Advancing Quality - Frequently Asked Questions

Advancing Quality (AQ) is an innovative NHS quality programme focused on enhancing standards in patient care. It aims to give patients a better experience of health services, and ultimately, a better quality of life. 

AQ launched in October 2008 in 24 acute trusts across the North West of England in five high-frequency clinical focus areas agreed by North West clinicians. They are: heart failure, heart bypass (CABG), heart attack (AMI), hip and knee surgery and pneumonia.

Following the early success of the programme, Advancing Quality expanded into new treatments areas, mental health and stroke, and soon primary and community services.

At its core is a strong focus on making quality an operating principle for health reform and development. 

The programme aims to transform the experience of patients across the North West. This will mean patients will have an overall better experience in hospital which will ultimately result in them having a better quality of life. They will also have more say and influence, as their opinions and experiences of care they receive in hospital will be taken into account and acted upon.

Advancing Quality will save lives, reduce re-admission rates, reduce complications in procedures, and significantly reduce the time patients have to spend in hospital.

Hospital costs will reduce significantly, allowing Trusts to reinvest their savings in improving facilities and care.

The skill, expertise and reputation of doctors and nurses will be acknowledged. They will be able to expand their skills and knowledge by sharing what works well and what doesn't in their hospitals or clinics with colleagues across the region.

AQ drives and rewards improvement in the quality of care provided to patients undergoing treatments in these areas by measuring against three elements that are clear and easy to understand for NHS staff, patients and the public:

• Clinical Process and Outcomes Measures - the quality of clinical care that has been delivered to patients
• Patient Reported Outcome Measures (PROMs) - the improvement of a patient’s quality of life following a treatment or surgery
• Patient Experience Measures (PEMs) - the patient’s general experience of hospital care

For each of the areas of clinical areas AQ focuses on, a series of process measures and outcomes have been identified. Clinicians are responsible for ensuring the clinical process measures are followed and that data is collected (manually and/or through existing electronic systems) and outcomes monitored. This helps identify where improvements can be made.

The data is then assured by the Audit Commission and results are publically reported annually. Data from Year 1, which ran from October 2008 to September 2009, was released in June 2010. Year 2 ran from October 2009 until March 2010, to bring the AQ programme in alignment with the new financial year. The results were released in June 2011.

It means that, for the conditions AQ covers, there will be a North West clinical standard of care which should be delivered for all patients. By recording compliance with these standards, staff can identify where there are opportunities to improve care further. If AQ pans out in line with a similar programme from the US (HQID), it should improve the overall quality of care and reduce readmissions, length of stay and mortality rates.

The programme will give GPs and their patients access to comprehensive data collected against the indicator measures.

As patients increasingly seek to make their own choices about where to seek treatment and look for data to drive informed decision making, AQ data can be used to inform their decisions.

It introduces a benchmark for quality measures in commissioning and allows commissioners to understand where there are variations in quality standards, and to work with providers to redress these.

The Advancing Quality programme ensures patients have an overall better experience in hospital, which will ultimately result in them having a better quality of life.

The success of AQ will help to save lives, reduce admissions, reduce complications and decrease the length of time patients have to spend in hospital.

Patients also have more say and influence, as their opinions and experiences of care they receive in hospital will be taken into account and acted upon.

In turn, this will enable the hospitals to reduce costs and the savings can be ploughed back into improving care and facilities, along with the financial rewards they will receive for good performance.

We believe patients are beginning to experience changes in the care that is being delivered in these clinical areas now that the programme is up and running.

Measuring the success of the programme requires data analysis and this will take place as part of an ongoing process. Results from Year 1 showed an improvement in standards across all five of the original clinical areas - heart attack, heart failure, heart bypass, hip and knee replacement surgery and pneumonia. You can see the results here.

The greatest improvement was in heart attack (AMI) where the overall average per cent improvement increased by 7.27% to 95.94%. A full analysis of Year 1 is available here. 

Results for the stroke and mental health will be available later in the year.

