Arguably, quality in health care was first recognised by Florence Nightingale, who was a pioneer of systematic observation, standard setting and improvement of care and who clearly advocated the importance of quality in health care as early as the 19th century. During the Crimean War, Nightingale realised that admission to a battle hospital actually increased a soldier’s chances of death, so she set standards against which she measured practice. This process led to a drastic reduction in the rates of hospital-acquired infection and dramatically cut the mortality rate. Furthermore, Nightingale (1863) reiterated the need to collect data and measure outcomes in health care:

In 1959, the publication of the Platt Report, entitled ‘Welfare of Children in Hospital Report’ (Ministry of Health 1959), was an early attempt to raise standards in the care of sick children in hospital, although the aspirations of this report went largely unfulfilled. For several decades the wise words of Nightingale and the key features of the Platt Report went relatively unheeded, although voluntary organisations maintained an impetus for the need to improve quality of care. In particular, the work of Action for Sick Children, previously known as the National Association for the Welfare of Children in Hospital (NAWCH) made important contributions to the quality of care afforded children in hospital and introduced a ‘Charter for Children in Hospital’ in 1984. This charter encouraged nurse managers to monitor standards of care in children’s departments.

In general, the nursing profession had an interest in quality care, which grew with the development of the Royal College of Nursing and the RCN Standards of Care Project (Parsley & Corrigan 1999). From this work, nursing embraced the dynamic standards-setting system based on the Donabedian (1966) structure–process–outcome framework, but three main factors have resulted in an upsurge of interest in quality in recent years:

In response to these factors, the UK government introduced a significant set of reforms in the NHS, which shifted the focus towards quality of care and formed one of the main principles underpinning the incoming Labour government’s agenda for the NHS. In the White Paper ‘The New NHS: Modern Dependable’ (Department of Health (DoH) 1997), the government declared that the new NHS would have quality at its heart; quality was to be the driving force for decision making at every level of the service and the agenda for quality was set in the White Paper ‘A First Class Service’ (DoH 1998). This paper identified three main components for ensuring high-quality care:

Figure 16.1 shows the relationship between these components; clinical governance being pivotal to this model.

Defining quality in health care has been fraught with difficulties, with many examples of attempts to describe in detail what good quality is in any service. The work of Donabedian (1966) highlights the inherent dangers in this, stating that the criteria of quality are nothing more than value judgements. Basically, quality can be almost anything to anyone, based on their own values, beliefs and goals within both health care and society in general.

Quality as a concept is important in so far as we want to be able to measure it to improve it, and the identification of components of quality are one way in which this has been attempted. One such example is Maxwell’s six dimensions of quality (1984), which are:

Importantly, the information gained from such performance measures is only meaningful if it is used to bring about improvement. It is therefore more useful to consider quality as a cycle of improvement (Fig. 16.2).

Quality is therefore represented as being a continuous process, which is an organisation-wide endeavour. Two such organisational approaches, which have been adopted within the NHS, are total quality management (TQM) and continuous quality improvement (CQI). CQI aims at embedding continuous quality improvement at all levels and across all services with the goal of achieving changes in practice that improve patient outcomes. Within the NHS, TQM and CQI are often used synonymously and interchangeably.

TQM is a business philosophy that was first introduced by Deming and Juran in the USA. It is a method of managing quality issues throughout every aspect of an organisation. Deming (one of the proponents of TQM) advocated a systematic approach to problem solving and promoted the PDCA cycle: Plan, Do, Check and Act. Juran, who is considered the father of quality, established a theory of quality management which evolved during the 1940s, 1950s and 1960s (Parsley & Corrigan 1999) and involves everyone and everything that happens in an organisation. Quality is therefore a continuous process expanding across departments and professional boundaries; it is:

For health care to become more patient focused, and if quality improvements are to be made, then health care professionals need to embrace the wider aspects of care, which include:

A substantial shift in the culture of the NHS was required so that quality improvement became central to the work of the NHS, with an emphasis on collaboration rather than competition. To achieve this cultural shift the government determined that clinical governance would be used as a framework, with the patient–professional partnership at the pinnacle of a temple model supported by seven pillars (Scally & Donaldson 1998) (Fig. 16.3).

Each pillar represents professional and managerial processes integral to quality improvement. Clinical governance acts like an umbrella under which all aspects of quality can be gathered and monitored and the WHO’s description of quality as being composed of four elements forms the basis for the development of clinical governance. These four elements are:

Clinical governance is defined as:

Clinical governance is to be the framework used to bring about a new culture, which places quality as central to the work of all in the NHS. It covers the organisation’s systems and processes for monitoring and improving services. This culture will be manifest in the ten C’s of clinical governance (Heard et al 2001):

Importantly, clinical governance encourages health care professionals to take control and demonstrate their ability to self-regulate and maintain public service accountability. Health care professionals are to take the lead in quality improvement strategies within a structure of increased external accountability. Clinical governance is part of a strategy for quality improvement in the context of a nationally coordinated programme of clinical guideline development with a nominated individual in each organisation responsible for clinical governance. Clinical governance is quality at a local level and focuses on processes of care, which include clinical decision making, appropriateness, clinical effectiveness and evidence- based practice (Pickering and Thompson, 2003 and Swage, 2000). The key features of clinical governance (Scally & Donaldson 1998) are:

Figure 16.4 is a mind map of the key activities associated with clinical governance.

In July 2004 the Department of Health issued ‘Health and Social Care Standards and Planning Framework 2005/06–2007/08’. This document outlined priorities for the NHS as follows: