Necessary measures

All clinicians want to provide patients with the best possible standard of care. Many believe that they can do this by focusing on the individual patient in front of them. Whilst true in itself, the only way clinicians can be certain about the quality of care they provide is by measuring what actually happens and comparing this to established best practice. Only then will clinicians be able to know what action to take to improve the care they provide.

Measuring practice locally against established standards is critical to informing clinicians’ views about the quality of care they provide. Research funded by The Health Foundation has found that national evidence and policy statements about problems in healthcare provision are on their own unlikely to lead to changes in care at the local level(1). For example, fewer than 20 per cent of organisations assessed by the Healthcare Commission met all the audit criteria for heart failure set by The National Institute for Clinical Excellence (NICE) and the National Service Framework in 2005/6(2).

“Although many clinicians know what they would like to improve about their service organisation, sometimes they may need a lot of evidence to persuade them that their individual practice needs to change,” Wendy Buckley, Assistant Director at The Health Foundation, explains. “The only way to really understand whether the care patients are actually receiving is the best possible is to measure and compare individual practice and services with established standards. This is the best way to convince clinicians that practice can improve.” Of course, every clinician is also part of a multi-disciplinary team, in which all members’ actions affect the patient’s outcome. Another purpose of clinical measurement is therefore to understand the impact of the whole team on standards of care, in a way that may not always be apparent to individual clinicians.

Cycles of change 

The clinical audit cycle is a well established way for clinicians to take forward quality improvement work. Using this model, clinicians measure their own practice against established national standards. Once they have data about their own performance, they take action to improve it, and measure again to see if this has been successful.

Making these changes can be hard. Sometimes clinicians do not know how to respond to the results of an audit or do not have access to the support they need. In some cases, results are disputed because of concerns about data reliability or because clinicians fear that managers will use the data to justify cost cutting activities.

Clinicians have reported other barriers to their involvement in quality improvement projects. These include insufficient time or resources, lack of expertise or advice and problems within organisations that make change difficult to achieve. The national context also makes a difference. Recent changes in the NHS structure and continuing reorganisation of services can make it harder for clinicians to engage in quality improvement work, because of disruption to organisations(3).

1. Healthcare professionals’ views on clinician engagement in quality improvement, Huw Davies, Alison Powell and Rosemary Rushmer, The Health Foundation, April 2007.
2. Pushing the Boundaries, Improving Care for People with Heart Failure, Healthcare Commission, July 2007.
3. The Health Foundation, April 2007.

The Health Foundation is currently running two schemes based around engaging clinicians in quality improvement, including clinical measurement. These are the Engaging with Quality Initiative, which is focused on secondary care, and Engaging with Quality in Primary Care.

As part of the secondary care work, Dr Keith Leiper, Consultant Gastroenterologist at the Royal Liverpool University Hospital, is leading the first national audit of the care of Inflammatory Bowel Disease (IBD) in the UK. The audit is a collaborative project involving gastroenterologists, surgeons and patients.

“Inflammatory bowel disease affects about 1 in 400 people in the UK,” Keith explains. “The two main types of IBD are ulcerative colitis and Crohn’s disease – different disorders, but with a considerable overlap in terms of disability and health service care.”

Regional variation

Seventy five per cent of acute hospitals took part in the first round of the audit in March 2007. It highlighted marked variation in IBD care, both in terms of resources and individual patient management. Crucially, the audit found that about half of acute hospitals in the UK do not have an IBD clinical nurse specialist. It also found that less than half of patients with IBD have a stool sample sent for standard culture and C. difficile testing. Furthermore, only 52 per cent of patients admitted with Crohn’s disease, a condition often associated with weight loss and malnutrition, were weighed and only 37 per cent were seen by a dietician.

“Around three quarters of acute hospitals in the UK took part in our audit which is an incredibly high participation rate,” Keith continues. “While some people were reluctant to get involved due to time constraints and work-load, I think most saw the long-term benefits. The rationale is clear; if you have no data to show how well or poorly your service is performing, then how can you possibly attempt to improve care?”

