Commissioning for Quality in Rheumatoid Arthritis (CQRA) aims to standardise and improve the quality of rheumatoid arthritis (RA) service delivery in the UK based on current best evidence (NICE RA Guidelines) by developing and driving implementation of clinically-relevant, patient-driven and meaningful key commissioning metrics. These metrics can be used by commissioners as indicators to ensure they are commissioning a high quality RA service and to drive early development and implementation of quality metrics in RA services. The implementation of these commissioning metrics will assure consistent quality of RA patient services and improved outcomes.
This example was originally submitted to demonstrate implementation of NICE guidance (CG79). The guidance has now been updated and replaced by new guideline NG100. The example has been reviewed and the practice it describes remains consistent with the updated guidance. The updated guideline NG100 should be referred to if replicating practice described in this example.
Aims and objectives
The overarching aim of the CQRA initiative is to standardise and improve the quality of RA service delivery in order to drive the improvement of patient outcomes through implementation of best clinical practice (NICE RA Guidelines) in the management of RA. CQRA aims to impact RA services and thereby outcomes for RA patients by developing and driving implementation of clinically-relevant and meaningful key commissioning metrics. The implementation of these commissioning metrics will assure consistent quality of RA patient services and improved outcomes.
The aim of the CQRA metrics is aligned with the aim of NICE guidelines to drive implementation of best practice ensuring consistent and equitable quality of care for patients. A key aim was to disseminate and drive implementation of the quality commissioning metrics by sharing data and data analysis with other organisations. CQRA have shared their data with other organisations including the highly regarded British Society for Rheumatology (BSR) and National Institute for Health and Care Excellence (NICE) through publication and presentation of the quality commissioning metrics and data from pilot data collection and analysis, as well as direct discussion and face to face meetings with interested organisations and individuals.
Sharing of data will drive use and implementation of the metrics to improve the quality of RA services and positively impact patient outcomes. The main objective of the initiative was to develop, pilot, refine and disseminate a set of clinically-relevant quality commissioning metrics for RA, measuring current services against an agreed best practice standard to enable commissioners and providers to improve the quality of services delivered to RA patients and to improve patient outcomes.
Specific objectives were to: standardise data collection and analysis through development of standardised data collection forms; to share data and data analysis with other organisations in order to understand existing service delivery; to use the data to identify areas for improvement in the quality of RA service; to use the data for ongoing monitoring of service delivery and improvements.
To ensure management of the full spectrum of RA patients was captured, CQRA metrics and data collection forms include patients with established and recent onset disease. The commissioning metrics and data collection forms have been piloted in the clinical setting, refined and are available for wider use via the National Rheumatoid Arthritis Society (NRAS) website. Currently 7 RA centres across the UK have adopted the RA commissioning metrics. As part of the CQRA work stream, a communication plan has been developed to ensure dissemination of findings to relevant healthcare providers and to facilitate implementation of the metrics at all levels of the NHS. The communication plan identifies opportunities for dissemination and engagement including: poster/abstract presentations at national (British Society for Rheumatology) and international (European League Against Rheumatism) conferences; presentation at NICE conference; national and regional meetings; peer review publication; dissemination via the NRAS website; and development of a CQRA information pack including the metrics, background information and guidance for use as well as case studies.
Reasons for implementing your project
NICE clinical guidelines offer best practice advice on care of adults with RA. A National Audit Office (NAO) report highlights: variation in implementation of NICE guidelines; that people with RA are not being diagnosed or treated quickly enough; that coordination of services is suboptimal. At present, there is not a robust data collection process in place within the NHS for the ongoing monitoring of RA service quality and clinical monitoring is not routinely carried out for all RA patients. The overall cost to the UK economy of productivity losses due to RA is £8 billion per year. Local variations in the quality of NHS musculoskeletal services exist in England. In order to improve the quality of RA services, and demonstrate efficient use of resources through implementation of best practice it is essential to have a dataset of key commissioning metrics which can be used for ongoing quality monitoring. RA service providers can use the metrics to demonstrate their high quality of service, provide evidence of resource level need and facilitate prioritisation of resources. Commissioners can use the metrics as indicators to ensure they are commissioning a high quality service and for ongoing quality monitoring.
