Table 1

Outcome, process and balance measures for the action period

Measure type	Measure name	Operational definition	Analysis	Validity and reliability
Outcome measure	No. of items prescribed for methotrexate 10 mg tablets for high prescribing cohort versus all other ICSs/CCGs in England.	Data sourced from OpenPrescribing ‘Methotrexate 10 mg tablets by all STPs or CCGs’ and aggregated into respective cohorts.20 25 ICS (STP) data used where the ICS focused on reducing methotrexate 10 mg tablet prescribing across all CCGs in their geographical footprint.20 CCG data used where the ICS focused on reducing methotrexate 10 mg prescribing in specific CCGs in their geographical footprint.25	Line graph comparing ICSs/CCGs participating in QI intervention versus all other ICSs/CCGs Individual Moving Range (XmR) control chart for both cohorts.	OpenPrescribing uses prescribing data published by NHS Business Services Authority (NHSBSA) Prescription services. Data processes are internally audited and exceed 99.5% accuracy at all times. Accuracy data are published on NHSBSA website for transparency.26 Well-established and managed processes to ensure reliability of data, with data collected and processed in the same manner from a single source, NHSBSA.
Process measure	No. of items prescribed for methotrexate 10 mg tablets for each individual ICS in high prescribing cohort	Data sourced from OpenPrescribing ‘Methotrexate 10 mg tablets by all STPs or CCGs’. See previous for how data were selected based on ICS/CCG focus.	Time series analysis using an Individual Moving Range (XmR) control chart.
Balancing measures	No. of patient safety incidents, resulting in harm, reported to National Reporting & Learning system (NRLS) following methotrexate 2.5 mg/10 mg tablet misadministration. No. of patient safety incidents, related to methotrexate 2.5 mg/10 mg tablet misadministration in high prescribing cohort. ICS reported patient experience of QI intervention in high prescribing cohort. ICS reported staff experience of QI intervention in high prescribing cohort. Total cost of methotrexate tablets for high prescribing cohort.	Methotrexate 2.5 mg/10 mg tablet misadministration safety incidents identified from free-text search of NRLS database for all incidents containing methotrexate.27 Stratified by level of harm. Methotrexate 2.5 mg/10 mg tablet misadministration safety incidents shared with MedSIP team from ICS/CCG leads involved in QI intervention. Patient experience feedback shared with MedSIP team from ICS/CCG leads involved in QI intervention. Staff experience feedback shared with MedSIP team from ICS/CCG leads involved in QI intervention. Data sourced from OpenPrescribing ‘Analyse’ webpage, with prescribing of ‘methotrexate 10 mg tablets’ and ‘methotrexate 2.5 mg tablets’ highlighted by STP or ICS.28	Count of safety incidents, with accompanying themes. Count of safety incidents, with accompanying themes. 3 and 4. Approach, based on Woods et al,23 was used to gather and collate data. 5. Time series analysis using an Individual Moving Range (XmR) control chart.	Systems and processes in place to increase validity and reliability of patient safety incident reporting. NRLS is a systematic and nationally managed system. However, levels of reporting between different organisations can vary greatly, with reporting far greater in secondary care than primary care. ICS staff may be aware of incidents or near misses that have not been reported through incident reporting systems. Information reported through this route not systematic and dependent on strength of networks and connections in ICSs. 3 and 4. ICS well placed to receive patient and staff experience as they led work locally. However, information reported through this route not systematic and dependent on strength of networks and connections in ICSs. 5. See previous for validity and reliability of OpenPrescribing data.

CCG, clinical commissioning groups; ICS, integrated care systems; QI, quality improvement; STP, Sustainability and Transformation Partnerships.