Leading Better Care. Report of the Senior Charge Nurse Review and Clinical Quality Indicators Project

Transcription

1 Leading Better Care Report of the Senior Charge Nurse Review and Clinical Quality Indicators Project

2 Leading Better Care Report of the Senior Charge Nurse Review and Clinical Quality Indicators Project The Scottish Government, Edinburgh 2008

3 Crown copyright 2008 ISBN: The Scottish Government St Andrew s House Edinburgh EH1 3DG Produced for the Scottish Government by RR Donnelley B /08 Published by the Scottish Government, May 2008 Further copies are available from Blackwell s Bookshop 53 South Bridge Edinburgh EH1 1YS The text pages of this document are printed on recycled paper and are 100% recyclable

4 Contents Preface by the Chief Nursing Officer Foreword for Senior Charge Nurse Review Foreword for Clinical Quality Indicators Project v vi vii 1. Introduction 1 2. Senior Charge Nurse Review 4 Outcomes of Stakeholder Views of Senior Charge Nurse Role 4 Clinical co-ordination, leadership and management functions of the Senior Charge Nurse 6 Framework for SCN Role 7 Summary of SCN Review Clinical Quality Indicators Project 13 Background 13 Objectives of CQI Project 13 Challenges of CQI Project 14 Developing robust quality indicators 14 Progress on electronic data-capture to support improvement 15 Development of agreed indicator set in the development phase of the Review of the SCN Role 16 Develop a model to ensure continuous review and development of the CQIs 17 Summary of CQI Project Implementation framework 21 Clinical Facilitator Network informing implementation 21 Key Stakeholder Groups informing implementation 22 Implementation and Action Plan 23 References 26 Appendix 27 iii

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6 Preface by the Chief Nursing Officer Providing safe, effective care that enhances patients experiences of services is a central driver of Scottish Government policy for the NHS, as set out in Better Health, Better Care. This aspiration is echoed in Delivering Care, Enabling Health, which provides the underpinning elements for rights-based, values-based nursing, midwifery and allied health professional services. The delivery of the vision for the NHS described in these two documents will depend to a large extent on strong and inspirational clinical leadership. It will require clinical leaders who are highly skilled, highly knowledgeable, highly motivated and highly recognisable as the leaders of their teams. It is in this context that I launched the Review of the Senior Charge Nurse/Midwife Role and committed to working jointly with NHS board nurse directors to develop a core set of Clinical Quality Indicators (CQIs) for nursing and midwifery. The projects ran in parallel, complementing and supporting each other. This report from the projects gives us the impetus and the evidence we need to enable us to reposition the senior charge nurse/midwife as the arbiter and guarantor of patients experiences in clinical areas. Empowered by their new role definition and equipped with the CQIs, senior charge nurses/midwives will be the guardians of clinical standards and quality of care for patients and families. They will be the visible embodiment of clinical leadership in NHS settings, coordinating patient care, marshalling and inspiring the nursing or midwifery team and advocating on patients behalf with members of the multidisciplinary team. They will also engage more explicitly with efforts to meet strategic objectives at organisational and national level and will enjoy proper recognition for the vital contribution they make. But the ultimate beneficiaries of the actions we have set in place in this report will be patients and families accessing NHS services. The development of strong nursing and midwifery clinical leadership in the NHS, backed by quality indicators that set benchmarks for service delivery, will provide the basis for improved patient outcomes, improved experiences of care and improved opportunities for patients and families to have a real say in the way their care is planned and delivered. I am grateful to all those who have led and contributed to the projects and the development of the report. By redesigning and re-energising the role of the senior charge nurse/midwife, I believe we have created a very powerful driver for positive change in the NHS. Paul Martin Chief Nursing Officer v

7 Foreword for Senior Charge Nurse Review I am delighted to contribute a few words of introduction to this very important report. I believe, and this report confirms, that the Senior Charge Nurse role is pivotal to the successful implementation of Scottish Government policy through delivery of organisational objectives of safe, effective and timely person-centred care that is evidenced through a positive patient experience and excellent clinical outcomes. Getting the focus on that role right and providing the individuals who take on these challenging roles with the support they need to maximise their impact is crucial. The success of these roles depends on individuals in terms of their skills, knowledge, behaviour and attitude, the teams within which they work, the systems of how care is delivered and supported by the organisation and how the Senior Charge Nurse is positioned within the organisational culture. I am confident that this Review of the Senior Charge Nurse role and the associated workstreams that support it provide a very strong and clear message about what the focus of the role should be and provide tools to support the role and thereby improve quality of care. The challenge now for NHSScotland is to implement it in a way that really delivers benefits for patients and carers. It has been a great privilege to Chair the Project Board that has guided and influenced this work and I wish to thank everyone who has been involved across Scotland. Together we have laid the foundations for a bright future. Now, as a Board Director, I look forward to the challenge of making it a reality. Heather Tierney-Moore Nurse Director vi

