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Developing an end-of-life benchmark in acute care

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Measuring standards in end-of-life care to raise awareness of best practice across a trust

In this article…

  • Essence of Care Benchmarking is a national tool designed to improve quality of care
  • Nottingham University Hospitals developed its own end-of-life benchmark
  • This provided a baseline of current practice and increased awareness of standards5 key points



Tracey Warren is practice development matron, Sarah Freer is lead Macmillan nurse, both in the palliative care team; and Melanie Molinari is deputy team leader theatres; all at Nottingham University Hospital.


Warren T et al (2011) Developing an end-of-life benchmark in acute care. Nursing Times; 107: 43, early online publication.
Nottingham University Hospitals used the Essence of Care Benchmarking programme to review and improve end-of-life care.
The trust developed and implemented its own end-of-life benchmark. This provided a baseline of existing practice and led to greater awareness of standards of best practice in all clinical areas.

Keywords: End of life/Benchmarking/Palliative care

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article


5 key points

  1. Essence of Care was relaunched by the Department of Health in 2010
  2. Its process for benchmarking can be used to assess and raise standards of care
  3. Improving end-of-life care in the acute sector is paramount
  4. Employee involvement in benchmarking development is vital
  5. Benchmarking can help raise awareness of best practice


Essence of Care, first published in 2001, was recently relaunched by the Department of Health (DH, 2010). It states that “providing high-quality care and assessing that quality has become increasingly central to the provision of services in the 21st century”.
The Essence of Care benchmarks can help all health professionals take a patient-focused approach to care and provide assurance that it is the best it can be.
During the spring of 2008, Nottingham University Hospital relaunched Essence of Care to encourage staff ownership and involvement in quality improvement processes and raise standards in fundamental aspects of care.
The benchmarking process was reviewed and developed, based on feedback from staff and consultation with patients. The result is a robust and consistent approach with all clinical areas benchmarking at the same time in the same way (Haines and Warren, 2011).
A set of indicators of best practice was developed for each of 12 benchmarks. These indicators reflect the Essence of Care tools (Department of Health, 2010) but have been adapted to suit the needs of an acute trust. The indicators were developed through a systematic process of ongoing consultation with staff, patients, and other key stakeholders. The resulting tool is streamlined, easy to use, and relevant and meaningful to all clinical areas.
The trust has a mandatory rolling programme for scoring in all clinical areas. Clinical teams score each benchmark within a two-month period and achieve an overall score of gold, green, amber or red, depending on how many indicators of best practice are achieved.
Wherever possible, the benchmarks are aligned to other quality initiatives, for example the Eight High Impact Actions for Nursing and midwifery (NHS Institute, 2009) and the Productive Ward initiative (NHS Institute, 2007). All indicators have been linked directly to the Care Quality Commission’s regulatory standards. An Essence of Care steering group oversees the whole process.

Developing an end-of-life care benchmark

The End of Life Strategy (DH, 2008a) and the Quality Markers and Measures for end of life care (DH, 2009) emphasise that improving end-of-life care in the acute setting is paramount, given that half of all deaths occur there. In addition, the High Impact Actions (NHS Institute, 2009) recommend improving discharge processes and the coordination of services across the many providers of health and social care, to allow people to die in their preferred place of care.
In Essence of Care, there is no benchmark that focuses on end-of-life care. Measuring the quality of end-of-life care is recognised as being difficult (DH, 2009; 2008) and the individual communication and holistic needs of patients and carers can be complex. Despite this, if was felt within Nottingham University Hospitals that it was important to establish an end-of-life benchmark to provide a baseline for this aspect of care.

Developing benchmark indicators

The palliative care and nursing development teams at the hospital put together the benchmark indicators working with stakeholders, including the bereavement team and patient partnership group.
The indicators were then reviewed by representatives from all directorates. The resulting benchmark contains 15 indicators of best practice, encompassing issues important to staff and patients (Table 1).


One particular challenge was to develop a benchmark of best practice relevant to all clinical areas. In the initial stages, it became clear that a separate benchmark was needed for children’s areas, which was developed with specialist input from the paediatric practice development nurse and the specialist children’s palliative care nurse.
Also, scoring the end-of-life benchmark in critical care areas showed it did not meet the specialist needs of these areas and a separate benchmark is under development.


