Ding ding, seconds out….. round 4
I've had a few goes at the question of what should our outcome framework look like for our ACP, ACS, ACxxxx.
See the references.
Here's next instalment. In short note format.
There’s not single pithy answer.
I know you know that
The task = probably impossible…. But there you go
Indicator sets should be directly related to the programmes, which should be directly related to the scope (ie what budget lines? / services) and mission.
Im not sure we’ve got the mission 100% straight yet, the programmes are mostly there in terms of BAU, maybe not the transformational bit.
The thorny question of whether the setting of a “new” metric framework will change behaviour – either boardroom or shop floor….
Im not convinced on that. I hope I'm wrong
Unless we genuinely live it and make a focus on (say for example) delivery of smoking very brief advice and intervention as importance as 4hr wait
There are existing frameworks. Don't reinvent them
The domains in those have some overlap
Other stuff that’s about at the moment
ONS Understanding local needs for wellbeing
These are pretty handy – widerthan health care, oviously
CHE – inequalities indicators
NHS equity indicators – Centre for Health Economics
Re inequalities – Marmot indicators re H Ineq – cant recommend better
These are mainly outcome indicators and only collected once every 2y or so
So may not do for performance framework
Similarly PHE Wider Determinants tool
You may have a HWBB Outcome Framework
The CCG Assurance framework and maybe your local authority performance framework
The latter will be home to a host of indicators on what some folk call wider determinants
Perhaps a space to think of use of indicators in terms of setting culture… and the sort of direction we want to fly in??
- Outcome – making outcome focused (as opposed to service throughput focused….. even for the service throughput indicators… what pop level outcome do they contribute
- Secondary to primary shift– do the indicators you select help in that regard – for eg indicators be that would be suggestive of transformation ie 4hr wait for GP appointment, % of the NHS budget spent in primary care (demand management).
- Moving away from indicators that are “core NHS target and hospital centric”….and thus danger that we then default to continuing to deliver these and not transforming + outcome measures + primary care / community care.
- The ongoing difficulty o the measurable vs the important.
- Where does NHSE / I and CQC expectaitons fit.
- Levels of granularity, clinical input needed to address.
- Get the clinical indicators right – eg don't overlook the excellent stuff in the national clinical audits and similar?
- Something in the framework needs to focus us on the “A” bit of ACS rather than just the “C” bit.
- There's also something about the “P” or "S" bit is that the partnership or system needs to collectively work together for the outcomes at pop level. Nobody wants to be accountable for population outcomes not within the sphere of individual services, or sets of services.
Any other business, as I can't fit it anywhere else.
Some thoughts on financial process measures Indicators
· %of budget envelope that is subject to outcome based payment
· % of physician salary at risk for qual outcomes
· % of contracts that are subject to up and down side risk sharing
· % of budget that is capitation
· % of budget that is spent on hospital vs out of hospital.
· £ / capita on district nursing.
· What is the trajectory of GP v hospital v mental health expenditure.
· OP procedure rate (efficiency)
· Day case rate (efficiency) – aim on cutting down on bed use. We may already fare well in this respect.
· % of visits (OP and GP) conducted by phone as opposed to face to face
· % of referrals that are e consultations.
Cost measures –
· cost / patient month – needs more sophisticated data than we currently have, and needs to be done in segmented pops
Volume 1- outcome measures for ACO
Volume 2 – What outcome measure for an Accountable Care System – how will we know its working
Volume 3- Outcomes at population level in the context of accountable care
The framework used by CMS – Quality indicators in the USA ACO programme http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ sharedsavingsprogram/Quality_Measures_Standards.html