8 Foreword for Clinical Quality Indicators Project Better Health, Better Care recognises that organisations who will best meet the needs of the public are those that focus across the six dimensions of quality: patient centred, safe, effective, efficient, equitable and timely. The direct contribution of nursing and midwifery across the six dimensions of quality is recognised and celebrated in many quarters. However, nursing and midwifery in NHSScotland is driven by the experience of patients and the provision of safe and effective care is a fundamental right for patients that we were determined to understand, as well as capturing the quality of care delivered and making radical improvements where indicated. It has been a great honour to Chair the CQI Development Project Board and I can confirm that we have, in the delivery of this commitment from Delivering Care, Enabling Health, been driven and guided by the values, principles and aspirations above. Furthermore, I am absolutely confident that not only can this ground-breaking work contribute significantly to the National Patient Experience, Safety and Improvement Agenda, but also offers an unparalleled opportunity for nursing and midwifery professions to be clear and articulate about our contribution to the modernisation, efficiency and productivity commitments within Better Health Better Care. As a board nurse director, I have seen first hand during the CQI development stages the powerful leadership, action and improvement of care at the bedside. This work ensured that Senior Charge Nurses and their frontline teams had ownership and access to real-time data. These data immediately reflected to the teams the processes and outcomes of the nursing and midwifery care that is delivered each and every day. Crucially, this knowledge, combined with improvement methodology skills, the development of the Senior Charge Nurse role and the focus on leadership that this brings, led to significant and measurable improvements in quality, safety, efficiency and experience of care. The Data Capture and Reporting System that has been developed by Information Services Division (eqips Electronic Quality Improvement Programme Scotland) is in itself quite an achievement. It enables frontline teams to make changes in practice and articulate improvement. Our ability in Scotland to use these data to have a clear picture of the quality of patient care places nursing and midwifery in a strong and unique position. In closing, I would like to extend my thanks and gratitude to the public, patients, carers and frontline nursing and midwifery staff across Scotland who have actively influenced, participated and shaped this work. In addition, I would wish to express my grateful thanks to the CQI Development Project Board with a particular mention to Eileen McKenna and Diane Campbell for their leadership, energy and commitment to the success of the project and support of the work of the Project Board. Angela Wallace Nurse Director vii

9 Section 1 Introduction

10 This publication brings together the outcomes of two important projects: the Senior Charge Nurse/ Midwife (SCN) Review and the Clinical Quality Indicators (CQI) Project. The outcome of the SCN Review highlights the benefits of having a consistent framework for Senior Charge Nurses in hospitals across NHSScotland. The CQI project has developed indicators for adult in-patient areas and made progress towards developing CQIs for other in-patient settings. Although these projects shared a similar methodology and both aim to support continued improvements in quality of care for patients in hospital, their outcomes will be considered separately. Methodology for projects The projects were designed to encourage wide stakeholder involvement. This approach enabled the projects to include the views of patients, health care professionals and NHS executive directors. In addition each Senior Charge Nurse had an opportunity to participate. The contributions of all these stakeholders have driven the development of both the Senior Charge Nurse role and the CQIs. The project methodology is summarised in Figure 1. Each project was tested over a six-month period. This was carried out in collaboration with all NHS boards. Five boards (NHS Fife, NHS Forth Valley, NHS Grampian, NHS Greater Glasgow and Clyde and NHS Lanarkshire) were involved in testing and refining the Framework for the SCN role and CQI dataset, and the remaining territorial boards were involved in creating a network of facilitation and support. 1

11 Figure 1: Projects processes Stakeholder engagement Survey of senior charge nurses A questionnaire was designed to gain insight into the demographic profile of current post holders and to measure perceptions of their work environments and their personal beliefs about their role. Performing stakeholder interviews and hosting stakeholder workshops Interviews were held with NHS board executive directors and workshops were held for a range of stakeholders. Patient interviews Patients from two NHS board areas were interviewed to explore their views on the current and future role of the senior charge nurse. Project boards and reference groups Project boards were formed for each project, with stakeholder and practitioner reference groups. Review of the Senior Charge Nurse Role and Clinical Quality Indicators Project Development phase Testing CQIs and ward profile data set The 30 wards participating in the development phase tested the CQIs and ward profile data set. Senior charge nurse activity analysis The 30 senior charge nurses involved in the development phase were invited to complete an activity analysis to establish current work patterns. The questionnaire was based on the framework for the role with additional items relating to the time they spend delivering direct care to a caseload of patients, managing bed capacity outwith their own department, providing hospital or directorate cover and general administrative duties. Stakeholder questionnaire The aim of the questionnaire was to reach consensus regarding the components of the senior charge nurse role and identify the priorities for CQI development. 2 Literature reviews Extensive literature reviews were carried out to ensure evidence from the national and international literature informed the outcome of both projects. Senior charge nurse learning and development needs analysis Carried out to assess the needs of the senior charge nurses within the development sites, informing an education and development framework.

