Quality, Efficiency and Value: what Non-Executive Directors need to know

Opportunities for improving efficiency in healthcare

What does the evidence tell us?

The Health Foundation report 'Does improving quality save money? A review of evidence of which improvements to quality reduce costs to health service providers, provides a useful source of information and research evidence on the potential link between quality and efficiency.

'The most successful hospitals or primary care organisations are not the ones which just deliver the best evidence-based clinical services, or are most focused on safety, or whose services are highly customer-oriented, or which consistently managed to balance their budgets. The most successful healthcare organisations are the ones which recognise the multi-faceted nature of their endeavour and manage to deliver across all of the dimensions of quality. For most of the last decade, organisations have become accustomed to times of plenty- their challenge has been to improve patient care and health outcomes and they have been given the resources to do so. But the impending public sector spending crisis changes this context utterly. Every manager and clinician in the country should now be asking themselves how they can continue to improve quality while also cutting costs.'
Martin Marshall Director of Clinical Quality, the Health Foundation, 2009

There has been a growing recognition that healthcare has to attend to fundamentally reviewing and improving its care delivery systems to keep pace with challenges now and in the future.

Don Berwick, former President and Chief Executive Officer of the Institute for Healthcare Improvement and a high profile advocate of using quality improvement methods, identifies some systemic failures which lead to high volumes of waste and if addressed, could result in large gains in efficiency and quality. The contention is that as with all other large, complex organisations the pursuit of efficiency and high-value care has to be well-led, focused and relentless.

• Failures of Care Delivery - the poor execution of care processes and the lack of widespread adoption of known best care processes results in potentially unsafe and inefficient health practices.
• Failures of care coordination - the waste that occurs when patients follow fragmented care systems and results in unnecessary complications, delays and errors. To improve this requires a fundamental shift to organising care along pathways designed in collaboration with those who receive the care to ensure maximum value.
• Overtreatment - the waste that comes from undertaking procedures where there is little evidence of clinical value to patients and in some cases may cause harm. Overtreatment diverts capacity and resources away from areas of greater need and does not deliver effective person-centred care.
• Administrative Complexity - administration systems which are overly complex and not joined up effectively across care pathways, cost healthcare a huge amount of money and increase the likelihood of errors and delays in the system.

What approaches support increasing quality, efficiency and productivity?

In its publication of the 2020 Framework for Quality, Efficiency and Value, the QuEST team in Scottish Government has identified an approach and a number of principles which should guide the work of quality and efficiency.

http://www.qihub.scot.nhs.uk/quality-and-efficiency/2020-framework-for-quality-efficiency-and-value.aspx

Three-part approach to undertaking the quality, efficiency and value journey:

• Identify and diagnose - identify where you wish to concentrate improvement efforts
• Improve - use quality improvement tools and methods that have been proven to be successful
• Evaluate - check whether you have or have not made a difference

Principles

The approach to improving quality, efficiency and value is underpinned by 10 key principles which are well evidenced by research as important to delivering improvement.

1. Reduce unwarranted variation in service provision, remove waste and eliminate harm
2. Improve healthcare quality by increasing the safety, effectiveness, experience and responsiveness of services
3. Use resources effectively - reduce costs, improve productivity and release efficiencies to enable reinvestment in front-line patient care
4. Use good quality benchmarking and performance data, together with insight into service provision, to identify where productive opportunities lie
5. Encourage innovative approaches to service redesign and use of technology
6. Adopt a whole system approach to service redesign
7. Collaborate and partner with other NHS Boards, local authorities and the third sector
8. Ensure clinical decision-making takes precedence over short term efficiency gains or achievement of targets
9. Encourage a more productive and empowering workplace culture
10. Identify, spread and sustain good practice

Enabling tools and resources

Improvement means doing things more effectively and efficiently in the future to deliver better quality patient experience and outcomes.

There are a range of approaches and tools available to support NHS Boards to deliver improvements in quality, efficiency and value.

Health economics

This can inform and improve decision-making about the allocation of scarce healthcare resources. Population, preventative and healthcare interventions can all be prioritized through the analysis of their costs and benefits to ensure that benefits are maximized. Realising the benefits of different approaches should be undertaken systematically to ensure the outcomes are quantified as well as the costs so an assessment can be made of the merits of an improvement project.

Data for Improvement

Benchmarking is the process of comparing processes and performance to other NHS organizations or to best practice elsewhere in the public, private or third sector.

Learning through using benchmarking data can provide assurance as to the effectiveness of existing ways of working as well as providing a valuable means for identifying opportunities for improvement. NHS Boards are encouraged to use data for improvement approaches and the development of new versions of these is ongoing. For example, Discovery is a newly developed web-based information system that will provide easy access to comparative information to help review, monitor and plan services and support quality improvement. This is available to managers and clinicians who will benefit from using comparative and benchmarking information to underpin service planning and delivery. More information about this can be found at www.discovery.scot.nhs.uk

Sharing learning about what works

This is an important aspect of increasing efficiency and productivity is ensuring we use a wide range of approaches to share knowledge of what works.

The ability to spread learning and encourage the adoption of best practice has to be systematically planned for and encouraged in order to ensure that learning from tests of change and pilots which prove effective are translated into business as usual as soon as possible.

Supporting staff to network and providing spaces, both virtual and face-to-face, where people are able to share success and discuss challenges are vital to supporting organisations' improvement efforts.

The QI Hub is a national partnership between special NHS Boards and the Scottish Government which aims to facilitate this through the provision of a website which enables access to a suite of case studies and an online networking community, People Connect, where staff from across NHS Scotland can access information and advice from colleagues and exchange learning.

Spread and Sustainability - the Challenge

In common with healthcare systems across the developed world, NHSScotland needs to improve its ability to spread well-tested and proven best care delivery processes at pace and scale. An evidence assessment undertaken by the QI Hub in 2014 and made available in the publication, 'The Spread and Sustainability of Quality Improvement in Healthcare: A resource to increase understanding of the ten key factors underpinning successful spread and sustainability of quality improvement in NHSScotland'.

http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-topics/spread-and-sustainability.aspx

NHSScotland must continue to strive to learn and adopt and adapt from the best-known practice and this is a critical aspect of driving value and continuously improving the use of our financial as well as human resources and a key focus for leaders across our systems.

Sustainability - quality and efficiency

Adapted from Slideshare: The King's Fund 2012 Annual Conference: Derek Feeley: Scotland - why quality is the best response to the financial challenge

Non-Executive Directors of NHS Boards play an integral role in governing the delivery of health and social care services. Listed below are some of the things that Non-Executive Directors can do to ensure that the NHS Board plans and delivers services from a quality perspective.

What Non-Executive Directors can do to promote quality, efficiency and value

Consider what role you have to champion quality improvement both within and out with your Board Determine whether the leaders in your organisation are advocating for action to promote Quality Improvement Is the Board learning from initiatives and practices undertaken by high performing organisations? Are Board delivery plans informed by evidence of good practice nationally and internationally? Does the Board ensure that Quality has a focus in each of its sub-committees? What process does the Board use to scrutinise how good quality delivery is measured? Does the Board look at the potential impact of performance targets on Quality? Enquire to what extent the Board's monitoring of staff governance incorporates 'Quality'