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How to ensure good clinical engagement with new quality indicators.

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The government wants to introduce quality indicators to measure nurses’ performance. Helen Mooney looks at how to ensure good clinical engagement with the new metrics

How do you measure a smile? Although something of an oversimplification, this is one of the questions the government is currently grappling with as it attempts to develop measures – or metrics – with which to rate the performance of nurses and the quality of the services they provide within the health service.

As part of its consultation, which aims to measure quality rather than just quantity in the NHS, Department of Health mandarins hope to come up with a formula that measures nurses on how compassionate they are towards patients.

Health secretary Alan Johnson wants to see the performance of every nursing team in every ward across the NHS measured. Announcing the proposals at the NHS Confederation’s annual conference in June, he said: ‘What nurses tell us is that you can have the best surgeon in the world, who carries out the most terrific operation on you but your stay in hospital won’t be satisfactory if you don’t get the highest level of compassion and care.

What makes a good indicator?

Indicators must be measurable with available data at reasonable cost

  • There must be evidence of variability associated with nursing and this variability must be substantial

  • For process or structure measures, evidence must support links to important health outcomes

  • The indicator must be recognised as important (by the public, managers and nurses) and the contribution of nursing must also be recognised by nurses and by others

  • Nurses must have responsibility for actions that lead to the outcome in terms of legitimate authority, self-perception and sphere of practice

  • There must be sufficient knowledge to inform remedial action

  • Measures should be chosen to minimise the risk of gaming, where improving performance on the indicators detracts from overall performance

  • Measures need to be risk adjusted to ensure comparability across settings

Source: State of the art metrics for nursing

‘If your experience involves nurses looking grumpy, or someone being rude, or not getting people there when you need them, then it ruins the whole experience,’ he added.

It is a bold move, and one the government has shied away from – until now. For the first time it hopes that the input of nurses and the essence of what they do can be measured in a way that will document the difference nursing care makes both to the patient experience and health outcomes.

‘The NHS is so effective because in the majority of cases that care and compassion, that smile, that welcoming atmosphere, that ambience is there all the time. But the nurses don’t get the recognition for this that they deserve,’ Mr Johnson said.

In November the government launched a consultation on possible national quality indicators to measure the performance of nurses and other NHS staff, looking at existing benchmark areas as a starting point in the process.

The DH asked staff to consult on the measures on the published list and identify any they thought were absent.

Health minister Lord Darzi said: ‘We can only improve the quality of care we give to patients if we constantly and methodically measure it. Developing a set ofquality indicators in partnershipwith frontline staff will allow clinicians to measure their team’s performance in a constant strive to improve and compare it with their peers across the NHS.’

Lord Darzi said he hoped the indicators would be used as a ‘resource to challenge and stimulate NHS staff to drive up standards in health care’.

Nurses could see themselves rated on such things as good handwashing, patient nutrition, falls reduction, how well they inform patients on the progress of their treatment and how they minimise pain.

Measuring the performance of nurses and the job they do in a more positive way is definitely a step in the right direction. In the past the emphasis has been on the negative impact of nurses on the patient experience. These fall into the safety measurement category such as failure to rescue – death among patients with treatable complications – falls, drug errors, healthcare-associated infections and pressure ulcers.

Neither effectiveness nor compassion are strongly represented among existing measures. The government hopes that new metrics, coupled with the existing indicators, will start to measure outcomes not just processes.

Earlier this year the National Nursing Research Unit based at King’s College London published a report, State of the art metrics for nursing: a rapid appraisal, which is seen as the first step in trying to quantify and measure some of the things nurses do and what could be used as nursing metrics.

The report aims to review the evidence base on nursing metrics and provide a road map and set of recommendations to take nursing forward. It is heavily reliant on the quality indicators currently used in the acute sector, which already attempt to measure what nurses do in terms of both patient experience and outcome.

Peter Griffiths, director of the National Nursing Research Unit, says that directly measuring the human quality of compassion is ‘hugely challenging’.

