The importance of measurement tools in building a safe environment John Tingle
T
he topic of measurement in patient safety is a very important one as it underpins the whole care process. Outcome measures are needed so that we may judge the success or failure of a care quality process or initiative. Outcome measures in health care can include mortality figures, number of complaints received, adverse incidents, and so on. There is in reality a plethora of outcome measures that can be used. Once the measures have been chosen then delivery systems are generally matched to those measures. For example, if there is an outcome measure based on the number of complaints received about a particular care service then resources normally would follow this measurement with the aim of monitoring and trying to reduce complaints. Resources may well be diverted from other areas in order to do this. The precise mechanism of patient safety and health measurement will have effects throughout the healthcare system so it is very important that they are chosen carefully. The Health Foundation has recently published two papers in this important area: A framework for measuring and monitoring safety (the guide) (Health Foundation, 2014a) and Measuring what really matters: Towards a coherent measurement system to support person-centered care (thought paper) (Health Foundation, 2014b).The Health Foundation is a charity that is helping improve the quality of care in the UK and is working on a number of important patient safety initiatives.
A framework for measuring and monitoring safety
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
534
Frameworks provide a broad template for action that can be tailored to particular environments. This publication functions as a practical guide and introduces a framework along with broad principles and prompts that can be used when applying it. The guide begins with an attempt at justifying the need for a new approach to measuring and monitoring safety in the NHS. The guide recognises that a wealth of data has been and is being collected on patient safety incidents and numerous reports on well-publicised patient safety tragedies. However, it questions how safe our care actually is. The framework contained in the guide includes the following questions that can be asked by those concerned with healthcare quality: ■■Past harm: has patient care been safe in the past?
■■ Reliability: are
our clinical systems and processes reliable? to operations: is care safe today? ■■ Anticipation and preparedness: will care be safe in the future? ■■ Integration and learning: are we responding and improving? (Health Foundation, 2014a: 18–22) The guide elaborates on each of the five questions. For example, on the question relating to past harm, the guide states that there are more ways care can go wrong than right. It provides examples of how and why patient harm might take place: ■■ Delayed or inadequate diagnosis ■■ Failure to provide appropriate treatment ■■ Treatment ■■ Over-treatment ■■ General harm ■■ Psychological harm (Health Foundation, 2014a: 18). The guide goes into further detail on the range of measures that might be included—for example, mortality statistics, systematic record review, and reporting systems. The use of the framework and reflection by health professionals on these questions will lead to a better and clearer understanding of the safety of their healthcare environment that they are working in: ■■ Sensitivity
‘The framework shifts the emphasis away from focusing solely on past cases of harm, and more on real-time performance and measures that relate to future risks and the resilience of organisations’. (Health Foundation, 2014a: 8) Along with the framework’s five underpinning questions the guide contains a number of prompts and key principles for using the framework. The framework is given in Figure 2 of the guide and the five questions appear along with prompts for each. Below is an example of the prompts for the question, ‘Anticipation and preparedness, will care be safe in the future?’: ■■ Don’t wait for things to go wrong before trying to improve safety ■■ Explore new opportunities to develop systematic ways to anticipate future risks ■■ Use a variety of tools and techniques to build an understanding of the factors that give rise to safety issues (Health Foundation, 2014a: 12). The strength of this framework lies in its simplicity and general usability. The relevance of the questions is immediately obvious and the framework is not intimidating. Some templates or frameworks can be worded in a very complex manner and this puts up an immediate barrier between the framework and user. This is not the case with
© 2014 MA Healthcare Ltd
John Tingle discusses two recent publications from the independent charity, the Health Foundation, on patient safety and person-centered care measurement systems.
British Journal of Nursing, 2014, Vol 23, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
patient safety this framework, which is very user friendly, well-structured and highly relevant. Four key principles are provided that users should consider when using the framework: open, thoughtful, reflective and inquisitive. The guide elaborates more on each of the principles. To give a further flavour of the framework, principle four is fully reproduced below: ‘Be inquisitive. The actual process of asking questions, rather than stipulating answers and “ticking them off ”, will increase the sense of ownership of safety in an organisation. An approach which focuses on measures that are helpful in the day-to-day management of care, and that also provides evidence to meet the requirements of external bodies, will offer benefits to staff, patients and the public like’. (Health Foundation, 2014a: 16) Section 6 of the guide includes a list of further resources, publications and websites.
