Emergency Department Clinical Quality Indicators

The Department of Health introduced five new headline Emergency Department (ED) clinical quality indicators from the 1 April 2011 with three supporting measures.

The five headline measures are:

• Unplanned re-attendance rate – Patients who return to A&E within seven days of the original attendance are classed as an unplanned reattendance if they have not been specifically asked to re-attend.


• Total time in the  accident and emergency department- This is measured from the time of arrival and registration on the hospital information system to the time that the patient leaves the department to return home or to be admitted to a ward bed.


• Left without being seen rate- Patients who have registered but leave the department without waiting to be seen by a clinician.


• Time to initial assessment – This applies only to patients who are brought in by ambulance and is measured from the time of arrival in the department to the time the patient has an assessment by the clinical team.


• Time to treatment – This is the time from arrival for all patients to seeing a doctor or nurse practitioner who will start the treatment for the patient’s condition.

The three supporting indicators are:

• Ambulatory care – Emergency departments are developing pathways of care for patients to avoid hospital admission and the two key areas of work at present are for patients who have Cellulitis and need antibiotics and for those who have DVT. The measure will reflect the proportion of patients who are able to be treated at home by these improved pathways and processes.


• Service experience – One of the key measures of the service quality is the experience of the patient. Trusts will be reporting the results of patient surveys as well as giving information about specific projects designed to provide a better experience or outcome for the patients overall.


• Consultant sign-off – While it is not possible or necessary for every patient to be seen by a consultant in A&E, there are certain conditions where the outcome can be improved by a senior doctor being involved in the case. The measure will demonstrate the proportion of those patients who have seen a senior doctor and will be measured twice a year by detailed review of notes and outcomes.

The patient groups for consultant sign-off:

• Adults (over 17 years of age) with non-traumatic chest pain


• Febrile children less than 1 year old


• Patients making an unscheduled return to the ED with the same condition within 72 hours of discharge from the ED

 

Emergency Department Clinical Quality Indicators

Functions, Role and Regulations of Care Quality Commission (CQC)

CQC is England’s health and social care services regulator. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage them to improve.

CQC’s principles are to:

• Put people who use services at the heart of its work


• Have an open and accessible culture


• Be independent, rigorous, fair and consistent


• Work in partnership across the health and social care system


• Commit to being a high-performing organisation


• Promote equality, diversity and human rights

What does the CQC do?

CQC carries out its role in the following ways:

• Setting national standards of quality and safety that people can expect whenever they receive care.


• Registering care services that meet national standards.


• Monitoring, inspecting and regulating care services to make sure they continue to meet the standards.


• Protecting the rights of vulnerable people, including those whose rights are restricted under the Mental Health Act.


• Listening to and acting on patient concerns and experiences.


• Working in partnership with other organisations and local groups.


• Challenging all providers, with the worst performers getting the most attention.


• Making fair and authoritative judgements supported by the best information and evidence.


• Taking appropriate action if care services are failing to meet the standards.


• Carrying out in-depth investigations to look at care across the system.


• Reporting on the quality of care services, publishing clear and comprehensive information, including performance ratings to help people choose care.

Who do CQC regulate?

CQC regulate:

• Treatment, care and support provided by hospitals, GPs dentists, ambulances and mental health services.


• Treatment, care and support services for adults in care homes and in people’s own homes (both personal and nursing care).


• Services for people whose rights are restricted under the Mental Health Act.

How are bodies regulated?

In accordance with ‘The Scope of Regulation – August 2013’ CQC Guidance Leaflet, the CQC say that all health and social care services in England need to register with them. In practice however, this is confined to those who carry out any of the CQC’s fifteen regulated activities.

These regulated activities are listed in Schedule 1 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2012. These include:

1. Personal care (which is provided to them in the place where those people are living at the time when the care is provided)


2. Accommodation for person who require nursing or personal care


3. Accommodation for persons who require treatment for substance misuse


4. Accommodation and nursing or personal care in the further education sector


5. Treatment of disease, disorder or injury (if provided by a listed health care professional, social worker or multi-disciplinary team)


6. Assessment or medical treatment for persons detained under the Mental Health Act 1983 (only in hospitals)


7. Surgical procedures (carried out by a healthcare professional, some exceptions for minor procedures, eg foot and nail treatment, tattooing, piercing, removal of hair and blemishes, etc)


8. Diagnostic and screening procedures (radiation, ultrasound and MRI etc)


9. Management of supply of blood and blood-derived products (includes NHS Blood and Transplant)


10. Services in slimming clinics (that include giving medicines AND are led by a registered medical practitioner)


11. Transport services (where the vehicles primary purpose is for transporting people who require treatment), triage and medical advice provided remotely (where the advice is medical AND responsive i.e. for immediate attention or action OR it constitutes triage AND is provided by a body responsible for that service)


12. Maternity and midwifery services


13. Termination of pregnancies (does not include the ‘morning after pill’ when used as an emergency contraceptive)


14. Nursing care (where not under another regulated activity)


15. Family planning services (services for the insertion or removal of an intrauterine contraceptive device by, or under the supervision of, a health care professional)

Any organisation that carries out these regulated activities in England must register with CQC. Separate provisions are available in the rest of the UK.