The starting point for AQ was to choose the clinical areas relevant to a large part of the North West population - heart failure, heart bypass surgery, heart attack, hip and knee replacement surgery and pneumonia. Following the success of the AQ programme, it was extended to stroke and mental health services and should continue to grow into additional clinical areas over time.

AQ has already been introduced for stroke, dementia and psychosis and, over the next few months, will be developing new measures to encompass care for long term conditions delivered out of a hospital setting.

The Department of Health (DH) has contracted the University of Manchester Business School to carry out an independent evaluation of AQ over a five year period to establish whether AQ has succeeded in meeting all its aims and objectives. This will determine AQ’s impact on financial savings, lives saved, reduced length of stay in hospital, reduced complications and reduced re-admissions.

It will also enable us to adapt the programme to ensure we learn from best practice and continue to attain best value for money.

The incentives will be distributed in the summer to the teams that have delivered. It is those teams that will influence how and where the money is spent. This could include spending it in areas which are not participating in AQ.

In Year 1, hospitals that are in the top two quartiles earned between two and four per cent top-up on the national tariff for patients they have treated under the Advancing Quality programme. These rewards will be invested back into patient care. Rewards are typically in the region of £10,000 to £300,000 per Trust. The scheme doesn't include any financial penalties for trusts not meeting standards in the Advancing Quality programme.

In the initial years of the programme, the top performing trusts, and the trusts who improved the most, were awarded financial rewards as follows:

Year 1 (Oct 2008 - Sept 2009): The top two performing quartiles received between two and four per cent top-up on national tariff to a value of up to £3.2 million across all trusts. There were also incentives for PROMs and patient experience.

Year 2 (Oct 2009 - Mar 2010): The top performers and the trusts who have improved the most since Year 1 were rewarded.

In Year 3 (Apr 2010 - Mar 2011) the programme became a part of the Commissioning for Quality and Innovation (CQUIN) payment framework, which enables commissioners to reward excellence by linking a proportion of trusts' income to the achievement of quality improvement goals, like the Advancing Quality measures. This means commissioners may withhold payment to a trust if it does not pass the Advancing Quality measures.

It is the Advancing Quality ethos that such quality payments are directed back to clinical teams for further investment in clinical services.

For each of the clinical areas AQ focuses on, there are key things that should happen to all patients, referred to as process measures. Some of the clinical areas have an outcome measure, and these have equal weighting to a process measure. For example, if there were four measures and five patients, then there are twenty opportunities that should be met. If all five patients received all four measures, then 20/20 is achieved; equating to a Composite Quality Score of 100%. If one of the five patients only received two of the process measures, and another patient received only three, then 15/20 is achieved; equating to a Composite Quality Score of 75%.

More details on all of the methodologies used can be found in the methodology document.

In line with national health data flows, it can take up to four months from the end of the month in which a patient was discharged for the data to be in the AQ tool (QMR - Quality Measures Reporter). This data is then validated, and then independently assured by the Audit Commission which takes another two months. We are constantly looking to shorten these timescales.

The Ambulance Service is involved in delivery of two of the eight AMI measures - aspirin and thrombolysis - and therefore they received 25% of any incentive paid out on AMI.

Quality accounts provide a comprehensive picture of the quality of care a trust is providing. AQ data may be included in Quality Account reports for the relevant treatment areas, if the Trust chooses to include it.

AQ is about delivering high quality care at all times which should safely reduce costs. Ultimately by delivering the AQ measures, length of stay and readmissions should reduce and therefore, costs will reduce. Our view is that quality without efficiency is unsustainable and efficiency without quality is unthinkable.

This shows the overall survival rate for heart attack patients within each Trust. If we are able to understand how many patient survive following their heart attack, we can continue to ensure that the best care is being delivered to all patients. Survival rates should always be looked at in combination with other indicators. They cannot be used to predict an individual's chance of survival as this will be affected by individual circumstances and risk factors. 

The rate has been calculated using the same methodology as used for the Hospital Standardised Mortality Ratios found on the NHS Choices website, however the AQ figures are representative of the heart attack patient cohort, rather than the much larger population presented on NHS Choices.

