Annex A > Chapter 18 - Medical and Clinical Audit > Audit: the national perspective > Nursing audit
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Nursing audit
The national context
113 In its written statement to the Inquiry, the Royal College of Nursing (RCN) stated:
`The RCN has a long history of supporting developments in the field of nursing quality and audit in the United Kingdom. A dedicated quality and audit unit, the Dynamic Quality Improvement Programme, has focused on developing work, including the following:
- `Developing a philosophy and framework for nursing quality evaluation
- `Developing systems for quality evaluation in healthcare
- `Developing specialist guidelines and standards
- `Undertaking research and development.' [137]
114 The RCN also provides support, and a forum, for nurses who have concerns about their practice and their profession. As its submission stated:
`The RCN provides support for nurses who wish to raise their concerns about the standards of nursing care and other professional issues. The RCN's structure to support nurses who raise concerns about professional practice and standards of care is through the local RCN Branches where concerns can be raised with local management and, if necessary, the Community Health Council and local Members of Parliament and local media. Nurses can also raise their concerns through Forums that can raise the issues at national conferences and also are able to lobby and influence nationally.' [138]
115 The RCN gave evidence to the effect that the nursing profession was progressive in its attitude to standards and audit. The RCN conducted research into these areas in the late 1980s:
`Drawing on the specialist knowledge of the membership groups within the RCN, an initial programme of work to develop national standards for particular specialty areas was undertaken during the late 1980s and early 1990s. This resulted in the production of standards for a whole range of specialist subjects, including paediatric nursing, school nursing, radiology nursing, cancer nursing, nursing in older people, and gynaecological nursing.
`The idea behind these types of specialist documents was that local practitioners could use them as a guide for developing standards within their own clinical area. More recently, however, the focus has moved towards developing evidence-based national guidelines for specific clinical topics, for example, the management of venous leg ulcers, the assessment of pain in children and the assessment and prevention of pressure ulcers. A shift from developing specialist standards of practice to more focused guidelines has been a response to the growing emphasis on evidence-based healthcare, and is aiming at ensuring that national guidance is based on the best available knowledge to promote quality improvement in practice.' [139]
116 The view of the RCN was that:
`Changes in managerial structures in the last decade may have had the unintended consequence of weakening the system for identification, monitoring and investigation of untoward incidents. Clinicians (both doctors and nurses) may be inclined to keep matters in their own hands and to resent enquiries by managers. This position may arise out of perceptions of managerial indifference, clinical freedom, unwillingness to admit problems, or even the reluctance to face the death of a patient.
` The organisational culture has a part to play in the reporting of untoward incidents. A combination of high stress levels, clinical inadequacies and punitive, authoritarian culture may provide a background in which not only do mistakes occur but energy is spent on damage limitation rather than open enquiry with a view to future prevention. The RCN has long argued for independent counselling to be provided for NHS staff.' [140]
The Dynamic Standard Setting System (DySSSy)
117 The Inquiry was given details of the work of the RCN in promoting the `Dynamic Standard Setting System' (DySSSy). This was developed by the RCN to enable health-care practitioners to define quality of care locally. The DySSSy involves a group of practitioners, assisted by a trained facilitator, moving around a cycle of describing, measuring and taking action, within a philosophy of continuous improvement in care. [141] It was described as follows in the National Institute for Nursing Report No 124, 1995:
`The Dynamic Standard Setting System depicts both a philosophy and a methodology for developing quality patient care. In terms of philosophy it makes explicit its definition of quality care and most importantly, identifies the organisational culture and values necessary for quality of care to improve and flourish.
`The framework for local standard setting was first outlined in 1989 in a publication entitled "A Framework for Quality" (Kitson 1989), which outlined a method for setting standards, but located it very clearly within a framework for quality assurance in health care for an entire organisation. The framework also clearly stated the need for a collaborative approach to setting objectives, stressing the importance of interprofessional negotiation.
`In 1990 the Dynamic Standard Setting System was launched as a formal workbook, based on the experience of three years of running workshops. It comprised an introductory text and accompanying overhead projector originals (RCN 1990). The workbook focused largely on the mechanics of the system of local standard setting, expounding the quality cycle in some detail. It also described the need for trained facilitators to enable groups of practitioners to move around the cycle, improving care to patients.
`The principles underpinning DySSSy were that all activities had to be patient or client focussed. Every standard set should clearly state what level of excellence of care a client could expect to receive, relating the standards to client experience rather than diagnostic label or issues of care management.
`In addition, DySSSy located the responsibility for the setting, monitoring and improving of standards with practitioners directly involved in client care. Staff must own and control the process of quality improvement, and be fully involved. Finally, standards have to be achievable and all quality improvement activities must recognise the contribution of the entire clinical team.
`The cycle of quality improvement
`The Dynamic Standard Setting System is based on a cycle of describing, measuring and taking action, resulting in the continuous improvement of care ...
`In the describing phase a group of practitioners are helped by a trained facilitator to select their topic for quality improvement, devise a standard statement which reflects the overall intention of the exercise, and identify the elements or criteria necessary for implementation. ... These elements can relate to the resources required, the activities undertaken by staff and the anticipated results of the intervention in terms of patients' experiences. Donabedian (1966) classified these as structure, process and outcome.