The audit also enabled some acute hospitals to apply for more funds. “Those who thought initially that they wouldn’t be able to take part used their results locally to present a business case for additional resources,” Keith explains.

“It is vitally important that clinicians stand for, and strive for, excellence in the quality of clinical care.”

Sleepless nights

The primary care teams, meanwhile, are measuring the gaps between current and best practice, to test ways to make improvements locally through networks of primary care practitioners. The insomnia project, for instance, aims to improve treatment for people with insomnia by promoting a range of treatment options beyond sleeping pills, which are not always the most appropriate course of action and carry the risk of side effects and addiction.

“We surveyed about 800 patients and 40 practices in Lincolnshire, focusing on patients who’d had a repeat prescription of sleeping tablets in the previous six months,” project lead Professor Niro Siriwardena explains. “We found that nine out of ten patients were on a repeat prescription that had been started by their GP. About two thirds took their medication every night, which is not a good thing to do because of addiction, and half had side effects like headache, dizziness and nausea. One fifth of the patients wanted to stop their tablets and at least half had said they’d tried to come off treatment.”

“We also surveyed GPs, who had beliefs about drug treatments that tended to promote prescribing of newer, more expensive sleeping tablets contrary to the evidence that these are no more effective,” he continues. “But they also had some good ideas on how to improve the situation.”

Testing it out

Based on the survey findings and other data, Niro’s team is planning to work with patients to understand what they need from a consultation and to work with a number of practices and primary care teams to test the impact of different approaches.

“There are some specific interventions that we know work for those who have been on long-term sleeping tablets, like writing to patients, review consultations with GPs, self help booklets and, in some cases, psychological therapies,” Niro says. “But there may be other things that practices can do to improve people’s experiences of insomnia management and to avoid starting drug treatment in the first place.”

The team will present data back to practices to analyse if prescribing is changing as a result of the new approach. If specific measures or combinations of measures are successful in the first five or ten pilot areas, they plan to spread the changes and learning more widely.

They also hope to link with commissioners in the county and to develop learning materials.

Full list of projects

Engaging with Quality Initiative

• Improving the quality of care for patients who self harm
• Improving the care of adult patients undergoing elective surgery
• Improving the quality of prescribing for serious mental illness
• Improving the assessment and management of perineal trauma
• Improving the quality and effectiveness of hospital care for people with chronic obstructive pulmonary disease
• Improving the quality of care and outcomes from treatment for cancer of the bowel
• Assessing and improving the quality and management of care for patients with epilepsy and for those with community acquired pneumonia
• Assessing and improving the quality of services for patients with inflammatory bowel disease

For more information, visit Engaging with Quality Initiative

Engaging with Quality in Primary Care

• Improving the diagnosis of gastrointestinal disorders
• Making healthcare more primary care led, patient centred and evidence based
• Reducing inequalities in health and in how healthcare is delivered
• Ensuring that people with back pain get the most appropriate care (two projects)
• Helping school nurses recognise and treat mental health problems
• Improving services for women experiencing domestic violence
• Improving the management of chronic kidney disease
• Improving treatment options for people with insomnia

For more information, visit Engaging with Quality in Primary Care

The teams involved in the Engaging with Quality schemes who are using the clinical audit cycle are at different stages. Some are beginning to measure for the first time, while others are now remeasuring. More established national audits, such as the National Audit of Continence Care for Older People, funded by the Healthcare Commission, powerfully illustrate the potential of audits to support quality improvement locally.

Between 30 and 60 per cent of people in long-term care settings have urinary incontinence and up to 25 per cent are affected by faecal incontinence. Relying on pads and catheters instead of helping patients to the toilet in hospital can lead to patients needing continence supplies for the rest of their life – but this is avoidable in many cases. Getting it right in hospital is not just good for the patient’s dignity and rewarding for staff but also improves the chance of the patient leaving hospital still able to cope for themselves.

The National Audit of Continence Care for Older People is the largest audit of continence care to be conducted in the UK. It aims to improve care for older people with continence problems across different healthcare settings and to demonstrate variations in standards of care and management of continence problems. It also aims to enable healthcare organisations to compare the quality of their care against evidence based criteria and to monitor progress towards establishing integrated continence services.

