Copyright MCB University Press Limited 1992WHY QUALITY AUDIT?
In the health care provider environment of the 1990s the quality of patient care available on wards will be one of the determining factors for referrals from GP fundholders, and the issuing of contracts from health authorities. Notwithstanding NHS Management Board directives, because of the nature of their business it is likely that hospitals and health authorities throughout the UK will wish to demonstrate commitment to quality assurance in patient care. Under the new purchaser/provider arrangements within the NHS, units will have to market their services. They will need to state how they guarantee and monitor the quality of service provided. Purchasing DHAs and providing units will have to demonstrate that quality assurance is a built-in process, and part of the management philosophy.
Many managers will argue that the quality of patient care on wards is and always has been a major concern, and that the best possible level of care is provided for inpatients within the resources available. But how is quality of patient care defined? Quality can be a fuzzy goal, with everyone having a slightly different idea of what is meant:
* Ward staff assume that "taking care" and "doing the job properly" will suffice.
* Nurse managers may assume that a competently staffed and managed ward will automatically guarantee quality care.
* Senior managers may set quality objectives across departments or units as an immediate response to get something done.
There is now, of, course a growing movement towards concern for quality with a capital Q, with slogans and posters designed to remind staff of the need for their personal commitment to the issue. Quality assurance working groups, committees, workshops and training sessions make recommendations, inform and motivate people, set an activity or project in motion. These methods all have valuable roles to play, but there must also be a practical means for managers to ensure that quality service is provided to patients on a continuing basis, and to be able to demonstrate the level of service attained. Managers must be able to maintain the impetus for staff at all levels to check and to continue to provide quality service.
To provide quality care, staff must know what is required and be able to recognize when it is deficient or lacking. People must be able to apply what they have learned in workshops or training sessions. The audit package described here helps in the culture change necessary for total quality management. We should aim for a culture where staff think:
* Am I doing it right?
* Am I going about it the right way?
* How could I do it better?
THE QUALITY ASSURANCE WARD AUDIT PACKAGE DEVELOPMENT
Lichfield and Tamworth Hospitals developed a methodology for auditing quality on wards as part of the South East Staffordshire Health Authority quality assurance drive. A working party, headed by a research nurse, was given terms of reference by the unit general manager to provide the unit with a quality assurance system to be used on the wards. Packages available at the time were assessed as to their appropriateness but, as no package met the requirements of the unit, the working party addressed the issue themselves and devised the quality assurance ward audit.
Terms of reference subsequently formed the objectives of the package:
(1) To identify the quality of the ward environment, ward management, patient care and administration of medicines and to highlight any areas of deficiency both from a nursing and a patient point of view.
(2) To provide management with information on the quality of patient care available in the wards.
(3) To ensure that nursing staff in charge of wards see the part which they have to play in maintaining and improving quality standards.
(4) To provide positive feedback to the nursing staff on areas of good practice.
(5) To produce action plans to enable ward and hospital objectives to improve the quality of patient care, and ensure that they are reflected in management objectives via the individual performance review programme.
Tagus, a consultancy specializing in performance improvement products and services, was asked to look at the completed project and to refine the materials for marketing. The self-contained pack provides units with a means of checking the standards of patient care available against observable measures (see Figure 1). (Figure 1 omitted)
The results can be used to maintain and, where necessary, improve standards on individual wards. The Lichfield and Tamworth unit know exactly how all their wards measure up in quality terms, what items have been improved and what actions are in hand to maintain and further improve quality of patient care.
TESTING
In the design and development of the package we took into account the needs of users, for example:
* HOW THE MATERIALS ARE USED DURING THE AUDIT
The practicalities of checking many items in a ward area, what can be observed, what questions need to be asked, in what order the items should be covered.
* THE NEED FOR ASSESSORS TO APPLY THE PACKAGE CONSISTENTLY AND SUCCESSFULLY
A clear explanation of how to conduct the audit, who to involve, what to take, how long to allow, how to use the results.
