Quality Standards in the National Service Framework - Literature review Example

Running Head: QUALITY STANDARDS IN THE NATIONAL SERVICE FRAMEWORK QUALITY STANDARDS IN THE NATIONAL SERVICE FRAMEWORK [Name Of Student] [Name Of Institution] INTRODUCTION The most simple definition of quality is a 'degree of excellence; general excellence' (Oxford Dictionary of Current English, 1994). However, such a general statement is of little use in assessing health or social care, where the specific dimensions of quality need to be considered. Readers of the North American literature may find that quality is limited to the scientific-technical ability of health staff and the humanity with which care is delivered (Black, 2000). Although both of these are important, such a definition could lead to superbly technical and human services, which were also ineffective, inequitable and inefficient. A better and broader definition states that quality of health care should include: Effectiveness (achieving the intended benefits in the population, under usual conditions of care); Acceptability and humanity (to the consumer and the provider); Equity and accessibility (the provision and availability of services to everyone likely to benefit); and Efficiency (greatest benefit for least cost). (Shaw, 1999; Black, 2000) Within acceptability and humanity, many professionals would also include mechanisms to empower patients and their families--so that they may in-crease control over the services received. Each patient should also be offered appropriate care, i.e. the selection, from the body of available interventions that have been shown to be efficacious for an illness, of the intervention that is most likely to produce the outcomes desired by that individual patient (Working Group of the NHS Management Executive, 2004). AIM OF THE PAPER The aim of this paper is to assess that whether national service frameworks and quality standards are necessary for improving services, and is there evidence that they are working. Moreover for this purpose I have used the healthcare sector as a case example as I believe that it is the most critical service framework that is of prime importance to the common man. MECHANISMS TO IMPROVE QUALITY Examples of mechanisms to improve quality include: clinical review and presentations, clinical audit, quality assurance, patients' charters, etc. Some of the widely accepted definitions are shown in Table 1. Numerous mechanisms exist to monitor and improve the quality of care for patients and families. These can be categorized according to two axes: first, who carries out the quality assessment--the local clinicians, managers or external organization; and second, whether the quality assessment considered the care of an individual or a few patients, or the whole organization or population. Common mechanisms to improve quality according to these two axes--internal vs external and individual vs organization/population--are shown in Fig. 1. The type of appropriate quality monitoring is determined by the setting. It is extremely difficult for those purchasing the services or external bodies to assess the clinical quality of care. Instead they are more likely to rely on organizational or environmental standards or when determining whether the professionals are employing proven high quality treatments, correct staff-mix and carrying out their own programmes of clinical audit. EVALUATING THE QUALITY OF SERVICES ASPECTS CONSIDERED IN EVALUATION Evaluation is the systematic and scientific method of determining whether a therapy or preventive act is successful in achieving pre-determined objectives (Shaw, 2000). When evaluating health services these can usually be considered in terms of: (a) structure/or inputs: resources in terms of manpower, equipment and money; (b) process: how the resources are used (such as domiciliary visits, beds, clinics); (c) output: productivity or throughput (such as rates of clinic attendance or discharge, throughput); and (d) outcome: achievement of intended change in health status or quality of life (Shaw, 2004). Structural aspects influence the process of care so that its quality can be either diminished or enhanced. Similarly changes in the process of care, including variations in its quality, will influence the output, and in turn the effect of care on health status and outcomes. Thus there is a functional relationship between these in that: structure --> process --> output --> arrow outcome. In evaluations structure is easiest to measure because its elements are the most stable and identifiable. However, it is an indirect measure of the quality of care and its value depends on the nature of its influence on care (Donabedian, 2000). Structure is relevant to quality in that it increases or decreases the probability of a good performance. Process is one step closer to changes in the health status of individuals. The advantage of process is that it measures the most immediately discernible attributes of care activities. However, it is only valuable as a measure once the elements of process are known to have a clear relationship with the desired changes in health status (Donabedian, 2000). Outcome reflects the true change in health status, and thus is the most relevant for patients and society. However, it is difficult to eliminate other causes for change, such as prior care. A useful approach is to focus on the difference between the desired outcome and the actual outcome (Shaw, 2000). Services can then identify whether or not their goals are being achieved and investigate any failings. Organizational evaluations tend to assess the structure and process of care, whereas clinical and medical evaluations often measure the process and outcome of care. This is important because whereas structure is easiest to measure it is furthest from influencing change in the patient and family. Outcome is most difficult to measure but is of direct relevance to the patient and family. Standards of structure or process are most useful when these are proven to improve care, or if there is a very strong consensus that these are desirable. Structure, process and outcome measures which have been either used or advocated