Unit Eight

Quality improvement

Unit key benefits

Reading this unit will:

  • explain how NHS organisations work to improve the quality of the care that they provide
  • describe the policies and procedures that support NHS organisations to improve the quality of care that they provide.

Everyone working in the NHS is responsible for contributing to the maintenance of quality and improving it where possible, as an integral part of their role and responsibility, depending on the nature of their post. The importance of quality improvement is indicated by the number and diversity of NHS and Department of Health Organisations involved. These include those listed below.

  • The National Patient Safety Agency (NPSA) http://www.npsa.nhs.uk – this organisation considers way of making the NHS safer for patients and encourages examination of sources of error. The NPSA incorporates the National Clinical Assessment Service (http://www.ncas.nhs.uk) that helps local organisations with the assessment of doctors and dentists whose performance gives rise to concern. It also provides advice on how to restore doctors and dentists to safe professional practice.
  • National Institute for Health and Clinical Excellence (NICE) http://www.nice.org.uk – evaluates treatments and management to try and establish what is the most cost-effective option.
  • Healthcare Commission http://www.healthcarecommission.org.uk – this is the independent watchdog that reports to parliament on the performance of Trusts in England and Wales.
  • The NHS Institute for Innovation and Improvement http://www.institute.nhs.uk – when the Institute was created in July 2005, the NHS Modernisation Agency (http://www.wise.nhs.uk), NHSU and NHS Leadership Centre were dissolved. The National Primary Care Trust Development Team (NatPaCT) that helped to increase the capabilities of PCTs has also been subsumed into the Institute (http://www.natpact.nhs.uk). The NHS Institute for Innovation and Improvement has expertise in service transformation, technology and product innovation, leadership development and learning. Many of the learning programmes and outputs of the previous organisations are still available (see http://www.nhsu.nhs.uk and http://www.wise.nhs.uk for materials such as core learning programmes for NHS staff [0800 0150 850] and the series of Improvement Leaders’ Guides that represent the best in known NHS improvement practice).
  • Clinical Governance Support Team http://www.cgsupport.nhs.uk – this body supports clinical governance developments.
  • National Primary Care Development Team http://www.npdt.org – this group works nationally and regionally to improve access to services and coronary heart disease care among other projects.
  • The Changing Workforce – this programme helps to redesign staff roles by combining tasks differently, expanding roles or moving tasks up or down a traditional ladder, as appropriate. It also aims to remove any obstacles to change, thereby ensuring new ways of working continue within the NHS (see Unit 7: Integration of health care assistants in the general practice workforce).
  • The National Audit Office (NAO) http://www.nao.org.uk – this body scrutinises public spending on behalf of parliament. They are currently undertaking a review of the implementation of clinical governance in PCTs and will publish recommendations.
  • The Audit Commission http://www.audit-commission.gov.uk – they are an independent public body responsible for ensuring that public money is spent economically, efficiently and effectively in health and other areas. Their mission is to be a driving force in the improvement of public services, promoting good practice and helping to achieve better outcomes.

Substantial improvements were seen in the quality of care for diabetes, asthma and coronary heart disease between 1998 and 2003, a time of widespread government and professional initiatives to improve quality of care.1 These changes were most marked for coronary heart disease.

Clinical governance

The transfer of patient care to health care assistants (HCAs) from registered health professionals, such as doctors, practice nurses and allied health professionals, affects clinical governance. Clinical governance is an umbrella term used to describe the different systems and processes that ensure the quality of the healthcare provided. The introduction of clinical governance in 1998 was designed to introduce a systematic approach to the delivery of high-quality health-care. The 1999 NHS Act placed a duty of quality on NHS organisations. The Act introduced corporate accountability for clinical quality and performance.

Clinical governance has been described as doing the right thing at the right time to the right person in the right way. It is ‘doing anything and everything required to maximise quality’.

Clinical governance looks at the whole system in an NHS organisation, eg a general practice, PCT and hospital trust. It seeks to ensure that:

  • patients are kept well informed and are given the opportunity to participate in their care
  • good information about the quality of services is available to those providing the services, as well as to patients and the public
  • variations in the process, outcomes and access to healthcare are reduced
  • NHS organisations and partners work together to provide good-quality services and improvements to services
  • doctors, nurses and other health professionals work in teams to consistently high standards, and identify ways to provide safer and even better care for their patients
  • risks and hazards to patients are reduced to as low a level as possible, creating a safety culture throughout the NHS
  • good practice and research evidence is systematically adopted.

Clinical governance requires changes at three levels: by individual healthcare professionals, by teams and by organisations.

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Seven pillars of clinical governance

Many of you will be familiar with the seven pillars of clinical governance that have been used to monitor and improve standards of care.

  1. Risk management – describes the systems to understand, monitor and minimise the risks to patients and staff, and to learn from mistakes.
  2. Clinical effectiveness – ensures that the approaches and treatments used are based on the best available evidence.
  3. Education, training and continuing personal development – covers the support available to enable staff to be competent in doing their jobs while developing their skills and the degree to which staff are up to date with developments in their field.
  4. Use of information – describes the systems in place to collect and interpret clinical information and to use it to monitor, plan and improve the quality of patient care.
  5. Staffing and staff management – describes the recruitment, management and development of staff, and includes the promotion of good working conditions and effective methods of working.
  6. Clinical audit – describes the continual measurement and improvement by health professionals of their work and the standards they are achieving.
  7. Patient/service user and public involvement – describes how patients can have a say in their own treatment and how they, and patient organisations, can have a say on how services are provided.

Standards for Better Health

The Healthcare Commission uses Standards for Better Health, which is based on seven domains:

  1. safety
  2. clinical and cost effectiveness
  3. governance
  4. patient focused
  5. accessible and responsive care
  6. care environment and amenities
  7. public health.

The original seven pillars underpin these standards and are the basis of quality assurance.

Summary

  • The NHS has a range of organisations and policies in place that work to improve the quality of care that patients receive.
  • Clinical governance systems need to take account of the delegation of tasks to HCAs.
  • Establishing effective clinical governance systems requires change at individual, team and practice level in order to succeed. 

References

  1. Campbell SM, Rowland MO, Middleton E, Reeves D. Quality of clinical care in English general practice 1998–2003: an observational study. BMJ 2005;331:1121–1123.
  2. Chambers R, Wakley G. Making Clinical Governance Work for You. Oxford: Radcliffe Medical Press; 2000.
  3. Commission for Health Improvement. Seven Pillars of Clinical Governance. London: CHI; 2000. http://www.healthcarecommission.org.uk
  4. Healthcare Commission. Standards for Better Health. London: Department of Health; 2004. http://www.healthcarecommission.org.uk