`Once criteria have been identified, refined and organised, the standard statement is reviewed and edited if necessary. In order to measure practice against the standard, an audit form is then devised by the group from the structure, process and outcome criteria. ... A sample is identified, together with data collection methods, a time frame for the collection of data and the individuals responsible ... Implementation and audit dates are then negotiated by the group in consultation with the wider team. ...
`The final phase of the cycle involves action planning. Data are summarised and brought back to the group to interpret the findings ... and decide on what action (if any) is needed. Actions are prioritised and individuals given responsibility for seeing that plans are carried out in an agreed period of time and a date for re-audit negotiated. ...
`DySSSy shares many common characteristics with other methods for clinical audit and quality improvement. What distinguishes DySSSy from other systems is its unique combination of the following features:
`(i) it is clinically as opposed to managerially led, though it must be supported by the organisation;
`(ii) it is locally based, emphasising the full participation of practitioners in all three phases of the cycle;
`(iii) it uses small group processes within the local quality improvement team to ensure commitment to developing practice;
`(iv) there is a clearly identified facilitator role, guiding and supporting local groups; the facilitator role is undertaken by a skilled and trained member of the team;
`(v) it involves the generation of explicit standards, with criteria for implementation developed for structure, process and outcome.' [142]
Comparing DySSSy and Medical Audit [143]
118 The overall assessment of the use of DySSSy by the National Institute for Nursing's Report was that:
`Improvements in patient care were described in all the sites visited, with DySSSy appearing to act as a catalyst. Time to commit to local quality improvement projects was commonly raised as a difficulty...
`The lack of information on audit contained within the original DySSSy information was raised as a problem in some places. The involvement of patients in DySSSy has varied, with all standards described as patient centred, although patients were rarely involved.
`The data suggest that the personality, skills and attributes of the key facilitator are highly influential in the development of a practitioner-led quality programme ...
`The lack of training and education in principles and systems for quality improvement and skills in group work and facilitation was raised as a barrier to further development in many areas. The problems appeared to centre around funding for the training itself, and releasing staff from clinical duties. The importance of integrating quality and audit into basic and post-basic education was also highlighted.
`Some of those interviewed felt that the biggest benefit of the purchaser-provider split was that quality issues had been introduced in areas where they had not previously featured. In addition, application for Trust status had helped some organisations draw existing initiatives together into a coherent strategy. This had given DySSSy and local quality improvement initiatives a much higher profile.
`DySSSy appeared to have been most useful in developing patient care in areas where it had become integrated with other issues related to quality ...
`A fragmented approach to quality strategy persisted in a large proportion of sites visited. An integrated approach appeared to require not only clear leadership, but also the full commitment of the management team in establishing systems and structures to support the many initiatives.
`DySSSy was being used successfully as a model for multi-professional clinical audit in a few of the sites visited. In other areas it appears that misunderstandings and tribal boundaries between professions persisted, hindering the development of genuinely multi-professional audit.
`... whilst DySSSy continues to provide a useful framework for practitioner-led quality improvement, additional work is necessary to develop the model further for use with multi-professional teams. Mechanisms for involving service users in quality improvement also need continued work.
`Time for quality improvement activities remains a major issue and needs addressing at all levels, by dissemination of innovation at a national level, by recognition of the resource implications at strategic level, and by good planning and prioritising of work locally.
`In addition, it is recommended that to maximise the potential of practitioner-led quality improvement initiatives, they must be firmly integrated within the strategic work of the Trust or provider unit.' [144]
Evaluation of the nursing and therapy audit programmes
119 The Inquiry was referred by Mrs Jenkins of the RCN to `A review of audit activity in the nursing and therapy professions: Findings of a national survey', a study conducted by CASPE in the second half of 1994 on behalf of the DoH.
120 The findings were as follows:
`The resources available for nursing and therapy audit were almost wholly obtained from centrally ringfenced monies, only 16% coming from other sources, much of that (7%) coming from provider units.
`Over 70% of the funds available were used to meet staff costs, with information technology using 10% of the resources. Training and dissemination accounted for very little expenditure and were considered to be under resourced. The management of resources seemed to have been effective in most cases ...
`The audit activities surveyed were each led by a named individual. There was a diversity in profession and status of those leading these activities although most were led by directors at board level or by service managers ...
`Whilst the majority of activities were led by nurses, when considered in proportion to the size of the profession, the distribution of leadership across professional groups was reasonably equitable. ... Audit leadership was commonly only one aspect of these people's work with the majority spending less than ten hours per week on it, which in most cases was not funded by earmarked audit monies but was a cost borne by the provider unit. ... This direct involvement of clinical staff in undertaking audit contrasts with the medical audit programme, where much data collection and analysis was undertaken by central support staff, and may have encouraged a greater integration of audit into routine clinical practice. Most of the audit activities within the nursing and therapy audit programme were multi-professional by nature, with about half involving four or more professions. Only 13% of activities were uniprofessional.
