Effectiveness of care provision must be demonstrated in the new NHS. Practice must be aligned to priorities for quality and true measurements of care recorded
Richard Shorney, BAC, MSc, is director, Real Healthcare Solutions, Cheshire.
Shorney R (2010) Measuring quality of wound care and tissue viability services. Nursing Times; 106: 35, early online publication.
Patient safety, effectiveness and patient experience have been identified as quality domains in the NHS white paper (Department of Health, 2010a). Tissue viability and associated services have an opportunity to use these to raise awareness of the care they provide. In addition, by using metrics, these services will be able to quantify the effectiveness of care provision and use this to argue for future resources and funding. This article explores the national quality agenda in light of the white paper (DH, 2010a) and the metrics relating to quality in wound care.
Keywords Quality, Pressure ulcers, Tissue viability
- This article has been double-blind peer reviewed
- Nurses should focus on the following to demonstrate the quality of their services:
- Understand the “new” NHS language;
- Be proactive in quantifying the quality of services provided;
- Convert data into meaningful information and publish quality results.
The future for the NHS
The NHS vision for the next five years is to achieve “equity and excellence” in healthcare (DH, 2010a), as the white paper focuses on patients’ experiences of care and of services provided. True and accurate measurements of quality care are essential if this objective is to be achieved.
The white paper aims to put patients at the heart of the NHS by offering greater choice and control of services. The key is shared decision making, summed up by the phrase “no decision about me without me” (DH, 2010a). Under the plans, the government is set to enable patients to rate hospitals and clinical departments according to the quality of care they receive. In addition there will be a focus on personalised care that reflects individuals’ health and care needs, supports carers and encourages strong local partnerships. Patients will be in charge of making decisions about their care and will be able to choose which consultant-led team, GP and treatment they have (DH, 2010a). Empowering patients to become involved in choosing their treatment through integrated care can help them achieve greater control (Wilson, 2010).
A new consumer body, HealthWatch England, will be introduced to support this patient led approach to care and will be part of the Care Quality Commission. This body will strengthen the collective voice of patients through initiatives led by local authorities and at national level. Local involvement networks (LINks) will become the local HealthWatch, creating a strong local infrastructure to enhance the role of local authorities in promoting choice and providing complaints advocacy.
It is interesting to note the timelines on the introduction of this “new consumer champion”. HealthWatch England will be established and fully operational by April 2012. This time delay gives clinicians an opportunity to be proactive and collect, collate and publish findings on patients’ experiences of the service they provide.
The annual budget for the NHS has more than doubled over the last decade to over £102bn and £1 of every £13 produced by the UK economy is spent on healthcare (DH, 2010a). The white paper says the NHS needs to concentrate on improving productivity and eliminating waste while focusing on quality. Cost efficiency savings of £15-£20bn need to be made by the end of the financial year 2013-14 and these will be reinvested in the service to deliver year on year quality improvements (DH, 2010a).
In order to move decision making as close to individual patients as possible, the DH will devolve power and responsibility for commissioning services to local consortia of GP practices. This change will build on the pivotal role that primary care professionals already have in coordinating patient care. The GP consortia will look after an £80bn budget and by 2012 take over responsibilities from PCTs, including leadership of the existing Quality, Innovation, Productivity and Prevention (QIPP) initiative (DH, 2010b). This initiative will continue with even greater urgency, but with a stronger focus on general practice leadership. QIPP is identifying how efficiencies can be driven and services redesigned to achieve the twin aims of improved quality and efficiency (Ousey and Shorney, 2009). Work has started on implementing what is needed to improve both quality and efficiencies at the same time, for example, by improving care for stroke patients, the Productive Ward programme, increased self-care and the use of new technologies for people with long term conditions. In wound care, the high impact action (HIA) for nursing and midwifery entitled Your Skin Matters has ensured improved pressure ulcer management and reduced burdens on acute care (NHS Institute for Innovation and Improvement, 2009a; 2009b).
Strategic health authorities and primary care trusts currently support QIPP and need to devolve leadership to emerging GP consortia and local authorities as quickly as possible, wherever they are willing and able to take this on.
