Contents
1 Policy summary
This policy relates to the trust participating in NHS benchmarking hosted by the NHS benchmarking network (NHSBN). The Benchmarking projects cover mental health and physical health; this policy is relevant to anyone listed in appendix A.
2 Introduction
The NHSBN provides a platform for organisations to work together to improve services and meet ambitions set out in the NHS long term plan.
A programme of regular benchmarking supports:
- delivering best value in provision of care
- development of a digitised NHS
- sharing best practice and innovation
- evidencing progress
- identifying unwarranted variation
- optimising the workforce
- priority setting for population health
The NHSBN was established in 1996 and hosts the benchmarking service for the NHS. It has over 230 registered member organisations and is a not-for profit organisation, hosted by East London NHS Foundation Trust. All subscription fees fund the work programme.
The NHSBN provides members with unique and definitive benchmarks on areas that are not covered by existing national comparisons. This includes analysis of population demographics, the NHS workforce, finance, outcomes, service effectiveness and productivity. The NHSBN publishes findings in regular reports, good practice bulletins and shares innovative practice at member events. The work programme is determined by members so that those areas of most importance are prioritised.
The trust has been a registered member with the NHSBN since April 2012.
3 Purpose
This policy sets out the approach taken by the trust to participate in NHSBN benchmarking and the supporting framework in place to ensure the benefits of membership are maximised.
4 Scope
4.1 Core programme
The NHSBN’s core work programme covers several projects across the mental health sector and the community sector (physical health). Participation in each project is optional.
The annual programme projects are available to view in the members area of the NHSBN website benchmarking login page (opens in new window).
Nominated colleagues working within the following care groups and
corporate functions are required to input into the benchmarking process:
- physical health and neurodiversity care group
- Doncaster adult mental health and learning disabilities care group
- North Lincolnshire adult mental health and talking therapies care group
- Rotherham adult mental health care group
- children’s care group
- health informatics
- human resources or workforce
- finance
- patient safety
- performance
- Mental Health Act office
- learning and development
This list is not exhaustive and may extend to other corporate functions
4.2 Bespoke projects
In addition to the core work programme, the NHSBN host in-year bespoke projects in conjunction with other stakeholders including NHS England (NHSE), Health Education England (HEE) and getting it right first time (GIRFT) which are focused on national agendas and priorities. These are normally mandatory and require immediate attention.
For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.
5 Procedure or implementation
5.1 Quick guide
5.1.1 Launch
- IQO presents proposal to the clinical leadership executive and participation status for each project agreed.
- IQO or assistant IQO notifies NHSBN of participation status and completes registration process.
- CGD nominates operational service lead(s) for each project.
- IQO or assistant IQO notifies corporate managers to enable forward workload planning.
5.1.2 Data collection
- QO or assistant IQO undertakes mapping, agrees and documents a data collection plan with nominated lead(s).
- IQO or assistant IQO liaises with NHSBN to agree definitions if or as appropriate.
- Data collection undertaken within operational and corporate services, coordinated by IQO or assistant IQO.
- Any challenges with submission escalated to CLE if or as appropriate.
5.1.3 Validation
- Nominated lead(s) undertake pre-submission validation.
- Care group director (CGD) oversight.
5.1.4 Submission
- IQO or assistant IQO submits project within agreed deadline.
5.1.5 NHSBN validation
- NHSBN release draft outputs.
- Nominated lead(s) undertake post-submission validation.
- IQO or assistant IQO liaises with NHSBN to agree definitions if or as appropriate.
- IQO or assistant IQO re-submits project.
5.1.6 Output
- NHSBN release outputs.
- Nominated lead(s) attends national event.
- Local analysis undertaken by nominated lead and shared with relevant colleagues.
- Development of localised action plans if or as necessary.
- Key findings reviewed by each care group at delivery reviews.
- CLE to maintain oversight to identify organisational learning.
- Opportunity to network with peers via unique code sharing agreement.
5.2 Notification of annual programme
The information quality officer (IQO) will be notified by the NHSBN of their annual programme at the beginning of the financial year and will be invited to register participation status for each project. This will form a proposal that will be presented to the clinical leadership executive (CLE). Upon decision for each project in the programme, the IQO or assistant IQO will confirm the participation status to the NHSBN and to corporate and operational managers that are expected to be involved in the data collection and validation process to assist in forward workload planning.
The annual programme is available to view in the members area of the NHSBN website benchmarking landing page (opens in new window).
