achieve this, our approach will be designed to be:

• Person-based : reflecting the uniqueness of the individual, their experience of their health, illness and health care, and enabling them to share in decision making about their care, to manage their own health, and illness though support and access to advice and informaiton.
• Staff-based : Building capacity and making the right thing the easiest thing to do.
• Systems-based - simplifying policy/delivery landscape, re-enforcing priorities expressed through Better Health Better Care, and shifting emphasis from performance management to continuous improvement
• Partnership-based : NHS working with public and third sector partners, staff, contractors, patients and carers

The Key Drivers of Quality

In order to be recognised as world leading we need to set out a clear set of measureable and achievable objectives related to the key drivers which we propose to pursue.

Better Health, Better Care was built on the Institute of Medicine's six Dimensions of Quality. It is proposed that six dimensions will remain the key foundation of our approach to systems-based healthcare quality improvement:

Institute Of Medicine 6 Dimensions of Quality

• Person centred: providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide all clinical decisions
• Safe: avoiding injuries to patients from care that is intended to help them
• Effective: providing services based on scientific knowledge
• Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy
• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socio-economic status
• Timely: reducing waits and sometimes harmful delays for both those who receive care and those who give care

By focusing on what really matters to people, we will raise the quality of healthcare from the current high standards to world-leading by concentrating our priority action and interventions in three of these dimensions:

• Put people at the centre of care and ensure that all staff, patients and carers can report that they are supported to work together in a relationship which recognises their needs and plans to deliver care to meet those needs
• Improve clinical effectiveness, with a focus on reducing unnecessary and harmful variation in the models and methods of delivering care and treatment, and on the standards of care for long-term conditions
• Improve safety throughout primary, community, and acute services, achieving significant reductions in mortality and adverse events

We have chosen to focus on improvement in these 3 areas, as we believe that through our shared pursuit of these ambitions for every patient, every time, we will also continue to pursue maximum value for the investment we make in our healthcare services. There is clear evidence that improving effectiveness, safety and person centredness have significant positive impacts on reducing costs, and rely on maintaining the unprecedented improvements we have made in waiting times and access to primary, secondary and emergency healthcare services. We will also ensure that the high quality health services we deliver are provided on an equitable basis - to everyone in Scotland, no matter who they are, or where they live. To do this we will establish an effective and appropriate Quality Infrastructure which will ensure the integration required across all programmes of work. Therefore, while the primary focus for action will be on the 3 key drivers, we are also committed to pursuing these in a way which ensures equity, efficiency and timely access.

The Key Interventions

In order to provide a clear and shared understanding of the ambitions of the Quality Strategy, we propose to focus on supporting the fundamental shift in culture required to create person-centred, clinically effective and safe care by setting out a number of specific areas of actions which will create the momentum needed to deliver our aims across the whole NHS in Scotland. The extended version of the Driver Diagram below sets out the areas of activity associated with each Driver, and related to these, the proposed key improvement interventions. We will confirm the areas for action and the key interventions and agree the details actions required to make progress. One of the primary requirements of the Quality Strategy is that we take an integrated approach across all the actions. We will ensure that the governance and delivery structures across NHSScotland support this linking activity across every programme.

Driver Diagram 2 - Proposed Specific Improvement Interventions

Person centred: We have a number of programmes and pilots in operation at present which are aimed at putting people at the centre of care and at supporting the development of relationships between NHS staff, patients and carers which result in shared decision making, better experiences and outcomes for patients and carers, and greater job satisfaction for NHS staff. For example, there is the Patient Experience Programme (currently focussing on inpatients, Primary Care and long term conditions), the Self Management Strategy, the Delivering Patient-centred Care Programme underpinned by 'Curam', the Carer Information Strategies, Scotland Cares and the other work streams underway in the Chief Nursing Officer Directorate to develop further the caring and enabling aspects of the Nursing Midwifery and AHP professions. We have recently expanded considerably the scope of our patient experience surveys for GPs and will explore how similar approaches could be applied elsewhere in primary care. There is also the work to establish NHSScotland as a Health Promoting Health Service.

We propose that the Quality Strategy will set out how we will bring this and other work together more coherently, visibly and consistently and how we will integrate it with new developments such as the work on supporting 'relationship-based care', and shared decision making tools (for which there is strong evidence of improved patient choice, better experience and lower utilisation of expensive interventions). We will also ensure that our investment in our capital infrastructure provides the appropriate environment to support high quality healthcare experience and outcomes.

We also plan to establish an appropriate approach for measuring individual patients' own assessments of the quality of the outcome of their healthcare episode, whether in primary, secondary or emergency care, so that a patient-based measure of health outcome and experience can also be used to drive improvement in the quality of healthcare services.

In order to capture patients' assessment of their relationship with the healthcare professional supporting them, in such a way that it can be used to inform improvement, a measurement technique known as the Consultation and Relational Empathy ( CARE) measure has been developed in Scotland. The CARE measure has been well validated with doctors, both with GPs in primary care and consultants in secondary care. We will pursue the introduction of the use of the CARE measure in all clinical appraisals, and in the development of revalidation. We will be able to use these measures to highlight action needed to ensure equity in terms of health outcomes and experience.

