Policy: Compliance with the Performance Metrics in Contracts with Host Clinical Commissioning Groups

Transcription

1 CORPORATE Policy: Compliance with the Performance Metrics in Contracts with Host Clinical Commissioning Groups DOCUMENT CONTROL SUMMARY Status: New Version: V1.0 Date: Author/Owner: Rob Abell, Senior Performance Development Manager Approved by: Policy and Procedures Committee Date: 21 st Ratified: Trust Board Date: 28 th Related Trust Strategy or Aims: Implementation Date: Provide high quality services, built on best known practice and evaluated through service user and carer feedback and clear process and outcome measures. Deliver all regulatory performance, quality standards and compliance indicators Review Date: September 2020 Key Words: Indicators, Measures, Performance, SOPs, Standard Operating Procedures, Commissioners, Contractual Performance Measures

2 Policy: Compliance with the Performance Metrics in Contracts with Host Clinical Commissioning Groups CONTENTS 1. INTRODUCTION PURPOSE SCOPE and TRUST EXPECTATIONS OF STAFF NON-COMPLIANCE PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS REFERENCES... 5 Version History Log Version Date Implemented Details of significant changes 1.0 IT IS THE RESPONSIBILITY OF ALL USERS OF THIS POLICY TO ENSURE THAT THE CORRECT VERSION IS BEING USED All staff should regularly check the intranet site for information relating to the issue of new or revised versions of this Policy. This Policy will normally be reviewed every 3 years unless changes to the legislation require otherwise. Page 2 of 5

3 1. INTRODUCTION Since 1 April 2013 all NHS foundation trusts need a licence stipulating specific conditions that they must meet to operate. Key among these is financial sustainability and governance requirements. On 1 April 2016, NHS Improvement became the operational name that brings together Monitor, the NHS Trust Development Authority (TDA), Patient Safety, the Advancing Change Team and Intensive Support Teams. The specific legal duties and powers of Monitor and TDA persist. Single Oversight Framework (SOF) NHS Improvement undertook a review of their approach to overseeing and supporting NHS trusts and foundation trusts and has introduced a Single Oversight Framework which replaced Monitor s risk assessment framework and the Trust Development Authority s (TDA) accountability framework. The framework which was published in September 2016 will help NHS Improvement identify where trusts may benefit from, or require, support to improve in five areas: Quality of care (safe, effective, caring, responsive) Finance and use of resources Operational performance Strategic change Leadership and improvement capability (Well led) The Single Oversight Framework will support the delivery of NHS Improvement s 2020 objectives, including helping more providers achieve CQC good or outstanding ratings, reducing numbers of trusts in special measures and achieving aggregate financial balance from 2017/18 as well as meeting NHS Constitution standards. The framework also outlines how they will segment the provider sector according to the level of support each provider requires. Non-compliance with the Single Oversight Framework will affect our segmentation rating and hence our level of autonomy. NHS Improvement has strict rules about how we manage our finances and corporate governance. On-going evidence and submissions are required to demonstrate that we are achieving good performance in the five areas listed above. Key to achieving this is ensuring that our data is going into our systems accurately and so coming out meaningfully. The risk here is that we could lose our licence and so our authorisation as an FT if we do not comply with their requirements. This could mean we would not be able to bid for new business or deliver projects such as the Shelton site redevelopment or the Stonefield House move. These projects are important to improving the quality of care we provide in the medium to long term, and we have only been able to plan these because of the financial flexibilities FT authorisation gives us. Trust governance Good governance is essential to support the quality of care a trust provides and ensure its financial sustainability. Governance issues can provide early warnings of problems that have yet to manifest themselves in, for example, quality issues or financial underperformance. NHS Improvement s role as a sector regulator includes overseeing governance at NHS trusts; governance requirements were set out in the NHS foundation trust governance condition (FT4), which form a specific condition in NHS foundation trust licences. NHS Improvement expect providers to demonstrate three main characteristics effective boards and governance, continuous improvement capability and effective use of data as part of this theme. Use of data: Effective use of information is an important element of good governance. Well-led providers should collect, use and, where required, submit robust data. Where NHS Improvement Page 3 of 5

4 have reason to believe this is not the case, they will consider the degree to which providers need support in this area. 2. PURPOSE A set of Standard Operating Procedures (SOPs) were developed in 2011 for all of the performance measures in Monitor s Risk Assessment Framework following a data quality audit of three of these measures. The results of the audit suggested that procedure notes were not comprehensive or widely available for staff, and there were concerns over the robustness of data collation, validation and reporting. On 1 April 2016, NHS Improvement became the operational name that brings together Monitor, the NHS Trust Development Authority (TDA), Patient Safety, the Advancing Change Team and Intensive Support Teams. The Trust reviewed and updated these SOPs to reflect the introduction of the Single Oversight Framework in September 2016 which replaced Monitor s risk assessment framework and the Trust Development Authority s (TDA) accountability framework. Whilst the majority of the performance measures in the Single Oversight Framework are in the contracts with host Clinical Commissioning Groups, there are other key performance measures in the contracts which are not in the Single Oversight Framework. Therefore a decision was made to produce a set of SOPs to cover some of the key performance measures in the CCG Performance Frameworks. The first SOP to be developed can be seen in table 1, it is anticipated that further SOPs will be developed over time. Table: 1 SOP SOP/01 Delayed Transfers of Care (DToC) 3. SCOPE and TRUST EXPECTATIONS OF STAFF The associated SOPs apply to the following directorates; Mental Health, Specialist Family Services, Forensic and Criminal Justice Service, Learning Disabilities, Inclusion Services, Information and Technology Development, The Performance Development Team Staff read and understand the associated SOPs Ensure they undertake responsibilities set out in the associated SOPs Meet the mandatory and commissioner requirements Use the Trust s clinical information systems to record all activity against the indicators, including all contacts, appointments or groups in accordance with the Trust s data quality requirements Accurately record the activity in the Trust s clinical information systems in-line with Trust guidance Record the activity in the Trust s clinical information systems in a timely manner in-line with the Trust s data quality requirements The distribution of information and data regarding these indicators will only be shared with external agencies through nominated contacts. The Trust Information Team will validate all requests for information and data regarding this indicator prior to their distribution. 4. NON-COMPLIANCE These indicators feature in the Trust s contracts with the host CCGs, and as such are local priority targets which NHS Trusts are expected to achieve. Failure to provide accurate, comprehensive, timely and up to date information to CCGs on these measures could result in a breach of our NHS provider license. Performance against the indicators is reported to CCGs on a monthly basis and non-compliance with the associated SOPs could result in performance notices, monetary penalties and so affect the funding available for patient care. Page 4 of 5

5 5. PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS Regular reports are available against each of the key performance indicators and this performance information is reported on a regular basis to; Trust Board Subcommittees, clinical divisions, national reporting requirements and host Clinical Commissioning Groups. 6. REFERENCES Appendix Guidance documents on the clinical processes for RiO Link to the monthly CCG Performance Reports Trust Policy on Choice Link to the Trust Dashboard where CCG and team level data is available The SQL code used to produce the information from the SSSFT data warehouse and reports See latest guidance on the RiO Quick Reference Guides and Manuals website G.aspx or contact the RiO Support Team on for further support and assistance G:\WorldRead\BI_Reports\CCG Performance Reports Contact the Trust Information Team who will provide you with the latest version of the SQL code used to produce reports Page 5 of 5