Today's healthcare environment dictates that management decisions are clinically sound, operationally efficient, financially responsible and supportive of current health service strategic initiatives and policies.

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INTRODUCTION

Today's healthcare environment dictates that management decisions are clinically sound, operationally efficient, financially responsible and supportive of current health service strategic initiatives and policies. Furthermore, it is also recognised that clinical decisions should be based on the best possible evidence of effectiveness (National Health Service Executive, NHSE 1998).

However, there has been increasing recognition that many practices in health care are based on tradition or local circumstances. Some commentators assert that healthcare suffers from a lack of relevant, comparative information based on clinical outcome measures (Teisberg, Porter and Brown, 1994).

The National Health Service in the United Kingdom (UK) is being encouraged to ensure uniform provision of high quality health care (Department of Health, DoH 1997). According to Ellis (2000a), the concept of quality as it relates to health care is a complex, seldom defined and requires constant analysis and clarification. Notwithstanding this, the modern health service has extended the requirements for assured quality of care by introducing the notion of clinical governance (DoH 1998) which suggests that quality can be identified, evaluated and managed (NHSE 1998).

Ellis (1995) put forward the idea that clinical practice benchmarking might be one evaluative technique available to nurses that provides a quality assessment framework and a cycle of continuous quality improvement which supports the development of quality of care. With her colleagues from the University of Central Lancashire and Preston Acute Hospitals NHS Trust, Judith Ellis demonstrated the value of clinical benchmarking in paediatric services by developing a series of benchmarks to inform practice during the 1990s. The success of this work led to the development of benchmarking networks in other areas of nursing practice and health visiting. Culminating in the development of a set of national benchmarks and an accompanying toolkit which was published in 2001 (Essence of Care, DoH 2001).

The benchmarking toolkit 'The Essence of Care: Patient focussed benchmarking for health care practitioners' (DoH 2001) is recognised as the first nurse led quality assurance (QA) process aimed specifically at improving patient outcomes to be developed in over a decade. As such, it has received great attention from the nursing community since its release nearly two years ago and has been compared to both the nursing process and clinical audit as a quality improvement cycle.

However, despite the expression of enthusiasm for the principles of clinical benchmarking from the nursing community across the UK. It is recognised by many commentators (e.g Bland 2001) that the toolkit developed to assist nursing staff to evaluate and compare local practice is unnecessarily complex with terminology that is confusing to the uninitiated. Thus, the development of benchmarking has been thwarted in some health care settings by the lack of clarity in regard to the implementation process. White (2002) suggests that the philosophy of the benchmarking process, which originates from mass manufacturing and serves to weaken the notion of individualised care. In addition to this White (2002) asserts that the national toolkit concentrates on what should be done to improve patient outcomes and does not offer guidance on how to achieve this.

Furthermore, there is also a need to ensure that benchmarking is clearly situated within the organisation's governance framework and is aligned with other quality assurance techniques such as clinical audit, special cause variation analysis and capacity planning (Fitzgerald, 1998). This will ensure that nursing and business managers are informed of potential practice changes (e.g via trust audit and research forums, clinical governance meetings, clinical group reviews etc) as well as the clinical staff involved in the exercise. Involving health care management should be seen as an essential component of the change management process as additional resources are often key to the implementation of practice changes (Ellis, 1998).

My empirical experience of clinical benchmarking activity as the head of clinical effectiveness at a large district general hospital, is that little interface exists between modernisation initiatives, clinical audit programmes and the development and implementation of benchmarking processes. Thus, it is often difficult to identify benchmarking activity and support practice changes when it is not recognised corporately and the concept of benchmarking is not promoted centrally.

As Fitzgerald (1998) points out, benchmarking as a process of information gathering will not provide stringent directives for health care but it is an important activity because but it can be used to keep abreast of current trends and provide best practice justifications for decisions and local policymaking. It is clear from the experiences of our American colleagues that benchmarking can be a useful clinical and managerial tool but little is known about the impact of the introduction of benchmarking in the UK (Cole, 2000).

The problem lies in part, with the fact that benchmarking in nursing practice is a relatively new concept in the UK and structures have not yet been developed to support the implementation of the national benchmarks. A second challenge stems from the fact that unlike our medical colleagues, nurses are not afforded protected time for evaluating practice and as such the practical problem of convening meetings which all the key stakeholders can attend contributes to the lack of progress. Similarly, the lack of protected time for clinical practice in the nursing profession has also been cited by many commentators as a contributory factor for the failings of clinical audit as a change management process (e.g Crombie et al, 1995). Finally, the complexity of the toolkit itself has led to confusion and simplification of the steps required is necessary before the process is likely to be adopted nationally.