As part of the incentives for quality improvement, quality measures in national clinical audits and payment arrangements will be linked. The DH will extend the scope and value of the Commissioning for Quality and Innovation (CQUIN) payment framework, to support local quality improvement goals. Payment will depend on quality of care and outcomes, not just volume. Penalties for poor quality will encourage providers to get care right the first time.
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.
All those working for or on behalf of the NHS are required to quantify the quality of the service they provide, as part of the DH quality agenda. The quality accounts, or reports, will be expanded to all providers of NHS care by April 2011; currently, only those working in acute care have been tasked to complete these reports. In addition, nationally comparable information on the quality accounts will need to be published by June of that year.
The domains of quality outlined in the white paper (DH 2010a) are described in Box 1.
Box 1. Domains of quality
Safety: examples include: levels of healthcare-associated infections; adverse events; and avoidable deaths.
Effectiveness: examples include: mortality rates (this could include mortality from heart disease, and one year and five year cancer survival); emergency re-admission rates; and patient reported outcome measures.
Experience: examples include: information on average and maximum waiting times; opening hours and clinic times; cancelled operations; and diverse measures of patient experience, based on feedback from patients, families and carers.
Source: DH (2010a)
While it may be assumed that all healthcare professionals aim to provide care that meets these domains of quality, the challenge is to identify the metrics and provide actual figures to prove this is the case. These ideals are reflected in From Good to Great (DH, 2009a), published before the election, and are the cornerstone of the patient centred approach to healthcare. The NHS next stage review (DH, 2008) placed a strong emphasis on the need to put quality of care at the heart of NHS services.
It could be argued that quality, in the context of the NHS, should be a constant in the mindset of healthcare professionals and patients (Fox, 2010). The latest DH policy documents demonstrate that quality is taking a leading role in determining what is deemed to be acceptable and non-acceptable practice.
Despite the fact that much of what has been published recently addresses and focuses on quality from a strategic perspective, it is important to put these theoretical models into practice and make them fit for purpose. What does this mean for nurses in real terms? How are these theoretical, national ambitions and ideals from the DH transferred into everyday practice and, importantly, who is accountable for delivering on the metrics of quality care? The white paper (DH, 2010a) goes some way to address this, but areas of best practice and actual case studies need to demonstrate how quality can and should be measured.
In the domain of patient experience, many areas of the country already collect valuable information in the form of patient experience data, real time feedback data, patient experience surveys and patient reported outcome measures (PROMs). The DH plans to expand the use of these tools and assess the validity and reliability of those currently used (DH, 2010a).
It is essential that all healthcare professionals involved with direct patient contact maintain their skills and ensure that the care they give is not only evidence based but also concentrates on improving patients’ experience of care provided (Ousey, 2010). While there are some concerns about ethical issues involved in measuring patient experience, what needs to be taken into account is the subjective nature of patient satisfaction and the manner in which it is collected.
Quality in tissue viability
Tissue viability is currently a nurse-led speciality with a relatively low profile – both publicly and within the healthcare system. The problem lies with the indistinct perception of what tissue viability entails, and the variable cost to the NHS of typical disorders such as pressure ulcer prevention and treatment, leg ulceration, aspects of skin care and protecting at risk skin (Ousey and White, 2009).
While there is currently no consensus on what constitutes tissue viability, areas of care covered include: managing acute and chronic wounds; pressure ulcer prevention and management; infection control in wound care; and protecting skin at risk from trauma (White, 2008).
Wound care is estimated to cost the NHS anywhere between £2.3bn-£3.1bn per year (based on 2005–06 costs) (Posnett and Franks, 2007). Wound care specialists need to assess and understand the key determinants of care costs (listed in Box 2).
Box 2. Variables in wound care costs
- Hospital admission rates
- Number of procedures
- Mean length of stay
- Time to heal
- Frequency of dressing change
- Cost of all dressing materials per dressing change.
Source: White (2009)
The Framework for Quality Accounts (DH, 2009b) suggested that healthcare professionals should implement tools that continually monitor quality and outcome measures. So what are the metrics of quality for wound care and tissue viability services?
Auditing and comparing data collated over a period of time can be useful to demonstrate how service provision can improve patient outcomes (Vowden and Vowden, 2010). In addition there are a number of nurse related quality indicators, such as those covering pressure ulcers (Dowsett, 2010).