Early adopters

Danielle Harari, Elderly Care Consultant, and Carlene Igbedioh, Continence Nurse Specialist, at the Older Persons Continence Service at Guy’s and St Thomas’s NHS Foundation Trust have been involved in the audit from the start. They started by inputting data about continence care from across the hospital, including in-patient and out-patient services.

“For the first round, we did not really know what to expect,” Carlene comments. After the first audit we made changes and we wanted the second audit to show that the service had improved.”

Danielle and Carlene fed the results back to their colleagues at the Trust. Using the results of the audit, they worked together to identify where practice could be improved and undertook further work to understand how to change it. This included additional surveys to get a more detailed picture of how practice might need to change.

“The results showed that the use of pads was quite high, so we did a mini-audit on that and we looked at patient preferences and staff preferences,” Carlene explains. “The mini-audit looked at everything: the time it takes to fit a pad, the number of people involved, nursing time and laundry. Based on this, we trialed a different pad that a nurse can fit on a patient on their own, even if the patient is immobile.”

“Another thing we found was that people were not being walked to the toilet enough,” Danielle adds. “This was particularly the case in acute medicine and surgery. We developed a care plan for these patients around toileting. We also have a nurse and physiotherapist who screen all patients aged 70 years and over who come into acute medicine for continence problems. Alongside Carlene, they deliver the message on the ward to support older people being properly assessed and treated for bladder and bowel problems, including being walked to the toilet.”

Links in the chain

Another change made as a result of the audit was setting up a system of link nurses. “These are nurses on each ward who have had bowel and bladder continence training,” Carlene explains. “I pass information on to them, and they then pass it on to the wards. We used the audit as a way of promoting the link nurses’ role and ensuring they have time to do their link nursing role.”

Both Danielle and Carlene believe that clinical audits are a good starting point for making improvements to patient care, but that more work needs to be done to address the issues they raise. “The national audit highlights areas of concern but you have to look right into the detailed process of care so you can improve things,” Danielle explains. “The audit is quite time consuming, so you have to feel it is going to benefit your practice. You have to make it work for clinicians.”

Reaching out

Sam Harvey runs a primary care continence clinic in Essex. The service includes outreach work in residential care. She got involved in the National Audit of Continence Care for Older People because she wanted to see what was happening in the residential care homes and to use the results from the audit to improve care for residents. “As well as showing what needed to change, the audit also highlighted good practice we were not aware of, which was heartening to see,” Sam comments.

“We started by going through all the care records,” she explains. “We looked at the records of all the people in the home, not just those who were using continence products. This was important because it highlighted how some homes were enabling people with continence problems to avoid the need for products altogether.”

Sam was pleased with the way the care homes reacted to the audit: “The staff were very receptive,” she says. “They made all their notes available. They were keen to know what the outcomes were and what they could do to change. Two of the homes are now keen to do the audit themselves.” Sam believes that the results of the audit should be made available to members of the public, particularly people who may be considering residential care. “If the home knows it is going to be chosen because they excel in continence promotion, tissue viability and fall prevention, it will help promote good practice and training,” she concludes.

Resources

Websites

• The Healthcare Commission
  
• Heart Surgery in the United Kingdom
  
• Royal College of Physicians audit of continence care for older people
• Royal College of Physicians inflammatory bowel disease audit
  
• Clinical Governance Support Team
• Institute for Healthcare Improvement

Publications

• Healthcare Professionals’ views on clinician engagement in quality improvement, Huw Davies, Alison Powell and Rosemary Rushmer, The Health Foundation, April 2007
• Pushing the Boundaries, Improving Care for People with Heart Failure, the Healthcare Commission, July 2007
• Engaging physicians in a shared quality agenda, J.L. Reinertsen, A.G. Gosfield, W. Rupp, J.W. Whittington, Institute for Healthcare Improvement, 2007
• Better: A Surgeon’s notes on performance, A. Gawande, Profile Books Ltd, 2007
• Measuring up, The Health Foundation, October 2006

The Health Foundation’s schemes are beginning to show how much can be achieved when clinicians are fully engaged in quality improvement and get involved in measuring their own standards of care. The experiences of more established national audits are also highlighting the power of the full cycle of clinical audit to drive best practice. Our schemes are enabling clinicians to test the method in different contexts and for different conditions.