We propose that the initial focus of action will be:

• Develop measures of patient reported experience and outcomes
• Introduce the CARE measure in all clinical appraisal and in revalidation
• Develop and introduce collaborative shared decision-making through relationship-based care, reflecting each individuals own circumstances

Effective: We will focus on shifting the balance of care and identifying and reducing inappropriate variation in community, primary and acute healthcare pathways, care packages and treatments so that the best care is consistently provided by the right person in the right place at the right time. We will also implement our proposals to improve standards of care for long-term conditions in hospital, in the community and through self-management. It is proposed that, through this driver we will ensure that clear and challenging outcomes and success indicators are established for the quality and performance of health services for people with long-term conditions, and that there is leadership and capacity to support improvement. Much of the work required to improve quality and ensure sustainability of services for patients with long-term conditions will involve primary and community care services, and supporting the drive to shift the balance of care away from hospital services towards the community. Shifting the balance of care has the potential both to make services more efficient and sustainable by avoiding unnecessary hospital admissions, and to improve patient experience. We will support those in our population most at risk by ensuring that each of them has an integrated and shared Anticipatory Care Plan in place. Making this aspiration a reality will require a firm commitment to excellent cooperation and communication between the different stages in the care journey.

We will also continue to deliver our policy of reshaping the medical contribution ot the clinical workforce, so that it is delivered predominantly by trained doctors, rather than doctors in training, in collaboration with non-medical members of the clinical team where that is best for patients.

We will also ensure that NHS staff are properly supported, through new development packages where necessary, to provide anticipatory health and healthcare advice and support to people and their carers which recognises the wider social and economic context of their lives.

We will support a step change in health literacy across the whole population, taking full advantage of existing and new approaches to communications, technology and resources to ensure that everybody has access to the information and advice they need, when they need it to support them in maintaining health, managing ill health and in making shared decisions.

Our key priorities will be to:

• Ensure that Anticipatory Care Plans are in place for the 5% most at risk in admission
• Shift the balance of care and reduce inappropriate variation so that the best care is consistently provided in the right place, by the right person
• Reduce re-admission
• Implement the Long-term Conditions Action Plan
• Reshape the medical contribution to the clinical workforce
• Ensure all our GP enhanced services are fit for the purposes of this strategy

Safe: The Scottish Patient Safety Programme is now making a significant impact across the NHS in Scotland. It represents an ambitious effort to make substantial safety improvements for the benefit of patients across a health system, and has gained significant ownership and buy-in from NHS professionals and staff. It aims to implement a set of key evidence-based interventions uniformly across all acute hospitals in Scotland, and to deliver significant reductions in mortality and in adverse events. We will roll out the successful focus on patient safety into a range of other care environments, and will develop appropriate approaches to improving safety in primary care and in mental health.

NHSScotland's eHealth Strategy launched in June 2008 is focussed on using information to improve quality. Good progress is being made in developing the information technology and improving the business processes necessary to ensure that we get benefit from our investment in eHealth. The aim is to build a 'virtual patient record' that will contribute towards safety, continuity of care and collaborative decision making. With additional investment planned for 2010/11, key eHealth contributions to better quality care will include;

• Developing the Emergency Care Summary ( ECS) to enable, for example, it's use in planned as well as emergency care
• Implementing the 'clinical portal' programme to enable better sharing of patient information
• Continuing to develop the 'patient portal' to allow patients access to information about their health
• Working on ways to bring clinical data to frontline staff

Finally we will ensure that the extensive work begin carried out to tackle HAI in hospitals is fully aligned with the safety work, and as a result with the full quality strategy.

Our key priorities will be:

• Accelerated spread of SPSP across acute care
• Develop approaches to patient safety in Primary Care and Mental Health
• Make the electronic Emergency Care Summary widely available
• Integrate the work on reducing the occurrence of HAI with the Scottish Patient Safety Programme

Quality Infrastructure: A key requirement in the realisation of our ambitions for a world leading healthcare quality system is that all of our systems and actions are integrated and aligned across the whole NHS system. To ensure that this is achieved, we will establish a new Quality Alliance which will oversee the implementation of the Quality Strategy, and for ensuring whole-system integration and alignment.

There is international evidence that the development of measures is a fundamental driver of large scale improvement. We therefore propose the development of a basket of high-level measures which define what we mean by high quality healthcare services. These measures will be underpinned by a 'Quality Dashboard' of indicators which will give us rapid feedback and allow us to identify and manage risk, and to support continuous improvement in pursuit of our aims. The availability, timeliness and quality of the data used to support the high level Quality Measures, the Quality dashboard, and the range of improvement measures required to inform the continuous improvement activity required will need to be assessed and where necessary, NHS: QIS and NHS: NSS: ISD will need to work together to take action in order to establish the appropriate data sources.

