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.

These resources were last accessed on 13 March 2013. Some of the resources are in PDF format - see how to access PDF files

Clinical audit

1000 Lives Plus: The quality improvement guide nursing edition
This guide developed by 1000 Lives Plus in Wales and adapted from the original generic guide, aims to describe a useful set of techniques that nurses and nursing at all levels can use in different settings. This includes the Model for Improvement which provides a framework to structure improvement efforts and aligns closely with the clinical audit process. Within the guide each of the eight RCN Principles of Nursing Practice has also been mapped to an example of improvement work. Scroll down the page to access this nursing edition.
See also the Patient Safety First's How-to guide for measurement for improvement (PDF 340KB) which explains what measurement for improvement is and provides guidance on the process of collecting, analysing and reviewing data.

Clinical Audit Tools
This website has been developed by the Clinical Audit Support Centre in association with a number of partners. The website includes a wide range of electronic tools aimed at making clinical audit accessible and achievable. One of the tools available is the Clinical Audit Ready Reckoner (CARR) which can help staff to consider whether their planned clinical audit is viable.  Discussion boards are available on a number of topics which include quality improvement and clinical audit generally; local audit and national audit more specifically.

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 2011 is 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: Into practice
This page section of the National Institute for Health and Clinical Excellence website 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. The section includes educational tools and examples via a shared learning process.

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

CHAIN (Contact, Help, Advice and Information Network)
CHAIN is a well-established networking tool and has a community of almost 12,000 people who are willing to share their experience and ideas with one another. These include frontline healthcare practitioners from all professions, managers, educators, researchers and knowledge specialists. Membership is free and benefits include: access to a searchable online directory of health and social care professionals, detailing their interests, experience and aspirations and the ability to pose questions, seek advice or find collaborators from a diverse pool of members. 
CHAIN also has a number of Sub-groups and Special Interest Groups. These include groups focussing on: Quality improvement; Improving patients’ experience; Patient and public involvement; Safer Patients Network.

Clinical Governance: Learning to Improve
Produced jointly by NHS Quality Improvement Scotland (NHS QIS) and NHS Education Scotland (NES) in 2007, 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 (2009)
    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 (2009)
    Aims to help you to look at your own practice, to identify areas for improvement.
  • Planning for improvement (2009)
    Focuses on identification of potential improvements, by focusing on the patient journey.

Patient safety

See also the RCN's resource on Patient safety and human factors.

For guidance specifically see Patient safety - guidance.

Quality improvement tools and techniques

1000 Lives Plus: The quality improvement guide nursing edition
1000 Lives Plus is a national improvement programme, supporting organisations and individuals, to deliver the highest quality and safest healthcare for the people of Wales. The guide, adapted from the original generic guide, aims to describe a useful set of techniques that nurses and nursing at all levels can use in different settings. This includes the Model for Improvement which provides a framework to structure improvement efforts. Within the guide each of the eight RCN Principles of Nursing Practice has been mapped to an example of improvement work. Scroll down the page to access this nursing edition.

Department of Health: Quality and productivity
This section in the Department of Health’s website brings together information about the Quality, Innovation, Productivity and Prevention (QIPP) programme, case studies illustrating quality and productivity in action, and information about the National Quality Board. A separate area provides information about quality accounts and supporting resources.

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.

Leading Better Care
Leading Better Care (LBC) is supporting Senior Charge Nurses/Midwives (SCN/Ms) and Team Leaders (TLs) in Scotland "to ensure safe and effective clinical practice; to enhance the patients experience; to manage and develop the performance of the team; to ensure effective contribution to the delivery of the organisations objectives" by March 2013 and be able to demonstrate this. Also by this date nurses and midwives will be able to demonstrate the contribution they make to quality and experience of care that patients receive under the three themes - safe, effective and person-centred care. Further documentation is available on the website.

The Releasing Time to Care (RTC) programme is closely integrated with LBC and since November 2011 has been managed and co-ordinated by Healthcare Improvement Scotland. A report on the main findings and themes of the RTC programme makes recommendations for the ongoing implementation, spread and sustainability of the programme's work - see Releasing Time to Care stocktake report.

NHS Change Model
"Everything we know about delivering change in the NHS, all in one place". The model consists of eight components which can support a shared approach to change and transformation. Each of the eight areas includes practical information and tools, and invites comments and sharing of ideas.

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 Institute for Innovation and Improvement (NHS Institute): 15 Steps Challenge toolkits
The 15 Steps Challenge is a series of toolkits which are part of the resources available for the NHS Institute’s Productive Care work stream. The challenge arose from a comment made by a parent "I can tell what kind of care my daughter is going to get within 15 steps of walking on to a ward". The toolkits have been co-produced with patients, service users, carers, relatives, volunteers, staff, governors and senior leaders, to help look at care in a variety of settings through the eyes of patients and service users, to help capture what good quality care looks, sounds and feels like. Each toolkit provides a series of questions and prompts to guide patients, service users, carers and NHS staff through their first impressions of a care setting. There are now three toolkits available for different contexts: acute services; mental health services; community services - focussing on care in people's own homes.

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.

Patient Safety First (2009) The how-to guide for measurement for improvement
This uses the Model for Improvement which is also advocated in the Quality improvement guide nursing edition produced by 1000 Lives Plus in Wales (see above), and focuses on measurement of improvement. It aims to explain what measurement for improvement is and how it can be made meaningful, and provides guidance on the process of collecting, analysing and reviewing data.

Quality indicators  

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.

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.