For any bodies that carry out these services in England from neighbouring countries for short periods of time (eg. Ambulance services) the CQC have said that they will take a ‘proportionate’ and ‘reasonable’ approach to registration.

Registration takes many forms and varies slightly for different practice groups (eg. Corporate groups, franchises, partnerships). This includes the fact that a GP surgery is normally registered under their partner’s (lead doctor’s) name, rather than the surgery itself.

Failure to register

Any service that provides one or any of the fifteen regulated activities who fails to register will be liable for a criminal offence and may face prosecution.

Section 10 of the Health and Social Care Act 2008 states:

(1) Any person who carries on a regulated activity without being registered under this Chapter in respect of the carrying on of that activity is guilty of an offence.

(4) A person guilty of an offence under this section is liable—

• on summary conviction, to a fine not exceeding £50,000, or to imprisonment for a term not exceeding 12 months, or to both;


• on conviction on indictment, to a fine, or to imprisonment for a term not exceeding 12 months, or to both.

Exemptions to regulation

The following bodies aren’t covered currently, even though they provide regulated activities:

• Scottish, Irish, Welsh and non-Mainland UK services


• Non-NHS primary pharmaceutical services – eg. Boots, Superdrug, Lloyds


• Non-NHS primary ophthalmic services – eg. Specsavers, Vision Express


• Some mobile treatment units – eg. Blood donation, breast scanning. Often broader registration is kept with the CQC.


• Some fertility clinics after 01 October 2013


• Independent practitioners – acting as a ‘designated body’ providing services in a surgery or consulting room, treatment does not include anaesthesia or intravenous sedation, childbirth services and termination of pregnancy, certain cosmetic surgery, haemodialysis etc.


• Independent midwives - exemption if midwife is self-employed AND providing non-NHS care AND providing services to their patient ONLY in their home.


• Third party exemptions - Occupational health schemes; defence medical/dental teams for the armed services; forensic medical service (eg in police custody); medical assessment or treatment linked to insurance schemes (does not exclude services through private medical insurance schemes); medical services organised by a government department that do not involve treatment requiring admission to hospital (eg. medical assessments to determine eligibility for social security benefits).


• Individual budgets, individual user trusts and self-funded personal care or nursing care - Where a person, or a related third party on their behalf, makes their own arrangement for nursing care or personal care, and the nurse or carer works directly for them and under their control without an agency or employer involved in managing or directing the care provided, the nurse or carer does not need to register for that regulated activity.


• Any health or social care activity carried out by a carer for a member of their family or someone in a personal relationship – where there is no commercial consideration.


• School nurses - who are employed and managed by the school and who provide services to the school"s pupils. In general, this will exempt school nurses in independent schools, but not in public sector schools where the school nursing service will be included in the registration of the relevant provider.


• Aircraft operators – that only carry out the activity of transport services and do not carry out other regulated activities (such as treatment of disease, disorder or injury)


• Aircraft operators or air ambulance providers within the confines of event grounds - may fall out of regulation if their transport is confined to the event ground.

Archived services

Beyond these exempted services, the CQC have also removed a number of healthcare providers from their website.

These services include those where:

• The provider has voluntarily closed it – for example, a service closed because it is no longer profitable.


• The CQC has taken enforcement action to close it – for example, a service whose registration is cancelled after CQC inspectors found evidence of poor care or abuse.


• The legal entity providing the service has changed – for example, a service where a sole trader has been replaced by a partnership as the provider.


• The service has changed address - for example, a service that has moved to a new building to take advantage of better facilities.


• The provider is no longer required to be registered with the CQC - for example, some fertility clinics that have no longer been regulated by the CQC since 01 October 2013.

This means that it is very important to record the correct name of the healthcare provider when taking feedback from a helpline caller. Common mistakes may include recording a trust under a generic name (eg ‘Manchester Hospital’) or failing to specify which trust is being discussed.

What are the potential risks for service users?

When services are exempted by CQC, service users cannot feedback their experiences. This means that if poor care is experienced, or members of the public know that poor care is being provided, the information cannot be collected and acted upon by the CQC, these cases are not included in the CQC pilot.

CQC continues to expand in the services it regulates and covers. Changes to the CQC regulations were made following a consultation by the Department of Health in 2011. These amendments were then approved by Parliament in 2012. These changes mostly address technical points in the regulations that make them clearer in order to provide greater clarity.

Further changes in October 2013 meant that some further healthcare providers were no longer required to be registered with the CQC. The CQC have responded by saying that many of these services were already exempted by the regulations by another means.

With input from AVMA

 

Functions, Role and Regulations of Care Quality Commission (CQC)