Quality improvement - other support

Guidance and tools

This section includes resources which can help with the understanding and implementation of particular aspects of policy, and support processes for improving care.

This is not a comprehensive listing. If there are any tools you are using in your workplace which you feel should be included here, please let us know. The documents are listed alphabetically by title. 

You may also find relevant guidance and tools in RCN publications and RCN products and services.

Some of the resources below are in PDF format - see how to access PDF files

Clinical audit

Guidelines and Audit Implementation Network (GAIN): Clinical audit
The tools section of the Northern Ireland GAIN website provides some general information on clinical audit which includes: the five stages of audit; planning your audit; writing your audit report; what makes a good/bad audit. Tools for specific audits are also available.

Healthcare Quality Improvement Partnership: Local clinical audit
This area of the Healthcare Quality Improvement Partnership (HQIP) website provides information about how HQIP supports local clinical audit in England and Wales. This includes guidance on delivering a comprehensive clinical audit function and information about legislation,  professional standards and clinical audit, training opportunities and the development of clinical audit resources - see HQIP guidance and resources. 

National Clinical Audit Forum (NCAF)
This is a professional forum for people interested in clinical audit. Users might include clinicians, audit managers, patients, managers or commissioners. NCAF allows users to make contacts, join groups and networks, consult and be consulted, share news, post and review documents, and share ideas about clinical audit and quality improvement. The NCAF is made available on the Healthcare Quality Improvement Partnership (HQIP) website.

Nursing Standard: Identifying best practice principles of audit in health care
This article by S. Patel is in the Nursing Standard Learning Zone continuing professional development series and describes the different stages of the clinical audit process. The article can be found in Nursing Standard 24(32) 14 April 2010 pages 40-48 and can be accessed in full text with an RCN membership number via the RCN e-library.

Principles for best practice in clinical audit
The authors of this book include staff from the Royal College of Nursing. It was published in 2002 in collaboration with the Commission for Health Improvement, the National Institute for Clinical Excellence (NICE) and the University of Leicester, and provides guidance on what clinical audit involves, how to prepare for and undertake a clinical audit project, and what helps in making and sustaining improvements through the audit process. A downloadable version is made available on the website of the National Institute for Health and Clinical Excellence (NICE). An updated version published in January 2011is available in hard copy only - see: Revised 'Principles of best practice in clinical audit'.

Scottish Intercollegiate Guidelines Network (SIGN): Audit tools
Audit tools have been developed by SIGN to accompany their guidelines and can be used to measure and compare practice at local level.

Clinical effectiveness

NICE: Implementation tools
This page within the website of the National Institute for Health and Clinical Excellence provides generic and specific tools to support the implementation of NICE guidance. Generic tools support all types of NICE guidance and guidance-specific tools support the implementation of a specific piece of NICE guidance at local level.

There is also a searchable area on the NICE website for sharing tips with other organisations - See Shared learning: implementing NICE guidance.

Also available is the ERNIE database which is a source of information on the implementation and uptake of NICE guidance. It aims to provide a searchable bank of guidance-specific NICE implementation uptake reports produced in-house, and references to external literature which includes reports from other organisations - See Evaluation and review of NICE implementation evidence (ERNIE) .

NHS Evidence
NHS Evidence is a portal to high-quality clinical and non-clinical evidence and best practice designed to meet the needs of all users across the NHS. It was launched in April 2009 by the National Institute for Health and Clinical Excellence as an outcome of Lord Darzi's report 'High quality care for all'.  It incorporates the resources formerly brought together as the National Library for Health in England and now called 'Health Information Resources', but a key activity of NHS Evidence is also to identify trusted sources of information and set best practice standards.

NHS Scotland: Knowledge Network
The Knowledge Network offers a wide range of resources and services for everyone working and learning in Scotland’s health and social services. It supports evidence-based practice, communication and collaboration by communities, and access to e-learning. These resources include a range of specialist portals. The Evidence into Practice portal helps clinicians to find and share and apply evidence to practice to deliver the best quality patient care.

Learning and networking

CHAINs - Contact, Help, Advice and Information Networks
CHAINs are online networks for people working in health and social care. They are free to join and are multi-professional, providing people with a simple and informal way of contacting each other to exchange ideas and share knowledge. There are three CHAINs which focus on research and evidence-based practice, work-based and e-learning, and innovation and improvement. Membership of any CHAIN gives access to the directories of all CHAINs in order to facilitate networking across the different areas. Within CHAIN there is a quality improvement sub-group which was set up with the support of The Health Foundation and which aims to reach all CHAIN members who are involved or interested in quality improvement in health and social care.

