The author has been assigned the task of critically reviewing mechanisms used to monitor and audit the quality in care services with reference to their own practice experiences.

The author has been assigned the task of critically reviewing mechanisms used to monitor and audit the quality in care services with reference to their own practice experiences. Part two of the assignment will describe in detail methods of utilising resources effectively to achieve maximum quality outcomes.

Task 1

For professionals working with clients it may seem that quality of care has always been an issue of importance. Most work places will have some sort of quality assurance system in place and it is assumed that quality can therefore be measured. As definitions relating to quality tend to be less concrete, measuring quality is a complex matter. One mechanism used to monitor quality is the audit. The audit in healthcare is used to examine the outcomes resulting from the utilisation of resources, and it is not restricted simply to an examination of the quality of outcome; it could involve themes such as equity, acceptability and effectiveness. Audits can be carried out at a ward / team, departmental, Unit, District or regional level. Audits can be internal – organised by internal auditors of the organisation, or external – e.g. through Registration and Inspection Units. The audit will be discussed in depth later on in the task.

There is a definite relationship between quality and the processes of management in the care sector. Quality Control refers to a methodology for ensuring that specific standards of care are attained. Based on methodologies adapted within the industrial sector where the processes of production, and the outcomes from production, are generally clearly defined. In health and care this clarity does not always exist, making effective quality control more complex. We can relate this process – outcome to Donabedian who developed a conceptual approach for the examination of how an organisation functions; Donabedian’s approach examines Structure, Process and Outcome. This conceptualisation can be used to facilitate the examination of quality in a multidisciplinary setting as it provides a framework that allows for different interpretations by different service delivery agencies or organisations.

The NSF (National Schizophrenia Fellowship) has a ‘Quality Promise’ statement that pledges the following:

To plan and deliver quality services.
To meet the agreed needs of people using our services effectively, consistently and in line with equal opportunities.
To enable the people who use and the people who deliver our services to achieve their potential.
To strive constantly for improvement.

In order to achieve this, quality standards had to be developed.

A standard is: ‘an explicit statement defining a desired level of performance’.

It describes what should be done, who should be doing it, when it should be done and what records should be kept. Standards do not describe how a task should be carried out, as this is described in national or service operational policies or procedures.

In 1998 the Quality Focus group developed Quality Standards for all NSF’s Day and Employment Services. These standards were set with full involvement of staff at all levels, users, carers and Board of Trustees. There are twenty-six standards in total, however some standards only apply to certain services. Each standard comprises a reference number (1 – 26), a title, a statement of the standard and the elements (sometimes referred to as criteria), which describe the actions that services take to ensure that a standard is met.

In house training was provided to guide services as to how they should review their operation against all the Quality Standards using specific assessment techniques. The assessment process is based on the collection of evidence of compliance with the standard; evidence can be gathered in the following ways:

Talking to – questioning service users, staff, volunteers.
Observing practice.
Examining records.
Reviewing working practice.
Collecting / capturing statistical information sampling.

In some circumstances there will be no action required following assessment; however there will be instances where services do not comply with the standard – either the entire standard or more usually some of the elements within the standard. In this case the service will consider how to achieve compliance and identify the necessary action points.

For the purpose of this assignment the author will give reference to one of NSF’s Quality standards by way of example:

Involvement of people who use the service

People who use the service are actively invited and enabled to be involved in ...

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For the purpose of this assignment the author will give reference to one of NSF’s Quality standards by way of example:

Involvement of people who use the service

People who use the service are actively invited and enabled to be involved in all aspects and at all stages of the planning, delivery and monitoring of services.

In order to achieve this services must be able to adhere to certain elements (see appendix 1). Before assessing the service against this standard a plan must be put together to determine how the standard is to be evaluated, what evidence is to be collected, timescale and resources needed to undertake the assessment. This is recorded on the planning assessment form.

The Planning Assessment Form (see appendix 2)

A separate planning assessment form is used for each standard, to complete this form one must enter the reference number and title of the standard being monitored and the individual elements. It must be determined how each standard element is to be assessed. The expected start and end dates are entered in the appropriate field. These should be reviewed regularly to check progress.

The Assessment and Action Form (see appendix 3)

A record of the assessment must be kept whether or not it has been achieved, what evidence has been obtained and any actions that should be made to enable the service to meet the standard or improve on what it already does. Completion of this form allows each service to monitor its own progress on meeting each standard. Each form contains a table that needs to be completed each time a specific standard is reviewed and a standard element (A, B, C, etc), while each column is used to demonstrate progress on achieving it – ‘Not yet achieved’, ‘Unable to complete’ and ‘Achieved’. The remaining columns illustrate what evidence is being used to prove that each standard element has been met and any actions that should be taken where they are not being met.