to evaluate the care of elderly people are shown in Table 2. WHO SHOULD ASSESS QUALITY? Whether the patient, professional, family members or external professional makes the assessments is often determined by the aspect care to be assessed. Each approach has advantages and limitations. The patient is normally assumed to be the most appropriate person to assess their health status and satisfaction with care, and similarly carers are best at assessing their own strains and satisfaction. However, in patients who are very sick or unable to respond interviews can lead to selection bias of only those who are most fit. In some instances traditional interview techniques are not sensitive to change. Clark & Bowling (2000) assessed care for elderly people in long-stay hospitals and nursing home care using both survey methods--including an interview to assess functioning, mental state, satisfaction--and observational methods where an observer logged activities, interactions and mood using a pre-agreed schedule. The observational methods provided insights into behavior, moods and interactions and showed differences between the institutions, which had not been found in the patient interviews. Assessments from patients with severe mental illness or with cognitive impairment may also be unreliable. Maguire (2000) warned that a far greater proportion of patients than usually realized may have impaired attention, concentration or memory, which can seriously affect recordings (Miller, 2002). As an alternative, relatives and friends can be used, but this limits assessments to cases where a close relative or friend exists, and the assessment may be altered by the stresses of caring. Epstein et al. (1999) tested for correlations between the ratings of 60 subjects and found that correlations between patients and their carers were good if they were in close contact, but if the subjects were in poor health or there was little contact, or the subjects and carers lived apart significant correlations were not found. External assessors can provide an independent view of the patient's circumstances, free from many of the biases of professionals or the family, but these are often costly for small evaluations, and Miller (2002) has argued that they may not witness the full range of symptoms in one interview. Finally, assessments can be made by the clinicians caring for the patient. These may be biased by their own expectations and hopes. Slevin et al. (1998) showed that, using standard instruments, professionals gave different assessments of quality of life and care compared with patients themselves. However, clinicians have the advantage of being able to provide data on all of the patients in their care, rather than just those fit enough to complete the forms or those with carers. Thus, there is no ideal choice of assessor. However, it is important not to change from one assessor to another (e.g. from patient to carer), because their assessments may not correlate. JCAHO STANDARDS Since its beginnings, the JCAHO has been recognized as the leading assessment and accreditation body in health care. Although its standards had always referred to assessing and improving the quality of care, it was not until 1975 that hospitals were required to "demonstrate that the quality of patient care was consistently optimal by continually evaluating care through reliable and valid measures." The JCAHO's initial work was inspection based and viewed as punitive by physicians and other health care professionals. Although the process was characterized as voluntary, lack of JCAHO accreditation meant that a health care organization could be excluded from receiving federal or state funds for health services provided. In the past decade, a greater understanding of quality improvement efforts led the JCAHO to move from an inspection-oriented approach to one of quality improvement. Called The Agenda for Change, this major change in process began in 1997 and entailed a multiyear effort. Beginning in 1994, JCAHO standards incorporated principles and techniques to foster continuous improvement in performance quality. The JCAHO recommends that to prepare for accreditation, organizations should undertake an annual mock survey every three years. This enables institutions to address problem areas well in advance of the surveyors' visit. The mock survey tool can be obtained by contacting the JCAHO. RESULTS OF EVALUATIONS Community services Patients in the community are known to come into contact with a large number of different services. Livingston et al. (2000) showed that in the previous month the services which patients aged 65 years and over came into contact with most often were: general practitioners, hospital visit, home help (only for patients with dementia) and district nurse (Table 3). Patients who saw a general practitioner were more likely to be depressed and with limited activity. Older patients were more likely than those aged 65-74 to have a district nurse or health visitor and less likely to attend a hospital visit. Evaluations of services such as meals on wheels, home help, etc. have shown these reduce carer burden and stress (Jones & Vetter, 2005; Gilleard Ct al., 1994; Melzer et al., 2002). However, few of these interventions have been evaluated in isolation and the best means of offering care is not known. In Canada, a formalized support programme for carers was found, in a randomized trial, to offer a similar or slightly better quality of life and to be cost effective compared to traditional community nursing and home care services (Drummond et al., 2001). Evaluations of general practitioners are notoriously difficult and rare, and evaluations are made more difficult because of difficulties identifying patients who are most ill or receiving poor care (Higginson et al., 2000). An attempt at evaluation of psychological care in general practice showed high patient satisfaction (80%) and achievement of the goals (e.g. improved sleeping patterns for a person with insomnia) which had been agreed between patient and general practitioner (Grossley et al., 2002). Early intervention, domiciliary visits, day care, respite There is some evidence that early