Clinical Governance: Learning to Improve
Produced jointly by NHS Quality Improvement Scotland (NHS QIS) and NHS Education Scotland (NES), this resource has been designed to be used as a programme of learning, a reference source or a training resource to help health professionals with using clinical governance, risk management and quality improvement methods in their work. The resource includes areas on managing clinical effectiveness; managing risk; involving patients; patient safety and incident reporting; and using evidence. While promoting a Scottish perspective on clinical governance, the website also draws on the resources available from the English, American, Canadian, Australian and New Zealand health services.

Nottingham University School of Nursing Educational Technology Group (SONET): Reusable Learning Objects (RLOs)
Resusable learning objects (RLOs) are usually web-based self-contained units of learning that support a specific learning object. SONET on its own and in collaboration with external projects has developed many RLOs. These include the following titles on improvement activities which are arranged alphabetically and can be accessed via browse all RLO titles. 

  • Improving care
    Introduces the concept of improvement within health and social care showing how people and processes in health and social care are involved in making improvements.
  • Improving your practice
    Aims to help you to look at your own practice, to identify areas for improvement.
  • Planning for improvement
    Focuses on identification of potential improvements, by focusing on the patient journey.

Patient safety

See also the RCN's resource on Patient safety.

Health Foundation: Patient safety 
The Health Foundation is working with hospitals throughout the UK to explore ways of making hospitals safer for patients via a number of programmes and initiatives.  For information about the foundation's continuing work around patient safety, what the foundation has learnt so far and its key priorities for the future see: patient safety update.

The Health Foundation programmes include: 

  • Safer Clinical Systems
    This was launched in October 2008. This programme has developed out of the Health Foundation's Safer Patient Initiative (SPI) which highlighted the need to take a clinical systems approach to improving safety as clinical processes and systems often contribute to breakdowns in patient safety. The programme will test and demonstrate ways to improve these systems and processes.
  • Safer Patients Initiative (SPI)
    In this initiative, which ran from 2004 to 2008,  the Health Foundation worked in partnership with the US-based Institute for Healthcare Improvement. The SPI involved 24 hospitals across the UK and concentrated on five clinical areas. For further information see the briefing: Making our hospitals safer: journeys on the Safer Patients Initiative.

National Patient Safety Agency (NPSA): Patient safety resources
The NPSA makes available a range of different tools and guidance to support practitioners in putting patient safety into practice. These include: 

  • Being Open
    The National Patient Safety Agency's Being Open policy deals with communicating honestly and sympathetically with patients and their families when things go wrong. The NPSA promote this as a vital component in dealing effectively with errors or mistakes in their care.  The policy advises health care staff to 'apologise to patients, their families or carers if a mistake or error is made that leads to moderate or severe harm or death, explain clearly what went wrong and what will be done to stop the problem happening again'. Information about Being Open training workshops is also available on this page from the National Patient Safety Agency website.
  • Foresight Training Programme
    These resources for training are aimed at frontline healthcare staff and have been developed to improve awareness in nursing and midwifery of the factors that combine to increase likelihood of patient safety incidents. The resources aim to increase understanding of risk prone situations and those that could be considered a near miss, and have been designed to be used as flexibly as possible for example, in training sessions, meetings and handovers. The pack, which is made available on the National Patient Safety Agency's website, includes a range of training scenarios, examples around the three buckets model and supporting materials for facilitators.
  • Incident Decision Tree
    The Incident Decision Tree is a tool for NHS managers and senior clinicians to use when faced with a decision to suspend (exclude) staff after a serious patient safety incident and to identify appropriate management action. The goal is to promote fairer and more consistent treatment of staff in these circumstances. The tool is made available by the National Patient Safety Agency.
  • Manchester Patient Safety Framework (MaPSaF)
    The Manchester Patient Safety Framework (MaPSaF) is a survey tool designed to help NHS organisations assess and monitor their progress in developing a more mature safety culture. Health care teams can use MaPSaF to highlight strengths and weaknesses of their organisation's approach to patient safety and redirect resources appropriately. The framework has been made available on the National Patient Safety Agency website.
  • Root Cause Analysis
    This online learning programme from the National Patient Safety Agency contains six modules. The first four provide an overview of Root Cause Analysis (RCA) for those who need to undertake an RCA of a patient safety incident. The last two modules provide more of the theory behind the process. The Root Cause Analysis toolkit can be accessed from the National Patient Safety Agency website.
  • Seven Steps to Patient Safety - your guide to safer patient care
    This publication from the National Patient Safety Agency sets out a seven point strategy for tackling patient safety issues in the health service. Aspects covered by the document include attributes of leadership, promotion of patient incident reporting, engagement with patients and the public, learning from incidents and implementing safety solutions. There are three versions of the seven step strategy:
    Seven steps for all healthcare settings
    Seven steps to patient safety for primary care
    Seven steps to patient safety in mental health.