‘Nurses being measured on how smiley they are sets out the challenge. Although this can be as important as other things to patients, it greatly misses the point,’ he explains. ‘We need to begin to capture things like this as part of the indicators we use in terms of measuring the environment patients are placed in and the care they receive in terms of human understanding.’

Mr Griffiths stresses that it is imperative for nurses to have a ‘loud say’ in what they think are the appropriate measures that should feed into quality metrics.

Professor David Sines, executive dean of London South Bank University’s faculty of health and social care, applauds the report as the first step to measuring the role nurses play in patient care. However, he says that it cannot be used as a ‘toolkit’ to be applied directly in a care setting.

‘It is very acute-care focused and it will have to be adapted for primary care, mental health and children’s and learning disability services,’ says Professor Sines.

He agrees that it is very important that the nursing profession is measured and held accountable for what it does.

‘We as a profession are saying that we should be accountable and have a voice at board level that is evidence based and that has got to be right,’ he says.

Howard Catton, policy adviser at the RCN, hopes that developing a way to measure quality and the work of nurses will raise their visibility. ‘We still have not got sufficient visibility in nursing and the profession itself needs to do more to highlight and show the nursing contribution in a more tangible way,’ he explains.

Mr Catton says there is a ‘real opportunity’ to shape government and NHS policy drivers for the future. ‘Nurses really do need to be leading this stuff.’

Case study: 'We are taking the rhetoric and turning it into action'

Nurses at five hospitals across the north west of England are winning monthly cash prizes if they follow and achieve seven quality indicators to improve patient care. NHS North West is the first strategic health authority to introduce financial performance-related incentives to staff to improve the quality of care and services patients receive. Three of the indicators used – healthcare-associated infections, pressure ulcers and falls – are identified in the National Nursing Research Unit’s report as some of the potential nursing metrics that could be used in the first national roll-out of such measures.

According to Jane Cummings, the SHA’s director of nursing, the initiative has been ‘hugely motivational’ among nursing staff. ‘It has had a positive impact on morale because the nurses are able to see the impact the care they deliver has on patient care.’

The programme is running in conjunction with another overall quality measurement programme called Advancing Quality. It is the SHA’s attempt to deliver on the government’s NHS Next Stage Review commitments, as well as NHS North West’s regional vision to incentivise and report on quality. Acute trusts in the region are being paid bonuses by the SHA for performance against clinical quality measures – the trusts themselves decide how to use the money to reward staff performance. Trusts that perform in the top 10% on quality receive a maximum of £180,000. All hospital trusts in the region are recording process and outcome data for five procedures: coronary artery bypass graft; acute MI; congestive heart failure; hip and knee replacement and community-acquired pneumonia. The programme is expected to be extended to stroke and mental health in its second year.

NHS North West chief executive Mike Farrar said: ‘This takes the rhetoric on quality and turns it into action, the key challenge.’ He said patient-reported outcome and patient experience measures, which are still being developed, would also have a role. ‘It is important to avoid a narrow view of quality. The worst thing that could happen is you could improve outcomes but from the patient’s point of view it doesn’t feel any different.’

Ms Cummings says that the five care groups measured in Advancing Quality are ‘quite medical’. ‘We wanted to do something that is important for nursing metrics, the key areas are medicine management, food and nutrition, pressure ulcers, falls, prevention and observation and infection and control.

‘We have a set of pilots in several organisations ranging from DGHs to large acute trusts and we are gradually rolling this out. We are looking to expand the metrics to cover maternity and paediatrics. There are also some that are relevant to mental health and we are talking with primary care nurses as well,’ Ms Cummings explains.

She says the SHA has seen a 26% reduction in falls since the falls metrics were introduced, and that they have also ‘really motivated’ staff. ‘It gives local teams the ability to see where they are and motivates them. Most people have got a competitive edge to them and they do want to see how they are doing in comparison with others but they also want to see month-on-month improvements for themselves

Metrics will be used to evaluate nurses’ performance in a variety of ways. Existing indicators, which check whether particular tasks have been carried out, will remain as one of the easiest ways to measure performance. However, other measures will be introduced. Patient experience and patient survey results will feed into nursing metrics as well as indicators that measure patient satisfaction.

