Fracture Liaison Service Implementation Toolkit

Introduction

This template
This resource has been created by the National Osteoporosis Society as part of the Fracture Lia
a new Fracture Liaison Service (FLS) or improving an existing one. This template has been creat
practice. It has been designed to save the user the time and trouble of researching, drafting and

You are free to use, change, edit or adapt this template as you wish. We trust that you will find
at the National Osteoporosis Society. If you would like to see or to download other tools, please
Disclaimer
This template is provided free as part of the FLS-IT by the National Osteoporosis Society. This te
that the information contained within this document is accurate and in full compliance with UK l
information contained in this template and use of this template is entirely at the users risk and

Instructions for use

The template is fully editable. Formatting has been kept to a minimum to allow flexible use eith
and/or sections where local information may need to be entered. These have been highlighted [
necessary font or formatting changes.

[Please delete this box when you use the template]

Using this tool

This workbook has been designed for use by provider and funders to develop an agreement on
service being provided. The workbook acts as an illustration of the method and as a working tem
particularly in relation to outcomes. Examples of several types of outcome measure are include

Note that this is not a contract or service level agreement and any indicators, payments or othe
workbook is very useful in facilitating the discussion and can be used to help both parties reach

The workbook contains one sheet in addition to this Introduction sheet. The Indicators sheet
have been achieved. It goes into some detail about the precise metric, methodology and definit
Agreeing indicators, standards and outcomes - some thoughts

Improving quality and outcomes over time - indicators and standards can, of course, be ra
Also some standards become redundant over time as quality improves and can be replaced. Ea
satisfaction, to be captured or systems to be in place. As time goes on the information collecte

Retention and reward - it is possible to link performance to payment for the service and diffe
(e.g. minimum standards) for which a fraction of the payment for the service can be withheld. In
must state that this money will be withheld and paid over at the year end on satisfactory subm
reward over and above the agreed contract or agreement value. This also needs to be formall

Achievability - the provider must always believe that the indicators and standards are fair and
the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurem
not conform to the proposed method of measurement. The provider may therefore be unfairly p
where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement sho

must state that this money will be withheld and paid over at the year end on satisfactory subm
reward over and above the agreed contract or agreement value. This also needs to be formall

Achievability - the provider must always believe that the indicators and standards are fair and
the standard and the outcomes will not improve.

Never 100% - standards that require 100% achievement are subject to problems of measurem
not conform to the proposed method of measurement. The provider may therefore be unfairly p
where full compliance is required.

Data sources and collection - where possible data to support reporting and achievement sho
more time with patients. The costs of collecting and reporting must be proportional to the rewa

Sampling - where there is no routine data collection and the costs of collection are high it may
patients that are very happy with the service). You may need to take expert advice from colleag

Exceptions - some thought needs to be given to exceptions, i.e. occasions when the data cann
to try to collect data. To address this standards can be made conditional e.g. '50% of patients sa
would then be made only if all conditions are met.

ntation Toolkit - Outcome and Performance Indicators

ety as part of the Fracture Liaison Service Implementation Toolkit (FLS-IT). The aim of the toolkit is to take s
This template has been created by working professionals in the NHS in each of the four home nations and m
ble of researching, drafting and editing a document or workbook from scratch. References have been include

sh. We trust that you will find this tool useful; if you have any queries or would like to make any suggestions
download other tools, please go to: www.nos.org.uk/tookit

l Osteoporosis Society. This template does not represent the views of the National Osteoporosis Society. Eve
nd in full compliance with UK law and with best practice at the time of writing. There is no guarantee as to th
entirely at the users risk and no liability whatsoever is accepted by the National Osteoporosis Society.

mum to allow flexible use either editing this template or copying material to use in local documents. The tem
These have been highlighted [using bold text in square brackets]. Please delete or overwrite these secti

to develop an agreement on how a FLS can demonstrate that it is achieving good outcomes and other meas
e method and as a working template that can be adapted for local use. It is therefore a tool for both developi
outcome measure are included such as PROMS, PREMS and activity and cost. These are suggested and may

y indicators, payments or other details will need to be agreed between provider and funder in order to popul
sed to help both parties reach agreement.

n sheet. The Indicators sheet describes the outcome or quality measure and suggest indicators that may be
etric, methodology and definition. This sheet is fully editable and cells, columns and rows may be overwritten

ghts

tandards can, of course, be raised each year to leverage improvement such that a standard of 50% this year
oves and can be replaced. Early in the life of a new service it may be appropriate to set a standard that sim
es on the information collected by the system can be used to drive improvement such that satisfaction rates

ment for the service and different approaches to incentives can be used. One useful method is to make a dis
the service can be withheld. In this way, if a provider fails to achieve these standards it acts as a penalty. To
ear end on satisfactory submission of information and achievement of agreed standards. To balance this, som
. This also needs to be formally documented and clearly understood by both parties.

ors and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that th

ject to problems of measurement and verification. It is likely that there will always be some data that are inc
er may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this sim

eporting and achievement should be readily available from existing sources and systems. This helps to minim

ear end on satisfactory submission of information and achievement of agreed standards. To balance this, som
. This also needs to be formally documented and clearly understood by both parties.

