The RCN has also identified three main topic areas within QI that help nurses improve the quality of care for patients: these are patient safety, clinical effectiveness and clinical audit.

Patient Safety

Patient safety refers to the concept that patients in healthcare settings are achieving intended outcomes. Ensuring patient safety involves the establishment of systems and processes that reduce the likelihood of errors and increase the likelihood of intercepting them before any harm occurs (Royal College of Nursing 2013).

There are two comprehensive resources available that can provide renal nurses with practical help in addressing patient safety issues. One is the Institute for Health Improvement (USA) and the other the NHS Institute for Innovation and Improvement. The NHS Institute closed in March 2013 but publicly available content is still available on The National Archives website: http://webarchive.nationalarchives.gov.uk/*/http://institute.nhs.uk (accessed 23 May 2013). The IHI has a wide range of freely available resources and downloads (upon registration) to help nurses in every-day practice (http://www.ihi.org/, accessed 23 May 2013). 

One example (Luther and Resar 2013) describes a methodology that helps frontline staff to ‘see’ patient safety problems in their systems and enables them to solve the problems and share that learning with others. The methodology is constructed around an informal unit visit and designed to be a ‘conversation’ about safety issues, versus an inspection or evaluation. This approach seeks to identify problems as they occur and solve them as soon as they are seen. A renal nursing manager could implement this type of ‘conversation’ with staff on a monthly basis. A detailed example is shown in Table 14.1

Table 14.1 The patient safety conversation.

Kidney Care Atlas of Variation

As patient safety on a wider level refers to how far patients in health care settings are achieving intended outcomes, it is important to be knowledgeable about the ‘benchmark’ at which to aim. For many years the UK Renal Registry (www.renalreg.com, accessed 20 May 2013) has provided a source of comparative data for audit/benchmarking, planning, clinical governance and research. More recently the Renal Registry launched the world’s first interactive maps showing details of achievement of quality measures in the care of patients in kidney units, called the Atlas of Variation. The NHS Atlas of Variation is intended to support local decision making to increase the value which a population receives from the resources spent on their healthcare. It supports the search for unexplained variations, the identification and attention to unwarranted variation, helping clinicians to understand what is going on in their area and where to focus attention to improve the care they provide. The first NHS Atlas of Variation was published in November 2010 and in 2012 an Atlas for Kidney Care was published (www.rightcare.nhs.uk/index.php/atlas/kidneycare, accessed 20 May 2013). It includes 18 maps of indicators relating to chronic kidney disease, renal replacement therapy, acute kidney injury and patient experience.

Key findings from the 2012 Atlas included:

• A 2.3-fold variation among primary care trusts in the ratio of reported to expected prevalence of chronic kidney disease.
  
• The proportion of patients receiving dialysis (haemodialysis and peritoneal dialysis) at home ranged from 0.0% to 30.4% across renal centres in England. In eight of the 52 centres, more than 25% of patients were on home dialysis; in seven centres, less than 10% of patients were on home dialysis.
  
• An 11-fold variation in pre-emptive transplantation in England.
  
• A 2.8-fold variation in the rate of admissions for acute kidney injury per all emergency admissions in England.

Nursing leaders can therefore use these maps to review their nursing service (number of people on home dialysis for example) by benchmarking against other units, prior to putting patient safety mechanisms into place.

Clinical effectiveness: implementing clinical practice guidelines

Over the past 20 years, the renal specialty has seen the emergence of a number of national and international standards for renal care. When the government’s way of setting clear national standards was announced in 1998, the main strategy for this was through National Service Frameworks (NSF) and through a National Institute for Clinical Excellence (NICE). In early 2004 and early 2005 the National Service Frameworks for Renal Services were published. This was the first NSF to be published in two parts and although the original publications were disseminated almost one decade ago, their publication has had a tremendous impact on how renal services have developed.

National service frameworks

As outlined in the Department of Health (1997) paper, The New NHS, the government will work with the professions and representatives of users and carers to establish clearer, evidence-based NSFs for major care areas and disease groups. That way, patients will receive greater consistency in the availability and quality of services, right across the National Health Service (NHS). The government uses them as a way of being clearer with patients about what they can expect from the NHS.

In summary the NSFs have:

• set national standards and defined service models;
  
• put in place programmes to support implementation;
  
• established performance measures against which progress within an agreed timescale will be measured.

Part One of the NSF for Renal Services (Department of Health 2004) set five standards and identified 30 markers of good practice that will help the NHS and its partners manage demand, increase fairness of access and improve choice and quality in dialysis and kidney transplant services. Part Two of the NSF for Renal Services (Department of Health 2005) sets four quality requirements and identified 23 markers of good practice to help the NHS limit the development and progression of chronic kidney disease; minimise the impact of acute kidney injury, and extend palliative care to people dying with kidney failure. Each of these documents is discussed in further detail in relevant chapters of this book.

In September 2005 a summary of progress to date towards achieving the standards and early actions set out in the Renal NSF, together with a review of the modernisation programme supporting delivery of the NSF, was published by the Department of Health (2005). In 2007 a second progress report was published and in 2009 another report (Department of Health 2009) highlighted the successes from the previous five years.

In June 2006 the National Service Framework for Renal Services: Working for Children and Young People was published. This document related specifically to the care of children and young people, in greater detail. It also brought together the recommendations from the NSF for Children, Young People and Maternity Services, to make an accessible, user-friendly document for all those with an interest in services for children and young people with kidney disease.

Many related projects and documents have been published following publication of the NSF for Renal Services, and many of these documents, such as practical advice for patients, can be found on the publication pages of the Department of Health website www.dh.gov.uk/health/category/publications/ (accessed 20 May 2013). More recently, a variety of projects and documents have been produced by NHS Kidney Care, who work with healthcare professionals and commissioners to improve every aspect of kidney care for patients. These resources can be found at http://www.dakc.nhs.uk/# (accessed 23 May 2013).

In renal nursing practice we are fortunate to have a variety of clinical standards and guidelines to help us achieve clinically effective practice. In other words, many of the clinical guidelines that are available have been based on research evidence or expert opinion, so we do not have to examine all aspects of our care as it has already been done for us. There now follows a review of the most important clinical standards and guideline documents available for renal nurses.

National Institute for Health and Care Excellence (NICE)

The National Institute for Health and Care Excellence produces and disseminates clinical guidelines based on relevant evidence, associated clinical audit methods and information on good practice. The Institute identifies new and existing health interventions, collects evidence, considers the implications for clinical practice, disseminates the findings, implements at a local level and monitors the impact. The guidelines produced by NICE that are specifically relevant to renal practice are to be found in Table 14.2.

Table 14.2 Renal-specific NICE guidance.

For further details, see the NICE website: http://www.nice.org.uk/guidance/index.jsp?action=byType&type=2&status=3 (accessed 23 May 2013).

NICE quality standards are a concise set of statements designed to drive and measure priority quality improvements within a particular area of care. The standards are derived from the best available evidence and are developed independently by NICE, in collaboration with NHS and social care professionals, their partners and service users.

The NICE quality standards are central in supporting the government’s vision for an NHS and Social Care system focused on delivering the best possible outcomes for people who use services, as detailed in the Health and Social Care Act 2012. A quality standard for Chronic Kidney Disease was published in 2011 and covers the identification, assessment and clinical management of CKD in adults. The NICE quality standards for CKD are shown in Box 14.1.

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