Commissioning For Improvement: Harm Free Care CQUIN

NHS Greater Manchester

Authors: Margaret Williams, Associate Director Nursing & Quality Improvement

Leadership and Teamwork

By engaging commissioning teams in change management and large scale change processes we led the development of a Greater Manchester strategy that transformed traditional approaches to CQUIN implementation. We wanted to inject creativity into the national Harm Free Care CQUIN across NHS Greater Manchester for improved patient outcomes and experience. Collectively we noted the opportunity to build upon commitment across the health economy, recognizing from previous improvement programmes that an energized workforce naturally leads innovation and improvement. We acknowledged early, a potential disconnect between providers and the perceived benefits that the Harm Free Care CQUIN would reap for their patients. We listened to and enabled clinical experts to shape CQUIN indicators for measurement and put in a facilitative support package to kick start the process.

We visited senior leaders from across commissioning and provider services, held numerous commissioner engagement events, produced newsletters and co-ordinated the development and sharing of best practice with the support of AQUA, Advancing Quality Alliance (AQUA) and the NHS Leadership Academy. We then agreed our aim: the systematic leadership requiring commitment from acute providers to achieve 95% Harm Free Care by March 2013 and for other providers of NHS funded care to embrace the NHS Safety Thermometer tool for improvement.

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Strategic team Ward-led team
Hilary Garratt
Dr Raj Patel
Anita Rolfe
Margaret Williams
Sue Savage
Grace Wall
Michael Robinson
Ross Dargan Peel
Helen Clarke
Traci Berry,
Sian Schofield
NHS GM Continuing Health Care Leads
NHS GM Quality & Risk Leads

Creating and Integrating a Plan

Greater Manchester is large and complex:

• 2.6 Million people across the health economy

• NHS Greater Manchester = 1 cluster PCT (from 10 PCT’s) (to be NCB Local Area Team)

• 12 Clinical Commissioning Groups ( 460 GP practices)

• 9 Acute Providers

• 8 Community Providers

• 3 Mental Health Trusts

• 1 Specialist Cancer Trust

• 600 + Independent Sector Providers • ( Care Home and domiciliary care)

• 10 Local Authorities In April 2012 NHS Greater Manchester published The Integrated Plan 2012-2013.

The plan brought together all key requirements for NHS Greater Manchester, its constituent Primary Care Trusts and Clinical Commissioning Governing Bodies across the areas of quality, resources, reform and transition. The aim, "to secure safe, sustainable, high quality and cost effective, health care & wellbeing services for the whole of Greater Manchester”. One of the promises we made was to ‘keep you safe’, the delivery of Harm Free Care, being one of the methodologies used. In May we produced a one page Greater Manchester Harm Free Care Strategy. This approach was very effective for stimulating discussion on what was truly important, and because done collaboratively identified the most critical priorities for success. On a single page we displayed the ‘big picture’ and linkages to The Integrated Plan and described ‘who we are’, ‘where we are going’, and ‘how we would get there’.

Planning SMART objectives
New World of Clinical Commissioning
Patient focused outcomes from both commissioner and provider through joint commitment
A CQUIN that focused on improving patient experience and nursing care
A stretch to providers beyond the National CQUIN of 12/13
Assessment of baseline – was the 95% achievable by any provider? ( 4 out of the 9 Acute Providers very close in March 2011)
A supportive commissioning approach that enables providers to achieve improvements
Provision of expert nursing commissioning resource to assist with hearts and minds of culture change
Real opportunity to commission to reduce harm where it exists across the Health Economy
Specific: To achieve and deliver 95% Harm Free Care
Measurable: Using the NHS Safety Thermometer
Achievable: With leadership, commitment and engagement
Relevant: To patient safety and improving quality of care
Timebound: By March 2013

Implementing the Plan

We assigned clear accountability for accomplishment of specific plan objectives and tactics to individuals through the CQUIN process. Accountable leads from commissioning, and provider services came together and galvanized collective energy for improved outcomes. Responsibility for specific elements of the plan was delegated to Risk and Quality Leads, Contracting Teams and Continuing Health Care Leads. The plan was kept 'alive' by embedding into meeting agendas at every level of the organisation and at collaborative events. The Large Scale Change Team continually reinforced the aim of the plan and listened to all collaborators to enable improvement activity across the health economy.

For example (please click on the table for a more detailed view):

Implementation - Assessment and Diagnosis Implementing and Planning
Viewing and noting baseline of what we have available
Discussions and site visits noting direction for action
Some providers stated ( we’re not doing it – it’s impossible)
Some commissioners ( we commission it already – they didn’t they just thought they did)
Unanticipated response from the Independent Sector (Great idea - when can we start
Huge variety in understanding but it got people talking and it is keeping them talking too
CQUIN contracting negotiation and aligning improvement to incentivise
CQUIN construction with Clinical Commissioning Governing Bodies, Risk & Quality leads
Greater Manchester Clinical Commissioning Governing Body Council consideration and agreement of implementation across Greater Manchester
Discussion with PCT Quality & Safety leads about local implementation
Listening, discussion and negotiation exercise with NHS providers
Commissioner workshops to discuss implementation
Joint workshops for Continuing Health Care Leads and Independent Sector staff to identify support
Agreement of commencement of data collection
Leadership Academy aspiring leaders days attended by nurses in commissioning hosted
Large Scale Change Team secured
Partners with Advancing Quality Alliance strengthening communication and highlighting commissioners for improvement as partners
Events calendar developed and plan to publish
Commenced collaborative learning sessions with Commissioners, Acute, Community, Mental Health, Independent Sector Organisations
Plan to publish and present GM HFC nationally
CCG led commissioner visits with Acute Trust colleagues and stakeholder
Stock take and realign support as needed, Commissioner and Provider

Measuring and Results

We mapped the board strategic aims into a driver diagram. This supported the break down of the improvement action into manageable components, increasing the level of understanding and engagement required for success.

We considered 95% harm free care and began to articulate the primary drivers that would incentives and stimulate innovation for improved outcome. We realised early on that incentives alone would not necessarily achieve the target and therefore set about pulling together a series of primary and secondary measures aligned with the NHS Greater Manchester Integrated Plan and Greater Manchester Harm Free Care CQUIN.




For a more detailed view, click on the driver diagram. 






The Greater Manchester CQUIN worked by 50% of incentive payment being allocated to the use and review of nursing care indicators, these would be measured in partnership during clinical reviews and site visits, the remaining 50% of CQUIN will be issued on demonstration of 95% harm free care via the NHS Safety Thermometer as a % of all 4 harms (acute inpatient setting only).

Current Position: 

Spreading the Message

The NHS Greater Manchester Harm Free Care strategic objectives are designed to support clear messaging and interaction with people inside and outside of the Organisation. Its aim is to promote significance and expectation of what the campaign is about and begin to bring about shared ownership, ‘a want’ to get involved in the campaign.




Please click on the image for a more detailed view.