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Changing practice

Implementing quality care indicators and presenting results to engage frontline staff 

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This article describes the implementation of seven quality care indicators – or metrics – and the way data was presented to frontline staff


Suzanne Hinchliffe, CBE, RN, RM, DMS, MBA is chief operating officer/chief nurse at University Hospitals of Leicester NHS Trust and was previously director of nursing and governance/deputy chief executive at St Helens and Knowsley Teaching Hospitals NHS Trust.


Hinchliffe, S. (2009) Implementing quality care indicators and using related data to engage frontline staff. Nursing Times; 105: 25, early online publication.

This article describes the development and implementation of seven nursing care indicators identified in a review of clinical records and assessment processes. The indicators were chosen because they were common to most trusts, had associated national guidance and/or emerged from patient complaints. Indicators were measured and presented to staff using spidergraphs, which provided staff with data in a visual and understandable format.

  • This article has been double-blind peer-reviewed

Keywords:Quality care indicators, Spidergraphs, Metrics


  • Healthcare providers are increasingly required to demonstrate the effectiveness of their performance and to achieve centrally developed targets.
  • Performance indicators and targets that identify ‘good’ and ‘bad’ hospitals have been criticised as simplistic.
  • Targets do not always engage healthcare professionals in a way that motivates them to change clinical practice, and they are often unaware of what is being measured.
  • The introduction of nursing metrics - indicators that measure performance on a range of aspects of care – aims to generate meaningful information to enable and motivate nurses to change their practice to improve patient outcomes.


In an organisation as large as the NHS, the links between clinical practice and patient outcomes are often distant and rarely direct. The use of basic performance indicators and targets that identify so-called ‘good’ and ‘bad’ hospitals has been criticised as being simplistic and unfit to lead to real clinical change and better outcomes. NHS practitioners have not always been engaged by targets and other indicators used to manage and assess performance. In some cases they were unaware of the targets being measured or what indicators contribute to performance ratings, which means they are unlikely to use them to help improve the quality of their services.

In response to these issues a suite of care indicators or metrics were developed. These evidence-based measures of care can be used to benchmark, monitor and improve clinical outcomes and patient experiences. They have been subsequently supported by NHS North West, successfully piloted in a number of organisations and further built upon from both an evidence base as discussed below and by different specialty mix.

Practice points

  • Indicators against which to measure nursing practice can be selected on the basis of national guidance or patient complaints.
  • Indicators should be meaningful to practitioners and measure aspects of care over which nurses have real influence.
  • Data collected on indicators should be presented in a way that enables staff to quickly and easily see how care provided in their ward or unit measures against best practice.
  • Giving nurses ownership of care indicators can motivate them to improve their practice.

The indicators

Following a review of all clinical records and assessment processes, the indicator topics were selected because they were common to most trusts, had associated national guidance and/or emerged from patient complaints. An initial selection of seven care indicators was chosen. These were:

  • Falls assessment;
  • Food and nutrition;
  • Pressure area care;
  • Pain management;
  • Patient observations;
  • Infection prevention and control;
  • Medicine prescribing and administration.

The indicators are discussed in turn below, and the key issues to be considered in relation to each are listed.

Falls assessment

Patient falls are the most common patient safety incident reported to the National Patient Safety Agency (NPSA). In an average 800-bed acute trust there will be around 24 falls every week – over 1,260 a year. Associated healthcare costs are estimated at a minimum of £92,000 per year for the average acute trust (Healy and Scobie, 2007).

Key issues:

  • Patient safety and lifestyle;
  • Reduced length of stay and cost;
  • Falls reduction strategies.

Food and nutrition

Chronic poor nutrition leads to deficiencies in capacity, immune function, wound healing, organ function, mental state and growth. However, the presence of disease can lead to under-nutrition by reducing digestion and absorption, altering metabolism and reducing appetite and therefore food intake. Long-term enteral and parenteral nutrition are life-saving therapies for some patients but many who would benefit from this and other nutritional support are simply not receiving it (Kelly, 2001).

Effective nutritional management requires systematic patient assessment on admission, at scheduled intervals, in response to changes in patient’s condition and before discharge. Poor dietary intake should be regarded as a vital sign and recorded as regularly as other vital signs, such as pulse and blood pressure.

Key issues:

  • Multidisciplinary team approach;
  • Staff are competent to implement any care plans for effective nutritional management;
  • Evaluation and care planning whenever possible.

Pressure area care

The primary cause of pressure ulcers is unrelieved pressure to the skin, while secondary causes include exposure to cold or skin abrasion. Other contributing factors to the development of pressure ulcers include poor nutrition, weight loss and diabetes (Butcher, 2005). These wounds have been estimated to cost the NHS £1.4-2.1bn a year (Bennet et al, 2004) and this cost may be added to by litigation. The wounds are slow to heal and associated with significant morbidity so in terms of human cost, pressure ulcers affect quality of life and can contribute to cause of death.

Key issues:

  • Decreased risk of infection;
  • Decreased pain;
  • Decrease in length of stay.

Pain management

Most inpatients will experience some degree of pain during their stay in hospital. In addition to the obvious discomfort for the patient, poor pain management can result in delayed wound healing, extended hospital stay and chronic pain syndromes (Bonnet and Marret, 2005).

Effective acute pain management requires systematic patient assessment on admission, at scheduled intervals, in response to new pain and before discharge. Pain intensity should be regarded as a vital sign and recorded as regularly as other vital signs, such as pulse and blood pressure.