The end-of-life benchmark was scored in all adult inpatient areas, except for maternity, theatres, radiology, and short stay and critical care areas; day case areas were also excluded. All 60 eligible wards submitted scores. Areas were scored by at least two staff members and an independent scorer.

Good practice

Nine wards achieved all 15 indicators with an overall gold score; 12 of the 15 indicators of best practice were achieved by at least 80% of the wards. In total, 98% of areas reported that nurses referred to the clinical guidelines found in the “last days of life pathway” and knew how to manage common symptoms in dying patients. Staff in 98% of areas could explain how they helped relatives and carers to remain with the dying patient.

End-of-life care in theatres

Although theatre areas were not formally required to score the benchmark, they did use the tool to review practice and ensure they were following guidelines and policy. The work was led by the dignity champions who had identified the need to raise awareness of care of the dying patient.
To support staff, a teaching package was put together and a practical session was given during a specialty development day. These updated theatre practitioners’ knowledge and practical skills. It also gave them opportunities to ask questions and dispel ritualistic practice and behaviour, as well as to discuss their fears and lack of experience.
It was also discovered that trainee operating department practitioners were not taught this aspect of care and these skills are learnt in practice as and when the opportunity arises.
The processes of delivering end-of-life care and continuing care of the patient after death has now improved with:

  • Only staff who are actually needed are present in the area when providing end-of-life care;
  • Equipment needed for last offices is kept together in an end-of-life box, preventing practitioners having to leave theatre or patients;
  • When providing end-of-life care, staff work in teams of three. Two care for the patient and one liaises with relatives, ward staff and people in other significant departments;
  • Theatre practitioners now have a greater understanding of the whole process and sources of support. For example, they know where to obtain information on the cultural and spiritual needs of patients and relatives;
  • Good working relationships have developed with the bereavement centre;
  • Charity funding and support has been secured to provide facilities for bereaved relatives;
  • A room for relatives has been identified, where they can speak to the doctor and use a telephone in private;
  • Patients who have received palliative surgery and are at the end of their life are “fast tracked” through recovery or relatives are included in their care in the department. Relatives have expressed their gratitude for the respect shown to them and patients;
  • Staff are routinely supported after a death in a debriefing session;
  • Theatre practitioners have been supported to perform the final act of care for their patients with dignity, respect and support. Relatives are provided with correct information and psychological support.

Areas for improvement

As part of the benchmarking process, all areas develop local action plans to address points of concern. Where trust-wide issues are identified, actions are implemented on a trust-wide basis. Three such areas for development were identified.
First, not all areas had access to Liverpool care pathway leaflets to support relatives and carers.
The process has made staff more aware of these leaflets. All wards are required to have a supply and ensure that all staff are familiar with the content, and offer them to relatives and carers as appropriate. The hospital palliative care team continue to promote their use through a rolling programme of educational conferences and the launch of the new version of the Liverpool care pathway during 2011.
Not all staff were aware that, when discharging a patient at the end of life, they should use a specific discharge planner - a relatively new initiative that had been developed with health professionals from primary and acute care. The final version was only finalised in early November 2010 and some wards did not have access to it before scoring took place during that year. Scoring the benchmark helped raise awareness and the palliative care team have continued to roll it out across the trust.
Not all areas had a robust system of recording the number of patients who have died on the last days of life pathway every month. There is a need to document the use of the pathway to meet CQUIN expectations (DH, 2008b) and this data will need to be recorded as part of the next National Care of the Dying Audit starting in April 2012. Before benchmarking, ward areas were prompted to phone the palliative care team when a patient was placed on the pathway but this practice has been inconsistent. To improve record keeping, an electronic form has been created.


The development and scoring of this benchmark has provided a baseline of existing practice. The scoring process raised
awareness of standards of best practice for end-of-life care across the trust.
The palliative care team continues to provide specialist advice and a programme of educational conferences for the multi-professional team.
Continuing development of the benchmark tool will be necessary to raise the number of gold scores in all areas and will need to reflect the expected publication of the NICE end-of-life guidance this year.

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