Clinical Quality Panel Target Setting Framework Agreed 13 June 2011, Endorsed 21 November 2011

Target Setting Framework ‘Really excellent’ performance for the long-term Based on international benchmarks, literature and expert opinion [Public Health to take lead on setting these goals] Aspirational Goal Absolute Threshold Improvement Target The threshold of acceptable performance below/ above which compliance processes may be invoked Average in AD poorest quartile in previous year (may be amended if performance across the board is deemed to be unacceptable) Rate provider/payers are expected to achieve in a 12 month period AD median in previous calendar year

For endorsement: Target Setting Framework [Quarterly] Reports published on profile healthcare facilities and payers, comparing them against indicator thresholds, targets and goalswww.shafafiya.org Facilities and Payers may submit comments on their performance, which can be added to the published profile Healthcare entities are provided with entity-specific reports (including clinician level data) ahead of audit inspection Auditors may review indicator performance with entity during the audit inspection Failure to meet the Absolute Threshold for one or more indicators may constitute a service deficiency, which: –Is recorded in the Audit report –Requires entity to submit and act on corrective plans –Triggers violation procedures if not corrected Quality Audits Publication