Our key priorities will be:

• Establishing the Quality Alliance
• Developing a 'Quality Dashboard'
• Agreeing high level Quality Measures which reflect the shared understanding of the features of high quality healthcare, ensuring alignment with HEAT, the National Performance Framework, the Quality Dashboard and any new governance and risk management standards developed by NHSQIS.
• Establishing appropriate data to support developments of measures and continuous improvement

Proposed framework of potential areas for measurement

Efficiency, Equity and Access

We propose to focus our interventions primarily around person-centredness, clinical effectiveness and safety because we know that we will take appropriate action in these areas which will also drive equity, efficiency and access. We also know that these are the key priority areas for patients, their families and the people who work in NHSScotland. We are absolutely clear that the other 3 dimensions of quality as set out by the Institute of Medicine; efficiency, equity and access, must not be compromised. There is robust and extensive evidence that pursuing person-centred, safe and effective care, for every person, every time, will result in significant cost savings, in streamlining and improving access and by definition in improving equity. For example, the pursuit of reduced rates of re-admission as part of the clinical effectiveness focus will have a positive impact in terms of reducing costs, and increasing efficiency.

Efficiency: Pursing improvements in whole-system healthcare quality through the 3 drivers set out above has the potential not only to improve care but also to prevent avoidable costs. We know that amongst the biggest drivers of avoidable costs are infections, inappropriate hospitalisation of people with chronic disease, and variation in practice. Evidence from healthcare systems that have applied shared decision making tools is that these too can reduce avoidable costs. People will often choose to have a less intensive and invasive procedure (at lower cost) when they get the opportunity and the data to make an informed choice. We also know that good communication contributes positively to wellbeing, hastens recovery and enhances effective self management in long term conditions. Patients who have an empathetic, patient centred experience are more likely to retain health information, and to comply with advice and prescribed therapy. While the primary purpose of the Strategy will not in any way be to reduce cost, at the same time it can often be the case that better quality needn't cost more and indeed can cost less. There is also significant evidence of the interplay between patient experience and staff experience. Specific strategies used by top performing health providers to ensure staff engagement and resilience in patient centred care, have been shown to have an impact on the overall efficiency and productivity of the organisation. (As demonstrated, for example, in "Seeing the Person in the Patient: The Kings Fund Point of Care Programme Report"). The work being taken forward with NHS Boards through the national Efficiency and Productivity Framework will be aligned with the Quality Strategy, and will align with the 3 key drivers set out above.

Equity: The NHS is committed to understanding the needs of different communities, eliminate discrimination, reduce inequality, protect human rights and build good relations by breaking down barriers that may be preventing people from accessing the care and services that they need, as well as meeting the legal duties in relation to race, disability and gender. It aims to address inequalities by recognising and valuing diversity, promoting a patient-focused approach and involving people in the design and delivery of health care. Equally Well sets an ambitious and radical programme for change across the key priority areas of children's very early years; the big killer diseases of cardiovascular disease and cancer; drug and alcohol problems and links to violence; and mental health and wellbeing. An implementation plan has been developed to support further progress and change, both at local and national level, with NHSScotland working in partnership with the rest of the public sector and with third sector organisations. There are strong linkages between some of the key actions required and being taken forward to address health inequalities in Scotland, and proposed drivers of our quality strategy. In particular the patient centredness and clinical effectiveness drivers (specifically through long-term conditions) have the potential to address the health problems of many of those who carry a disproportionate burden of ill-health in our communities.

Access: 'Better Health Better Care' set out the importance of improving the timeliness of healthcare services, and described the work required to secure an 18 weeks whole journey standard from GP referral to treatment. It also discussed the more integrated approach required in local areas in the delivery of unscheduled care services. There is a range of improvement activity currently underway to improve access to GP/Primary Care, unscheduled care, ambulance services and to planned treatment following GP referral. This will provide a key supporting strand of work within the quality strategy, particularly contributing to clinical effectiveness and to patient centredness.

Mutuality

In ' Better Health Better Care' we set out our proposal to create a mutual NHS in Scotland where staff, patients and carers fully understand their rights and responsibilities, and what they should expect from their NHS. A mutual NHS is an underpinning requirement of person-centred healthcare, so we will continue to pursue as part of this Quality Strategy.

Working in partnership

This Quality Strategy will underpin all that we do, at our own hand or with others. We propose that the new Quality Strategy will extend to cover the activities of NHSScotland which are primarily focussed on preventative and anticipatory care and are in pursuit of reducing health inequalities and in improving health. It will form the basis for our relationship with independent contractors. We further propose that the Quality Strategy provides a basis for NHSScotland to work with partners through Community Planning Partnerships and in the Third Sector in securing progress towards the Quality Strategy target, and the higher level outcomes agreed locally and nationally through the Single Outcome Agreements and the National Performance Framework. An example of this is the support required from other public sector partners in establishing the Keep Well health checks through providing follow-up activities to promote well-being and healthier lifestyles.