The following steps will apply for each project that the trust participates in:
5.3 Data collection tool
The NHSBN provide a bespoke data collection tool for each project. This is usually a multi-tabbed Excel spreadsheet which incorporates definitions.
For some projects, the data collection tool will be hosted via the NHSBN’s website and will need to be completed online.
The common sections within all projects are:
- service model
- access
- activity
- workforce
- quality, effectiveness and safety
- finance
5.4 Data collection process
At the outset of a project, the IQO or assistant IQO will work in conjunction with nominated leads to undertake an extensive mapping exercise to ensure that extracted data will align to definitions. Where definitions are not clear, the IQO or assistant IQO will liaise with the NHSBN to ensure correct and consistent interpretation. A bespoke data collection plan (one plan per project) will be agreed with the nominated lead and documented by the IQO or assistant IQO. This will clearly set responsibilities and deadlines for each section of the project.
Where the nominated lead is responsible for providing information or data, they will do so in line with the data collection plan. Where it has been identified that data needs to be provided by other colleagues, the IQO or assistant IQO will send requests for this data and monitor responses in line with the data collection plan. The IQO or assistant IQO will populate and maintain a master copy of the data collection tool.
Locality specific data collection will be undertaken as far as possible and, where the NHSBN offer the flexibility to receive multiple submissions, locality specific submissions will be sent.
A normal project data collection timescale range between 1 and 3 months. A structured approach should be applied as follows:
5.4.1 Stage one
- Identify nominated leads via care group director (CGD) or deputy CGD.
- Undertake mapping and agree data collection plan.
- Commence data collection.
5.4.2 Stage two
- Complete data collection.
- Robust validation.
5.4.3 Stage three
- Corrections completed.
- CGD or deputy CGD oversight.
- Submit data by deadline.
5.5 Source data
Data is extracted from key centralised sources as part of the data collection process including:
- electronic staff record
- finance ledger
- RePortal
- risk management system
- Mental Health Act register
If activity data held in SystmOne is not readily available via the existing suite of RePortal (staff access only) (opens in new window) reports satisfying a request from the NHSBN, a request for a report development or extract of this data will be submitted via Redmine.
The data source for each metric will be documented within the data collection tool.
5.6 Pre-submission validation with nominated lead
The IQO or assistant IQO will work with the nominated lead(s) to undertake robust validation on the data collected. This could include:
- sense check by in-service expert
- year on year comparison of historic data submitted to NHSBN
- checking logic applied to the extracted data has been correctly aligned to NHSBN definitions
- reviewing other data sources that present similar data
5.7 CGD oversight
The IQO or assistant IQO will meet with the CGD or nominated deputy to share an overview of the progress against the data collection plan and present any challenges that have emerged during the data collection process. The IQO or assistant IQO will highlight any gaps in the submission (where data has not been collected) and explain the rationale.
5.8 Submission
The completed data collection tool will be sent via email attachment to the NHSBN by the IQO or assistant IQO or will be submitted online via the NHSBN website.
5.9 Post submission validation
The NHSBN will issue a draft output to organisations highlighting any outlier positions to enable them to undertake further validation prior to issuing final reports. The IQO or assistant IQO will liaise with nominated leads to undertake this additional validation and will submit revised data to the NHSBN if or as appropriate.
5.10 Issue and distribution of final reports
All final reports issued by the NHSBN in PDF format will be sent to the IQO or assistant IQO in the first instance who will ensure the further distribution to the Care Group Leadership team and nominated leads.
For each project, the NHSBN issue an overarching summary report and a bespoke organisational report. If locality specific submissions were accepted, the NHSBN will issue a bespoke report for each locality.
To supplement the reports, the NHSBN provide an online toolkit which expands on the content of the reports and allows for detailed comparisons across thousands of metrics. These are available via the NHSBN’s website. The IQO or assistant IQO will ensure the nominated leads have access to and are able to navigate these toolkits.
5.11 Analysis
Nominated leads will undertake local analysis to determine learning outcomes, opportunities for improvement and to celebrate successes. If an improvement plan is indicated, this will be developed and maintained by the nominated lead. Findings from projects will be shared with colleagues at team or individual level if or as appropriate.
The NHSBN offer bespoke feedback sessions for services that can be arranged by request.
Output from benchmarking projects and good practice examples will be reviewed by each care group at delivery reviews to determine any focussed work streams.
The CLE will maintain oversight of any organisational learning achieved via participation in benchmarking.
