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Patient information: Part 5. Quality standards and evaluation

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Mark Duman, MRPharmS.

Freelance Health Communications Consultant

Quality standards should ideally be applicable to all patient resources, irrespective of media. Many organisations have been developing initiatives to identify key standards and criteria for providing high-quality patient information. Some schemes are designed for specific media such as the web, while others can be applied more generally.

Quality standards should ideally be applicable to all patient resources, irrespective of media. Many organisations have been developing initiatives to identify key standards and criteria for providing high-quality patient information. Some schemes are designed for specific media such as the web, while others can be applied more generally.

An example of quality standards for web-based information can be found at the NHS EQUIP website ( The site uses key criteria to assess the quality of material available to patients (Duman, 2003). These include:

- Content

- Appropriateness

- Authorship

- Design and navigability

- Sponsorship

- Currency

- Legibility

- Accessibility.

Good guidance for web design and usability can be found at the US National Cancer Institute website (, which covers a range of topics including the following:

- Design process and considerations

- Content

- Page length and layout

- Reading and scanning

- Links

- Graphics

- Accessibility.

Following such guidance will enable the author to ensure that the final product is of good quality. Another way to vouch for the quality of the work is to use kitemarks, but the value of these is currently under discussion. There is disagreement as to whether consumers see a kitemark as an indicator that the information can be trusted or whether they simply ignore it because they do not understand what it represents. Should you wish to obtain a kitemark for your patient information package, you could choose the following options:

- The Crystal Mark from the Plain English Campaign. There is an editing fee for this kitemark, which is a measure of readability and meaning, but is not an assessment of content

- The TriangleMark from the Centre for Health Information Quality (CHIQ). This is designed to give consumers assurance that the information is of high quality in every respect.

Some consumers feel that an endorsement by one of the royal colleges is an indicator of the quality of a product. Care should be taken to ensure that agreement is met on the use of logos and thought should be given to users' perception of such an endorsement before it is sought.

Tools to ensure quality
The 'gold' standard of criteria for quality patient information was developed by the King's Fund during the 'Promoting Patient Choice' programme. Although these criteria (Box 1) have been shown to be difficult to achieve in their entirety, everyone producing patient information should aim to achieve them.

Other tools for assessing and ensuring good quality include the Hi Quality guidelines on health information quality, which were developed by the CHIQ with the intention of raising awareness about quality assurance (see

DISCERN, which stands for Developing an Assessment Instrument for the Clinical Appraisal of Written Consumer Health Information, is another tool developed by a team from the University of Oxford. It is written from the patient's perspective and is designed to help consumers to judge the quality of information. There is a handbook and materials are available free from the website (

The CHIQ is a useful organisation to consult during the production of patient information. In addition to the kitemark and guidelines cited above, it offers an appraisal service and provides training and consultancy with the express aim of ensuring that consumers can have confidence in the quality of the information they receive, which should be accurate, clear and relevant.

Piloting your information
Once you have personally assessed and ensured the quality of your package, it is time to pilot it. This process will allow you to get feedback and highlight any quality issues you may have missed. A pilot scheme should not be rushed: you must ensure you have sufficient time for discussion and consultation. A pilot will enable you to check whether patients find your package easy or difficult to use and whether they have understood the key messages you are trying to get across.

Once the first draft is ready, it should be reviewed by a cross-section of your target audience and clinical experts. To do this, devise a set of multiple-choice questions or short-answer questions to include with the draft. Ensure that you supply clear guidelines for reviewers and, if you require sign-off from senior management, set a deadline for receiving comments.

The first question you should ask yourself when considering the dissemination of your package is: 'Who are the people who come into contact with my target audience?' Successful dissemination and publicity can be achieved by using established networks and distribution channels.

Within your organisation, these may include other health-care professionals who work directly with patients and patient support groups. Nationally, patient and professional groups would be examples of distribution networks. If you are considering rolling out your information nationally, you need to consider implications such as the potential production and distribution costs; you will also need to publicise your work effectively. This can be done by:

- Contacting national patient and professional groups

- Linking your package to a relevant national awareness week

- Promoting your work at conferences or events

- Entering your information package for an award

- Getting advice on promoting your resource from the CHIQ.

If you want to publicise your patient information package at local level only, this can be achieved in a variety of ways, such as:

- By contacting the local media - newspapers, local television and radio. Prepare a press release that can be sent to interested parties

- Meeting your local special interest groups for whom your information package will have relevance. This should include patient support groups and voluntary health organisations

- Presenting your information package at local meetings of health professionals

- Considering approaching local NHS walk-in centres and GP practices that may be willing to promote and disseminate your resource.

Evaluating and updating your work
The final stage in producing a patient information package is getting it evaluated and updated. This process will be ongoing. Continual advances in research findings and knowledge mean that it will be important for you to evaluate and update your resource regularly. Ideally, once it is in the public domain patient information resources should be updated annually. The review process consists of four stages (Box 2).

Evaluation can also take place by way of including a feedback form with the resource at the point of distribution. This can be used to evaluate patients' overall satisfaction with the package and its impact on their involvement in decision-making about their treatment.

The aim of this series on producing patient information has been to outline the process in a manner that, hopefully, will encourage the reader to have a go at creating a resource for patients and their families and friends and to investigate the options in more depth.

- Mark Duman is author of Producing Patient Information: How to research, develop and produce effective information resources, on which this series is based. It is available from the King's Fund on 020-7307 2591 or at:

Papers in the patient information series
Duman, M., Clark, A. (2003)Part 1. Why provide information? Professional Nurse 19: 1, 58-59.

Duman, M., Clark, A. (2003)Part 2. Planning an information package. Professional Nurse 19: 2, 118-119.

Duman, M., Clark, A. (2003)Part 3. Collecting high-quality evidence. Professional Nurse 19: 4, 238-239.

Duman, M., Clark, A. (2004)Part 4. Content and presentation. Professional Nurse 19: 6, 354-355.

Duman, M., Clark, A. (2004)Part 5. Quality standards and evaluation. Professional Nurse 19: 7, 413-414.

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