Introduction

All healthcare practitioners are involved with continually examining ways in which care can be improved to enable the continuous delivery of high-quality care. This chapter examines a range of issues which are related to improving quality in care such as clinical effectiveness, audit, clinical governance, evidence-based care and quality indicators and outcomes. The student nurse needs to ensure that the knowledge and skills to deliver quality care need to be attained as an ongoing part of their learning and continued throughout their future practice as a qualified nurse in order to ensure competence in delivering and promoting quality in healthcare.

Figure 11.1 demonstrates the wide range of issues that can contribute to achieving quality in health care. This chapter refers to each of these issues with specific reference to the community nursing role.

Policy drivers

The Department of Health’s publication, ‘High Quality Care for All’ (DH 2008a) emphasised the significance of quality in health care for all practitioners and stated that service provision should centre on three essentials of quality:

In addition, the Healthcare Quality Strategy for NHS Scotland (Scottish Government 2010) focuses on similar ambitions for the quality of healthcare, namely, safe, effective and person-centred care. These strategic documents set the direction for achieving excellence in healthcare quality and drive forward initiatives at all levels of health and social care organisations.

Clinical effectiveness

You will have come across a number of key phrases that are involved in the promotion and sustainability of quality in care, including reference to clinical effectiveness. Clinical interventions are deemed clinically effective when they do what they are intended and achieve the best possible outcomes for people within the resources that are available. Bowers and Cook (2012) refer to the importance of district nurses being able to demonstrate their effectiveness and role within the multidisciplinary team in supporting health outcomes for patients. Clinical effectiveness requires an analytical and questioning approach at all levels of the organisation and a willingness to make changes according to the evidence of what works best. Methods to promote clinical effectiveness include clinical audit and different strategies to develop and utilise skills, knowledge and experience of staff. The continual evaluation of practice is also an essential part of clinical effectiveness and includes gaining feedback from service users, carers and members of the clinical team.

NHS Quality Improvement Scotland (NHS 2005; www.clinicalgovernance.scot.nhs.uk) describes clinical effectiveness as the right person (you) doing:

Assuring quality

The provision and promotion of quality services are an essential part of the healthcare practitioner’s role. As professionals, nurses are personally accountable for their actions and omissions and must adhere to the Nursing and Midwifery Council Code (NMC 2008b).

Some characteristics of professional behaviour are essential to ensure quality, safety and effectiveness of care. These include a commitment to learning and updating of knowledge and skills; willingness to accept responsibility and to stand accountable for one’s own practice; respect; compassion and empathy for clients and colleagues; and being able to act in the best interest of service users and carers. As a student, you are personally accountable for the care you provide and this includes saying ‘No’ to something for which you feel unprepared or inexperienced. Access the Guidance on Professional Conduct for Nursing and Midwifery Students, at: www.nmc.org which outlines your professional responsibilities as a student nurse.

Quality in health care

Quality can mean something different to different people, whether healthcare users or healthcare providers. The Institute of Medicine (2001) identified six dimensions of quality and these have been used widely in the UK to clarify the meaning and establish a shared understanding of quality in healthcare and are relevant to all practitioners. The Healthcare Quality Strategy for NHS Scotland (Scottish Government 2010) refers to the six dimensions, which are shown in Table 11.1.

Person-centred care, involving patients and the views of service users

Person-centred care was referred to in Chapter 5 and was defined as the provision of care that is responsive to individual needs and values. There are a number of programmes which place people at the centre of care and support the development of relationships between them, their carers and healthcare providers. This results in shared decision-making, better experiences of care and greater job satisfaction for staff. The Department of Health (DH 2010a) referred to the importance of patient involvement in decisions about their health care; emphasis has also been placed on the facilitation of this with the provision of information to help patients make informed choices.

An important aspect of quality healthcare provision is the attainment of feedback from people who use the health service. In England, patient reported outcome measures (PROMs) are used to measure a person’s health status or health-related quality of life and provide a way of assessing the effectiveness of care from the patient’s perspective. In Scotland, the Better Together programme is using the public’s experiences of NHS Scotland to improve health services.

The Care Quality Commission (CQC; www.cqc.org.uk) is a new independent regulator of all health and adult social care in England, which emphasises the importance of the patient’s perspective by listing a range of essential standards that clients should expect from health and adult social care services in England. This includes client expectation to:

Registration with the CQC provides assurance that essential levels of safety and quality are being met. An increasing number of healthcare providers are now registered with CQC in reference to healthcare associated infection. This requires that providers ensure clients and workers are protected against identifiable risks of acquiring a healthcare-associated infection. Service users can be reassured that quick action will be taken against those providers that fail to meet the requirements. (In Chapter 1, you will find reference to the organisations that perform this function in the other UK countries.)

During your placement you will be expected to contribute to the development of quality of care delivered to the patients and their families/carers – this will be relevant to all students regardless of which pathway they are pursuing towards registration as a nurse.

The role of the community nurse in promoting quality

The Department of Health publication, ‘The Nursing Roadmap for Quality: a signposting map for nursing’ (DH 2010b) has demonstrated the nurse’s essential role and contribution to promoting and achieving quality. Seven elements to maintaining quality are identified within this publication:

Quality standards

The first stage of the quality process ‘bringing clarity to quality’ is to ensure that practitioners and service users are clear about the standard of care to be achieved. This is facilitated by the utilisation of quality standards. Quality standards have been mentioned within earlier sections in relation to their role in practice placement educational experiences. The National Institute for Health and Clinical Excellence (NICE) has devised quality standards in relation to a range of different aspects of care. Those that are particularly relevant to community nurses include diabetes in adults, end-of-life care in adults, stroke and dementia. Healthcare practitioners can use quality standards to consider the quality of care to be achieved and clients can use the standards to consider the care they should expect.

Evidence-based care

Evidence-based care is an essential aspect of quality care; to deliver care which is based on recent evidence and not on out-dated thinking and which is safe and appropriate for the patient. It is the responsibility of all healthcare practitioners to provide care based on the best available evidence. The practice of evidence-based care requires specific skills which include the ability to:

Clinical guidelines

From your discussion with your mentor regarding the above activity, your mentor will have referred you to The National Clinical Guidelines Centre (NCGC), which is a multidisciplinary health services research team funded by NICE to produce evidence-based clinical practice guidelines which aim to improve the quality of patient care within the NHS in England and Wales. Scottish Intercollegiate Guidelines Network (SIGN) develops evidence-based clinical practice guidelines for the National Health Service (NHS) in Scotland. The clinical guidelines refer to many different aspects of clinical care, including: management of deficit disorder in children and young people; non-pharmaceutical management of depression; falls; pressure ulcers and venous leg ulcers, and are used by the NHS and health and care organisations across the UK. Other organisations also develop evidence-based guidelines for specific clinical conditions often in partnership with others, e.g. the British Thoracic Society (BTS) and SIGN.

Clinical Quality Indicators (CQIs) are evidence-based process indicators that support practitioners to focus on quality, safety and reliability of care (NHS 2008b). The transforming community services (TCS) programme identified 43 indicators for quality improvement of community services in England (DH 2009). The programme supports: the development of services by setting out clear ambitions and the actions to achieve these; the development of people to design, deliver and lead change; the reform of systems to put in place the strong organisations and incentives that are needed to respond to the needs of people in their communities. The indicators cover many aspects of community services that interface with GPs, secondary care and social services and are very relevant to community nurses as part of the community multidisciplinary team. Their use is voluntary and, consequently, they are not used in all localities. (A link to the indicators for quality improvement is provided at the end of the chapter.)

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