Fracture Liaison Service Implementation Toolkit - Outcome and Performance IndicatorsIntroduction

Using this toolThis workbook has been designed for use by provider and funders to develop an agreement on how a FLS can demonstrate that it is achieving good outcomes and other measures that demonstrate the quality of the service being provided. The workbook acts as an illustration of the method and as a working template that can be adapted for local use. It is therefore a tool for both developing and monitoring service quality, particularly in relation to outcomes. Examples of several types of outcome measure are included such as PROMS, PREMS and activity and cost. These are suggested and may be edited at will.

Note that this is not a contract or service level agreement and any indicators, payments or other details will need to be agreed between provider and funder in order to populate this workbook. However the workbook is very useful in facilitating the discussion and can be used to help both parties reach agreement.

The workbook contains one sheet in addition to this Introduction sheet. The Indicators sheet describes the outcome or quality measure and suggest indicators that may be used to determine whether outcomes have been achieved. It goes into some detail about the precise metric, methodology and definition. This sheet is fully editable and cells, columns and rows may be overwritten, inserted or deleted as required.

Agreeing indicators, standards and outcomes - some thoughts

Improving quality and outcomes over time - indicators and standards can, of course, be raised each year to leverage improvement such that a standard of 50% this year can become 60% or 70% next year. Also some standards become redundant over time as quality improves and can be replaced. Early in the life of a new service it may be appropriate to set a standard that simply requires information, such as patient satisfaction, to be captured or systems to be in place. As time goes on the information collected by the system can be used to drive improvement such that satisfaction rates increase year on year.

Retention and reward - it is possible to link performance to payment for the service and different approaches to incentives can be used. One useful method is to make a distinction between expected achievement (e.g. minimum standards) for which a fraction of the payment for the service can be withheld. In this way, if a provider fails to achieve these standards it acts as a penalty. To do this the contract or other agreement must state that this money will be withheld and paid over at the year end on satisfactory submission of information and achievement of agreed standards. To balance this, some payment should be offered as a reward over and above the agreed contract or agreement value. This also needs to be formally documented and clearly understood by both parties.

Achievability - the provider must always believe that the indicators and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that there will be little or no effort to achieve the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurement and verification. It is likely that there will always be some data that are incomplete or some patient records that do not conform to the proposed method of measurement. The provider may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this simply change a standard to 99% or 98% where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement should be readily available from existing sources and systems. This helps to minimise costs and allows providers to spend more time with patients. The costs of collecting and reporting must be proportional to the reward that the provider is able to achieve. If not then it is likely that the indicator will not have the desired effect.

Sampling - where there is no routine data collection and the costs of collection are high it may be appropriate to sample. Sampling should always be carried out in a way that minimises bias (e.g. only sampling patients that are very happy with the service). You may need to take expert advice from colleagues in clinical audit teams or public health on this subject.

Exceptions - some thought needs to be given to exceptions, i.e. occasions when the data cannot be collected because, for example the patient does not wish to comply. Equally there must not be an incentive not to try to collect data. To address this standards can be made conditional e.g. '50% of patients sampled report improvement in symptoms. Sample must comprise at least 30% of patients discharged'. Payment would then be made only if all conditions are met.

This templateThis resource has been created by the National Osteoporosis Society as part of the Fracture Liaison Service Implementation Toolkit (FLS-IT). The aim of the toolkit is to take some of the hard work out of establishing a new Fracture Liaison Service (FLS) or improving an existing one. This template has been created by working professionals in the NHS in each of the four home nations and makes use of current policy and best practice. It has been designed to save the user the time and trouble of researching, drafting and editing a document or workbook from scratch. References have been included where relevant.

