Advancing Quality NHS Advancing Quality Alliance


All our most frequently asked questions are provided here relating to what is Advancing Quality?how does it actually work? and many more.

What is Advancing Quality?

Advancing Quality (AQ) is an NHS quality improvement programme which aims to improve the standards of care patients receive while in hospital. It aims to give patients a better experience of health services and, ultimately, a better quality of life by making sure every patient gets the same high standards of care no matter which hospital they attend.

AQ launched in October 2008 five clinical conditions/operations which clinicians agree are some of the most common reasons people in the North West need hospital care. They are: heart failure, heart bypass surgery, heart attacks, hip and knee replacement surgery and pneumonia.

Following the early success of the programme, Advancing Quality expanded into new treatments areas: Stroke, Dementia and Psychosis. A further expansion has seen the total number of areas increase to 14 with the latest clinical conditions being included: acute kidney injury, alcohol related liver disease, chronic obstructive pulmonary disease, diabetes, hip fracture, sepsis.

How does it actually work?

Although the care given to a patient is tailored to their individual needs, clinicians from across the region have agreed a number of key things should happen, which, if carried out at the same time and in the same way for every patient, will ensure patients are receiving the best possible care when treated in these Advancing Quality focus areas. These are what Advancing Quality refer to as the Clinical Process Measures.

Each Trust has an AQ team. The data for each patient is recorded as part of the normal clinical record and AQ scores how well trusts are delivering against these key qualities of care measures. Each percentage score shows how successfully the doctors, nurses and other clinical staff are delivering to the agreed quality standards for their patients. The results are publicly reported once they have been assured by independent auditors.

How do I benefit from Advancing Quality?

It means that, for the conditions covered by Advancing Quality, there will be a North West clinical standard of care i.e. no matter which hospital you are attend, you will get the same treatment delivered with the same high standard of care. This will help you to have an overall better experience in hospital which will ultimately result in a better quality of life.

From measuring the experiences in care across the North West, hospitals are able to share their patients’ experiences and generate improvements for patients. During the first 18 months of Advancing Quality being introduced in North West England hospitals, these improvements have been associated with 890 fewer deaths and patients are spending 22,800 fewer days in hospital, resulting in savings of £4.4million. If this trend has continued throughout the first five years of Advancing Quality, it is estimated to have saved 3,000 lives, 76,000 bed days and saved £14.5million.

As patients increasingly seek to make their own choices about where to seek treatment and look for data to drive informed decision making, you can use the Advancing Quality website to see how well your local NHS provider trust is performing and use this information when deciding where to be treated.

Why choose these clinical areas?

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 more recently into six additional areas, they are: acute kidney injury, alcohol related liver disease, chronic obstructive pulmonary disease, diabetes, hip fracture, sepsis.

Are there plans to extend the measures into other clinical areas?

AQ has already been introduced for stroke, dementia and psychosis. We are currently working on a pilot to extend Advancing Quality into primary care for patients with Chronic Obstructive Pulmonary Disease (COPD) and, over the next few months, will be developing new measures to encompass care for other conditions such as fractured neck of femur, diabetes and alcohol-related liver disease.

You can find out more about our plans to expand into additional clinical areas by reading our Business Plan

What financial savings have been made as a direct result of AQ?

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.

The findings so far, published in the New England Journal of Medicine (ref: N Engl J Med 2012; 367:1821-8), has associated Advancing Quality with 890 fewer avoidable deaths within the first 18 months. Additional research by the same team of health experts and economists published online in Health Economics (ref: Health Econ. (2013) DOI: 10.1002/hec) estimated it to have saved £4.4million in reduced number of bed days and generated £105million for the region in health gains. Therefore every £1 invested in the programme generates an £8 return.

If this trend has continued throughout the first five years of the programme, analysts at AQuA have estimated the savings to have increased from £4.4million to £14.6million by reducing the number of bed days by 76,000 and to have generated £350million in health gains.

How is the appropriate care score calculated?

For each of the clinical areas we focus on there are key things that should happen to all patients, referred to as measures. In some circumstances, such as already taking medication such as blood thinning medicine, a patient may be excluded from a measure.

For example in the table below, where there are six measures and three patients; if all patients were eligible for all measures and received them the ACS would be 100% (in this situation every patient would have the outcomes of Patient A).

If one patient received all measures and one patient was excluded for clinical reasons from one measure but received all others then the ACS would still be 100% (in this situation the two patients would be Patient A and Patient B).

If however, two patients received all measures that they were eligible for but one patient received only four measures having failed two then the ACS would be 66% (in this scenario Patient A and B achieved ACS but Patient C did not).

