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

A hysterectomy service needs to:

• be effective and efficient
• be responsive to the needs of patients and support patient choice and access to clinically appropriate treatment
• provide treatment and care based on best practice, as defined in NICE clinical guideline CG44 on heavy menstrual bleeding
• deliver the required capacity
• be integrated with other elements of care for women with heavy menstrual bleeding (HMB), including pharmaceutical management, endometrial ablation, uterine artery embolisation and other surgical treatments for HMB
• define agreed criteria for referral, local protocols and the care pathway for women with HMB
• be patient-centred and provide equitable access, ensuring that women 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 patient treatment choices and outcomes to ensure clinically appropriate care of women with HMB
• 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 do not experience unnecessary delays), complaints procedures. Commissioners may wish to consider developing key performance indicators within contractual arrangements in line with the guidance in Care and resource utilisation; for example, by developing integrated care pathways and thresholds for treatment with clinicians, and seeking to manage levels of activity to an agreed local level for some procedures.
• Clinical governance arrangements, including incident reporting. Complication rates within units can be misleading, but should be explored further locally.
• 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 women with HMB who are offered a choice of different treatment options and monitoring of patient outcomes and complications. See audit criteria for NICE clinical guideline CG44 on heavy menstrual bleeding for further information.
• Health, safety and security: infection control, waste management, confidentiality procedures, legislative requirements.
• Patient satisfaction: patient surveys and perception of service provision could provide an indication of failed treatments.
• Patient outcomes: the number of women receiving clinically appropriate care. See audit arrangements above.
• Staff competencies: individual and team baseline requirements, monitoring and performance. All those involved in undertaking surgical or radiological procedures to diagnose and treat HMB should demonstrate competence (including both technical and consultation skills) either during their training or in their subsequent practice. Training programmes must be long enough to enable healthcare professionals to achieve competency in complex procedures when these are appropriate. These training programmes will usually be located in units with a particular interest and sufficient workload to allow experience of these procedures. This will require a robust clinical governance framework, including audit. See NICE clinical guideline CG44 on heavy menstrual bleeding.
• Information requirements, including patient-specific information (NHS number, referring GP, provision of high-quality information to patients), which could include subsequent re-referral or re-admission as an indicator of failed treatments.
• 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.
• 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. See the heavy menstrual bleeding 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 hysterectomy service can be obtained from the following sources:

• Royal College of Obstetricians and Gynaecologists 'Advanced training skills module: benign abdominal surgery'.
• Commissioners may find documentation used for the Uterine Fibroid Registry useful to inform the development of audit criteria, competency, and governance standards.
• 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 improving the patient experience metric number 11.
• 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 clinical health skills competency framework.