© 2014 MA Healthcare Ltd
Towards a coherent measurement system to support person-centered care Today, post-Francis and the Mid-Staffordshire patient-safety crisis, a new impetus can be clearly seen from government and NHS policy that is putting the patient first in all instances. Recent Department of Health patient-safety publications and government policies all can be seen to evoke a clarion call that today’s NHS should be ‘patient-centric’ and an ingrained patient safety culture should permeate throughout. All this is easier said than done and a massive culture change will not happen overnight. It can be said, however, that incremental progress is being made in this regard and that the NHS is going in the right direction, albeit fairly slowly. This new publication (Health Foundation, 2014b) will help focus health professionals’ attention on the development of measurement systems to support person–centered care. It takes as its central focus a hypothetical elderly patient, ‘Dorothy’, who has a number of long-term medical conditions. The thought paper advances ideas about how a healthcare system and the measures within it can best serve Dorothy’s needs. Principles of person-centered care are described within different contexts and consideration is given to using the right measurement systems. In section 2 of the thought paper four generic principles underpinning person-centered care are listed: ■■ Being person-centered means affording people dignity, respect and compassion (author’s emphasis) ■■ Being person-centered means offering coordinated (author’s emphasis) care, support or treatment ■■ Being person-centered means offering personalised (author’s emphasis) care, support or treatment ■■ Being person-centered means being enabling (author’s emphasis). (Health Foundation, 2014b: 5) The principles are described within the thought paper as overlapping, providing an operating framework and the essential ingredients of a person-centered system that can be mixed together in different degrees, depending in which
British Journal of Nursing, 2014, Vol 23, No 10
context they are being used. Section 3 of the thought paper discusses the implementation of the principles. Personcentered activities are described as: ‘Collaborative care and support planning, selfmanagement support and shared decision making are activities which can ensure that services reliably deliver the person-centered care and support principles’. (Health Foundation, 2014b: 7) Section 4 of the thought paper deals with the issue of matching person-centered activities to the clinical context. Other sections deal with other key issues. Section 6 and 7, for example, look at measurement and logic models. The thought paper presents a person-centered logic model if Dorothy were to experience a heart attack (in figure 5).The model described has five stages: admission and stabilisation, in-hospital recovery, point of discharge, recovery at home, and outcome. Next to each stage are a number of personcentered outcomes. For example, the outcomes in stage 2 of the model are: ■■ Shared decision making about treatments ■■ Support to self-manage in hospital instituted ■■ Coordination of care as Dorothy moves from coronary care unit to ward. (Health Foundation, 2014b: 13). This thought paper is detailed and thorough in its analysis of issues. Concepts are clearly explained and the construction of the Dorothy character provides a realistic peg on which to hang the discussion. The analysis is thought-provoking and, if widely adopted, will function as a real boost to the implementation of a person-centered health focus in care delivery.