It is clear from the discussion so far, that the extent to which benchmarking has been adopted in health care organisations since the launch of the national toolkit in 2001 has not been quantified. Nor has a mechanism for sharing best practice experiences been established in the UK. If benchmarking is to become embedded in nursing practice it is important that a transparent process for implementing benchmarking is established and that the reflections of practitioners with experience of benchmarking are widely published for others to learn from.

In brief, this dissertation sets out to examine the current literature in relation to the implementation of benchmarking processes in order to determine what factors contribute to the successes and failures of the benchmarking exercises in regard to practice changes. The dissertation also offers a proposal for further research to examine the exposure and experiences of nurses in regard to benchmarking from a wide range of health care settings. In an attempt to gauge the extent to which benchmarking has been adopted across the UK and to learn from the experience of practitioners involved in evaluative exercises.

AIMS OF THE DISSERTATION

The main aims of the study are to provide a critical appraisal of the literature and to offer a research proposal to explore nurses exposure and experiences of the introduction of benchmarking.

The literature review will examine the evidence in regard to the development and implementation of benchmarking exercises in nursing practice since the introduction of the concept in the mid-nineties. The review will concentrate on examining the literature in relation to the extent to which the authors describe the challenges and successes of the evaluations and what factors play a part in contributing to the success or failure of the benchmarking exercises.

The literature review will also seek to describe the development of benchmarking as a quality assurance (QA) tool in health care and the accepted model's used in nursing practice today. Secondary aims of the literature review are to include a brief account of the development of QA in healthcare since the 1970s, with particular reference to the evaluation of nursing practice.

The purpose of the research proposal is to outline a multi-method study to explore nurse manager's exposure to and opinions on the introduction of benchmarking and the extent to which benchmarking activity is taking place in their health care organisation. A more detailed account of the research proposal can be found on page 27.

LITERATURE REVIEW

The development of quality assurance in health care and the development of clinical practice benchmarking as a quality assurance tool

The development of health economics as a discipline has contributed greatly to the atmosphere of questioning and scepticism about the effectiveness of medicine in particular and health care in general (Mooney 1992). Sackett et al (1998) suggest that this is because medical treatments were often chosen through deduction on the basis of knowledge of pathophysiology and knowledge of the immediate physiological effects of particular treatments. Systematic study of the outcomes of such treatments did not become a feature of medical management until the development of QA models in the 1970s.

The QA agenda was borne out of growing concern regarding the organisation and functioning of the NHS during the 1950s and 1960s (e.g several scandals in the mental health sector). It was during the 1970s that the assumption made at the creation of the NHS, that the professional competence of the medical profession was the best guarantee of an acceptable level of medical care began to be questioned. In addition to this, economic instability led to a financial crisis in the UK, which also affected public sector funding. This prompted health care providers, professionals and politicians to consider how the increasing level of expenditure on health care might be controlled and whether it would be feasible to develop mechanisms for ensuring that the money was spent appropriately (Morris and Bell 1995).

Edgell and Duke (1991) assert that the 'Thatcher government' was 'ideologically committed to the reduction of public expenditure as a goal in its own right' and 'value for money' was central to policymaking for the public sector. Morris and Bell (1995) describe how the introduction of general managers and 'managerialism' into the NHS in the 1980s was intended as a move toward more coherent planning and cost control by the Conservative government. The idea of 'managerialism' involved the development of performance indicators and the setting of standards as a means of quality measurement.

The introduction of the health care management, the notion that the medical profession needed 'managing' and the need to demonstrate that medical care was both clinically and cost effective inevitably led to conflict between health care managers and the medical profession (Morris and Bell 1995).

However, medicine was not the only profession subjected to managerial scrutiny. Nursing and other health care professions and the functioning of the entire service was subject to review and reforms. The reforms of the 1990 NHS and Community Care Act (DoH 1989) served to increase the pressure to deliver cost effective services by building that pressure into the system of the internal market. Furthermore, the 1990 Act included an explicit requirement for compulsory medical audit (DoH 1989) which provided an incentive for the development of more sophisticated methods of quality measurement.
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In the context of QA, audit can be described as a system of monitoring and checking to establish if quality is being delivered against a set of agreed standards. The Department of Health (DoH 1993) describes it as 'the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient'. The whole process can be represented in an audit cycle. Crombie et al (1995) describes the key steps necessary to complete the audit cycle. The steps include ...

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