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How benchmarking can improve patient nutrition

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VOL: 98, ISSUE: 44, PAGE NO: 30

Jane Ellis, MSc, RGN, is clinical effectiveness coordinator, Homerton Hospital NHS Trust, London

Translating theory or a theoretical framework into practice can be a daunting task and it can be difficult to know how to get started. This article describes how The Essence of Care: Patient-focused Benchmarking for Health Care Practitioners (Department of Health, 2001a) was used in practice and, more importantly, how it made a difference to patients' experiences of the health care they received.

Translating theory or a theoretical framework into practice can be a daunting task and it can be difficult to know how to get started. This article describes how The Essence of Care: Patient-focused Benchmarking for Health Care Practitioners (Department of Health, 2001a) was used in practice and, more importantly, how it made a difference to patients' experiences of the health care they received.

What is benchmarking?
Benchmarking is a process in which practitioners compare and measure their own practices, processes, philosophies, policies and performance against those of high-performing, high-quality areas (DeLise and Leasure, 2001). It has been used in industry for many years and, although it can be described or implemented in slightly different formats, essentially always involves:

- Establishing what makes a difference in the customer's eyes;

- Setting standards according to best practice;

- Finding out how the best companies meet these challenging standards;

- Applying the experience of others and your own ideas to meet new standards - and exceeding them if possible (Department of Trade and Industry, 1993).

Although benchmarking has been carried out by teams in the NHS in the past, it came to the forefront as a quality-improvement tool after the launch of the national strategy for nursing and midwifery (Department of Health, 1999). This drew attention to failing standards in what was referred to as 'fundamental and essential aspects of care' and cited benchmarking as a proven tool that could support nurses in raising the quality of care. The strategy described benchmarking as 'a process through which best practice is identified and continuous improvement pursued through comparison and sharing'.

Benchmarking toolkit
After the launch of the nursing strategy, the work of getting nurses and other members of the multidisciplinary team to share and compare best practice began. The Essence of Care (Department of Health, 2001a) was launched to provide a toolkit that would enable them to do this. It focuses on eight areas that are crucial to the quality of care in patients' experience. They are:

- Nutrition;

- Continence;

- Tissue viability;

- Documentation;

- Privacy and dignity;

- Hygiene;

- Self-care;

- Safety.

Each element has been broken down into the components of practice (or factors) that support patient-focused outcomes. A scoring continuum is provided for each factor so that practitioners can score their own practice, from E as worst practice to A as best practice. These standards were developed and agreed by more than 2,000 patients, consumers and professionals during a number of months (Department of Health, 2001a). Box 1 gives an example of a nutrition assessment.

The toolkit provides a seven-staged cycle (Fig 1) which outlines the phases to be undertaken during benchmarking. These phases are easy to follow and help teams to progress with benchmarking to improve patients' experiences.

Translating benchmarking into practice
The seven phases of the cycle described in this article outline the experiences of nurses at the Homerton University Hospital as they worked through the seven phases of the benchmarking cycle outlined in The Essence of Care (Department of Health, 2001a).

Phase one:
After two sessions to raise awareness, a group of ward nurses (self-selected and of all grades) assembled to agree on how to progress with the project. It was decided that the trust-wide project would focus on two elements in the first year, accepting (and hoping) that other staff/groups would consider others. For example, the working group set up to look at the National Service Framework for Older People (Department of Health, 2001b) might want to start using the continence element of the toolkit.

As there appeared to be a common national interest in, and a large number of trusts in the region working on, the nutrition section, the group decided that this would be one of the two elements it focused on.

The second area was selected by ballot, with each nurse present having a first and second choice. Privacy and dignity received the most votes. Representatives from each ward or department were then asked to choose either privacy and dignity or nutrition as their initial project. Two facilitators were chosen to lead and support the groups. This article focuses on the work of the nutrition group.

Phase two
The first meeting of the nutrition comparison group was held and appropriate membership was agreed. The facilitator invited a range of relevant professionals to attend the next meeting. These included the catering manager, a dietitian, and a speech and language therapist. The purpose and vision of the group was agreed and basic ground rules were set.

Phase three
The group decided to skip phase three (agreeing best practice) because members decided that it was more important to begin by finding those pockets of good practice that often go unrecognised in an organisation. The group believed that the real value of the exercise would come from being able to take the time to examine an area of practice and to discuss this with colleagues - to 'share and compare'.

Phase four and five
Wards and department staff reviewed their practice against each component of practice (or factor), giving themselves a score between A-E (for example, see Box 1). They also stated how this score had been selected, identifying areas of good practice and areas in which they had problems. Each area did this in a way that suited the particular setting. For example, in some areas only the sisters were involved, but in others the factors and level of practice were discussed at team meetings. Although the ultimate goal was to involve all team members in the exercise, the group realised that this would take too much time so the main goal during the first cycle was to engage staff in whatever way worked for them.

Three or four factors, depending on time, were discussed at each meeting of the nutrition comparison group. Other members of the group, such as the speech and language therapist or the dietitian, were asked for their observations and impressions of practice related to each factor.

The group also discussed nutritional information obtained from patients by staff participating in the RCN Leadership programme or fed back from the Patient Advice and Liaison Service (PALS).

The ward or department teams generally used the paperwork provided in The Essence of Care pack, supplemented by notepaper, so no special stationery was required. The facilitator collated the scores and highlighted examples of good practice discussed at the comparison group meetings. Issues and problems that were common in many areas of the trust were also highlighted.

The examples given in Box 2 indicate the diversity of the issues discussed by the comparison group and show that small changes can often make a significant difference to patients' experiences.

Phase six
A trust-wide action plan was developed to deal with problems and issues that were common in many areas. Wherever possible the problem was delegated to existing teams who were asked to offer solutions. Ward teams developed their own action plans.

Phase seven
To disseminate information within the trust, senior nurses and midwives were regularly updated at the nursing and midwifery strategy group. Progress reports on the nursing and midwifery strategy, including the benchmarking work, were also made to the trust board.

Members of the comparison group were encouraged to set aside a regular slot at their team meetings to provide feedback on progress. A poster display was presented at the trust's annual clinical audit half-day in April and its quality day in July.

What next?
After the action plans have been completed, each area will rescore itself and should be able to show areas of improvement. While the action plans are being drawn up, the comparison group will continue to meet once a month and will begin to address phase three, identifying what constitutes best practice. We then hope to find similar departments from other trusts in our region that can form other comparison groups.

This article shows that The Essence of Care package (Department of Health, 2001a) can by used to make a difference to patients' experiences. This can be done on a trust-wide scale, as described, but it could also be used on a smaller scale to achieve similar results. Any group or team could discuss the practice on their ward or in their department using The Essence of Care framework and could suggest areas for improvement. Enthusiasm and a little time are the only resources required.

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