You are free to use, change, edit or adapt this template as you wish. We trust that you will find this tool useful; if you have any queries or would like to make any suggestions on how to improve it, please contact us at the National Osteoporosis Society. If you would like to see or to download other tools, please go to: www.nos.org.uk/tookit DisclaimerThis template is provided free as part of the FLS-IT by the National Osteoporosis Society. This template does not represent the views of the National Osteoporosis Society. Every effort has been made to make sure that the information contained within this document is accurate and in full compliance with UK law and with best practice at the time of writing. There is no guarantee as to the accuracy or reliability of any of the information contained in this template and use of this template is entirely at the user’s risk and no liability whatsoever is accepted by the National Osteoporosis Society. Instructions for useThe template is fully editable. Formatting has been kept to a minimum to allow flexible use either editing this template or copying material to use in local documents. The template may include guidance on use and/or sections where local information may need to be entered. These have been highlighted [using bold text in square brackets]. Please delete or overwrite these sections as you go along and make the necessary font or formatting changes. [Please delete this box when you use the template]

Using this toolThis workbook has been designed for use by provider and funders to develop an agreement on how a FLS can demonstrate that it is achieving good outcomes and other measures that demonstrate the quality of the service being provided. The workbook acts as an illustration of the method and as a working template that can be adapted for local use. It is therefore a tool for both developing and monitoring service quality, particularly in relation to outcomes. Examples of several types of outcome measure are included such as PROMS, PREMS and activity and cost. These are suggested and may be edited at will.

Note that this is not a contract or service level agreement and any indicators, payments or other details will need to be agreed between provider and funder in order to populate this workbook. However the workbook is very useful in facilitating the discussion and can be used to help both parties reach agreement.

The workbook contains one sheet in addition to this Introduction sheet. The Indicators sheet describes the outcome or quality measure and suggest indicators that may be used to determine whether outcomes have been achieved. It goes into some detail about the precise metric, methodology and definition. This sheet is fully editable and cells, columns and rows may be overwritten, inserted or deleted as required.

Agreeing indicators, standards and outcomes - some thoughts

Improving quality and outcomes over time - indicators and standards can, of course, be raised each year to leverage improvement such that a standard of 50% this year can become 60% or 70% next year. Also some standards become redundant over time as quality improves and can be replaced. Early in the life of a new service it may be appropriate to set a standard that simply requires information, such as patient satisfaction, to be captured or systems to be in place. As time goes on the information collected by the system can be used to drive improvement such that satisfaction rates increase year on year.

Retention and reward - it is possible to link performance to payment for the service and different approaches to incentives can be used. One useful method is to make a distinction between expected achievement (e.g. minimum standards) for which a fraction of the payment for the service can be withheld. In this way, if a provider fails to achieve these standards it acts as a penalty. To do this the contract or other agreement must state that this money will be withheld and paid over at the year end on satisfactory submission of information and achievement of agreed standards. To balance this, some payment should be offered as a reward over and above the agreed contract or agreement value. This also needs to be formally documented and clearly understood by both parties.

Achievability - the provider must always believe that the indicators and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that there will be little or no effort to achieve the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurement and verification. It is likely that there will always be some data that are incomplete or some patient records that do not conform to the proposed method of measurement. The provider may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this simply change a standard to 99% or 98% where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement should be readily available from existing sources and systems. This helps to minimise costs and allows providers to spend more time with patients. The costs of collecting and reporting must be proportional to the reward that the provider is able to achieve. If not then it is likely that the indicator will not have the desired effect.

Sampling - where there is no routine data collection and the costs of collection are high it may be appropriate to sample. Sampling should always be carried out in a way that minimises bias (e.g. only sampling patients that are very happy with the service). You may need to take expert advice from colleagues in clinical audit teams or public health on this subject.

Exceptions - some thought needs to be given to exceptions, i.e. occasions when the data cannot be collected because, for example the patient does not wish to comply. Equally there must not be an incentive not to try to collect data. To address this standards can be made conditional e.g. '50% of patients sampled report improvement in symptoms. Sample must comprise at least 30% of patients discharged'. Payment would then be made only if all conditions are met.

Fracture Liaison Service Implementation Toolkit - Outcome and Performance Indicators

Using this toolThis workbook has been designed for use by provider and funders to develop an agreement on how a FLS can demonstrate that it is achieving good outcomes and other measures that demonstrate the quality of the service being provided. The workbook acts as an illustration of the method and as a working template that can be adapted for local use. It is therefore a tool for both developing and monitoring service quality, particularly in relation to outcomes. Examples of several types of outcome measure are included such as PROMS, PREMS and activity and cost. These are suggested and may be edited at will.