12 Section 2 Senior Charge Nurse Review

13 Senior Charge Nurse Review The aim of the SCN Review was to create a modern clinical leadership role to enable frontline senior charge nurses to maximise their contribution to delivering safe and effective care by developing their leadership capacity and capability. The scope of the review included all nurses and midwives who lead a team that provides care to patients within hospitals. The review s objectives were to: seek stakeholder views on the role and its potential for development describe the clinical coordination, leadership and management functions of Senior Charge Nurses develop a framework for the SCN role provide guidance for NHS boards on developing SCN roles locally (this will be outlined in the Implementation section). Outcomes of Stakeholder Views of Senior Charge Nurse Role At the outset of this review we already understood that Senior Charge Nurses have a key role in determining quality of care within wards and departments. However, as health service management structures have changed, SCN roles and responsibilities have become multifaceted and now tend to vary in scope across NHSScotland. For some senior charge nurses, this has meant a shift away from the focus of providing clinical coordination and managing patient care in their areas of clinical responsibility. The early stages of the project examined how the SCN role was perceived both in the literature and by stakeholders. The key findings of this are outlined in Table 1. There was consensus among stakeholders that NHSScotland should recognise and value the SCN role. Stakeholders felt that standardisation of the role across NHSScotland, with key responsibilities defined, core competencies described and an exemplar job description and Knowledge and Skills Framework (KSF) outlines agreed, would be beneficial in this regard. To complement the stakeholder perspective, an activity analysis of senior charge nurses within development sites was completed. This demonstrated that SCN time was distributed equally between: ensuring safe and effective clinical practice enhancing patient experience managing and developing the performance of the team. This analysis also found little SCN time spent on explicitly contributing to the delivery of the organisation s objectives. Indeed, the disengagement between the strategic direction of NHS organisations and senior charge nurses as frontline clinical leaders was a key theme that emerged throughout the review process. 4

14 Table 1. Perceptions of role of SCN Source/stakeholders Patients and public Stakeholder workshops Survey of SCNs Learning and development needs analysis of SCNs Interviews with executive directors and chief executives Literature review (Prof. N Kearney, University of Stirling) Literature review (Eileen McKenna, Project Manager) Perceptions/findings Leadership and development of team is one of the most important roles of SCNs Concerned about amount of time SCNs spend on administrative duties 46% of patients interviewed were unable to identify the SCN from other nurses on the wards Expect SCNs to assume responsibility for the coordination of direct and indirect care Regard SCN as representing the hospital to patients and their families View SCNs as being pivotal to effective ward management and the delivery of high-quality patient care Find the job title confusing and believe levels of responsibility within the role are ill-defined Public and health professionals find it difficult to identify the SCN from other nursing and midwifery staff Individual SCNs spend a significant proportion of their time on general administrative duties There is a perceived gap in providing a range of development opportunities for SCNs related to their key responsibilities Feel they have limited access to opportunities for development, information, support and resources Feel they have limited impact on their organisations Have confidence to undertake their role with a degree of autonomy 37% are educated to degree level or above 75% have undertaken leadership development A range of development across the dimensions of the role is required Education needs to be tailored to meet individual needs Standardisation of the SCN role across NHSScotland would be beneficial Need to have succession planning in place Need to provide a range of development opportunities including management and leadership programmes SCNs influence departmental culture and team dynamics Role lacks clear performance criteria and expectations Patients, public and staff hold misconceptions about the complexity of the role and the skills necessary to carry it out effectively Determine context and culture of care within their wards and departments Significant impact on job satisfaction of staff Significant impact on quality of patient experience Influence patient outcomes 5

