Ensuring corporate and quality assurance

Commissioners should ensure that the services they commission represent value for money and offer the best possible outcomes for patients. Commissioners need to set clear specifications for monitoring and assuring quality in the service contract.

Commissioners should ensure that they consider both the clinical and economic viability of the service, and any related services, and take into account patient's and carer's views and those of other stakeholders when making commissioning decisions.

A cardiac rehabilitation service needs to:

• be effective and efficient
• be responsive to the needs of patients and carers
• provide treatment and care based on best practice, as defined in NICE clinical guideline CG48 on myocardial infarction (MI): secondary prevention
• deliver the required capacity
• be integrated closely with other services in primary and secondary care, ensuring that people requiring cardiac rehabilitation receive continuity of care at all four phases of the patient journey
• define agreed criteria for referral, local protocols and the care pathway for patients requiring cardiac rehabilitation
• be patient-centred and provide equitable access, ensuring that patients are treated with dignity and respect, are fully informed about their care and are able to make decisions about their care in partnership with healthcare professionals
• audit various components and submit this information to the ‘National audit of cardiac rehabilitation'
• demonstrate how it meets requirements under equalities legislation
• demonstrate value for money.

Local quality assurance

Any mechanisms for quality assurance at a local level are likely to refer to the following.

• Service and performance targets, including estimated activity levels and case mix, waiting and referral-to-treatment times (ensuring that patients and carers do not experience unnecessary delays), complaints procedures.
• Clinical governance arrangements, including incident reporting.
• Clinical quality criteria: appropriateness of referral, consenting procedures, clinical protocols.
• Audit arrangements: frequency of reporting, reporting route and format, and dissemination mechanisms; this should include auditing the proportion of eligible patients requiring cardiac rehabilitation who are provided with care, and monitoring of patient outcomes and complications. See audit criteria for NICE clinical guideline CG48 on MI: secondary prevention, which includes recommendations to link with the national audit of cardiac rehabilitation.
• Health, safety and security: infection control, waste management, confidentiality procedures, legislative requirements.
• Equipment: testing and calibration of exercise and monitoring equipment.
• Accreditation requirements: for some or all elements of the service, the premises and/or staff.
• Patient satisfaction: patient and carer perspective and perception of service provision, complaints.
• Patient outcomes: reduced risk of further cardiac problems, improved quality of life, reduction in hospital admissions, improved return to work rates, reduced blood pressure and cholesterol levels, improved patient knowledge and psychosocial well-being and reporting these outcomes to the ‘National audit of cardiac rehabilitation'.
• Staff competencies: individual and team baseline requirements, monitoring and performance. See Implementation advice for NICE clinical guideline CG48 on MI: secondary prevention for recommendations on assessing training needs.
• Information requirements, including both patient-specific information (NHS number, referring GP, provision of high-quality information to patients/carers) and service-specific information (referral-to-treatment times, workload trends, number of complaints).
• The process for reviewing the service with stakeholders, including decisions on changes necessary to improve or to decommission the service.
• Achieving targets associated with equalities legislation.

Further information

General information on quality and corporate assurance can be obtained from the following sources:

• The National Patient Safety Agency (NPSA) oversees the implementation of a system to report and learn from adverse events and near misses occurring in the NHS. The publication ‘Seven steps to patient safety' provides an overview of patient safety and gives updates on the tools that the NPSA is developing to support patient safety across the health service.
• NHS Alliance online resources. NHS Alliance is the representational organisation of primary care and primary care trusts, and provides them with an opportunity to network and exchange best practice. The alliance supports its members with an open-access helpline, in-house and joint publications and briefings, internal newsletters and a website.
• The DH commissioning framework provides guidance on the commissioning process in the context of the NHS reform agenda
• NHS Institute for Innovation and Improvement support for commissioners, includes Commissioning for Health Improvement products to accelerate the achievement of world class commissioning; The Productive Leader programme to enable leadership teams to reduce waste and variation in personal work processes, and Better care, better value indicators to help inform planning, to inform views on the scale of potential efficiency savings in different aspects of care, and to generate ideas on how to achieve these savings.
• ‘10 Steps to your SES: a guide to developing a single equality scheme'. This guidance has been developed to assist NHS organisations that have a duty, as public authorities, to comply with the race, disability and gender public sector duties, and in anticipation of new duties in relation to age, religion and belief, and sexual orientation.

Specific information on quality and corporate assurance for a cardiac rehabilitation service can be obtained from the following sources:

• ‘Better metrics' is a pragmatic project that provides clinically relevant measures of performance to support the development of measurable local targets and indicators for local quality improvement projects. See heart disease and stroke metric.
• The ‘Quality and outcomes framework (QOF)' was designed to deliver substantial financial rewards for high-quality care. The framework sets out a range of national standards based on the best available research evidence.
• ‘Skills for health' works with employers and other stakeholders to ensure that those working in the sector are equipped with the right skills to support the development and delivery of healthcare services. See details of the coronary heart disease competency framework.
• ‘A skills-based operational framework for practitioners with a special interest in cardiology' from the Heart Improvement Programme sets out a national standard for training courses for practitioners with a special interest in cardiology and is endorsed by many national organisations including the Royal College of General Practitioners.