There will be networking opportunities for nominated leads to contact peers who have agreed to share their unique identifier code.
5.12 Events
The NHSBN host an annual event for each project featured on their core programme which provides members with an opportunity to review findings and share evidence based good practice and innovative ideas. All nominated leads are registered to attend.
6 Training implications
There are no specific training needs in relation to this policy however, all employees need to be aware of its contents.
7 Equality impact assessment screening
To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.
7.1 Privacy, dignity and respect
The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.
Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).
7.1.1 How this will be met
No issues have been identified in relation to this policy.
7.2 Mental Capacity Act
Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.
Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.
7.2.1 How this will be met
All individuals involved in the implementation of this policy should do so in accordance with the Principles of the Mental Capacity Act (2005).
8 Links to any other associated documents
- SystmOne guidance and videos (staff access only) (opens in new window)
- Data quality policy
- Healthcare record keeping policy
- Information governance policy and management framework (includes data protection policy content)
- Information governance handbook
- Information technology (IT) security policy
9 References
10 Appendices
10.1 Appendix A Responsibilities, accountabilities and duties
10.1.1 The IQO
The IQO is responsible for presenting the core work programme to the CLE.
The IQO and assistant IQO will:
- manage RDaSH user access to the members area of the NHSBN website which hosts data collection tools, reports, and interactive toolkits
- maintain a list of nominated leads
- agree and document a data collection process for each project
- liaise with the NHSBN if or as necessary to agree definitions
- coordinate data collection
- coordinate robust validation
- submit data to the NHSBN
- distribute reports published by the NHSBN
- liaise with the NHSBN to arrange bespoke feedback sessions for services
- share details of upcoming events with relevant colleagues and encourage attendance
- support nominated leads to contact peers via the unique code sharing agreement
10.1.2 Colleagues within care groups or corporate functions (finance, workforce, patient safety)
Colleagues within care groups or corporate functions (finance, workforce, patient safety). Any colleague nominated by their manager to provide information should utilise systems available to them to extract the necessary data and should submit this as per instruction and within agreed deadlines. Where possible, data should be inputted directly onto the data collection tool.
10.1.3 Nominated leads
Nominated leads are responsible for ensuring that requests for information from the IQO or Assistant IQO are allocated to an appropriate colleague for action and are responded to within agreed deadlines.
They should also oversee this work and undertake robust validation of information that is gathered. They are also responsible for undertaking analysis of output to identify any opportunities for improvement and progressing local action plans developed in response to findings if or as necessary. They may wish to contact peers to further contextualise outputs via the unique code sharing agreement.
Nominated leads will work very closely with the IQO or Assistant IQO throughout the benchmarking process and be encouraged to attend annual events hosted by the NHSBN.
10.1.4 CGD supported by deputy CGDs
CGD supported by deputy CGDs are responsible for the implementation of this policy within their locality and for nominating leads to work closely with the IQO or assistant IQO.
For each project, upon completion of the extensive data collection and validation process that has been undertaken with nominated leads, CGDs will have oversight of the final submission where they are assured that:
- appropriate individuals from the care group have validated the data
- there are no obvious anomalies in the submission
10.1.5 The head of information quality and information quality manager
The head of information quality and information quality manager are responsible for supervising the IQO and assistant IQO in the overall coordination of benchmarking.
10.1.6 The director health informatics (DHI)
The director health informatics (DHI) is responsible for ensuring compliance with the procedure outlined below.
Output from projects will be received by delivery reviews with care group and corporate services to determine any focussed work streams and cascade learning to respective teams.
The CLE is responsible for reviewing the benchmarking programme and agreeing a participation status for each project. They will maintain oversight of the benchmarking process and will act as a point of contact during the data collection process for any issues that need to be escalated.
They will receive output from projects and identify any organisational learning.
10.2 Appendix B Monitoring arrangements
10.2.1 Analysis of output from all benchmarking projects
- How: Review of reports, toolkits and good practice bulletins.
- Who by: Nominated leads, delivery reviews with care group and corporate service, CLE.
- Reported to: CLE.
- Frequency: Ongoing.
Document control
- Version: 2.1.
- Unique reference number: 620.
- Approved by: Corporate policy approval group.
- Date approved: 25 January 2024.
- Name of originator or author: Information quality officer.
- Name of responsible individual: Director health informatics.
- Date issued: 25 January 2024.
- Review date: 30 November 2026.
- Target audience: All colleagues.
Page last reviewed: October 29, 2024
Next review due: October 29, 2025
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