Note that this is not a contract or service level agreement and any indicators, payments or other details will need to be agreed between provider and funder in order to populate this workbook. However the workbook is very useful in facilitating the discussion and can be used to help both parties reach agreement.

The workbook contains one sheet in addition to this Introduction sheet. The Indicators sheet describes the outcome or quality measure and suggest indicators that may be used to determine whether outcomes have been achieved. It goes into some detail about the precise metric, methodology and definition. This sheet is fully editable and cells, columns and rows may be overwritten, inserted or deleted as required.

Agreeing indicators, standards and outcomes - some thoughts

Improving quality and outcomes over time - indicators and standards can, of course, be raised each year to leverage improvement such that a standard of 50% this year can become 60% or 70% next year. Also some standards become redundant over time as quality improves and can be replaced. Early in the life of a new service it may be appropriate to set a standard that simply requires information, such as patient satisfaction, to be captured or systems to be in place. As time goes on the information collected by the system can be used to drive improvement such that satisfaction rates increase year on year.

Retention and reward - it is possible to link performance to payment for the service and different approaches to incentives can be used. One useful method is to make a distinction between expected achievement (e.g. minimum standards) for which a fraction of the payment for the service can be withheld. In this way, if a provider fails to achieve these standards it acts as a penalty. To do this the contract or other agreement must state that this money will be withheld and paid over at the year end on satisfactory submission of information and achievement of agreed standards. To balance this, some payment should be offered as a reward over and above the agreed contract or agreement value. This also needs to be formally documented and clearly understood by both parties.

Achievability - the provider must always believe that the indicators and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that there will be little or no effort to achieve the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurement and verification. It is likely that there will always be some data that are incomplete or some patient records that do not conform to the proposed method of measurement. The provider may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this simply change a standard to 99% or 98% where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement should be readily available from existing sources and systems. This helps to minimise costs and allows providers to spend more time with patients. The costs of collecting and reporting must be proportional to the reward that the provider is able to achieve. If not then it is likely that the indicator will not have the desired effect.

Sampling - where there is no routine data collection and the costs of collection are high it may be appropriate to sample. Sampling should always be carried out in a way that minimises bias (e.g. only sampling patients that are very happy with the service). You may need to take expert advice from colleagues in clinical audit teams or public health on this subject.

Exceptions - some thought needs to be given to exceptions, i.e. occasions when the data cannot be collected because, for example the patient does not wish to comply. Equally there must not be an incentive not to try to collect data. To address this standards can be made conditional e.g. '50% of patients sampled report improvement in symptoms. Sample must comprise at least 30% of patients discharged'. Payment would then be made only if all conditions are met.

This templateThis resource has been created by the National Osteoporosis Society as part of the Fracture Liaison Service Implementation Toolkit (FLS-IT). The aim of the toolkit is to take some of the hard work out of establishing a new Fracture Liaison Service (FLS) or improving an existing one. This template has been created by working professionals in the NHS in each of the four home nations and makes use of current policy and best practice. It has been designed to save the user the time and trouble of researching, drafting and editing a document or workbook from scratch. References have been included where relevant.

You are free to use, change, edit or adapt this template as you wish. We trust that you will find this tool useful; if you have any queries or would like to make any suggestions on how to improve it, please contact us at the National Osteoporosis Society. If you would like to see or to download other tools, please go to: www.nos.org.uk/tookit DisclaimerThis template is provided free as part of the FLS-IT by the National Osteoporosis Society. This template does not represent the views of the National Osteoporosis Society. Every effort has been made to make sure that the information contained within this document is accurate and in full compliance with UK law and with best practice at the time of writing. There is no guarantee as to the accuracy or reliability of any of the information contained in this template and use of this template is entirely at the user’s risk and no liability whatsoever is accepted by the National Osteoporosis Society. Instructions for useThe template is fully editable. Formatting has been kept to a minimum to allow flexible use either editing this template or copying material to use in local documents. The template may include guidance on use and/or sections where local information may need to be entered. These have been highlighted [using bold text in square brackets]. Please delete or overwrite these sections as you go along and make the necessary font or formatting changes. [Please delete this box when you use the template]

Using this toolThis workbook has been designed for use by provider and funders to develop an agreement on how a FLS can demonstrate that it is achieving good outcomes and other measures that demonstrate the quality of the service being provided. The workbook acts as an illustration of the method and as a working template that can be adapted for local use. It is therefore a tool for both developing and monitoring service quality, particularly in relation to outcomes. Examples of several types of outcome measure are included such as PROMS, PREMS and activity and cost. These are suggested and may be edited at will.

