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

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

2. Target Setting Framework Absolute Threshold 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) Improvement Target Rate provider/payers are expected to achieve in a 12 month period AD median in previous calendar year Aspirational Goal • ‘Really excellent’ performance for the long-term • Based on international benchmarks, literature and expert opinion • [Public Health to take lead on setting these goals]

3. For endorsement: Target Setting Framework Publication Quality Audits • [Quarterly] Reports published on www.shafafiya.org profile healthcare facilities and payers, comparing them against indicator thresholds, targets and goals • 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