Lichfield and Tamworth Hospitals have been using the quality assurance ward audit for three years. The package was validated at East Birmingham Hospital (whose help in this we would like to acknowledge) where it was piloted in special areas unavailable in the Lichfield and Tamworth Hospitals. These areas included:
(1) Coronary care unit
(2) Intensive care unit
(3) Paediatric surgery
(4) Paediatric medicine
(5) Isolation unit (infectious diseases)
(6) Emergency medical admission ward
(7) Emergency surgery admission ward.
THE AUDIT PROCESS
The audit should not be seen as a checking device only, to be conducted by and providing information for managers. The process followed in using the audit package means that it does more than produce a record of standards met at one particular point in time.
The assessor, who may be a nurse manager, nursing officer, quality assurance officer or manager (with nursing background) conducts the audit with the sister or nurse in charge of a ward. Nurses in charge of wards should be made aware of all the quality standards against which their wards are being measured. only if they know what is wanted can they try to meet those expectations. The assessor and nurse in charge can refer to the standards required on every item looked at during the audit, as they are part of the document. This enables proper discussion to take place and, if need be, to find ways of meeting the requirements. Both the assessor and the nurse in charge are then working towards the same objectives. There is less likelihood of ward sisters or nurses in charge perceiving the assessor to be an adversary against whom they must try to score points, without being too sure of the rules of the game.
During and after the audit, an important part of the assessor's role is to give feedback to ward staff on areas of good practice and improvements which have already been made. Receiving positive feedback and encouragement motivates staff and maintains their willingness to keep quality issues to the fore in their work. The assessor, in conjunction with the ward sister or nurse in charge, also records a list of items requiring improvement in a realistic priority order.
A summary of customer opinion forms part of the audit results presented to unit managers and is also fed back to staff in charge of wards. To obtain this the ward audit package also includes a simple questionnaire for patients to complete. We took into account the population being targeted with the questionnaire and the need to overcome difficulties which patients may have in writing, reading, holding, concentrating, understanding, formulating answers or thinking. Patients are assured that ward staff will not see their replies (they can return questionnaires, which in any case do not have their name on, in sealed envelopes). Guidelines are included on how to administer and interpret patient questionnaires.
Immediately following the audit the assessor or quality assurance manager draws up action plans to address items requiring improvement. These are fed back to those responsible through individual performance reviews, so that ward staff and others have clearly defined objectives to meet and managers will have the information to check on progress and ensure that planned actions are taken.
The results of the audit can now be analysed on a microcomputer package called Key Quest. This gives the facility to obtain comprehensive reports from a menu, including year-by-year comparisons of data. It has an integrated text and graphics capability and can also be used with other questionnaires to enhance the management enquiry facility necessary with any audit system.
RESULTS
Some of the positive results being achieved from using the quality assurance ward audit are:
* Any problems identified across several wards can be addressed as unit issues. For example, laundry and pharmacy were issues highlighted and resolved locally, but involving district officers.
* Projects for block or minor capital expenditure are agreed in priority order and staff are informed. This awareness encourages the team approach to quality and, although many wards may not have cost improvements in any one year, the staff will be fully aware of which wards have priority in that particular year. Then, as improvements are being achieved, they are supportive to the scheme rather than antagonistic.
* Each year sisters and staff are motivated to achieve many no-cost improvements and, with the support of senior staff, can also achieve some low-cost improvements.
* Senior managers can demonstrate that the use of unit resources effectively raises the overall quality score. For example, funds spent on study days for managers have been demonstrated to improve the ward management result. Unit issues which are resolved will effectively raise the quality scores over several wards, as in the instances of laundry and pharmacy.
The package is now being used in many hospitals and health authorities throughout the country. The unit is also running half-day seminars on quality assurance audit. Further audit packages are being developed for outpatients and accident and emergency departments.
FURTHER READING
Telford, W.A., Cropper, S. and Ackermann, F., "Managing Quality", Lecture Notes in Medical Informatics, 40. Proceedings of Medical Informatics Europe, 1990.
Julie Spicer is NHS Account Manager at Tagus PIPS Ltd, Loughborough, UK; Sandra Walker is Senior Nurse Manager at Lichfield and Tamworth Hospitals; and Bert Telford is Director of Operations at Burton, Lichfield and Tamworth Hospitals, UK.
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