Commissioning for Quality

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Commissioning for Quality

• Dr Henriette Coetzer

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BUPA is a major commissioner of healthcare

• BUPA globally commissions 2bn of healthcare per
  year
• In the UK
• Commissions healthcare services worth over 1bn
  per annum from the NHS and independent sector
• Currently has contracts in place with over 500
  hospitals and 15,000 medical consultants
• Integrates data and information in all management
  activities to improve the quality of care,
  identify challenges early, encourage cost
  reduction in providers and minimise premiums for
  customers

• The BUPA promise
• We treat and care for you as an individual"

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The Cochrane Principle

• Best clinical practice often represents
• best financial value in healthcare

Cochrane AL (1999) Effectiveness and Efficiency.
Random Reflections on Health Services. March.
3rd Edition. Royal Society of Medicine Press,
London. ISBN 1-85315-394-X
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Enabling choice and quality

• Key challenges
• The provider market is not generally competitive
  and there are usually few real alternatives
• Providers normally have far more information than
  commissioners on patient behaviour and provider
  performance
• Providers have the relationship with patients,
  who will act as the ultimate commissioner of
  services in a free choice environment
• Typically the biggest improvement opportunities
  require significant clinical and operational
  changes within hospital providers
• Changing capacity and operational procedures in a
  hospital normally takes significant time,
  resources and support across clinical and public
  stakeholders

• Therefore, it is important to
• Build a cooperative relationship with providers
  in primary, community and secondary care
• Support providers with information analysis and
  stakeholder alignment to design and implement the
  case for change
• Apply multiple levers to address areas of
  opportunity, e.g.
• SLA and compliance league tables
• Pathway design and contracting for key
  specialties
• Demand management
• Introduction of new providers
• Engage providers in new service expansion
  opportunities
• Improving relationship between GPs, other health
  care professionals consultants and hospitals, etc.

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Data and Information Needs in Commissioning
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Translating pathways and evidence into standards
Guidance, policies and regulations
Patient/Setting quality parameters
Synthesis Supplementary EBM
Accreditation Contracting /Monitoring KPIs
Annual and ongoing review
NICE/SIGN
Clinical Tasks
Provider review and accreditation
Competencies
Quality parameter contract terms
Unpacking in discrete care tasks
Royal Colleges
Equipment
Standardised Reviews
PROM and Patient satisfaction
Staffing
Targets
Clinical indicator review
HCC/DH
Access
Frameworks
Provider satisfaction
Quality and value indicators
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Using ICPs to optimise commissioning activities

• Unpacks guidance into discrete tasks with clear
  roleplayers and identified points of integration
  and referral
• Informs targeted analysis of data to identify
  where this is not happening consistently
• Provides a provision and quality-assurance
  framework against which to audit current reality
  and plan integration and provisioning activities
• Provides a clear fact-based framework for
  discussion to help set priority, clear targets
  for service integration and coordination in a way
  that does not lead to inefficient overlaps

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Managing and engaging with providers
Provider Management Framework

• Periodic Provider development report and meeting
• Measure providers performance against targets and
  Specialty KPIs
• Specialty Volumes, revenues, prices, etc
• Specialty Outcomes and Quality indicators ,
  comparison to Network lower, mid and upper tier
• Identify activities to improve performance (from
  provider as well as BUPA)
• Exception monitoring of providers
• Ongoing monitoring of
• Complaints, Media coverage
• Service levels, Billing accuracy,cost/billing
  patterns
• Clinical and PROMs - statistical performance

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Example Acute and chronic back pain

• Example Acute and chronic back pain
• 2004 - total spend on back pain treatment
  growing at 15 per year and significant cost
  associated with time off work
• Costs driven by surgical and non-surgical
  interventions data indicated treatments not
  evidence based with patient cycling among various
  health care professionals.
• Established evidence based treatment planning for
  diagnostics and surgical and non-surgical
  management
• Nurse led case management team
• Clinical pathways based on a worldwide evidence
  review we undertook and in consultation with UK
  clinicians and professional bodies.

