commvita™
Connected care platform
GOVERNANCE & ASSURANCE EDITION

Quality Impact Assessment

A change to a service is a decision about care until somebody says otherwise. The QIA is the record that they did — nine domains, scored before and after mitigation, versioned rather than edited, and refused at four points rather than warned about.

Live vs demonstrated: Live — real, API-backed platform logic (wired end-to-end today) Demonstrated — representative control surface with seeded data / illustrative UI mock-up

1What a Quality Impact Assessment is for

A service redesign, a savings scheme or a change to who is eligible is a decision about care whether or not anybody writes that down. A Quality Impact Assessment is the record that somebody did — what was expected to get worse, on what evidence, what was done about it, and who accepted the residual risk. It is made before the change, and reassessed after it.

commvita implements the National Quality Board quality impact assessment framework (NHS England, publication reference PRN01920_i, published 24 June 2025) together with its assessment tool and RASCI template. The framework explicitly replaced 2012 guidance that framed the whole exercise around cost improvement — and the list of triggers shows why that mattered.

A QIA is not a savings instrument — twelve triggers, of which cost improvement is oneThe 2025 framework explicitly replaced the 2012 guidance that framed quality impact assessment around CIPs alone.Changing what a service isservice redesign and major service changechanges to eligibility criteria or accesscommissioning and procurement of new servicesdecommissioning of services or contractsmergers and acquisitionsChanging how it runssystem prioritisation of services and pathwaystemporary and urgent change, including EPRRpiloting new ways of workingworkforce change and new rolesChanging the money or the leadershipcost improvement and efficiency programmes,including CUMULATIVE effect over timebusiness cases and investmentsorganisational policy affecting staffchanges in leadership models
Cost improvement is one trigger of twelve. Reading a QIA as a savings document is the specific error the 2025 framework was written to correct, and it is the reason a decommissioning or a leadership change reaches the same gate as a CIP.

2Nine domains, scored twice

Every domain carries an initial consequence and likelihood and a revised pair after mitigation. Both are kept, because a single score cannot show whether the mitigation moved anything — and the gap between the two is precisely what a reviewer is being asked to accept.

Nine domains, each scored twice — before and after mitigationSix are the National Quality Board quality domains. Three (workforce, performance, strategic objectives) come from the assessment tool alongside them.INITIALAFTER MITIGATIONNQBPatient safety126Clinical effectiveness96Experience84Well led66Sustainable44Equitable156Workforce96Performance128Strategic objectives66The score is consequence × likelihood and is DERIVED, never stored — a stored rating drifts from the score sitting beside it.
Six are the National Quality Board quality domains; workforce, performance and strategic objectives sit alongside them in the assessment tool. The risk score is DERIVED from consequence × likelihood at read time, so a stored rating can never drift away from the numbers beside it.

Insufficient evidence is not a neutral impact. The tempting simplification is to score an unevidenced domain as neutral and move on — which converts we do not know into no harm expected on the face of a board paper. An evidence gap is recorded as a gap, reported separately from impact, and requires an action plan before the assessment can be submitted.

3Where it refuses

Four conditions block submission outright, each naming the failing domains rather than warning about them. A gate that warns is a gate that gets clicked through.

Submission is refused on four grounds — and names every oneThe completeness gate sits at SUBMIT rather than at review, so the author learns what is missing before a panel is convened.A domain is unassessedA QIA that skips a domain is not a lighter QIA. It is a claim that nobodylooked.A negative impact carries no mitigationRecording harm and proceeding anyway is the outcome the assessment exists toprevent.A mitigation was never re-scoredAn unrescored mitigation tells a panel nothing about whether it moved anything.An evidence gap has no action planInsufficient evidence is a DATA GAP, not a neutral impact. Reported separately.409, with the failing domains named — not a warning, and not a checkbox somebody ticks to make it go away.
The gate sits at SUBMIT, not at review, so the author finds out what is missing before a panel is convened rather than in front of one.

4Review, and the fail-closed default

Review has two stages and four possible outcomes: approved, requires further information and re-submission, amendments required to reduce impact on care quality, and not approved to proceed. Every outcome requires a rationale — an outcome with no reasoning cannot be challenged or learned from.