15 Clinical coordination, leadership and management functions of the Senior Charge Nurse The outcomes of the stakeholder consultation and activity analysis informed the development of the description of the clinical coordination, leadership and management functions of senior charge nurses. These outcomes are outlined below. Clinical coordination From their consideration of the SCN role, stakeholders were able not only to define the elements of the role they believed to be crucial, but also to identify current role components they believed were not essential parts of their function. Stakeholders concerns over parts of the current role were highlighted by the outcomes of the SCN activity analysis, which demonstrated that a lot of SCN time was spent on general administrative duties, with a small number also providing hospital or directorate cover and a significant number providing direct clinical care to a caseload of patients. The clinical coordination aspect of the role has generated a great deal of discussion and there is a risk that this may be misunderstood. To define the role of clinical coordination, it may help to identify some of what this does and does not encompass (Table 2). Leadership Senior charge nurses across Scotland already have a good platform to continue to build on their leadership skills as 75% of those responding to the SCN survey have been involved in a leadership programme. It is clear from the views gathered from patients and public that they perceive senior charge nurses as having a clear leadership role. They want then to be: visible identifiable accessible approachable authoritative. Table 2. Scope of clinical coordination Aspects of SCN role in clinical coordination Clinical expert and coordinator for all patients in the ward/area Inspiring patient confidence Setting and maintaining high standards of care Monitoring quality of care Ensuring consistency of care for all patients Resolving clinical issues Communication with patients and relatives Communication with multidisciplinary team Responding to patients concerns and acting on them Role model for their team Ensuring delivery of safe and effective care Not part of SCN role in clinical coordination Providing care by having a direct clinical case load Participating in management of hospital site Having responsibility for allied health professionals Spending significant amount of time on administrative duties 6

16 The senior charge nurse has a significant clinical leadership role that includes: developing a culture of person-centred care leading the delivery of clinically excellent, high-quality services ensuring a culture of continuous quality improvement influencing and facilitating change. Management function Senior charge nurses also carry the functions of manager for their ward/department. These include: efficient and effective use of resources managing the performance of the team planning and monitoring staffing levels to match requirements of workload ensuring compliance with local and national standards, policies and legislation. Framework for SCN Role The views and consensus from the extensive stakeholder involvement, literature review and the SCN activity analysis were used to inform the development of a framework for the SCN role. The starting point for this was the identification of areas of responsibility: to ensure safe and effective clinical practice to enhance patient experience to manage and develop the performance of the team to contribute to the delivery of the organisation s objectives. The key result areas linking to these four main areas of responsibility are highlighted below (see Figure 2). The details relating to these areas of responsibility are defined in Table 3. 7

17 Figure 2. Responsibilities and key result areas of SCN role Service development Political and strategic awareness Evidencebased and clinically effective practice Patient safety Leadership Networking Organisational objectives Safe and effective practice Senior Charge Nurse Quality improvement Managing practice setting Performance of team Enhance patient experience Coordination of journey Facilitating learning and development Role model Personcentred culture Clinical expertise 8

18 Table 3. Details of SCN Role Framework 1. Ensure safe and effective clinical practice 1.1 Clinical leadership and team working As clinical leader, promote teamwork within a multiprofessional environment, demonstrating critical analysis and decision-making skills; lead the delivery of a clinically excellent, high-quality service; influence and facilitate change within the ward/department and, where appropriate, the organisation. 1.2 Evidence-based, clinically effective practice Act as a change agent, lead the development of clinically effective practice through the effective use and integration of evidence; set, implement and monitor evidence-based policies, procedures and protocols. 1.3 Continuous quality improvement Ensure a culture of continuous quality improvement through the use of audit, patient feedback and reflection on practice by self and other members of the team. 1.4 Patient safety Promote a clean and safe environment for staff, patients and visitors by ensuring compliance with legislation, policies and protocols, including health and safety, healthcare associated infection, risk management and critical incident reporting and analysis; assess and manage actual and potential risks to health and well-being. Ensure a high standard of record keeping in accordance with Nursing and Midwifery Council requirements, national legislation and local standards, facilitating effective communication with the multi-professional team regarding patient care. 2. Enhance patients experiences 2.1 Coordination of the patient journey Ensure coordination of the patient s journey by planning and coordinating the episode of care, including the smooth transition to other settings, promoting effective discharge and communicating with multidisciplinary and interagency teams as required. 2.2 Clinical expertise Coordinate nursing/midwifery interventions, influencing clinical decisions and monitoring the quality of patient care provided through using expert clinical knowledge relevant to their own field of practice, underpinned by theory and experience. 2.3 Promote a culture of person-centred care Within a multidisciplinary team environment, develop a culture of person-centred care; maintain high visiblity within the ward/department; communicate regularly with patients, relatives and/or carers; promote a caring environment where equality and diversity issues are respected and patients are enabled to be partners in their care. Identify opportunities to develop care and services by ensuring that there are effective systems in place to access patients and carer experience/feedback and ensure complaints are managed in line with organisational policy, including the dissemination of learning points. 9