Note that this is not a contract or service level agreement and any indicators, payments or other details will need to be agreed between provider and funder in order to populate this workbook. However the workbook is very useful in facilitating the discussion and can be used to help both parties reach agreement.

The workbook contains one sheet in addition to this Introduction sheet. The Indicators sheet describes the outcome or quality measure and suggest indicators that may be used to determine whether outcomes have been achieved. It goes into some detail about the precise metric, methodology and definition. This sheet is fully editable and cells, columns and rows may be overwritten, inserted or deleted as required.

Agreeing indicators, standards and outcomes - some thoughts

Improving quality and outcomes over time - indicators and standards can, of course, be raised each year to leverage improvement such that a standard of 50% this year can become 60% or 70% next year. Also some standards become redundant over time as quality improves and can be replaced. Early in the life of a new service it may be appropriate to set a standard that simply requires information, such as patient satisfaction, to be captured or systems to be in place. As time goes on the information collected by the system can be used to drive improvement such that satisfaction rates increase year on year.

Retention and reward - it is possible to link performance to payment for the service and different approaches to incentives can be used. One useful method is to make a distinction between expected achievement (e.g. minimum standards) for which a fraction of the payment for the service can be withheld. In this way, if a provider fails to achieve these standards it acts as a penalty. To do this the contract or other agreement must state that this money will be withheld and paid over at the year end on satisfactory submission of information and achievement of agreed standards. To balance this, some payment should be offered as a reward over and above the agreed contract or agreement value. This also needs to be formally documented and clearly understood by both parties.

Achievability - the provider must always believe that the indicators and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that there will be little or no effort to achieve the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurement and verification. It is likely that there will always be some data that are incomplete or some patient records that do not conform to the proposed method of measurement. The provider may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this simply change a standard to 99% or 98% where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement should be readily available from existing sources and systems. This helps to minimise costs and allows providers to spend more time with patients. The costs of collecting and reporting must be proportional to the reward that the provider is able to achieve. If not then it is likely that the indicator will not have the desired effect.

Sampling - where there is no routine data collection and the costs of collection are high it may be appropriate to sample. Sampling should always be carried out in a way that minimises bias (e.g. only sampling patients that are very happy with the service). You may need to take expert advice from colleagues in clinical audit teams or public health on this subject.

Exceptions - some thought needs to be given to exceptions, i.e. occasions when the data cannot be collected because, for example the patient does not wish to comply. Equally there must not be an incentive not to try to collect data. To address this standards can be made conditional e.g. '50% of patients sampled report improvement in symptoms. Sample must comprise at least 30% of patients discharged'. Payment would then be made only if all conditions are met.

Using this toolThis workbook has been designed for use by provider and funders to develop an agreement on how a FLS can demonstrate that it is achieving good outcomes and other measures that demonstrate the quality of the service being provided. The workbook acts as an illustration of the method and as a working template that can be adapted for local use. It is therefore a tool for both developing and monitoring service quality, particularly in relation to outcomes. Examples of several types of outcome measure are included such as PROMS, PREMS and activity and cost. These are suggested and may be edited at will.

Note that this is not a contract or service level agreement and any indicators, payments or other details will need to be agreed between provider and funder in order to populate this workbook. However the workbook is very useful in facilitating the discussion and can be used to help both parties reach agreement.

The workbook contains one sheet in addition to this Introduction sheet. The Indicators sheet describes the outcome or quality measure and suggest indicators that may be used to determine whether outcomes have been achieved. It goes into some detail about the precise metric, methodology and definition. This sheet is fully editable and cells, columns and rows may be overwritten, inserted or deleted as required.

Agreeing indicators, standards and outcomes - some thoughts

Improving quality and outcomes over time - indicators and standards can, of course, be raised each year to leverage improvement such that a standard of 50% this year can become 60% or 70% next year. Also some standards become redundant over time as quality improves and can be replaced. Early in the life of a new service it may be appropriate to set a standard that simply requires information, such as patient satisfaction, to be captured or systems to be in place. As time goes on the information collected by the system can be used to drive improvement such that satisfaction rates increase year on year.