Conclusion Sadly, in the past there has been very little conceptual underpinning in NHS patient-safety and health-quality initiatives. Clinical risk management schemes and regulatory NHS ‘arm’s length’ bodies have been created in a seemingly reactive uncoordinated manner to deal with the latest crisis. There has been a history of over- and uncoordinated health quality, patient-safety regulation in the NHS with no distinct reliance or underpinning on academic theory. This appears to be changing and a distinct body of patient safety, health quality, and academic literature has been developing in recent years. The two publications discussed are prime examples of BJN the excellence that can be achieved in this area. Health Foundation (2014a) A framework for measuring and monitoring safety, Health Foundation, London. http://tinyurl.com/lnyjmjp (accessed 13 May 2014) Health Foundation (2014b) Measuring what really matters, towards a coherent measurement system to support person-centered care. Health Foundation, London. http://tinyurl.com/llg9ppd (accessed 13 May 2014)
535
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
T
he topic of measurement in patient safety is a very important one as it underpins the whole care process. Outcome measures are needed so that we may judge the success or failure of a care quality process or initiative. Outcome measures in health care can include mortality figures, number of complaints received, adverse incidents, and so on. There is in reality a plethora of outcome measures that can be used. Once the measures have been chosen then delivery systems are generally matched to those measures. For example, if there is an outcome measure based on the number of complaints received about a particular care service then resources normally would follow this measurement with the aim of monitoring and trying to reduce complaints. Resources may well be diverted from other areas in order to do this. The precise mechanism of patient safety and health measurement will have effects throughout the healthcare system so it is very important that they are chosen carefully. The Health Foundation has recently published two papers in this important area: A framework for measuring and monitoring safety (the guide) (Health Foundation, 2014a) and Measuring what really matters: Towards a coherent measurement system to support person-centered care (thought paper) (Health Foundation, 2014b).The Health Foundation is a charity that is helping improve the quality of care in the UK and is working on a number of important patient safety initiatives.
A framework for measuring and monitoring safety
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
534
Frameworks provide a broad template for action that can be tailored to particular environments. This publication functions as a practical guide and introduces a framework along with broad principles and prompts that can be used when applying it. The guide begins with an attempt at justifying the need for a new approach to measuring and monitoring safety in the NHS. The guide recognises that a wealth of data has been and is being collected on patient safety incidents and numerous reports on well-publicised patient safety tragedies. However, it questions how safe our care actually is. The framework contained in the guide includes the following questions that can be asked by those concerned with healthcare quality: ■■Past harm: has patient care been safe in the past?
■■ Reliability: are
our clinical systems and processes reliable? to operations: is care safe today? ■■ Anticipation and preparedness: will care be safe in the future? ■■ Integration and learning: are we responding and improving? (Health Foundation, 2014a: 18–22) The guide elaborates on each of the five questions. For example, on the question relating to past harm, the guide states that there are more ways care can go wrong than right. It provides examples of how and why patient harm might take place: ■■ Delayed or inadequate diagnosis ■■ Failure to provide appropriate treatment ■■ Treatment ■■ Over-treatment ■■ General harm ■■ Psychological harm (Health Foundation, 2014a: 18). The guide goes into further detail on the range of measures that might be included—for example, mortality statistics, systematic record review, and reporting systems. The use of the framework and reflection by health professionals on these questions will lead to a better and clearer understanding of the safety of their healthcare environment that they are working in: ■■ Sensitivity
‘The framework shifts the emphasis away from focusing solely on past cases of harm, and more on real-time performance and measures that relate to future risks and the resilience of organisations’. (Health Foundation, 2014a: 8) Along with the framework’s five underpinning questions the guide contains a number of prompts and key principles for using the framework. The framework is given in Figure 2 of the guide and the five questions appear along with prompts for each. Below is an example of the prompts for the question, ‘Anticipation and preparedness, will care be safe in the future?’: ■■ Don’t wait for things to go wrong before trying to improve safety ■■ Explore new opportunities to develop systematic ways to anticipate future risks ■■ Use a variety of tools and techniques to build an understanding of the factors that give rise to safety issues (Health Foundation, 2014a: 12). The strength of this framework lies in its simplicity and general usability. The relevance of the questions is immediately obvious and the framework is not intimidating. Some templates or frameworks can be worded in a very complex manner and this puts up an immediate barrier between the framework and user. This is not the case with
© 2014 MA Healthcare Ltd
John Tingle discusses two recent publications from the independent charity, the Health Foundation, on patient safety and person-centered care measurement systems.
British Journal of Nursing, 2014, Vol 23, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
patient safety this framework, which is very user friendly, well-structured and highly relevant. Four key principles are provided that users should consider when using the framework: open, thoughtful, reflective and inquisitive. The guide elaborates more on each of the principles. To give a further flavour of the framework, principle four is fully reproduced below: ‘Be inquisitive. The actual process of asking questions, rather than stipulating answers and “ticking them off ”, will increase the sense of ownership of safety in an organisation. An approach which focuses on measures that are helpful in the day-to-day management of care, and that also provides evidence to meet the requirements of external bodies, will offer benefits to staff, patients and the public like’. (Health Foundation, 2014a: 16) Section 6 of the guide includes a list of further resources, publications and websites.