Two-stage review — and what happens when nobody configured the thresholdSubmittedStage 1 — expedited sign-offAllowed only where residual risk sits BELOW theorganisation's configured escalation threshold.Stage 2 — multidisciplinary panelEverything else. The framework lists 21 possible panel roles;commvita offers them as a checklist and asserts no organisationhas them.FAIL CLOSED — no threshold configured means stage 2, not stage 1With no escalation threshold set for the jurisdiction, commvita cannot know what this organisation considers acceptable — so a stage 1 sign-off is REFUSED andeverything routes to the fuller review. Expediting on an assumed number would trade the rigour of the assessment for a figure nobody chose.The author of an assessment cannot review it (403). A self-review is not a review, and the framework asks for multidisciplinary scrutiny by people other than theproposer.
An unconfigured escalation threshold routes everything to the fuller review rather than expediting on a number nobody chose. That is the same fail-safe direction the platform applies to jurisdiction resolution: unknown sees the more rigorous path, never the convenient one.

Reassessed, never edited. A material change creates a new version that supersedes the previous one, which is retained. What a panel actually saw when it approved something stays readable afterwards. An assessment that can be quietly edited after approval is not evidence of anything, and the question an inquiry asks is what was assessed when this decision was taken.

5The seam to financial recovery

The framework's own trigger list includes cost improvement programmes “including the effect of cumulative CIPs within a service over time”. That sentence is the direct join to Financial Recovery & SIP: four individually acceptable schemes landing on one population is the failure a per-scheme assessment cannot see, and GET /qia/cumulative adds them up and names the schemes behind the total.

A scheme's impact level: derived from an assessment, or just a word somebody typedWithout a linked QIA — self_declaredRecoveryScheme.impact_level is a free string the scheme owner types, and theapproval gate checks only that a LABEL EXISTS.That is a field which looks like it means more than it does.commvita returns the typed value and reports it as self_declared, with anote saying no assessment is behind it.With a linked QIA — derived_from_qiaThe level is DERIVED from the assessment's residual position, and the typedvalue is IGNORED.A caller-supplied status is not trusted over a computed one.The response says which value was ignored, so nobody has to guess why theboard pack changed.So a board can see which savings schemes carry an assessment and which carry only a word.
A scheme's impact level either has an assessment behind it or it does not, and the API says which. Where a QIA is linked the level is computed and the typed word is discarded.

6Where it lives, and its honest edges

PartWhereStatus
Assessment, nine domains, mitigations, reviews, RASCI /quality-impact-assessmentLive
API/qia/ — 15 endpointsLive
Framework, triggers, panel roles, RASCI keyGET /qia/framework Live
What is enforced, and what cannot beGET /qia/methodology Live
Cumulative impact across schemesGET /qia/cumulative Live
Scheme impact with provenanceGET /qia/scheme-impact Live
Seeded assessments for demonstration— Demonstrated

Source provenance, stated because the API states it. The framework, the assessment tool and the RASCI template were supplied as files and parsed. They were not retrieved from england.nhs.uk, which is refused by this build environment's egress policy (measured: CONNECT tunnel failed, response 403), so any of them may have been superseded. Read-from-a-supplied-document is a weaker fact than retrieved-from-the-publisher and the product does not collapse the two.

One reference framework, because one was read. Offering a second “international” or “generic” domain set would attribute a construct to an authority nobody consulted. An organisation in any jurisdiction may adopt this framework as good practice — a recorded decision with a named adopter — or define its own domain set. Both are first class; neither is a default, and an unconfigured jurisdiction gets neither.

What commvita cannot do. It cannot judge whether an assessment is correct — only that the steps were taken, the evidence was cited and a named person accepted the residual risk. A well-formed QIA can still be wrong. It supplies no clinical judgement and neither convenes nor trains the panel. Publication is an organisational decision: commvita records whether a QIA was published and does not publish it. And an assessment done by email or in a document outside commvita is invisible here — which must never be read as an absence of assessment.

Models: QualityImpactAssessment · QIADomainAssessment · QIAMitigation · QIAReview · QIARasciEntryAPI: /qia/ (15 endpoints) · Route: /quality-impact-assessment · Framework: NHS England PRN01920_i (24 June 2025) · Non-SaMD
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