Retention and reward - it is possible to link performance to payment for the service and different approaches to incentives can be used. One useful method is to make a distinction between expected achievement (e.g. minimum standards) for which a fraction of the payment for the service can be withheld. In this way, if a provider fails to achieve these standards it acts as a penalty. To do this the contract or other agreement must state that this money will be withheld and paid over at the year end on satisfactory submission of information and achievement of agreed standards. To balance this, some payment should be offered as a reward over and above the agreed contract or agreement value. This also needs to be formally documented and clearly understood by both parties.

Achievability - the provider must always believe that the indicators and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that there will be little or no effort to achieve the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurement and verification. It is likely that there will always be some data that are incomplete or some patient records that do not conform to the proposed method of measurement. The provider may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this simply change a standard to 99% or 98% where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement should be readily available from existing sources and systems. This helps to minimise costs and allows providers to spend more time with patients. The costs of collecting and reporting must be proportional to the reward that the provider is able to achieve. If not then it is likely that the indicator will not have the desired effect.

Sampling - where there is no routine data collection and the costs of collection are high it may be appropriate to sample. Sampling should always be carried out in a way that minimises bias (e.g. only sampling patients that are very happy with the service). You may need to take expert advice from colleagues in clinical audit teams or public health on this subject.

Exceptions - some thought needs to be given to exceptions, i.e. occasions when the data cannot be collected because, for example the patient does not wish to comply. Equally there must not be an incentive not to try to collect data. To address this standards can be made conditional e.g. '50% of patients sampled report improvement in symptoms. Sample must comprise at least 30% of patients discharged'. Payment would then be made only if all conditions are met.

This templateThis resource has been created by the National Osteoporosis Society as part of the Fracture Liaison Service Implementation Toolkit (FLS-IT). The aim of the toolkit is to take some of the hard work out of establishing a new Fracture Liaison Service (FLS) or improving an existing one. This template has been created by working professionals in the NHS in each of the four home nations and makes use of current policy and best practice. It has been designed to save the user the time and trouble of researching, drafting and editing a document or workbook from scratch. References have been included where relevant.

You are free to use, change, edit or adapt this template as you wish. We trust that you will find this tool useful; if you have any queries or would like to make any suggestions on how to improve it, please contact us at the National Osteoporosis Society. If you would like to see or to download other tools, please go to: www.nos.org.uk/tookit DisclaimerThis template is provided free as part of the FLS-IT by the National Osteoporosis Society. This template does not represent the views of the National Osteoporosis Society. Every effort has been made to make sure that the information contained within this document is accurate and in full compliance with UK law and with best practice at the time of writing. There is no guarantee as to the accuracy or reliability of any of the information contained in this template and use of this template is entirely at the user’s risk and no liability whatsoever is accepted by the National Osteoporosis Society. Instructions for useThe template is fully editable. Formatting has been kept to a minimum to allow flexible use either editing this template or copying material to use in local documents. The template may include guidance on use and/or sections where local information may need to be entered. These have been highlighted [using bold text in square brackets]. Please delete or overwrite these sections as you go along and make the necessary font or formatting changes. [Please delete this box when you use the template]

Using this toolThis workbook has been designed for use by provider and funders to develop an agreement on how a FLS can demonstrate that it is achieving good outcomes and other measures that demonstrate the quality of the service being provided. The workbook acts as an illustration of the method and as a working template that can be adapted for local use. It is therefore a tool for both developing and monitoring service quality, particularly in relation to outcomes. Examples of several types of outcome measure are included such as PROMS, PREMS and activity and cost. These are suggested and may be edited at will.

Note that this is not a contract or service level agreement and any indicators, payments or other details will need to be agreed between provider and funder in order to populate this workbook. However the workbook is very useful in facilitating the discussion and can be used to help both parties reach agreement.

The workbook contains one sheet in addition to this Introduction sheet. The Indicators sheet describes the outcome or quality measure and suggest indicators that may be used to determine whether outcomes have been achieved. It goes into some detail about the precise metric, methodology and definition. This sheet is fully editable and cells, columns and rows may be overwritten, inserted or deleted as required.