Standstill Form (see appendix 4)

In order to see at a glance what progress has been made, in assessing and subsequently taking action, on each standard and standard element, services are required to complete a ‘Standstill Form’ (see appendix 4) at the end of each month. The current status of each standard element is noted by entering the element letter into one of the three columns – not yet achieved, unable to achieve, achieved. If all elements are completed then the date of completion should be entered.

Internal Audits

Each service will be audited by a NSF manager from a different operations area, trained in auditing techniques accompanied by a user of a similar service. The director of Service Development, produces an audit plan for the year that will be agreed by the operations N.I Directors. Directorate meetings will discuss the audit plan and let the relevant services know the timetable. The auditors discuss with the Service Manager prior to the audit:

-Scope

-Objective

-Who is to be involved and how

-Timescales

-Forms to be completed and other information provided.

The Service Manager is to complete and return copies of the Assessment and Action Forms and the Services Operational Plan to the auditors. After which the auditors carry out the inspection and prepare a draft report with recommendations for action. The auditors, Service Manager and Line Manager will then meet to agree the contents of the report and recommendations. A final draft of the report is then made and sent to the Service and Line Managers. It is the responsibility of the Line Manager to ensure that the service implements any recommendations.

External audits

NSF Services such as the ‘Fortwilliam Haven Residential’ as well as being internally audited, will receive visits from the ‘Registration and Inspection Unit’. The main aim of the Registration and Inspection Unit is to register, monitor and inspect care units in order to promote and actively encourage the development of a good standard of residential care services. This in turn will directly and positively influence the quality of life for the users of these services. The Unit is detached, objective and free from any outside influence. They have explicit values and measurable standards which will be agreed and made known across all sectors. The same standards are applied across the Voluntary, Private and Statutory services in order to maintain a consistent method of inspection. All inspection reports will be published and made available to the public. Again like the NSF’s auditing process these inspections will fully involve the providers and users of the service in the evaluation of the service provided. Two formal inspections take place - one announced and one unannounced. Units are given four to six weeks notice with request for completion of checklist / questionnaires in advance, as a starting point for engaging Units and managers in the process. The inspection is the evaluation of a service at a particular point in time, including:

-The resources devoted to the provision of the service.

-The processes involved in provision of the service.

-The quality and quantity of service provisions.

-The quality of life of the users.

This is done through an inspection of the building by the ‘Estate Services Officer’, an inspection of the administrative records / management systems and finally an evaluation of service through interview with residents, relatives and staff. On completion of the inspection verbal feedback is given and includes both identification of good practice and where there are concerns in any structure or practice. The inspector also offers constructive advice on how improvements might be made. Agreed further action and timescales are negotiated. All discussions and observations are recorded and complied into a detailed written report.

The value to staff and service users of the NSF in the quality control process, is knowing beyond doubt that their service fully complies with the NSF’s standards. It is a chance to identify those areas causing concern and take action were it is needed and as a result an improved quality service is provided. Participants do not have to operate alone as it is a multi dimensional process involving different professionals and service users. The service users involvement throughout this process is imperative as it encourages motivation, increases empowerment and promotes a feeling of ownership. Although time consuming to begin with, once practiced, ultimately standards will enable service managers to manage more efficiently and effectively, leaving less room for negligence and as a result negligence claims. The standards will enable services to be less vulnerable to external pressures and externally set measures, as each service will be able to demonstrate that they are meeting or working towards achieving the NSF Standards.

As the NSF is continually seeking to improve and to offer services nationally, standards are therefore part of this process to ensure that what is being offered at one service in any part of the country is of the same standard as another similar service in any other part of the organisation. The External audit by the Registration and Inspection Unit will give both service users and potential service users peace of mind that the service has been evaluated by an external, objective and non-biased agency. Their open system of reporting means that anyone can access reports on any service. Funders will only consider contract providers who are in a quality system; it is also in the best interests of the NSF who rely on funding to have these procedures in place.

However as there are advantages to this process there are also some disadvantages. Evidencing is quite time consuming and can contribute to a culture whereby there is more attention paid to the letter of the law than the spirit of the law. A lack of resources such as expertise, finance and training may make it difficult to successfully implement these quality-auditing mechanisms. Some staff will have a resistance to change as the whole process requires much re-organisation. As audits are planned and arranged, services are given plenty of warning as to when they will take place and can prepare for the auditors visit; therefore it is hard to say how true the results from the audit actually are.