Patient A Patient B Patient C
Measure 1 Met Met Failed
Measure 2 Met Met Met
Measure 3 Met Met Failed
Measure 4 Met Met Met
Measure 5 Met Exempt Met
Measure 6 Met Met Met
Appropriate Care Score Yes Yes No

Why does it take so long for the data to be published?

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 available to Advancing Quality. This data is then validated, and then independently assured by external auditors which takes another two months. This ensures that the data you see is robust and accurate.

We are constantly looking to shorten these timescales to ensure patients can have access to timely data.

Why is some data displayed differently?

Data displayed with diagonal lines is provisional data. We have made these changes so that you can get access to data as soon as possible.

When data appears for your trust that is provisional it has met internal thresholds and eligibility criteria for public reporting as well as being verified by your local hospital trust. Once the data has been independently audited the website will be updated to reflect any changes.

Shouldn’t the NHS already focus on quality?

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.

Why aren’t hospitals delivering consistent, quality care without this scheme?

The results show 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.

Is this just another target setting initiative?

Not at all. We believe this scheme has rapidly made a real difference and results are showing that, between October 2008 and March 2012, the standards of care provided in the five original clinical areas has continually improved – as much as 30% in heart failure.

Above all, Advancing Quality is clinically-led and is strongly endorsed by doctors and nurses across the North West.

Given the current financial situation, should funding this scheme be a priority?

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.

What plans are in place to help/support lower scoring hospitals?

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.

One of the original principles of Advancing Quality agreed by all North West acute and mental health trusts is a commitment to transparency and sharing best practice. We achieve this by hosting a number of learning collaboratives focusing on each clinical condition. AQ teams from all the trusts attend the workshops to learn about the latest results, speak to the trusts that are performing the best about how they are achieving their results, and share any issues/problems they may be having.

Why is there no data for my local hospital?

There are several reasons why data may not appear for your hospital.

  1. They do not participate in the clinical condition area e.g. Only mental health hospitals will deliver the AQ clinical areas of Dementia and Psychosis. Other conditions such as Stroke may be centralised at a particular hospital in your region. As the programme grows and develops we assist hospitals in prioritising clinical areas that have the biggest impact for their local population so over time their inclusion in certain clinical conditions may alter.
  2. The hospital did not meet their coding completeness. When you are admitted to hospital your condition is recorded in your notes and assigned a universally used diagnosis code. The diagnosis code is the main method of hospitals and AQ identifying if your admission should be monitored by the programme, if a hospital’s diagnostic coding is below 95% e.g. less than 95 out of every 100 patients are coded, their results will not be published as we cannot assure that the additional information about your stay in hospital is correct.
  3. The hospital did not satisfy the independent assurance audit. A sample of the information provided by the hospital is audited by an independent body. This audit ensures that the information your hospital is reporting is accurate and reflects the actual care you received. If there is evidence that the hospital has misreported information their results will not be published as we cannot assure that the information about your stay in hospital is correct.

What is a Clinical Commissioning Group?

A Clinical Commissioning Group, or CCG, is typically made up of several GP practices and are responsible for ensuring that the health needs of the population they serve are met by the appropriate health and care services. Commissioners pay hospitals i.e. providers, to provide care for the population they serve, this is done through the NHS Standard contract framework.

My local trust is performing poorly for one of the AQ areas does this mean that future doctors and nurses are being trained by poor practitioners?

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.

Why haven’t we done this before – it seems obvious?

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.

How can we be assured that these figures are accurate and reliable?

All stakeholders work closely together to provide assurance over the completeness and accuracy of the data that underpins the Advancing Quality programme.

Reports are compiled monthly to monitor adherence to a variety of robust measurements within the programme. These themselves link into performance targets, which form the basis for financial incentives and public reporting eligibility. For example, data completeness and coding completeness must reach at least 95% over the year.

Independent external auditors provide assurance over the accuracy of the data itself by conducting quarterly audits. These culminate in the provision of documentation commenting upon Trusts’ internal arrangements for data definitions, data input and data checking.

Targets are reassessed each year to encourage continual improvement. For example, auditors originally were assessing a benchmark of 70% for data accuracy but this is now set at 80%.

What is AQ’s relationship with AQuA?

Advancing Quality is the flagship programme of AQuA (Advancing Quality Alliance), the North West’s health care quality improvement organisation. AQuA operates on a not-for-profit basis helping organisations provide the best possible healthcare services.

How is Advancing Quality funded?

Advancing Quality was historically funded by all the Primary Care Trusts in the North West who gave a small proportion of their budget each year to develop Advancing Quality. From April 2013, Clinical Commissioning Groups sign up for membership of the AQ programme and wider services offered by AQuA.

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