19 Table 3. Details of SCN Role Framework (continued) 3. Manage and develop the performance of the team 3.1 Role modelling Act as a role model, creating a supportive ethos to empower staff to contribute to the delivery of high-quality, person-centred care. 3.2 Learning and development Support the learning and development of all staff; create a learning environment that ensures effective learning opportunities for staff and students, including appropriate orientation and induction programmes and a range of clinical support strategies (mentoring, coaching, clinical supervision and action learning) and planning ongoing mandatory training and relevant education/development opportunities. Support the career pathway of individual team members by ensuring all staff have opportunities for individual performance review and personal development plans and maintain an up-to-date knowledge of current clinical, professional and legal issues. 3.3 Manage the practice setting Manage the practice setting, ensuring effective use of resources and workforce planning by monitoring workload and, through efficient rostering, maintain appropriate staffing levels and skill mix, taking account of role and competence of staff when delegating work; contribute to the management of the ward/ department budget. Manage the nursing/midwifery team, ensuring compliance by self and others with professional standards, legislation, national and organisational policies; leading recruitment, selection and attendance management initiatives; ensure grievance and disciplinary matters within own department are identified, actioned and reported to the appropriate manager. 4. Contribute to the delivery of the organisation s objectives 4.1 Networking Network with peers across professional groups, promoting the exchange of knowledge, skills and resources. 4.2 Service development Work in partnership with a range of clinicians and managers in the planning or development of own service, promoting the involvement of patients and the public. 4.3 Political and strategic awareness Develop and maintain a working knowledge of local, national and professional strategy and policy; ensure that organisational goals are reflected in personal objectives and in ward/department development plans and demonstrate the ability to contribute to policy and strategy development at departmental and organisational levels and, where appropriate, national level. 10

20 Table 4 demonstrates how the four key functions within the Framework for the SCN link with the Knowledge and Skills Framework. Table 4. Links to Knowledge and Skills Framework of the four dimensions of the SCN Role Framework for the Senior Charge Nurse Role 1. Ensure safe and effective clinical practice 1.1 clinical leadership and teamwork 1.2 evidence-based, clinically effective practice 1.3 continuous quality improvement 1.4 patient safety 2. Enhancing patients experiences 2.1 co-ordination of the patient journey 2.2 clinical experience 2.3 promote a culture of person-centred care 3. Manage and developing team performance 3.1 role model 3.2 facilitating learning and development 3.3 managing the practice setting 4. Contribute to the delivery of the organisation s objectives 4.1 networking 4.2 service development 4.3 political and strategic awareness NHS KSF 1.1 Core 1, Core 4, Core Core 4, Core Core 5, IK2 1.4 Core 1, Core 3, HWB2 2.1 Core 1, HWB2 2.2 Core 2, Core 5, HWB2 2.3 Core 1, Core 4, Core 6, HWB2 3.1 Core 2, Core Core G4, G6, IK2 4.1 Core 1, Core Core Core 2, Core 4 The publication of the Education and Development Framework for Senior Charge Nurses (NHS Education for Scotland, 2008) will equip senior charge nurses with a tool to guide and support them in their development journey. This can be accessed at Summary of SCN Review Senior charge nurses have an important role in providing clinical leadership to their teams to ensure that patients in their wards/departments receive high-quality care. This is not just about how they perform as individuals, but also how their teams are developed. The framework developed during the course of the SCN Review, which is outlined in detail above, will contribute to ensuring that there is a consistent approach to the role across NHSScotland. Senior charge nurses across NHSScotland are motivated to continue to build on the quality of care and experience for patients in their areas of responsibility. The SCN Review will assure senior charge nurses that they are valued in this role and that their significant contribution to health care is recognised. This focus on quality is also supported by the results of the CQI project. 11

21 Section 3 Clinical Quality Indicators Project

22 Clinical Quality Indicators Project Background The background to this project is the Audit Scotland report Planning Ward Nursing Legacy or Design? (Audit Scotland, 2002). This report emphasised that despite high numbers of nursing and midwifery staff in the NHS workforce, there was limited information available to compare nursing numbers, costs and impact on quality. Among its recommendations were: NHSScotland should develop and agree clinical quality measures that focus on continuous improvement NHS boards should review the quality indicators regularly and take action when problems arise. This led to a pilot project commissioned by the Chief Nursing Officer Directorate and hosted by NHS Quality Improvement Scotland (NHS QIS). This project tested the feasibility of developing clinical indicators for nursing and midwifery and the outcomes were published in The Impact of Nursing on Patient Clinical Outcomes (NHS QIS, 2005). When Audit Scotland published a follow-up report in 2007 (Audit Scotland, 2007) they recognised the progress that had been made in developing quality indicators but noted that: Boards are still measuring quality in a variety of ways and challenges [remain] in working towards a national system of quality indicators. The recommendations of the Impact of Nursing on Patient Clinical Outcomes report have been progressed through the Clinical Quality Indicators Project, which has developed a core set of clinical quality indicators (CQIs) in collaboration with NHS QIS, ISD and NES. Objectives of CQI Project The objectives achieved by the project were: develop robust quality indicators that demonstrate the nursing and midwifery contribution to care develop an electronic data-capture and analysis system to enable monitoring of CQIs in NHS board areas to inform continuous quality improvement use the agreed indicator set in the development phase of the Review of the SCN Role develop a model to ensure continuous review and development of the CQIs. This project was carried out in collaboration with five NHS boards NHS Fife, NHS Forth Valley, NHS Grampian, NHS Greater Glasgow and Clyde and NHS Lanarkshire. The aim was to test and refine the CQI set in conjunction with the Framework for the SCN Role. 13