As all agencies are different in the service that they provide, is it useful to audit the same standards of each service? Although it produces consistent results, there is a danger of overlooking elements that are of more relevance to a particular type of service e.g. the NSF employment based service at Magherafelt has a workshop in which they produce various pieces of furniture, obviously Health and Safety is going to be one of the biggest issues here and should therefore be given priority over all other standards. It would perhaps be more practical to modify each audit to the service being audited.

Task 2

It is all very well having quality systems in place, but to actually achieve total quality requires more. Total quality isn’t a system, it’s behaviour - it requires every member of staff to: be committed, co-operate, communicate and have the right skills, knowledge and attitude. Outcomes can be improved without increasing the resource input; equally they can deteriorate on a fixed or increasing resource input. Shared values, a common purpose and a shared knowledge can facilitate an improvement in the quality of care and the resulting outcomes. Staff at all levels should be aware that providing a poor quality service can actually prove more costly than providing a good quality service. Staff must feel that their contributions are important in the delivery of care. The aim is to establish a quality culture, with staff involvement as the key ingredient. Again this requires more than training staff in mechanical and statistical techniques. It means educating the workforce in the new way of doing things.

Establishing effective channels of communication is vital; team identity is strongest when all members know the common goal and are clear about how to achieve it. Monthly or quarterly newsletters are a good medium to generate a sense of belonging among employees. Such newsletters can be used to highlight problems, commend good performance, enhance training efforts or introduce new practices. Circulating good practice benefits and encourages others. It motivates people to higher endeavours and passes on experience without coming across to others as being condescending.

Good communications are essential if staff and service users are to share, know and understand the quality initiatives that are to be introduced. In order to achieve good communication within an organisation requires an identification of those staff that need to be informed. These staff can form a communication network. The communication network should address both who is involved, who should be involved and how much they need to know. Those people in the network need to understand the rationale for the network and their importance of their role in it. As quality is a comprehensive issue in which staff from almost every department and function need to be involved, all staff groups should be taken into consideration when identifying the network as they are generally inter related and cannot function in isolation if they are to provide care effectively. Team meetings help to brake down barriers between departments and are a good channel of informing other professionals about service improvements. Where possible communication should take place face to face, this ensures that the message is received and understood. During talks it is important to listen to everyone, communication is a two way process. People’s opinions must be valued; examining different ideas produces innovative solutions. Important things should be noted in writing in order to eliminate confusion, e.g. minutes; verbal agreements leave room for interpretation.

Management plays an important role in the process of achieving maximum quality outcomes. The role of the manager is to manage! To manage resources - people, things and ideas e.g. manpower, equipment and finance. The manager is responsible for managing the resources effectively and efficiently. Managers are appointed to ensure that the outcome is achieved in a satisfactory manner and that the end product is a quality outcome. Management is a big responsibility and involves competency in all areas. They should have the appropriate skills knowledge and attitude for the job.

Service managers should demonstrate a high level of professional competence and leadership and a strong commitment to high standards. A good manager will create confidence and inspire others, promote and represent the service effectively. They should be approachable, helpful and impartial with all staff, and have an accurate picture of the demands placed on staff and of the tasks they are expected to perform. They should be able to communicate effectively using understandable language and terminology and listening to what people have to say. It is also important that they are able to handle confrontation skilfully.

Service managers play a central role in promoting a positive ethos and in promoting teamwork throughout the service. They should encourage staff to develop initiative and leadership in relation to their own work. Service managers can establish, in discussion with colleagues, the core values and priorities of the service, supporting all staff in practising effectively within agreed parameters and standards, as described in service policies and guidelines.

Everyone involved needs a thorough understanding of the overall concept of quality assurance and how it will affect him or her and their role in the quality programme. They should also gain some understanding of the value of the quality assurance programme to themselves, the client, other staff and the organisation as a whole.

To ensure maximum use of information and at the same time maintain the trust and commitment of staff, the issue of who receives what information requires careful consideration. The circulation of detailed information needs careful negotiation with the clients. Confidentiality should be adhered to were appropriate for e.g. making service users satisfaction surveys anonymous.

Above all the service should adhere to standards of practice that derive from policies operating within the law and legislation. These are set out in well-designed written policies and practice guidelines in relation to key aspects of service provision and are regularly monitored and reviewed. This will include ‘the Code of Conduct’ and ‘Equality of Opportunity Policy’. Legislation that may be relevant to care services is:

Human Rights Act
Disability Discrimination Act
Mental Health Order

To conclude, the author, has detailed various methods of using resources effectively to obtain maximum quality outcomes; but we have not yet discussed what that quality outcome may be. Any business or service whether in the industrial or care sector strives to satisfy the customer, to meet their needs. In the case of health and care practice, basic needs can be defined as: physical, psychological, spiritual and sociological. It is important that these needs are met in order for survival. How these needs are met will determine the quality of life a person has.