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 patients´ and carers views and those of other stakeholders when making commissioning decisions.

A heart failure 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 CG5 on chronic heart failure
• deliver the required capacity
• be integrated with other elements of care for people with chronic heart failure
• define agreed criteria for referral, local protocols and the care pathway for people with chronic heart failure
• 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 the percentage of patients with chronic heart failure whose diagnosis has been confirmed by echocardiography, prescribed ACE inhibitors and beta-blockers; who receive a copy of NICE CG5 on chronic heart failure: information for the public are reviewed 6-monthly; and where appropriate, have a pre-discharge management plan in place to ensure treatment is optimised
• 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. Rapport data provides further information on patient wait times for echocardiography and is available from the Heart Improvement Programme and the cardiac networks. Commissioners should monitor wait times for diagnostics and access to specialist services to ensure timely access is available for patients.
• 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 people with chronic heart failure who are provided with care, and monitoring of patient outcomes and complications (see the technical detail on the criteria for audit for NICE clinical guideline CG5 on chronic heart failure for further information).
• Health, safety and security: infection control, waste management, confidentiality procedures, legislative requirements.
• Equipment: training and quality control. Commissioners will need to ensure that procedures for testing, calibration and maintenance of BNP testing equipment are in place, particularly for point of care testing.
• Accreditation requirements: for some or all elements of the service, the premises, equipment and/or staff.
• Patient satisfaction: patient and carer perspective and perception of service provision, complaints.
• Patient outcomes: reduced mortality for patients with chronic heart failure and reduce recurrent hospital stay. The Healthcare Commission ‘Framework of assessment' (figure 1) identifies patient and service outcomes for heart failure service.
• Staff competencies: individual and team baseline requirements, monitoring and performance for diagnosis and diagnostic reports, specialist skills and up-titration of pharmacological therapy.
• 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:

• ‘Implementing care closer to home: convenient quality care for patients. Part 3: accreditation of GPs and pharmacists with special interests'.
• 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.
• ‘Delivering the 18 week patient pathway' provides a range of resources to support the key NHS objective to deliver an 18 week patient pathway from GP referral to the start of treatment by the end of 2008, and the breathlessness (heart failure) pathway.
• 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 heart failure service can be obtained from the following sources:

• ‘Practitioners with a special interest (PwSI) in cardiology: a skills-based operational framework for practitioners with a special Interest (PwSI) in cardiology' has identified service requirements for practitioners with a special Interest in cardiology, and in particular patients presenting with symptoms of breathlessness.
• Specialist heart failure nurse training ‘Principles of care management for the patient with chronic heart failure' provides an academically accredited educational programme to prepare registered nurses and other allied health care professionals to manage patients with chronic heart failure.
• ‘Transthoracic accreditation' and ‘Accreditation in community echocardiography' provide guidance on standards for the provision and training for echocardiography.
• The Healthcare Commission's heart failure benchmarking toolkit is a resource provided by the Healthcare Commission to enable commissioners to review heart failure services and compare them with other healthcare providers and primary care trusts.
• ‘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 2.10 ‘percentage of patients with a diagnosis of coronary heart disease and left ventricular dysfunction who are currently treated with ACE inhibitors (or A2 antagonists)'.
• 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 relevant competencies, including the 'Monitor individuals diagnosed with heart failure' competency in the coronary heart disease framework.