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Benchmarking: how do you do it?

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VOL: 97, ISSUE: 42, PAGE NO: 30

Jacqueline Martin, BA, DipHE, RGN, DN, is transfer of care coordinator, Burnley Health Care NHS Trust, and chair of north-west district nurse liaison/transfer of care coordinators benchmarking group

Improved quality and effectiveness in the NHS is a key aim of clinical governance (Department of Health, 1998), and the most efficient way to achieve it is by sharing good practice. Discharge planning, which needs to be patient-centred, safe and seamless, depends on sharing good practice.

Improved quality and effectiveness in the NHS is a key aim of clinical governance (Department of Health, 1998), and the most efficient way to achieve it is by sharing good practice. Discharge planning, which needs to be patient-centred, safe and seamless, depends on sharing good practice.

This article describes how a team of liaison nurses at Burnley Health Care NHS Trust created a network with their counterparts in other trusts so that information could be exchanged, leading to an improved service. The nurses hoped that the network would also provide professional support.

Benchmarking seemed to be the best approach as it covers practice, process and performance (NHS Executive, 1995). Making a Difference (Department of Health, 1999) supported benchmarking, stating that 'it is a process through which best practice is identified and continuous improvement pursued through comparison and sharing'. Its advantages, as identified by Gondringer (1997) (Box 1), motivated the team further.

Setting up a network
Other district nurse liaison staff in the region were also keen to network so we arranged a bi-monthly evening meeting. The first meeting covered the ground rules, explained the principles of benchmarking and offered an introduction to each member's role and challenges. We gelled well in the first session, which can be attributed to the identification of common themes: feelings of isolation, time pressures, shared frustrations and feelings of responsibility for some problems.

The first year's forums facilitated informal benchmarking and discussion around the planning of care between primary and secondary settings. This included identifying relevant evidence from various levels of the 'classification of evidence' hierarchy (Box 2).

Members shared their experiences of discharge planning, including successes, challenges and unsuccessful attempts at change. In the absence of higher levels of evidence, benchmarking allowed us, as experienced practitioners, to credit our consensus of opinion on good practice. This principle is supported by Ellis (2000), who states that 'the identification of benchmarks of best practice should preferably be based upon, but not limited by, the availability of a scientific evidence base'. Plsek (1997) also argues that benchmarking does not require research results as such rigour is not routinely demanded in the industrial world, where the concepts of benchmarking and best practice were developed.

Bearing in mind that benchmarking should focus on a specific process and not attempt global comparisons (Bromley and Hove, 1997), we addressed topics individually. To replicate others' best practice, it was essential to compare like with like, understand why ideas had or had not worked in other trusts and compare differences between trusts. It is argued that to achieve credibility of comparisons, understanding and well-defined definitions are key components of superior benchmarking (Gondringer, 1997).

Action learning
At the end of the first year, some changes were made to the group at grassroots level. In the second year we adopted an action-learning approach alongside the informal benchmarking process. In a non-threatening environment, the group focused on the owners of the 'problem' and discussed how they perceived it, with the aim of agreeing on an action plan with time goals. During group sessions members provided feedback on progress, discussed any blocks met and, if necessary, formulated a further action plan. The success that year proved how trusting and safe group members felt. We could challenge each other's attitudes and practices without damaging the group dynamics.

At the beginning of the third year it became clear that we needed to formalise the benchmarking process. The group wanted to move forward using benchmarking as a tool to identify successes along with the need for change. Sometimes managers want to hear only good news, but this needs to change so that staff do not feel threatened and are encouraged to identify problems for improvement (NHS Executive, 1995).

We all need to be aware of the argument that 'when the health agenda is not driven by quality but cost, benchmarking loses its real meaning as a quality tool and becomes another method of cutting resources' (Bromley and Hove, 1997).

The benchmarks
The model we adopted is based on the north-west paediatric practice benchmarking project and, in our specialty, runs alongside the Department of Health's eight 'fundamental and essential aspects of care', as outlined by Coombes (2001). To select our initial benchmarks we identified some key areas of practice, along with desired patient-focused outcomes. The next step was to identify structures and processes that would allow the outcomes to be achieved.

We compiled continuum statements for all the key factors. These start with a description of best practice identified from the evidence, end with 'worst' practice and identify all the stages in between. Benchmarks require the identification of best practice from the highest level of evidence available. They must apply clear definitions and be referenced as appropriate.

The continuum statements feature a scoring range, which enables trusts to determine their scores and add comments on actual practice. Network members can use the comparative scores and discussion on practice to share development and innovations and formulate action plans for change. Comments are used to consider the parity of scoring and objectivity of the benchmark continuum statements, but most importantly they support the actual sharing and compilation of action plans (Ellis, 2000).

The future
The group has written four benchmarks so far, and is continuing the process. We now understand that, while formulating continuum statements is more difficult than it looks, it is not necessarily the content of the continuum or scores that are crucial but the consequent discussions and changes in practice.

Our initiative was never intended as a competition between trusts. Without willingness to share practice, benchmarking cannot begin. Gondringer (1997) suggests that it is a step-by-step process that will take many steps, patience and perseverance. However, it can enable us to meet the changing demands of health care, confident that we can provide cost-effective, highly efficient, quality patient care.

We intend to bring specialists into the group for expert opinion on some areas of practice and are considering how we may involve service users when appropriate in future work. Only by working in close collaboration, using this multidisciplinary approach, can we ensure the benchmarks are robust enough to meet users' needs (Bland, 2000).

To further validate our work, we hope to share it with other practitioners in our specialty - an external review panel - to ensure best practice has been identified, as suggested by Greenidge (1998).

In time we hope to include more trusts, ensuring that evidence on best practice is taken from as wide a perspective and range of experience as possible, and consequently increasing its validity. Equity of quality care is a standard all nurses have a responsibility to aspire to. By benchmarking between trusts we will move nearer to achieving this.

Conclusion
This article provides an overview of the processes involved in setting up our group, and we hope that our experiences may inspire others. We are meeting our aim and feel the group is an example of good practice. We are confident that the group's progress and practice developments will continue as long as we accept O'Dell's (1994) definition of benchmarking - it is a question of being humble enough to admit that someone else is better at something, and wise enough to learn how to match and even surpass them.

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