23 All remaining NHS boards were involved in the development phase through releasing a clinical facilitator to work two days per week on the projects. A national network of clinical facilitators was established to ensure shared learning and strengthen the outcome of both projects. Challenges of CQI Project The Impact of Nursing on Patient Clinical Outcomes report highlighted the substantial challenges posed to practitioners by the lack of a national approach to measuring and improving quality in nursing and midwifery services. This has led to a situation in which nationally there are: no comparative data with which to measure the impact of nursing numbers on costs and quality no agreed quality measures that focus on continuous quality improvement no measure of impact of available evidence on practice and outcomes. Audit Scotland acknowledged that, as summarised in the NHS QIS report: this is a complex area and many confounding factors exist that make it difficult to isolate and clearly identify the impact made by nurses. In this challenging context, the CQI Project has made significant progress in establishing CQIs for nurses and adopting a model for progressing CQIs in other areas of nursing and midwifery. Developing robust quality indicators The literature reviews conducted to inform the NHS QIS report and Measuring and Reporting the Quality of Health Care: Issues and Evidence from the International Research Literature review (Davies, 2006) were used to inform the development of CQIs for nursing and midwifery. This process determined that the CQIs would focus on continuous improvement rather than performance management. Their development has also been informed by activities carried out as part of the projects stakeholder engagement (see Figure 1). This reinforced the requirement to develop CQIs across the six dimensions of quality defined in Better Health, Better Care (Scottish Government 2007): safe, effective, efficient, patient-centred, timely and equitable health care. Stakeholders also identified priorities for indicator development. The literature searches and stakeholder engagement informed the next stage of the project. The three key outcomes were that CQIs should: focus on continuous quality improvement rather than performance management include process indicators which measure aspects of nursing care such as assessment and interventions include nursing-sensitive patient outcome measures, which improve in the context of the quality of nursing care. 14

24 Developing quality indicators is complex and stakeholder consensus decreed that the initial focus would be on four CQIs that would be applicable to in-patients in a variety of specialities, including acute hospitals, old-age psychiatry, rehabilitation areas and community hospitals. They were: food, fluid and nutrition falls pressure ulcer prevention monitoring and observation. The indicator development also included collecting data on the profile of staffing in the ward to reflect not only the process and outcomes of care in the CQIs above, but also the structure of care as indicated by the supply and skill level of nursing staff. The dataset for the ward profile was developed in collaboration with the Nursing and Midwifery Workload and Workforce Planning Programme commissioned by the Chief Nursing Officer Directorate. The profile provides information about effective rostering, sickness/absence data and information on use of additional staffing. Any systematic approach to improving quality should include plans to monitor, evaluate, maintain and embed change into practice. The eqips system has been designed around a simple model that will support clinical teams to develop, test, implement and evaluate change. Progress on electronic data-capture to support improvement One of the objectives of the project was to develop an electronic data-capture and analysis system to support senior charge nurses in continually monitoring and improving practice. Following consideration of the options, it was agreed that the Chief Nursing Officer Directorate would work with the Information and Statistics Division (ISD) to develop a national data-capture and reporting system. This would be underpinned by the ehealth-aligned clinical information standards, as developed by the National Clinical Dataset Development Programme (NCDDP) (see: This has resulted in a unique national electronic Quality Improvement Programme for NHSScotland (eqips). The indicator sets have been developed from the best evidence available and the system is based on the Model for Improvement (Langley et al. 1996), a simple but powerful tool for accelerating improvement that has been used very successfully by hundreds of health care organisations in many countries. It is also the methodology used by many of NHSScotland s national programmes. Two parts of the Model for Improvement are incorporated into eqips: three fundamental questions: what are we trying to accomplish; how will we know that a change is an improvement; and what changes can we make that will result in improvement; (these can be addressed in any order). the Plan-Do-Study-Act (PDSA) cycle to test and implement changes in real work settings, which guides the test of a change to determine if the change is an improvement. 15

