Getting the measurements right: QIPP in 2013

The main objective of any cost-reduction programme is to positively redirect patients into the right services of care, while changing the behaviour of general practice, and to get a grip on acute spending.

Here are a few ways to ensure delivery of any cost-efficiency plan, and when the time comes, to be able to start implementation, which is managed by a few principles.

The process begins when health providers and the “human doers in the system” start building QIPP plans to match the prescribed target for 2013. For a target to be adhered too, the scope of change is recognised and strategists have understood:

• Out of hospital strategy
• Activity shifts into community and other providers
• Reduce inpatients
• Increase outpatients
• Manage referrals by GPs
• Develop pathways for referral standardisation
• Review fortuitous prescribing trends
• Corporate budget review
• Manage consultant to consultant referrals
• Manage frequent fliers
• Facilities, estates, fixed cost review
• Back office review

Develop integrated care services across different sites

• Review reserves and recurrent spend − what happened or did not happen last year.
• Review productivity opportunities.
• Benchmark wate-to-efficiency (WTE) activity rates, by band, against target for patient hours per day.

The assumed planning inputs

• All cost-efficiency plans would be aligned to the commissioning intentions and out of hospital strategies.
• Measures for each scheme would be able to capture the benefits accurately.
• Financial plans would confirm run rate, and cost pressures from last year and fed into the plans for this year.
• Bottom-up analysis of 2013-14 QIPP plans by initiative would be competed.
• Structural issues, would be solved so that all resources would be understood to drive delivery.
• Reinvestment has been identified and understood how it will be measured over the year.
• Phasing of all projects are agreed and aligned to financial reporting.
• Risk measures have been decided and post and pre risk savings have also been approved.
• Governance systems would be in place, to support the framework of delivery.
• Last year’s lessons learned would be able to inform this year’s planning for QIPP plans.
• Provider impact, and contractual negotiations would be all compete, so everyone would understand the minimum and maximum take agreed.
• Systems would be able to support reporting information.
• Business intelligence tools would be developed and ready for reporting.
• Detailed initiative plans started to be developed, for implementation.
• All of the above has sign off, and ready for change.
• Month 1 begins, with reporting able to inform decision making through accurate data and business intelligence.

The QIPP list above is complex, and every health practitioner, and/or manager who knows what to do also needs to know how to do it.

In the end, it does not matter what the plan is or how much money it will save, it is the measure of how this will show the benefits it espouses which is the crucial bit. The QIPP programme will increase in performance by following just a few key points in how to count right and get the right results.

These are three weak examples for QIPP schemes and objectives:

“This project aims to re-design existing pathways and where required design new pathways to create a seamless patient journey.  Its main premise is to create an integrated system that meets and exceeds patient outcomes.”

“To improve the overall health and wellbeing of X resident; and to reduce disparities in health outcomes between groups, through prevention and early intervention.”

“To reduce the rate of unplanned hospital admissions and readmissions, and optimise length of stay, and thereby realise associated savings on acute hospital costs.”

strong language

Each one sounds OK, but what do they really mean? How are they going to be measured? Some theories would support SMART to define the objective by being ‘specific, measurable, achievable, realistic and timely’, as a way to control the measure and be able to ‘count’ success.

But it is still challenging to “count” if language is vague. One should try to avoid using phrases such as “continue to strengthen,”  “improve pathways,” “reduce spend by integrated care,” “ensure value for money,” “reduce costs by developing local services,” and “meet the needs of client.”

Use words that will be able to be counted, and think about how the plans are going to be captured and through what method.

If the objective is improved pathways, how are those pathways going to be captured to show financial success to the bottom line. Use words which can describe the process. If a plan does have weak language, ask how it will be counted.

Be curious

Ask questions such as which practices, which GPs, which system of collection, who will own the reporting, and which business intelligence will inform this objective? Also, what are the unknowns?

Also find out about which GPs and if anyone defined what they mean by secondary care, and where is the data for collection to measure success?

In 2013 the plans are to reduce excess bed days. Find out how will these be flagged on a daily basis to see change; how will this idea be counted to save cash; and who will count the actual beds, wards closure and bay closures. Be specific to make an informed choice.

Productivity gains are through more patient-facing time, effectively reducing staffing requirement. Again, key questions are:

• Who is defining these?
• How will they be captured?
• Is there a baseline for comparison?
• What is “more” patient facing time? (Define in numbers or percentage)
• What is effective?
• What is reducing? (Define in numbers or percentage)
• What system is capturing this objective?
• Does everyone have the supporting documentation about staffing requirements?

If the objective is to reduce the rate of unplanned hospital admissions and readmissions, and optimise length of stay, and thereby realise associated savings on acute hospital costs, key questions and areas to address are:

• Reduce by how much?
• The rate needs to be defined.
• Unplanned needs a baseline to show comparison during year.
• Optimise needs a definition.
• Level of spending needs to be defined.
• Is there a business case?
• How will this scheme be realised?
• Associated savings needs to be defined.

Ask: How are we going to capture the counting, by what system? Build a tool to capture the measure through identifying:

• Principal objective           
• Objective owner   
• Sub-objectives      
• Principal risk          
• Key controls           
• Gaps in control      

Risk score    

• Action plan  
• Sources of assurance       
• Positive assurance
• Negative assurance          
• Gaps in assurance 
• Action plan
• Will it be a contract negotiation?
• Is it transformational change?
• Redesign benefit?
• Benefit metric description          
• Benefit measurement description        
• Measurement owner
• Clinical owner
• Qualitative capture through what?
• SQL query   
• Data source(s)        
• Data frequency      
• Data lag        
• Double count risk?
• Action taken to mitigate double count risk    
• Other comments

Ask: what are the assumptions of this plan, and measure?

It is important to be clear about definitions. For example, musculoskeletal seems like a solid definition, so managing the objective of “reducing musculoskeletal outpatient activity by five per cent over two months” seems well defined. But what is musculoskeletal care, and how will this be counted? Usually it is counted as trauma and orthopaedic, pain management and rheumatology.

This definition may not give the perception of what is happening financially if we cannot count the true service redesign of particular patients.

‘QIPP is not easy, but asking “how” helps with the challenge’

In addition, there are several  flaws in this measure. Pain management can capture neurological disorders, or breast cancers which probably are not musculoskeletal. Also not every trauma and orthopaedic episode will equal a musculoskeletal count. If all outpatients are counted, most service redesign plans are cutting from that same pie of data, so one has to be careful of also double counting.

The solution is defining every definition, and then measuring it. The next move is to think about how will the data be captured, fed back and reported to help informed decision-making, and ensure the goal of saving money is achieved.

QIPP is not easy, but asking “how” helps with the challenge.

Keep asking how. How will this £1.4m project, for example, be monitored? How will it save money? How will this information be captured and reported back within a performance framework to show objectives are meeting target? How?

For every plan to save money in-year make sure it can be measured and reported on accurately to give an understanding of whether this is succeeding or not.

For every answer, there is another how, keep asking, and there will be an increase of delivery.

Leigh Cantero is interim head of Central London CCG, West London CCG, Hammersmith and Fulham CCG and Hounslow CCG, leigh.cantero@gmail.com