The DH (2009a) outlined an ambition to eliminate all avoidable pressure ulcers in NHS provided care and to significantly reduce the amount an average district general hospital spends on treating them, currently estimated at £600,000-£3m each year. This report (DH 2009a) hinted that a penalty and incentive system would be included to cover the number of grade 3 and 4 pressure ulcers that a hospital has at any one time. This adds a number of challenges not only for the care provided, but also for the correct assessment and diagnosis of the grade of pressure ulcers.
The launch of the high impact actions (HIAs) for nursing and midwifery in 2009 is an example of how awareness of tissue viability services has been raised (NHS Institute for Innovation and Improvement, 2009a). The project initially sought examples of best practice from the nursing and midwifery community that could demonstrate a response to the quality and productivity challenge. In particular the Your Skin Matters HIA has highlighted how nurses have embraced this challenge (NHS Institute for Innovation and Improvement, 2009b).
The tissue viability team at NHS Newham has been highlighted in this particular HIA. They looked at the prevention and correct management of pressure ulcers and identified how to reduce the number of people with pressure damage admitted from nursing homes to hospital. Box 3 features a summary of this initiative.
Box 3. Pressure ulcer prevention at NHS Newham
The tissue viability service at NHS Newham appointed a nurse to tackle the increasing incidence of pressure ulcers in nursing home patients, many of which resulted in hospital admission. This included increased frequency of visits for patient reviews and an educational programme for all nursing home staff.
Data from acute providers showed a decrease in the number of patients admitted from the community with pressure ulcers by 50% for the period April-August 2008/09. Results show that in 2008 there were 25-45 admissions compared with 0-12 patients admitted in 2009. Based on admission costs of £199 per night with an average stay of nine nights, the cost saving is £59,100 based on the highest number of admissions.
Source: NHS Institute for Innovation and Improvement (2009b)
The challenge for healthcare professionals is to ensure that daily practice is aligned to the quality agenda and true measurements of this care are recorded. The extent of this challenge cannot be underestimated, especially as it may require a change of mindset. In addition, the metrics that need to be measured have to be completed alongside the challenges of a busy work schedule and within current financial constraints.
Measurements of quality in wound care should be aligned to the national ideals of quality that focus on patient safety, effectiveness and patient experience. National tools used to collect and collate this information need to be identified to ensure that the quality of service can be assessed nationally.
Department of Health (2010a) Equity and Excellence. Liberating the NHS. London: DH.
Department of Health (2009a) NHS 2010–2015: From Good to Great. Preventative, Peopled-centred, Productive. London: DH.
Department of Health (2009b) The Framework for Quality Accounts: A Consultation on the Proposals. London: DH.
Department of Health (2008) High Quality Care for All:NHS Next Stage Review Final Report. London: DH.
Dowsett C (2010) High impact actions (HIAs) and tissue viability. Wounds UK; 6: 1, 14.
Fox J (2010) Quality: a changing world. British Journal of Nursing; 19: 8, 475.
NHS Institute for Innovation and Improvement (2009a) High Impact Actions for Nursing and Midwifery. Coventry: NHS III.
NHS institute for Innovation and Improvement (2009b) High Impact Action: Your Skin Matters. Coventry: NHSIII.
Ousey K (2010) The role of education in developing tissue viability to meet the quality agenda. Wounds UK; 6: 2, 94-98.
Ousey K, Shorney RH (2009) What are the quality indicators in wound care? Wounds UK; 5: 2, 53–5.
Ousey K, White RJ (2009) Quality accounts, quality indicators, QIPP and tissue viability: time to act. WoundsUK; 5: 4, 10–12.
Posnett J, Franks PJ (2007) The Costs of Skin Breakdown and Ulceration in the UK. The Silent Epidemic. Hull: The Smith & Nephew Foundation.
Vowden K, Vowden P (2010) The role of audit in demonstrating quality in tissue viability services. Wounds UK; 6: 1, 100-105.
White RJ (2008) Tissue viability in tomorrow’s NHS. Journal of Wound Care; 17: 3, 97–100.
Wilson J (2010) Breaking down barriers to patient engagement. British Journal of Nursing; 19: 8, 473.