25 Development of agreed indicator set in the development phase of the Review of the SCN Role It was identified that the act of measuring had a positive impact on what was being measured. This is demonstrated in the case study below from one of the development sites, which also highlights the synergy between the SCN Review and the CQI Project. Case Study At the start of the development phase of the project, one of the senior charge nurses involved was uncertain how this would impact on clinical practice and how she would manage to undertake the work within her clinical area, with the existing work pressures she experienced. At the time the ward area was about to expand and open a further four beds for high dependency patients and there were staff vacancies. This all contributed to additional pressures within the clinical area. The initial baseline data collection of the CQIs highlighted to the senior charge nurse areas for improvement. This confirmed what she, as the clinical lead for the area, had already suspected but had had little evidence to support. Following the initial data collection, the results were discussed with the ward team and Plan-Do- Study-Act (PDSA) change cycles were developed to improve compliance. These included communication reminders regarding timing of documentation, through documentation completion, with staff members being given the responsibility to ensure that the identified actions were completed. The senior charge nurse also noted that although an elective ward, over 70% of the patients were transferred to her clinical area rather than direct admission. This had implications with regards to compliance with CQIs out with her sphere of responsibility. The senior charge nurse re-audited the clinical area against the CQIs to ensure that improvements were being embedded into the clinical area. During this time the four HDU beds opened, staff vacancies were filled with regular bank staff but the senior charge nurse continued to practice in the role she had always practiced within, rather than being able to adopt the refocused role framework. Over this period, approximately 15 hours per week of the senior charge nurse s time was lost to providing hospital cover duties. In the fifth month of the development period, there was a concerted effort to change the role of the SCN to be more aligned to the role framework. During this period, hospital cover was removed from her role, she became non caseload holding and consequently was more visible and accessible for staff and patients. Her role in coaching, supporting and providing expert clinical opinion for clinical staff was used to assist in monitoring and improving clinical quality. Time to educate and implement new documentation (falls risk assessment tool and nutritional screening) was available, assisting in improving the compliance to CQI. This is demonstrated in the graph. 16

26 Improved compliance with CQI following introduction of revised SCN role Compliance with CQI with revised SCN role (Cycle 5) Revised SCN role implemented prior to Cycle Food, fluid and nutrition Pressure area care Monitoring and observations Falls 0 Baseline Cycle 2 Cycle 3 Cycle 4 Cycle 5 As the senior charge nurse and her team became more focused upon improving quality and implementing continuous quality improvements, compliance with the CQIs improved. (It is important to note that compliance was measured as having documented evidence, and the increased compliance indicates a marked improvement in record keeping in these areas.) This case study demonstrates the synergy between these two projects and highlights that focus and improvement in quality of care and experience correlates with the introduction of the revised SCN role. Develop a model to ensure continuous review and development of the CQIs One of the recommendations of The Impact of Nursing on Patient Clinical Outcomes was to consider the development of Centres of Responsibility for the development of Clinical Quality Indicators. With the concept of Centres of Responsibility, NHS boards would be responsible for developing CQIs. This would require an element of national coordination and support to ensure that the CQIs developed are prioritised, appropriately tested and valid for use in other NHS boards. A model for indicator development has been adopted and adapted for this purpose (adapted from Lloyd, 2004) (Figure 3). It is noted that there is a potential synergy with the NHS QIS Joanna Briggs Institute (JBI) project ( It is anticipated that access to the JBI system will support the development of further CQIs. 17

27 Figure 3. Model for the Development of Quality Indicators (adapted from Lloyd, 2004) Identify type of indicator (structure, process or outcome) Identify dimension(s) of quality to be measures Select specific indicator Develop clear operational definitions Develop a data collection plan (frequency, stratification issues, sampling design and collection issues) Test and refine Data collection Analysis Action 18

28 Summary of CQI Project The development of CQIs for nursing has a long history. There are now four generic indicators that are applicable across a wide variety of in-patient settings. The model of Centres of Responsibility has been developed to ensure that other indicators in progress for midwives and paediatric, mental health and learning disability nurses will continue to be developed. The focus of these indicators is to support nurses and midwives in delivering improvements in the quality of processes and outcomes of care in their areas. This will be further supported by eqips, which will be ready to be rolled out across Scotland by September This will provide nurses, when they are completing their CQIs compliance, with real-time reports and data to support where they are doing well, and highlight areas that require further work. In the implementation framework set out in the next chapter, CQIs are an important tool for senior charge nurses to establish a continuous quality improvement culture in their areas. 19

