Chapter 7 Improve Quality and Safety
Quality indicators
Care quality commission (CQC)
In England, all health care providers – both NHS and private – have to be registered with the CQC, which has a number of quality indicators that have to be met, called the Essential Standards of Quality and Safety (CQC 2010). If any part of your organisation does not meet these standards, the CQC has the power to temporarily suspend work or even shut down that department. At the time of writing, the CQC has already shut down 34 care homes and 8 agencies that did not meet the standards. They do, of course, give organisations adequate notice to improve first.
Commissioning for quality and innovation (CQUIN)
One good way of influencing such decisions is to find a way of becoming involved in the commissioning process. For example, some commissioning groups are stating what the staff to patient ratio requirements should be for their patients when admitted to certain units. There are various databases of quality indicators from which the commissioning groups can pick and choose. These include ‘nurse-sensitive outcome indicators’, which were previously known as ‘nursing metrics’ (NHS Information Centre 2011). They can also choose to include the indicators produced by the various initiatives outlined in the following section. At the time of writing, NHS Scotland are currently developing a specific database of clinical quality indicators (CQIs) for nursing.
Nursing quality indicators
There are various other quality initiatives in nursing, which include the following:
Quality, Innovation, Productivity and Prevention (QIPP) – A set of 12 ‘workstreams’ (subjects) such as end-of-life care and long-term conditions, chosen because of the need to improve efficiency and effectiveness.
The above list is just a small sample of the plethora of quality initiatives being implemented across England at the time of writing this book. In 2010, they were all incorporated under one framework called ‘Energise for Excellence’ (E4E) (see Box 7.1). Many are simply ways of trying to save money but without reducing quality. QIPP, for example, was specifically tailored to meet the £20 billion savings required by the government to be made by 2015.
Box 7.1 Energise for Excellence in Care
2. Deliver quality nursing and midwifery care.
3. Measure the impact of nursing and midwifery care.
4. Improved patient experience.
Identify mistakes and risks
Be open and say sorry
Generally, all patients want is an apology, an explanation of what went wrong and reassurance that mistakes will not recur, yet nearly half of all the complaints upheld by the Health Service Ombudsman in 2010 were because an apology was not given. ‘When things do go wrong, an apology can be a powerful remedy; simple to deliver and costing nothing’ (Parliamentary and Health Service Ombudsman 2010).
Saying sorry is not an admission of liability (NHS Litigation Authority (NHSLA) 2009); in fact, there have been various studies from hospitals in Australia, Singapore and the USA that have shown a marked reduction in the number of claims since policies were introduced that promote the concept of saying sorry when things go wrong (NPSA 2009). Do ensure that your team are all aware of this. Most organisations now have guidelines for staff on how to communicate with patients and their families when a mistake has been made, particularly when any harm has been caused. One recommendation for ensuring a good apology is to refer to the three Rs recommended by Armstrong (2010):
Support your staff
don’t take sides during an investigation, either with the patient or the health care professional
do not hesitate to ask for advice if the situation is a particularly difficult one.
Investigate complaints appropriately
Written complaints
1. Check you understand exactly what the complaint is about and what the complainant expects from you. In many organisations, a member of staff in the complaints department will have called the complainant and done this for you already. They will agree a plan with the complainant and forward it on to you. However, if you are not clear from the plan what they mean, call the complaints department to clarify or contact the complainant. Maintaining personal contact in the early stages will help ensure the complainant is confident that something is being done. It is positively encouraged through national policy to keep in contact with the complainant throughout the process.
2. Appoint and support a member of your team to help you investigate (your staff need the experience).
3. Once you have sufficient information, write a response/report or organise a meeting with the complainant and follow up with a letter.
4. Discuss the complaint, and any learning/actions from the investigation process, with your team.
Collate the written information
The complainant’s health records.
Any trust-wide or local policies/procedures relevant to the complaint.
Copies of relevant rosters or on-call rotas to identify who was on duty at the time.
A copy of the original complaint and any other correspondence.
Relevant papers from the medical records may include medical and/or nursing progress sheets, consent forms, test request forms, GP referral letters, etc. Remember that physiotherapists and occupational therapists tend to keep separate case notes stored in their own departments. These may need to be located too. It’s essential that you keep accurate notes of the investigation process in the form of a running log of events and findings. An example of an investigation progress sheet that could be used is outlined in Appendix 7.1.
Maintain confidentiality
The Data Protection Act 1998 requires all processing of data to be ‘fair and lawful’ and all ‘personal data to be protected against unauthorised or unlawful processing and against accidental loss, destruction or damage’. This means that while the investigator has the documents in their possession but is not using them directly, they should be kept in a locked drawer/filing cabinet and the office should be locked at all times when no one is there. The medical records should never be taken home under any circumstances.
As a health care professional, the investigator should follow their own professional code of confidentiality and the Caldicott principles (Box 7.2). You should also ensure they are aware of the appropriate NHS Code of Confidentiality which emphasises that patient information must remain confidential and seen only by those with direct involvement (Department of Health 2003, NHS Scotland 2008, NHS Wales 2005).