Agreeing indicators, standards and outcomes - some thoughts

Improving quality and outcomes over time - indicators and standards can, of course, be raised each year to leverage improvement such that a standard of 50% this year can become 60% or 70% next year. Also some standards become redundant over time as quality improves and can be replaced. Early in the life of a new service it may be appropriate to set a standard that simply requires information, such as patient satisfaction, to be captured or systems to be in place. As time goes on the information collected by the system can be used to drive improvement such that satisfaction rates increase year on year.

Retention and reward - it is possible to link performance to payment for the service and different approaches to incentives can be used. One useful method is to make a distinction between expected achievement (e.g. minimum standards) for which a fraction of the payment for the service can be withheld. In this way, if a provider fails to achieve these standards it acts as a penalty. To do this the contract or other agreement must state that this money will be withheld and paid over at the year end on satisfactory submission of information and achievement of agreed standards. To balance this, some payment should be offered as a reward over and above the agreed contract or agreement value. This also needs to be formally documented and clearly understood by both parties.

Achievability - the provider must always believe that the indicators and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that there will be little or no effort to achieve the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurement and verification. It is likely that there will always be some data that are incomplete or some patient records that do not conform to the proposed method of measurement. The provider may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this simply change a standard to 99% or 98% where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement should be readily available from existing sources and systems. This helps to minimise costs and allows providers to spend more time with patients. The costs of collecting and reporting must be proportional to the reward that the provider is able to achieve. If not then it is likely that the indicator will not have the desired effect.

Sampling - where there is no routine data collection and the costs of collection are high it may be appropriate to sample. Sampling should always be carried out in a way that minimises bias (e.g. only sampling patients that are very happy with the service). You may need to take expert advice from colleagues in clinical audit teams or public health on this subject.

Exceptions - some thought needs to be given to exceptions, i.e. occasions when the data cannot be collected because, for example the patient does not wish to comply. Equally there must not be an incentive not to try to collect data. To address this standards can be made conditional e.g. '50% of patients sampled report improvement in symptoms. Sample must comprise at least 30% of patients discharged'. Payment would then be made only if all conditions are met.

Fracture Liaison Service Implementation Toolkit - Outcome and Performance IndicatorsIndicators

Type Performance indicator Service outcome

Public health outcome measure

Reduction in number of hip fractures admitted to hospital from known population

Long-term reduction in fragility fracture

Clinical process measure

Proportion of fracture patients (all postmenopausal women and men aged over 50 years) identified by the FLS

Postmenopausal women or men aged 50 years and over with a new fragility fracture or a newly reported vertebral fracture, whether managed as inpatients or outpatients, will be systematically and proactively identified.

Clinical process measure

All identified patients to receive a bone health assessment and assessed for comprehensive falls risk assessment within 3 months of incident fracture

Improved identification of the population who will benefit from interventions leading to appropriate targeting of resources.

Clinical process measure

% of identified patients offered information

All patients identified will be offered written information about bone health, lifestyle, nutrition and bone-protection treatments.

Clinical process measure

% of patients who are offered bone-protection treatment after positive identification through standard fracture risk assessment (e.g. NICE TA161)

Patients at risk of further fracture will be offered appropriate bone-protection treatments.

Clinical process measure

% of assessed patients offered referral for falls assessment or an intervention.

Patients at risk of further falls will be offered appropriate assessment or interventions to reduce future falls.

Patient reported

experience measure (PREM)

Measure of communication – patients receive copies of discharge letters and other information

Management plans will be patient-centred and integrated between primary and secondary care.

Clinical process measure

% of patients recommended drug treatment who are reviewed within 3 months.

Patients who are recommended a drug to reduce risk of fracture will be reviewed within 3 months to ensure appropriate treatment has been started.

Improved quality of life.

Clinical process measure

% of patients recommended drug treatment who are assessed annually.

Patients who are recommended a drug to reduce risk of fracture will be reviewed every 12 months to monitor concordance with the treatment plan.

Clinical process measure

Evidence of effective clinical audit including improvement as a result of implementing audit findings.