29 Section 4 Implementation framework

30 The development phase showed that the synergy between these two projects can drive improvements in practice and that successful implementation of the framework for SCNs is achievable. Senior charge nurses and other stakeholders have welcomed the framework, but its success is dependent on a number of factors, including: the existing knowledge, skill and attitude of individual senior charge nurses the level of support and access to development opportunities available within the organisation the degree of flexibility within existing ward or department establishments. The following implementation framework has, like the two projects, been informed by the views of the stakeholders expressed through written feedback, the consensus conference that was held in January 2008, and the experience of the clinical facilitators. Clinical Facilitator Network informing implementation A key stakeholder group is the Clinical Facilitator Network. This has contributed to the development of the SCN exemplar job description, NHS KSF outline, the CQI dataset and the equips programme. The network worked with senior charge nurses, managers and other stakeholders in the development sites on individual change packages that helped Senior Charge Nurses make the necessary changes to their role. It was therefore important to incorporate the views of the clinical facilitators in implementation plans. These were based on their experience of working at board level regarding the key points for success. These are listed in Table 5 (these have not been prioritised). Table 5. Key points for successful implementation Effective leadership at national level Facilitation within boards Peer groups for facilitators and charge nurses Support and learning across NHS boards Potential resource gap as SCN role revised Accessible toolkit Need director level support in the boards Corresponding action in implementation framework Transitional Steering Group with key stakeholders Funding to support the appointment of clinical facilitators NES to develop a network for SCN implementation Continue with clinical facilitator meetings during transition and implementation Pilot of Productive Ward to release time to care Education and Development Framework for SCNs Exemplar job description KSF outline Implementation plans to have named executive sponsor 21

31 Key Stakeholder Groups informing implementation Stakeholder involvement was integral through the project phase and this has included gathering views from key stakeholders in developing an action plan for implementation. The views outlined below were gathered from written feedback to the stakeholder report and verbal feedback from the consensus conference in January The key areas that were agreed to be important to implementation are listed below: Performance measures To enable NHS boards to include implementation into their corporate objectives. For use at NHS board level to maintain ethos of the CQIs as measures of improvement, not judgement. Develop further links with other national programmes to demonstrate how implementation of SCN Role and CQIs supports NHS boards with delivery of key targets. Qualitative and quantitative measures should be included. Evaluation Formal evaluation of initiative both at national and board level linked to the achievement of performance measures. A national steering group should co-ordinate national evaluation. Local evaluation led by nurse directors. Timescale of evaluation to be on an annual basis for a three year period. Centres of Responsibility for development of CQIs Implement a model for NHS boards to develop further CQIs. Timescale for implementation A lead in time should be included to allow time for boards to plan implementation. After this lead in time, a two year period is allowed for implementation. In summary, analysis of both the responses to the stakeholders, feedback report and qualitative and quantitative data from the conference demonstrates a consensus of opinion. They asked that the final report and action plan should include plans for national coordination of implementation with detailed timescales. The model of a nationally coordinated model of clinical facilitators in each NHS board, implementation of the model of NHS boards as Centres of Responsibility, implementation of performance measures for NHS boards and an evaluation strategy were also supported. 22

32 Implementation and Action Plan Implementation of the Framework for the SCN Role and the Clinical Quality Indicators for Nursing and Midwifery will support NHS organisations to deliver corporate objectives and strengthen organisational approaches to improving patients experience of care. This supports the development of a culture of continuous quality improvement. The framework for implementation is outlined in the action plan in Table 6. The overall aims of the action plan are: for all senior charge nurses working in hospitals across NHSScotland to be working in the context of this revised role by to have CQIs in place in the majority of in-patient areas by the end of The implementation of both the SCN Role and Clinical Quality Indicators has the potential to bring benefits to not only senior charge nurses, their teams, and their organisations, but also to patients, carers and their families. 23

33 Table 6. Action Plan for Implementation Recommendations Related actions Lead responsibility Timescale 1 To implement the Senior Charge Nurse Role and Clinical Quality Indicators by the end of December (Implementation to commence in NHS boards in September 2008.) NHS coards to submit implementation plans to CNO Directorate by end of July NHS Boards July 2008 CNO Directorate to release funding once implementation plans received. CNO Directorate Funding will be released on submission of implementation plans. 2 To develop a national infrastructure to support implementation of revised SCN role and introduction of CQIs across hospitals in NHSScotland. Transitional Steering Group has been formed to establish the required structure of support for the implementation of both the SCN role and CQI roll out. CNO Directorate in partnership with executive nurse directors September To maintain strong communication links between NHS boards and Transitional Steering Group To have regular information sharing at the Scottish Government Nurse Directors Meeting on progress. Chair of Transitional Steering Group in partnership with CNO Directorate Ongoing 4 To monitor progress towards full implementation. NHS boards to submit regular progress reports and contribute to annual evaluation. CNO Directorate (for sending reminders and template for submission) Nurse directors (for submission to CNO Directorate) Baseline of measures to be submitted by December 2008, then timescale for further submissions to be agreed. Transitional Steering Group to develop performance measures to support evaluation process. During implementation phase, Recommendation 17 of the NMWWP project report (Scottish Executive, 2004) will continue to be taken into account while progressing implementation of the SCN Review; as boards achieve full role redesign, the protected time allowance will no longer be required. Transitional Steering Group The NMWWP Programme will ensure there is ongoing monitoring of the implementation of Recommendation 17 in the 2008 annual review of NHS boards progress September