Patient Safety First
Patient Safety First was a campaign, sponsored by the National patient Safety Agency, that ran from 2008 to 2010 with the aim of changing the culture within the NHS "to one that makes the safety of patients the highest priority and makes all avoidable death and harm unacceptable', and supporting interventions that were known to improve the safety of patient care.  Initially it focussed on leadership for safety and on four clinical interventions: reducing harm from deterioration; reducing harm in critical care; reducing harm in perioperative care; reducing harm from high-risk medicines. The website provides information and guidance for these interventions and continues to act as a hub for a number of programmes and resources including Safety Express. 

Quality improvement techniques

Guide to service improvement: measurement, analysis, techniques and solution
Published by the Scottish Executive in 2005 this guide introduces tools and techniques for improvement in getting to grips of delivering improved patient access. It explores a number of tools which offer a structured approach to analysing services and care processes for improving the patient journey, and tools to support service improvement and redesign.  It is not intended to be a detailed guide to every concept and its applicability. Where necessary it introduces a key concept and leads the reader to more detailed information.

Improvement Leaders Guides: General Improvement Skills
This model and accompanying guide has been designed by the NHS Institute for Innovation and Improvement (NHS Institute) for use by individuals and teams who are involved in local improvement initiatives. The sustainability model is a diagnostic tool to help assess the likelihood of sustainability for an improvement initiative. The sustainability guide provides guidance on what can be done to increase the chances that changes for improvement will be sustained. You will need to register on the NHS Institute website to download these publications. Further information about using the model and the guidance is also available on the NHS Institute website.

Improving quality in primary care
A practical guide published in 2009 and developed by the Department of Health for senior managers. It aims to support PCTs as commissioners of primary care, in working with local clinicians and other stakeholders - including patients - to promote continuous quality and productivity improvement in primary care services. The guidance is organised around the seven steps to high quality care identified in the NHS Next Stage Review report.

NHS Evidence: Quality, innovation, productivity, prevention (QIPP)
This is a collection of real examples of how health and social care staff are improving quality and productivity across the NHS and social care. The collection also includes topics from the Cochrane systematic reviews that may help to inform local intiatives. There is information about how to submit further case studies and best practice examples.

NHS Improvement
This website offers tools and guidance for practical service improvements and “demonstrates some of the most leading edge improvement work in England which supports improved patient experience and outcomes”.  It is arranged according to certain care areas and processes such as: heart, stroke, lung, cancer, diagnostics. The website includes the NHS Improvement System which aims to be  “a comprehensive, online tool to support sharing of quality service improvement resources in NHS services”, providing access to information and stories from around the country. You need to log in to access and to be an NHS staff member in England to access - see NHS Improvement System.

NHS Information Centre for health and social care: Map of information for QIPP
The map for information to support the Quality, Innovation, Productivity and Prevention (QIPP) challenge is organised into four main areas: plan preventive measures; analyse service productivity; identify cost efficiencies; measure quality outcomes. Each area displays a range of information sources including statistics, publications, services and tools to help frontline decision makers.

NHS Institute for Innovation and Improvement: High Impact Actions: The Essential Collection
The High Impact Actions have been developed from the examples of improvement ideas and projects sent in by nurses and midwives working on the frontline of health care. There are eight high impact action areas – background and other information about ongoing work in these areas is also available on this section of the NHS Institute website. The Essential Collection aims to highlight some of the stories behind the submissions from nurses and midwives providing illustrations of good practice and of ideas and actions that have made a difference.

NHSScotland: Quality Improvement Hub
The NHSScotland Quality Improvement Hub aims to support NHS boards with implementation of the Healthcare Quality Strategy.  Through effective partnership working between the collaborating organisations the Hub aims to provide support, education, training and technical expertise in improvement science. It includes the Quality Improvement (QI) Curriculum Framework which will help all NHSScotland staff to access learning in quality improvement thinking and techniques and plan their own learning and development.