Analysis of data from the commissioning metrics will provide an understanding of the pattern of service allowing areas for service improvement to be identified and specific goals to be set to monitor and measure improved service delivery. Data from 191 patients indicates that the metrics are robust indicators, readily applicable in the clinical setting, simple to use and able to provide data on RA service quality and identify areas for improvement in implementation of best practice. The standardisation of RA service delivery focussed on implementation of best clinical practice / NICE guidelines, through use of CQRA metrics has the potential to provide a more efficient and effective RA service encouraging best use of existing interventions in the management of RA.
How did you implement the project
The CQRA commissioning metrics and associated data collection forms were developed through a series of six workshops with national experts and patient partners. Published evidence on quality measures was analysed in conjunction with NICE guidelines to produce a manageable number of simple, meaningful and clinically-relevant quality commissioning metrics. Metrics were prioritised based on clinical, patient and commissioning importance, covering: speed of referral; regularity of disease activity assessment; rapidity of treatment escalation to achieve clinical remission or low disease activity; and regularity of comprehensive patient review.
The four metrics chosen reflect clinically important outcomes that indicate adherence to NICE guidelines resulting in good clinical practice and also reflect key issues important to patients. A corresponding metric data collection form was developed to facilitate standardised data collection. To ensure management of the full spectrum of RA patients was captured, CQRA metrics and data collection forms include patients with established and recent onset disease. The quality commissioning metrics for RA are the product of joint working project between the CQRA members-all members gave up their time to attend workshops. Roche have supported this joint working project by providing project management and facilitation support only.
Throughout the project, workshops were used to monitor and evaluate the metrics, with agreement and delivery of key project milestones.
- agreement of objectives
- scope and approach to metrics development
- definition of metrics and user validation
- refinement and piloting of metrics to provide an evidence base prior to wider implementation
- communication plan development and implementation to ensure dissemination of findings to relevant healthcare providers and to facilitate implementation of the metrics at all levels of the NHS.
Each of these key project milestones was achieved. Metrics have been developed, piloted and refined and are available for wider use. Dissemination activities include: poster/abstract presentations at national / international rheumatology conferences; presentation at NICE conference; national / regional meetings; peer review publication; dissemination via the NRAS website; and development of a CQRA information pack.
The CQRA Joint Working Project has provided a clinically meaningful way of measuring quality of services enabling improvements to be made by providing a tool for measuring and monitoring RA service delivery against best practice both from a commissioning perspective and a clinical perspective. Data from 118 patients to be presented at BSR 2012, indicates that for recent onset patients with DAS28>2.6 use of the metrics demonstrated improvement in DAS28 monitoring compared to similar audit in 73 patients carried out in 2010. For established patients with high/moderate disease activity, improvement in tight control was noted compared to 2010. For both recent onset and established RA patients, improvements were noted in 4 of 6 annual review categories compared to 2010. Analysis of metrics allows areas for service improvement to be identified and specific goals to be set by the units and the commissioners to monitor and measure service delivery.
Key learning points
A key learning is the importance of truly collaborative initiatives: this is reflected in the inclusive nature of the CQRA project which involves, providers, commissioners, patient representatives and industry, and the partnership approach through which the metrics have been developed, reviewed and refined. The CQRA project also reflects NICE imperatives and the value of joint working to achieve patient-focussed objectives of CQRA's partnership organisations.
The success of the CQRA project has been facilitated by the innovative approach that joint working allows. CQRA members identified common objectives and developed innovative solutions to achieve these through collaboration and partnership-developing a final deliverable that no single partner would have been able to achieve alone. The importance of patient-user involvement in projects with the ultimate aim of improving patient care and outcomes is also highlighted by the CQRA project.
The metrics were chosen both for clinical relevance and to incorporate outcomes which matter most to patients. Patient user involvement also identified the need to provide opportunities to share data so that patients are involved in their disease management and to provide opportunities for discussion as part of a positive experience of care. Working closely with NRAS ensured no duplication with their current patient experience project. Any initiative should also show tangible value and clinical relevance; the value of the CQRA metrics for commissioners has already been demonstrated. Former Ashton, Leigh and Wigan PCT produced a contract specification as part of a rheumatology service redesign. The rheumatology specific KPIs incorporate two metrics from the CQRA project in order to define and monitor the quality of RA service provision.
The RA Metrics are the product of joint working project between the CQRA members-all members gave up their time to attend workshops. Roche have supported this joint working project by providing project management and facilitation support only.