Local level

We believe that more could be done to support clinicians at the local level. The following common themes are emerging, in relation to what works and which barriers need to be overcome, to help clinicians use measurement to improve patient care at a local level:

> Clinicians need data about their own service

Clinicians need evidence to persuade them that their practice needs to change. Having a lead clinician undertake the audit and feedback results across the service can help persuade others to make changes in the care provided.

> Measurement needs to be done locally

Measuring practice locally against established standards is critical to informing clinicians’ views about the quality of care they provide. National evidence and policy statements about problems in healthcare provision are, on their own, unlikely to lead to changes in care at the local level.

> Audits should focus on quality improvement

The main motivation for getting involved in audits is to improve care and clinicians can be suspicious if they think that audits will be used as cost cutting measures. In fact, audits often provide evidence to managers that more resources or staff are needed, rather than the reverse.

> Commissioners should use audit to improve patient care

Commissioners need to take into account clinical and patient outcomes when making decisions about the purchasing of patient care. Clinical audit data can be a valuable source of information. We think that commissioners also have a responsibility to act to address any problems in the quality of care that audit data reveals.

> Clinical audits need to be robustly designed

Clinicians sometimes do not believe the data from clinical audits are accurate or valid and use this as a reason to ignore the results. Ensuring that clinical audits are high quality and well designed can help limit such criticism, as can involving clinicians in the design and running of the project, via their professional bodies. Also, if the measures are not right, the wrong areas might be tackled to seek improvement. Accurate and valid data is necessary to guide action.

> Clinicians should use the clinical audit cycle

The clinical audit cycle is a well established way for clinicians to take forward quality improvement work (see Figure 1). Using this model, clinicians measure their own practice against established national standards. Once they have data about their own performance, they take action to improve it, and measure again to see if this has been successful.

> Clinicians need support to make changes

Clinicians do not always know how to react to the results from national audits, or what to do to improve their service. They need access to quality improvement and leadership expertise to help them develop interventions. They may also need to undertake more measurement work based on headline issues identified by a national audit before they can make changes to services.

National level

We also believe more needs to be done at a national level to support clinicians locally to use clinical audit as a tool to improve patient care, including the following:

> A library of accredited audits

A ‘library’ of accredited audits, for use locally, regionally and nationally, would give clinicians access to accredited tools with which to carry out their own measurements. It would also avoid people reinventing audits or using ones that have not been quality assured, enable comparison between results from different places and help expose which areas of care need further work to develop robust measures.

> Clinical measurement for all areas of care

All clinicians need to be able to measure the quality of care their patients receive. However, these measures do not yet exist for all conditions. Regulators of organisations and individual professionals need to use information obtained from measuring clinical quality and patient outcomes to fulfil their function.

> A framework that enables local services to compare outcomes

With a move towards local rather than national targets, comparative clinical audit data will become increasingly important for stakeholders to agree local targets. Commissioners will increasingly measure success based on health outcomes and indicators which will be set nationally. This will establish a level playing field on reporting for healthcare providers whether they are NHS Trusts, Foundation NHS Trusts or independent sector organisations.

> Support for patients to interpret and use audit data

The results of national clinical quality measurement schemes need to be made public to provide an overview of healthcare quality and value. The publication of accessible and reliable information on the quality of care has already improved patient outcomes. The Healthcare Commission and the Society for Cardiothoracic Surgery in Great Britain and Ireland publication of survival rates for patients after heart surgery is a good example of this.

> More resources for making changes and acting on results

Expert advice needs to be more widely available for local services to make changes based on the results of audit. Few clinicians and managers have been trained in quality improvement skills. This means that even when audits provide information about quality and performance, providers may not have the skills necessary (or access to them) to improve services. Targeted support is particularly important in those organisations which are performing least well and are subject to the most instability and rapid change.

Figure 1: The audit cycle