ors and standards are fair and realistic and therefore achievable. If this is not the case then it is likely that th

ject to problems of measurement and verification. It is likely that there will always be some data that are inc
er may therefore be unfairly penalised for circumstances that may be outside their control. To avoid this sim

eporting and achievement should be readily available from existing sources and systems. This helps to minim
st be proportional to the reward that the provider is able to achieve. If not then it is likely that the indicator w

s of collection are high it may be appropriate to sample. Sampling should always be carried out in a way tha
ake expert advice from colleagues in clinical audit teams or public health on this subject.

occasions when the data cannot be collected because, for example the patient does not wish to comply. Equ
itional e.g. '50% of patients sampled report improvement in symptoms. Sample must comprise at least 30%

ance Indicators

e aim of the toolkit is to take some of the hard work out of establishing
of the four home nations and makes use of current policy and best
References have been included where relevant.

like to make any suggestions on how to improve it, please contact us

onal Osteoporosis Society. Every effort has been made to make sure
There is no guarantee as to the accuracy or reliability of any of the
nal Osteoporosis Society.

se in local documents. The template may include guidance on use

delete or overwrite these sections as you go along and make the

ood outcomes and other measures that demonstrate the quality of the
refore a tool for both developing and monitoring service quality,
These are suggested and may be edited at will.

r and funder in order to populate this workbook. However the

uggest indicators that may be used to determine whether outcomes

s and rows may be overwritten, inserted or deleted as required.

at a standard of 50% this year can become 60% or 70% next year.
ate to set a standard that simply requires information, such as patient
nt such that satisfaction rates increase year on year.

useful method is to make a distinction between expected achievement

ndards it acts as a penalty. To do this the contract or other agreement
standards. To balance this, some payment should be offered as a
arties.

he case then it is likely that there will be little or no effort to achieve

ays be some data that are incomplete or some patient records that do
their control. To avoid this simply change a standard to 99% or 98%

d systems. This helps to minimise costs and allows providers to spend

standards. To balance this, some payment should be offered as a

arties.

he case then it is likely that there will be little or no effort to achieve

ays be some data that are incomplete or some patient records that do
their control. To avoid this simply change a standard to 99% or 98%

d systems. This helps to minimise costs and allows providers to spend

it is likely that the indicator will not have the desired effect.

ys be carried out in a way that minimises bias (e.g. only sampling

s subject.

does not wish to comply. Equally there must not be an incentive not
le must comprise at least 30% of patients discharged'. Payment

Fracture Liaison Service Implementation Toolkit

Indicators
Type

Performance indicator

Public health Reduction in number of hip

outcome
fractures admitted to hospital
measure
from known population

Clinical
process
measure

Clinical
process
measure

Service outcome

Long-term reduction in fragility

fracture

Postmenopausal women or men

aged 50 years and over with a
Proportion of fracture patients
new fragility fracture or a newly
(all postmenopausal women and
reported vertebral fracture,
men aged over 50 years)
whether managed as inpatients or
identified by the FLS
outpatients, will be systematically
and proactively identified.

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.

All patients identified will be

offered written information about
bone health, lifestyle, nutrition
and bone-protection treatments.

Clinical
process
measure

% of identified patients offered

information

Clinical
process
measure

% of patients who are offered

bone-protection treatment after Patients at risk of further fracture
positive identification through
will be offered appropriate bonestandard fracture risk
protection treatments.
assessment (e.g. NICE TA161)

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.

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.

Patient
reported
experience
measure
(PREM)

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.

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

% of patients recommended
drug treatment who are
assessed annually.

Clinical
process
measure

Core clinical data from patients

identified by the FLS will be
Evidence of effective clinical
recorded on a database. Regular
audit including improvement as
audit and patient experience
a result of implementing audit
measures will be performed and
findings.
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.

Clinical
process
measure

The FLS should engage in a

Evidence of participation in peer
regular peer-review process of
review.
quality assurance.

Patient
reported
outcome
measure
(PROM)

Patient reported improvement

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

The FLS team will have

appropriate competencies in
secondary fracture prevention and
will maintain relevant CPD.

Improved quality of life.

Patient
reported
experience
measure
(PREM)

Clinical
process
measure

References
1
2

Patients have a good experience

Improvement in Friends and
of the service and are able to
Family Test score for the service.
recommend the service to others.

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 fra

Department of Health, 2010. Liberating the NHS: Transparency in outcomes: a fram

ation Toolkit - Outcome and Performance Indicators

Rationale

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

Not applicable

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.

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.

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 patients

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

10

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 peoples experiences of care
may be linked to clinical outcomes
and costs.

Presence of osteoporosis is confirmed

by DXA scanning.

prevention of fragility fractures: standards for fracture liaison services.

ency in outcomes: a framework for the NHS. London: Department of Health

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]

[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

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

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

% 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]

son services.
artment of Health

Definitions and methodology

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.

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)

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'.

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.

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.

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.

Date of initiation and date of review

should be recorded in patient's record
in a way that is easy to extract and
present.

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.

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.

Coding and recording of fracture risk

assessment and subsequent actions.

Notes

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.

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.

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.

This information should be available through the patient

administration system.

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.

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.

Review can be either face to face or by telephone.

Review can be either face to face or by telephone.

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.

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.

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.

This information should be available through the patient

administration system.