Core clinical data from patients identified by the FLS will be recorded on a database. Regular audit and patient experience measures will be performed and the FLS will participate in any national audits undertaken.

Clinical process measure

Review of competencies and training needs in annual appraisals including Continuing Professional Development (CPD) of staff.

The FLS team will have appropriate competencies in secondary fracture prevention and will maintain relevant CPD.

Clinical process measure

Evidence of participation in peer review.

The FLS should engage in a regular peer-review process of quality assurance.

Patient reported outcome measure (PROM)

Patient reported improvement in quality of life score recorded between 8 and 12 weeks from discharge.

References12

Patient reported

experience measure (PREM)

Improvement in Friends and Family Test score for the service.

Patients have a good experience of the service and are able to recommend the service to others.

Clinical process measure

Patients <75 years have a DXA scan.

Improved identification of the population who will benefit from interventions leading to appropriate targeting of resources.

National Osteoporosis Society, 2014 . Effective secondary prevention of fragility fractures: standards for fracture liaison services. Department of Health, 2010. Liberating the NHS: Transparency in outcomes: a framework for the NHS. London: Department of Health

Fracture Liaison Service Implementation Toolkit - Outcome and Performance Indicators

Rationale

Not applicable

1

2

FLS standard1

The number of emergency admissions due to falls and fractures results in more bed-days from falls and fractures than from heart attack, heart failure and stroke combined.2

Patients who have sustained a fracture are at higher relative risk of fracture than those who have not. Targeted interventions in this population will have most impact on reducing future fracture burden.

Assessments need to be conducted promptly as the risk of having a further fracture is increased in the first year.

3

4

5

6

7

Any postmenopausal woman or man aged 50 years or over who has had a fracture needs to be aware of the steps they can take to maintain healthy bones.

Appropriately targeted interventions reduce future fracture risk.

Evidence-based falls interventions are effective at reducing falls risk.

Effective communication is essential to ensure that long-term management is achieved and that patients are supported to engage with recommended interventions.

Treatments must be taken for a minimum period of [xxx] to be effective. Follow-up allows early identification of issues (side effects, compliance) with prescribed medications, reinforces need to take treatments and supports long-term concordance. Long-term management and follow-up should be carried out in primary care.

7

8

9

10

Treatments must be taken for a minimum period of [xxx] to be effective. Follow-up allows early identification of issues (side effects, compliance) with prescribed medications, reinforces need to take treatments and supports long-term concordance. Long-term management and follow-up should be carried out in primary care.

Data recorded will allow the FLS to audit and improve the service they provide ensuring that high standards are met and maintained. Initial data will provide a baseline from which improvements can be assessed.

All staff need appropriate knowledge, skills and experience to fulfil their role. Engagement with relevant CPD activities ensures that these are up to date.

Clinical peer review facilitates quality standard assurance, equitable access to services and provides a means of benchmarking and sharing best practice.

Understanding of the patient’s symptoms and subsequent effects. A scoring system which can demonstrate improvement during management across the whole spectrum of quality of life.

8

The way people experience health services is an important component of the quality of care. Measuring patient experience is important not only to guide service improvement, but also because people’s experiences of care may be linked to clinical outcomes and costs.

Presence of osteoporosis is confirmed by DXA scanning.

Effective secondary prevention of fragility fractures: standards for fracture liaison services. Liberating the NHS: Transparency in outcomes: a framework for the NHS. London: Department of Health

Fracture Liaison Service Implementation Toolkit - Outcome and Performance Indicators

Standard to be achieved (example only)

Aim to demonstrate incremental reduction of rate ratio of hip fractures for population stratified by age (45-55, 55-65 etc) and sex.

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of postmenopausal women and men >50 years identified by the service. This figure (X%) should be higher than the baseline or current value'].

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of eligible patients are assessed within 3 months of the incident fracture’. This figure (X%) should be higher than the baseline or current value]

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of patients offered information’. This figure (X%) should be higher than the baseline or current value]

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of patients that require treatment identified through fracture risk tools’. This figure (X%) should be higher than the baseline or current value]

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of patients assessed and identified at risk of future fall confirm that referral was offered’. This figure (X%) should be higher than the baseline or current value]

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of patients having assessment confirm that discharge letter was copied to them’. This figure (X%) should be higher than the baseline or current value]

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of patients on drug treatment are recorded as having had a review less than 18 weeks from initiating therapy’. This figure (X%) should be higher than the baseline or current value]

Submission of a report describing the current position on staff knowledge and skills.