Northern Ireland Practice and Education Council for Nursing and Midwifery: NIPEC Improving record keeping website
This website has been developed to help nurses make improvements in their record keeping practice. The tools and resources on this website have been developed for the acute nursing care setting but could also influence record keeping practices in other care settings, particularly those resources related to the Mandatory Requirements section.

Nursing Roadmap for Quality: a signposting map for nursing
The Nursing Roadmap for Quality, published by the Department of Health in 2010, has been designed help nurses and their teams understand the elements of the quality framework that relate to nursing practice. It aims to inform nurses and their teams of their role in supporting quality improvements against the seven elements of the quality framework and to reinforce the need for nurses to identify ways to reduce waste and repetition, by contributing to the quality and productivity challenge.The publication provides a ‘one-stop shop’ for key resources, identifying 41 resources across the seven elements of the quality roadmap and aligns to the workforce and career framework work already produced by the Department last year.

The seven elements to improve quality are: bring clarity to quality; measure quality; publish quality performance; recognise and reward quality; leadership for quality; safeguard quality; stay ahead.

Quality indicators  

Delivering quality and value: focus on benchmarking (2006)
Published by the Department of Health and co-authored by the Productive Time Delivery Board and the NHS Benchmarking Club, this is intended to support clinicians and managers in getting started with using benchmarking tools for improving services and increasing the productive time of staff. It highlights good practice, tools, techniques and data for benchmarking and can be accessed on the Department of Health website in poster and document form.

Essence of Care - England
Essence of Care has been updated and now contains 12 benchmarks, following a consultation exercise late in 2009. It provides a structured and patient-centred approach to identifying best practice and setting standards for these fundamental aspects of care, and highlights the importance of seeking patient and carer opinion. It acts as a tool for sharing and comparing practice, for developing action plans for improvement and audit, and for identifying education and training needs. The 12 areas, each of which has its own benchmarks, are: bladder, bowel and continence care; the care environment; communication; food and drink; personal hygiene; prevention and management of pain; prevention and management of pressure ulcers; health and wellbeing; record-keeping; respect and dignity; safety and self care. The Essence of Care (EoC), was first launched in 2001 and emerging from the 1999 nursing strategy 'Making a difference', formed the basis of a government strategy for improving the quality of care and became an integral element of the clinical governance agenda. This edition supersedes the previous versions originating since 2001.

Fundamentals of Care (2003)
Fundamentals of Care is a Welsh Assembly Government initiative providing guidance for improving fundamental aspects of health and social care for adults covering 12 key aspects of care. Each aspect contains a principle quality statement with a series of practice indicators which describe in greater details how the principle can be put into practice. The indicators are also cross-referenced to key standards. The document describing the Fundamentals of Care and how it can be implemented is made available in a range of languages on the Welsh Assembly Government's website.

Indicators for Quality Improvement (IQI)
The Indicators for Quality Improvement (IQI) have been developed as part of the quality agenda framed by Lord Darzi's report 'High quality care for all'. Initially there are more than 200 indicators which can be accessed from the NHS Information Centre's website either through a keyword search, or through browsing the three quality domains (effectiveness, safety and experience). Each indicator has a set of meta data providing further descriptive information about each indicator.

These indicators, which are mostly existing ones supported by clinicians and NHS professionals, have been brought together following a consultation survey run by the NHS Information Centre for health and social care in partnership with the Department of Health and supported by five royal colleges and the Cardiovascular Society. They are not mandated indicators but it is possible that some of them may be specified as core indicators to be used in Quality Accounts. For further information see Measuring for quality improvement.

Leading Better Care: Clinical Quality Indicators
In Scotland one of the two key aims of the Leading Better Care initiative is that the majority of in-patient areas will have Clinical Quality Indicators (CQIs) in place by the end of 2010. Three CQIs have been developed so far for falls, pressure area care, food and fluid and nutrition. They are currently process indicators, which measure aspects of nursing care such as assessments and interventions. A CQI frequently asked questions is also available. 

Quality and Outcomes Framework
The Quality and Outcomes Framework (QOF) is a component of the new General Medical Services contract for general practices, introduced from 1 April 2004. The QOF is a voluntary incentive scheme that rewards practices for the provision of quality care. This is a section on the website for the National Institute for Health and Clinical Excellence (NICE) which manages the process of developing the clinical and health improvement indicators for the QOF.