© 2014 MA Healthcare Ltd
Towards a coherent measurement system to support person-centered care Today, post-Francis and the Mid-Staffordshire patient-safety crisis, a new impetus can be clearly seen from government and NHS policy that is putting the patient first in all instances. Recent Department of Health patient-safety publications and government policies all can be seen to evoke a clarion call that today’s NHS should be ‘patient-centric’ and an ingrained patient safety culture should permeate throughout. All this is easier said than done and a massive culture change will not happen overnight. It can be said, however, that incremental progress is being made in this regard and that the NHS is going in the right direction, albeit fairly slowly. This new publication (Health Foundation, 2014b) will help focus health professionals’ attention on the development of measurement systems to support person–centered care. It takes as its central focus a hypothetical elderly patient, ‘Dorothy’, who has a number of long-term medical conditions. The thought paper advances ideas about how a healthcare system and the measures within it can best serve Dorothy’s needs. Principles of person-centered care are described within different contexts and consideration is given to using the right measurement systems. In section 2 of the thought paper four generic principles underpinning person-centered care are listed: ■■ Being person-centered means affording people dignity, respect and compassion (author’s emphasis) ■■ Being person-centered means offering coordinated (author’s emphasis) care, support or treatment ■■ Being person-centered means offering personalised (author’s emphasis) care, support or treatment ■■ Being person-centered means being enabling (author’s emphasis). (Health Foundation, 2014b: 5) The principles are described within the thought paper as overlapping, providing an operating framework and the essential ingredients of a person-centered system that can be mixed together in different degrees, depending in which
British Journal of Nursing, 2014, Vol 23, No 10
context they are being used. Section 3 of the thought paper discusses the implementation of the principles. Personcentered activities are described as: ‘Collaborative care and support planning, selfmanagement support and shared decision making are activities which can ensure that services reliably deliver the person-centered care and support principles’. (Health Foundation, 2014b: 7) Section 4 of the thought paper deals with the issue of matching person-centered activities to the clinical context. Other sections deal with other key issues. Section 6 and 7, for example, look at measurement and logic models. The thought paper presents a person-centered logic model if Dorothy were to experience a heart attack (in figure 5).The model described has five stages: admission and stabilisation, in-hospital recovery, point of discharge, recovery at home, and outcome. Next to each stage are a number of personcentered outcomes. For example, the outcomes in stage 2 of the model are: ■■ Shared decision making about treatments ■■ Support to self-manage in hospital instituted ■■ Coordination of care as Dorothy moves from coronary care unit to ward. (Health Foundation, 2014b: 13). This thought paper is detailed and thorough in its analysis of issues. Concepts are clearly explained and the construction of the Dorothy character provides a realistic peg on which to hang the discussion. The analysis is thought-provoking and, if widely adopted, will function as a real boost to the implementation of a person-centered health focus in care delivery.
Conclusion Sadly, in the past there has been very little conceptual underpinning in NHS patient-safety and health-quality initiatives. Clinical risk management schemes and regulatory NHS ‘arm’s length’ bodies have been created in a seemingly reactive uncoordinated manner to deal with the latest crisis. There has been a history of over- and uncoordinated health quality, patient-safety regulation in the NHS with no distinct reliance or underpinning on academic theory. This appears to be changing and a distinct body of patient safety, health quality, and academic literature has been developing in recent years. The two publications discussed are prime examples of BJN the excellence that can be achieved in this area. Health Foundation (2014a) A framework for measuring and monitoring safety, Health Foundation, London. http://tinyurl.com/lnyjmjp (accessed 13 May 2014) Health Foundation (2014b) Measuring what really matters, towards a coherent measurement system to support person-centered care. Health Foundation, London. http://tinyurl.com/llg9ppd (accessed 13 May 2014)
535
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