Submission of a report describing the current position on peer review.

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of patients on drug treatment are recorded as having had a review less than 12 months from initiating therapy or from previous review appointment’. This figure (X%) should be higher than the baseline or current value]

Submission of a report describing the audit and detailing any changes in clinical practice that have been put in place as a result of the audit

% of patients contacted between 8 and 12 weeks from discharge and score recorded.[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’. Where data collection is established and a baseline figure is known the standard might be expressed as ‘X% of fracture patients are identified by the service’. This figure (X%) should be higher than the baseline or current value]

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘Score improves by X% from baseline after four quarters’.]

[A suitable standard in the first year of a service would be ‘Establish data collection and publish baseline value’.

Where data collection is established and a baseline figure is known the standard might be expressed as ‘% of patients under 75 years offered scan’. This figure (X%) should be higher than the baseline or current value]

Effective secondary prevention of fragility fractures: standards for fracture liaison services. London: Department of Health

Definitions and methodology Notes

Coding of hip fractures, age cohort of patients and other details will need to be agreed and be consistently recorded. Where possible adjustment for population change from baseline year to measurement year should be made.

This indicator is challenging to monitor and should be done in collaboration with colleagues in public health. Numbers vary from year to year and this variation may mask any trend as a result of implementing a service. It would not be appropriate to attach financial rewards and penalties to this indicator.

Use non-vertebral fractures as a denominator. The denominator (and its total fractures minus vertebral fractures) is: the number of hip fractures + (hip fracture number x5)

For a hospital-based service this information should be available through the hospital's patient administration system. If the service is community based the date of incident fracture should be part of the referral or screening dataset.

Numerator should be number of patients assessed and denominator should be number of fractures recorded where patient is eligible for assessment. Consideration should be given to definition of 'eligible'.

For a hospital-based service this information should be available through the hospital's patient administration system. If the service is community based the date of incident fracture should be part of the referral or screening dataset.

Bone health assessment should comprise relevant comorbidities and current medications listed and considered for impact on skeleton and whether remediable; screening blood tests to rule out previously undisclosed morbidity; smoking/excess alcohol and weight-bearing exercise issues.

Review can be either face to face or by telephone.

Methodology by attaching letters/information sheets to fracture clinic letters etc. Admin staff to set up process.

Coding and recording of fracture risk assessment and subsequent actions.

This information should be available through the patient administration system.

In order to minimise risk of bias, measurement should be through survey of randomly selected sample of patients either via telephone or written media. Survey should be carried out by other than the FLS team.

Local audit teams can help with the design and/or carrying out of the survey. Budget may need to be allocated in order to carry out a systematic survey.

In order to minimise risk of bias, measurement should be through survey of randomly selected sample of patients either via telephone or written media. Survey should be carried out by other than the FLS team.

Local audit teams can help with the design and/or carrying out of the survey. Budget may need to be allocated in order to carry out a systematic survey.

Date of initiation and date of review should be recorded in patient's record in a way that is easy to extract and present.

Review can be either face to face or by telephone.

May form part of an annual service improvement plan.

May form part of an annual service improvement plan.

Suggest use of King's Health Questionnaire.

Date of initiation and date of review should be recorded in patient's record in a way that is easy to extract and present.

This should be a written report presented annually.

May form part of an annual service improvement plan. Service audit to be reviewed at yearly stakeholder meeting.Service should evidence audit activity in line with the requirements of their institution. Additionally, the service should share the results of audit with stakeholders and service users within a framework of governance.

This should be a written report presented annually.

This should be a written report presented annually.

Data to be collected by telephone call to patients. Sample of patients must be randomly selected and sampling method recorded.

Score in quarter 4 is compared with baseline score.

Other tests may be used but in every case the test should be simple and easy to administer so that response rates are high. Small numbers of responders will invalidate the measurement.

Coding and recording of fracture risk assessment and subsequent actions.

This information should be available through the patient administration system.