Quality of care has always been one of the guiding principles of the NHS. However, we recognise there are always improvements that can be made and Advancing Quality will continuously improve the quality of care delivered to patients.

Just as any other business would put customer service at the top of its priority list, we aim to do the same with the introduction of this programme. This programme will make patients more aware that their voices are influential and their experiences will be taken into account.

The results shows that hospitals are delivering, high quality care across our region. The AQ programme focuses on helping clinicians to deliver the best possible quality of care for all patients, at all times. It has identified critical interventions in each treatment pathway as well as how and when they should be implemented to help every clinician ensure they are following the very latest best practice and that this is clearly documented.

Not at all. We believe this scheme has rapidly made a real difference and results are showing that, between October 2008 and September 2010, the standards of care provided in the five original clinical areas are improving.

Above all, Advancing Quality has been strongly endorsed by doctors and nurses across the North West.

AQ helps the health service to deliver the best quality of care which, in turn, reduces costs by cutting mortality, complication and readmission rates helping trusts to meet their key current priorities. Advancing Quality helps all NHS staff plan world class care today and ensure it will continue to be delivered tomorrow.

There are lots of possible reasons why a trust maybe scoring low. For example, it could be that there is no documented evidence that a measure was met. 

Throughout 2009 and 2010, a number of collaborative workshop events were held to support the Trusts in more difficult areas of data collection, to share best practice and to develop shared approaches for improvement.

No. The NHS is staffed by highly qualified and experienced staff who have agreed the AQ measures as best practice and are working to ensure that these measures are met and that staff are trained accordingly across the North West.

There are many reasons why a Trust could be performing poorly, some of which may be in relation to documentation and some of which could be that the measure was met, but not within the agreed timescales. Trusts are constantly working to ensure the AQ measures are met for all patients and that they are documented.

It does seem obvious. Yet the question of how to improve quality and outcomes systematically across a whole healthcare system is something that health services right across the world have been asking themselves.

In the NHS we have been successful in making improvements in quality in a number of ways, which is excellent news. However, this programme offers something more. It is based upon a model that was successful in the not-for-profit sector of the healthcare system in the US. We are striving for a world class health system in the NHS in the North West and we believe that this programme will help us get there. It is a forward thinking and innovative programme designed to reward hospitals for the quality of care they offer to patients. In a competitive environment with patients choosing where they want to be treated, the reputation of healthcare providers is crucial. This also only makes sense if there is an approach to look at systematic improvement across multiple hospitals.

We believe this transparent system will see the level of care offered by clinicians rewarded and acknowledged. It will also allow them to share learning and best practice.

Premier Inc and the Audit Commission have worked together to provide assurance over the completeness and accuracy of the data that underpins the Advancing Quality (AQ) Programme.

Premier Inc has provided reports on data completeness for both clinical coding and Quality Measures Reporting (QMR) data. The AQ Programme has set performance targets for data completeness of 80 percent for clinical coding and 90 percent for QMR. Where a trust’s has not achieved either of these targets in a particular clinical area, then their data has not been publically reported on this website and they have not received an incentive payment. There are three cases where this has happened this year.

The Audit Commission has provided assurance over the accuracy of the data using different approaches for clinical coding and QMR data. For clinical coding data, the Commission has been able to use our online National Benchmarker tool to provide a statistical assessment of the likelihood of data inaccuracies. Where the Benchmarker has pointed to possible inaccuracies, the Commission has ordered external clinical coding audits to check the accuracy of the data. The Commission has done this ten times in Qs 3 and 4 (out of 192 possible opportunities, or in 5 percent of cases). The results of these audits revealed an average level of clinical coding accuracy of 87.5 percent.

For the QMR data, the Audit Commission has documented and commented upon trusts’ internal arrangements for data definitions, data input and data checking. The Commission has then conducted quarterly audits to test the accuracy of the data. The AQ Programme has set a performance target of 70 percent for data accuracy. Using the average of Qs 3 and 4 as the measure, every trust has achieved this level of accuracy and no trust has had its data excluded on the basis of accuracy.