Key issues:

  • Excellent pain assessment;
  • Enhanced patient satisfaction outcomes;
  • Reduced length of stay.

Patient observations

The primary role of monitoring patient observations is to make clinicians aware of the deteriorating patient. The National Confidential Enquiry into Patient Outcomes and Death has found that the patients who did not survive had often showed signs of deterioration long before they died (Cullinane et al, 2005).

Abnormal physiological values are often charted without action in the hours preceding an in-hospital cardiopulmonary arrest and up to 24 hours before ward patients are admitted to intensive care. The enquiry recommended that hospitals should pay more attention to physiological signs of decline, put in place ‘track and trigger’ systems for all patients and link these to a response team skilled in managing acute clinical problems.

Key issues:

  • Failure to measure basic observations of vital signs;
  • Lack of recognition of the importance of worsening vital signs;
  • Delay in responding to deteriorating vital signs.

Infection prevention and control

Healthcare-associated infections remain high profile in relation to national agendas, local priorities and public focus. Directives on reducing HCAI rates consistently guide healthcare providers towards developing cultures that embed infection prevention and control into all aspects of clinical care.

Key issues:

  • Patient experience, including safety and comfort, and awareness of infection status;
  • Early identification and appropriate management of known or suspected infections;
  • Reducing transmission risk;
  • Surveillance, analysis of potential acquisition and incident reporting;
  • Promoting an organisational culture that recognises the significance of infection prevention and control and responds to the challenges with both a strategic and clinical focus.

Medicine prescribing and administration

Medication errors tend to fall into three categories: prescribing; dispensing; and administering. All healthcare staff need to find ways to reduce the frequency of these errors.

Medication errors are the second largest category of error after slips, trips and falls reported to the NPSA’s National Reporting and Learning System (NRLS). Approximately 5,000 medication safety incidents are reported to the NRLS every month.

Key issues:

  • Patient safety;
  • Incident reporting;
  • Open and fair culture.

Other categories are equally important and, as confidence grew, further indicators were introduced, often based around patient safety guidance – for example, patient identification and control drug management. This resulted in a bank of over 20 indicators that complemented recommendations from national bodies, including the NPSA.

Communicating performance data to the individual

Every month trust boards are presented with trust-wide performance indicators as part of the drive to maintain performance and demonstrate care delivery standards. It is vital that care indicators and the data generated by them are ‘owned’ and understood by staff at all levels, not only to raise awareness but also to help and support them to improve their own areas. The recent National Nursing Research Unit report State of the Art Metrics for Nursing recognises that nurses ‘must have responsibility for actions that lead to outcome in terms of legitimate authority, self-perception and sphere of practice’. It also states: ‘there must be sufficient knowledge to inform remedial action’ (Maben and Griffiths, 2008).

Frontline staff are genuinely interested in clinically governed care, but need governance-related data to be presented in a meaningful and comprehensible way. By holding up a mirror to wards and departments, we enabled them to see what was and was not working well and then to identify the support needed to make improvements.

We believed that presenting data based on the seven indicators as a list of numbers might not be the best way to communicate performance, and the gaps in performance, for individual practitioners to use. We therefore decided to present the data in the form of spidergraphs – a visual reporting tool for the performance of a number of indicators (Fig 1). Also known as ‘radar charts’, these illustrate the gaps between current and desired performance with the aim of demonstrating at a glance how each specialty/ward in the hospital was performing against a range of care indicators. Bar charts were used to illustrate performance against single indicators over time (Fig 2).

The categories are relevant to staff who, until recently, might not have received detailed monthly reports on patient falls, medication errors or nutrition assessment, for example.

We found clinical staff were genuinely interested in patient safety, experience and clinical outcomes. Where they saw how they were performing against the indicators, healthy learning and change began to take place.

In areas that were struggling to perform, the problem was frequently associated with leadership issues – for example, the wrong staff mix, staff anxieties about caring for high-risk and high-dependency patients, capacity pressures or even having the right person but in the wrong job.

Taking time to look at a simple spidergraph enabled us to find causes and solutions.

The process

Each indicator chosen was complemented with:

  • An evidence base;
  • A patient, staff and organisational benefit of using care indicators
  • A range of criterion for measurement;
  • Visual products for reports for individual wards (Figs 1 and 2);
  • Visual products for corporate reporting.

Each indicator is measured on a monthly basis for 50% of patients across each ward area, with immediate feedback on results to ward staff followed up by both a pictorial spidergraph and a historic look back to view progress. Over time, the number of patients being monitored by indicators achieving high compliance may be reduced. The greater the compliance with each criterion of the indicator, the fuller the colour of the spidergraph.


As the support and involvement of staff at all levels grew, so did confidence and this led to an improvement with compliance with the indicators. This enabled further indicators to be developed.

Coupled with a range of additional support measures around specific indicators, for example, supportive falls plans or campaigns relating to reducing hospital acquired infections, positive results emerged which include over 90% compliance to risk assessments, reduction in reported falls of 26%, and compliance with the monitoring and management of infection prevention and control hygiene measures which helped in the achievement of MRSA and C. difficile markers.


We feel our experience in developing, implementing and encouraging the ownership and adoption of these indicators by practitioners has been a highly positive experience in fostering the drive to improve and maintain quality.

In particular, we feel the delivery of data in a purely visual, easily understandable form has been a key part of this success.

The recent publication of more than 200 new indicators – a key outcome from Lord Darzi’s report High Quality Care for All – will make the dissemination of indicator data more vital than ever in our attempts to measure the quality of care and benchmark our work against our peers (DH, 2008).


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