`The programme achieved a reasonably equitable distribution of activity across different types of provider units and, although not intended at the outset, also included the primary healthcare sector through the involvement of practice nurses in audit. The audit projects funded by the programme tended to look at specific areas in healthcare of particular concern to individual professionals. Not surprisingly, many of the projects focused on areas that had been suggested in national and regional documents. They tended to be selected either because they were of particular interest or concern to healthcare staff, or because there was known variation in clinical practice, they consumed a lot of resources or were considered to be of high risk to patients. Initiatives focused more on establishing the infrastructure for audit and included activities such as identification of audit topics, setting up an audit committee and facilitator role, awareness raising and dissemination as well as undertaking specific audits. The main aim of initiatives was recognised, by participants, as encouraging the establishment of audit throughout the unit. There was fairly widespread dissemination of information about activity, within and outside the host units. Written reports were distributed and nearly 70% of activities were reported at externally organised seminars or workshops. There were some difficulties in meeting all the aims set by the audit activities and finishing within set timescales. These were often due to the very limited resources available, but also to a lack of organisational and planning experience in audit.
`Eighty-three percent of audit activities funded through this programme were claimed to have brought about change. Audit initiatives were felt to have succeeded in raising the level of knowledge and awareness about audit and to have made some contribution to bringing about changes in clinical management and in the quality of communication with patients and other clinicians. It was thought, with rather greater frequency, that projects had also brought about change in these latter two areas and also in the quality of record keeping and patient documentation. However, very few (7% compared to 40%) felt that projects had brought about a change in knowledge or awareness across the organisation. The scale of resources available to audit activities appear to be important in determining its success. Small projects, for example those receiving less than £10, 000, had less chance of success than larger activities.
`The nursing and therapy audit programme was established in order to encourage the development of a framework for audit for the nursing profession and professions allied to medicine within every provider unit. A high proportion of projects funded by the programme had succeeded in encouraging healthcare professionals to undertake further audit projects, but only 15% had led to the development of a more permanent infrastructure for audit within the provider unit. This was not surprising since, by their nature, projects tended to be finite and discrete in their objectives, unlike the wider ranging initiatives that were funded. Indeed, in contrast to projects, 80% of audit initiatives continued, either with or without financial support, after the initial period of funding expired, thus leaving an infrastructure in place to support continuing audit activity.'
`... the nursing and therapy audit programme has been relatively successful in promoting the development of audit, particularly when the modest level of funding available to it is taken into account. It has resulted in a diverse range of both uniprofessional and multiprofessional audit activities, covering all aspects of healthcare; has succeeded in reaching many different professional groups; has resulted in changes in practice, service management and in culture and attitudes; and on the whole has had a lasting effect within provider units. Indeed, its achievements bear comparison with those of the much more generously funded medical audit programme.
`Some problems were commonly encountered by those undertaking nursing and therapy audit activities. Problems encountered as a result of the low level of resources could have been addressed by host provider units if they had decided to commit additional resources to these activities, thus acknowledging that they were an important element of the provider's business. This might have gone some way towards addressing another issue identified - that of a certain lack of commitment and enthusiasm for audit and its achievements, by those not directly involved in the activity.
`Although many nurses and therapists have become involved in audit over the last four years, because of the size of the professions concerned there remain very many clinicians who have had little or no contact with audit activity. As a result, there is still a considerable need to generate awareness of audit, interest and enthusiasm. In order to achieve this, additional support and education is required to provide healthcare professionals with the skills they need to undertake audit, and to enable them to participate in audit activities. This education and support should ideally come from within existing provider audit departments, and should aim to demonstrate to healthcare professionals that audit has the capacity to improve the quality of the care they provide.' [145]
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Footnotes
[137] WIT 0042 0005; statement of the RCN, submitted by Christine Hancock (former General Secretary)
[138] WIT 0042 0028 RCN (Christine Hancock)
[139] WIT 0042 0005 - 0006 RCN (Christine Hancock)
[140] WIT 0042 0027 RCN (Christine Hancock)
[141] WIT 0042 0451; RCN (Christine Hancock), referring to: `The Reality of Practitioner-Based Quality Improvement: A Review of the Use of the Dynamic Standard Setting System in the NHS of the 1990s', National Institute for Nursing, Report No 124, 1995
[142] WIT 0042 0460 - 0464 ; RCN (Christine Hancock), referring to: `The Reality of Practitioner-Based Quality Improvement: A Review of the Use of the Dynamic Standard Setting System in the NHS of the 1990s', National Institute for Nursing, Report No 124, 1995
[143] WIT 0042 0465 Christine Hancock; `The Reality of Practitioner-Based Quality Improvement: A Review of the Use of the Dynamic Standard Setting System in the NHS of the 1990s', National Institute for Nursing, Report No 124, 1995
[144] WIT 0042 0451 - 0452 Christine Hancock; `The Reality of Practitioner-Based Quality Improvement: A Review of the Use of the Dynamic Standard Setting System in the NHS of the 1990s', National Institute for Nursing, Report No 124, 1995
[145] WIT 0042 0252 - 0265 Mrs Jenkins