It is important to acknowledge that some nurses are suspicious of metrics and attempts to measure what they do because in the past this has often led to cutbacks in service and staffing levels. Indeed, if metrics are seen by nurses as just another performance management arrangement, they risk failing because they will not be fully embraced or used properly by nurses themselves.

The government must be careful to ensure that metrics are not imposed from the centre but from the bottom up as a way to improve service performance.

Mr Catton says metrics must be talked about at both ‘ward and board level’ to ensure their success. In many cases nurses being able to access their own and their team’s performance data on quality can act as the best incentive and it is often damaging for morale when staff do not have feedback on their performance.

Janice Sigsworth, director of nursing at Imperial College and former deputy chief nursing officer, is hopeful that metrics will be useful in measuring effectiveness, safety and patient experience. But she warns that they should not be used to show shortcomings or burden nurses with further bureaucratic tasks.

‘It is important to establish very early the purpose and the usefulness of the data being collected and be clear what it is trying to achieve. We need to be clear about what it is likely to be used for because we need good clinical engagement inthis,’ she says.

Professor Anne-Marie Rafferty, dean of the Florence Nightingale school of nursing and midwifery at King’s College London, says that an important issue to be tackled if nursing metrics are introduced is that of ensuring adequate nurse training.

‘One of the issues that we need to tackle is about nurses being comfortable with interpreting and handling data and they will need training in this,’ she says.

‘I don’t think nurses have anything to fear from using forms of measurement, they need to get stuck in,’ she adds.

There is also the risk – as with many other methods of measuring NHS work – of gaming. Mr Griffiths acknowledges this but he says that gaming is less of a risk when measuring quality. ‘It is harder to game with outcome measures because of the complexity of what nurses do, it is harder to substitute that with a proxy,’ he says.

Potential nursing metrics


  • Failure to rescue

  • Health-care associated pneumonia

  • Health-care associated infection

  • Pressure ulcers

  • Falls


  • Staffing levels and patterns

  • Staff satisfaction

  • Staff perception of the practice environment


  • Experience of care (patient reported)

  • Communication (patient reported)

Source: State of the art metrics for nursing

Another issue for discussion is the introduction of a system of performance-related pay or other incentives in a bid to encourage a better quality of performance from nursing.

Mr Johnson has previously said that he wants to promote friendly rivalry between wards in which nursing teams could compete over performance scores. The government also wants to publish each trust’s overall nursing quality score, to inform patients when they are choosing where to be treated.

The scheme will be piloted and first results are likely to emerge this year. However, Mr Johnson has stressed that he does not want to publish scores for individual nurses and he has no plans to use them as a basis for calculating performance pay.

Mr Catton warns that it would be extremely difficult to implement individual performance-related pay in the health service among clinical staff as ultimately all achievement is a ‘team effort’. ‘I am not against using some form of incentive system to drive improvements but I think we have to look in the territory of the effectiveness of teams and how you incentivise them to drive their performance.’

He warns that the boundaries for financial performance need to be ‘tightly and clearly defined’ so they are not seen by nurses and other clinical staff as ‘cost-cutting by stealth’.

Roger Taylor, director of research at Dr Foster Intelligence, has started to map out how quality can be measured in terms of patient satisfaction and warns that although there can be a role for financial incentives they must be strictly regulated.

‘There have to be structures in place so that perverse incentives are not created – no measure is perfect, if you get the incentive structure wrong it becomes an end in itself, which is the same problem we have with targets.’

Nursing metrics are definitely one of the new kids on the block in terms of the government and the NHS thinking on how to measure quality. It seems that developing them is crucial to raising the visibility of the nursing profession and making management understand the invaluable job nurses do.

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Readers' comments (1)

  • Instead of wasting money on useless data why doesnt the goverment put money into staffing wards so that the nurse to patient ratio is less. THEN NURSES WILL SMILE !
    D Furber-Cope a critical care staff nurse who would not risk her pin working on short staffed wards please support your ward staff !!!!! a 1:5 ratio would be good having got 10yrs exp on medical and surgical wards !!!!!!!!1

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