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Acute and chronic back pain
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Example Out-Patient MRI

• 80,000 OP MRI scans per annum
• In 2005, the volume of scans per unit of
  population was increasing year on year, as was
  the unit price
• Wide variations in unit price, even adjusting for
  case mix
• No recognised and generally accepted overall
  quality framework covering equipment and
  facilities, staffing, operational processes,
  health and safety, clinical protocols, audit and
  reporting
• Mixed service levels in terms of waiting time
  between referral and scan
• Delays between scan and reporting

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MRI Network

• Extensive data analysis
• geographical distribution, distance travelled by
  the patient, referral and reporting waiting times
• volume, price, case mix and percentage of scans
  as part of one stop clinic amongst existing
  providers
• consultation with both existing and potential new
  providers
• national tender with regional selection was the
  most appropriate approach with detailed quality
  and service specification
• paperless tender process
• over 400 bids leading to negotiated supplier
  agreements with 250 NHS and independent providers
  66 of evaluation on quality and service
• communications with radiologists, referring
  consultants, customers, patients and other
  stakeholders

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Our approach
Assessment Planning
Contracting Procurement
Performance management, settlement and review
Member engagement

• Population service
• needs
• Prioritisation
• Health Tech impact

• Supply needs
• Resource matching
• Performance
• excellence

• Communication,
• support and education

• Claims processing, adjudication and audit
• Demand management
• Outcomes and pathway comparison

Data merging, Mining. Modelling and Reports
Data Warehouse
Claims data, geographic and demographic
population profiles, Demand Management activity
Health Economic assessments, Best Evidence
Pathways, Patient Satisfaction and Outcomes
measurement
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BUPAs Quality message
Right Doctor
Right Time
Right Treatment
Right Hospital
Provider Assessment Assessment of Facilities,
focussing on Generic Quality criteria
Speciality Specific Criteria Assessment of
Speciality Specific Quality criteria
Consultant recognition Recognition criteria for
consultants recognition
Outcome measurements Collection measurement
of clinical outcomes to ensure, monitor and
validate quality
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Prioritising
Setting Bespoke analysis priorities
Illustrative
Level of difficulty
Potential benefits
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Clinical Research and Innovation
Quality Strategy
Clinical Escalation
Quality Goals
Plan
Act
Do
Study
Clinical Reviews
Clinical Plan
Clinical Scorecard
Model for improvement adopted by the Institute
for Healthcare Improvement (IHI)
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Clinical Research and Innovation
Quality Strategy
Quality Goals and criteria
Clinical Escalation
Plan
Act
Do
Study
Clinical Reviews
Clinical KPIs
Clinical Scorecard
Model for improvement adopted by the Institute
for Healthcare Improvement (IHI)
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Clinical Research and Innovation
Quality Strategy
Clinical Escalation
Quality Goals
Plan
Act
Do
Study
Clinical Reviews
Clinical KPIs
Clinical Scorecard
Model for improvement adopted by the Institute
for Healthcare Improvement (IHI)
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Clinical Research and Innovation
Quality Strategy
Clinical Escalation
Quality Goals
Plan
Act
Do
Study
Clinical Reviews
Clinical Plan
Clinical Scorecard
Model for improvement adopted by the Institute
for Healthcare Improvement (IHI)
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Performance Indicators

• Deaths/survival rates
• Unexpected re-admissions
• Unexpected re-operations
• Infection rates
• Adverse incidents
• Clinical complaints

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Contributors to health outcome
X-ray changes Range of Motion CLINICAL ASSESSMENT
Biological and Physiological variables
Pain and Stiffness PATIENT REPORT
Symptom Status
Ability to perform tasks PATIENT REPORT
Functional Status
Subjective rating by patient PATIENT REPORT
General Health Perception
Adapted from WilsonCleary, 1995
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The advantages of using PRO

• Create accurate profiles of overall treatment
  outcome that may not be shown by more traditional
  clinical endpoints
• Better reflect palliative and subjective,
  patient-valued outcomes of the holistic care
  experience
• Often reported as improved by patients even when
  major (clinically defined) treatment responses
  are absent

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Patient Satisfaction Survey

• Monthly survey to approx 5,000 randomly selected
  members who have had an inpatient or day case
  episode of care asking them for feedback about
  their hospital stay.
• Key themes below
• 85 of members rated the overall service provided
  by the contracted hospital as excellent or very
  good
• 94 of members said that the overall service met
  or exceeded their expectations
• 74 of members rated the overall level of comfort
  as excellent or very good
• 84 of members rated the hospital as very clean
• 80 of members rated the nursing staff as
  excellent or very good for each of the five
  questions relating to them (e.g.
  attitude/efficiency)

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Monitor
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Monitor
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Improve
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Improve
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Planning and execution of commissioning happen at
different timeframes

• PBC
• Daily decisions on patient referrals
• Monthly and annual reporting and monitoring of
  outcomes and budgets
• See changing needs of demand every day

• Provider commissioning
• 1-3 year contracts
• Monthly and yearly performance reviews
• It takes 2 months to 2 years to redesign services

• Health economy reconfiguration
• 5-15 year planning horizon
• 2-5 years to increase or reduce provider capacity
• Considers current and potential health needs

Commissioning Execution horizon
The challenge is to ensure consistency across all
elements of commissioning
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Commissioning for evidence based pathways of care
and treatment

• Dr Henriette Coetzer