intervention for depression shortens the period of Hiness and is cost effective, although treatment requires skilled clinicians and should include a continuing management plan (Gurland et al., 2000). Early intervention for other diseases specifically for elderly people is not known, although there is general evidence that an early intervention service improves outcomes in patients (Tyrer et al., 1999). However, in dementia, although early intervention will successfully identify those at risk, there is no evidence of improved outcomes or reduced hospital admissions--in fact hospital admissions appear to be increased (O'Connor et al., 2001). Domiciliary or community support teams for elderly people and case management are in the process of evaluation, and as yet some results are contradictory. However, using resources in this way has enabled some services to care for more patients in the community (Macdonald, 2001; Melzer et al., 2002). In one survey, 67 out of 85 general practitioners, reported that the domiciliary psychogeriatric visiting service was very important to their work (Hardy-Thompson et al., 2002) but there is no indication of whether a different service may have been preferred or how this service compares to other forms of home support. Orrell et al. (2002) showed that compared to low users of domiciliary visits, a slightly higher percentage of high users, were more likely to consider the patients physical disability as an important factor in requesting a visit, and were less likely to have undergone psychiatric training. Day care has been shown to relieve carer stress in about one third or more of carers but the ideal form of day care is not known and it does not appear that day care prevents eventual need for long-term care (Wood & Phanjoo, 2001; Zeeli & Isaacs, 1998). Respite care also appears to reduce carer stress but some findings are contradictory. Pearson (1998) reported relief for the carers of 25 admissions, but Rai et al. (2005) reported a high level of morbidity and mortality in elderly people admitted for respite care. This indicates a need to determine for which patients and families respite care is most suitable. Acute care The five main causes of admission for elderly people include: depressive disorders, dementia, other psychoses, schizophrenia and paranoid illness (Department of Health, 2001). These data are based on coding in the Mental Health Enquiry system, and therefore it should be assumed that some miscodings may occur. Evaluation of care needs to take into account the appropriate assessment, diagnosis and treatment of patients in care and also assess the environment, communication, and care of the family. Failings in follow-up of patients after discharge are well documented. A randomized controlled trial of geriatric follow-up home visits after discharge from hospital showed a reduced number of admissions to nursing home care (Hansen et al., 2002). Long-term care Grundy & Arie (2002) demonstrated a fall in the provision of local authority residential care between 1976 and 2001. This was followed by an increase in private and voluntary nursing and residential care, largely influenced by the government funding policies, which increased availability of this form of care (Vetter, 2002). Evaluations of long-term care have assessed environment, patient functioning, mental state, satisfaction, survival and perceived health status. In a randomized trial of NHS nursing homes, Donaldson & Bond (2001) and Bond et al. (1999) showed nursing home care to be more cost effective than hospital care. Observation studies by Clark & Bowling (2000) also showed advantages for smaller units which did not conform to Goffman's models of institutions, and where patients had higher nurse contact, received more encouraging comments and spend more time in small group activities. MODERN DILEMMAS IN EVALUATING QUALITY 1. Specific versus generic quality measures The advantage of using generic measures of quality is that it allows comparison of very different types of care. If a standard measure of health status is used (e.g. the Nottingham Health Profile or the SF36, Fletcher et al., 2002) then the change in health status for people receiving psychogeriatric care can be compared with those with different health problems--e.g. needing a hip operation. Comparing costs and outcomes in this way can allow cost-utility analysis. However, if the measure is not sensitive or appropriate to the aims of the care for older people then such an approach will not be possible. This has been a concern when some standard outcome measures have been used (Bond et al., 1999a; Fletcher et al., 2002; Jenkins, 2000). Even generic process measures may not be appropriate. Some of the generic nursing quality measures, such as Monitor and Senior Monitor and Qualpacs, have recently been criticized for poor reliability and validity, unwieldiness and obscurity in some of the terms (Red-fern et al., 2004). 2. Measuring quality in routine practice Although there are many instruments to measure health status, quality of life or quality of care, unfortunately these are often suitable only for research studies rather than routine practice. To agree possible outcome measures which might be used to assess community services for people with dementia Higginson et al. (2004) identified 79 possible measures from the literature. These were reviewed to determine their validity, reliability, responsiveness to change, and appropriateness of format for use in a multi-professional community setting. We also compared the domains (e.g. patient psychological well-being, carer psychological well-being) covered in the measures with those domains which three local community services, and a sample of carers, had identified as important for their care. No ideal measure was identified, although a shortlist of possible measures is currently being tested with the community services. Communication from staff and the co-ordination of services were identified as very important by staff and by carers, however, very few measures address these (Higginson et al., 2004). 3. Study design A number of different study designs for evaluation are available, but each has advantages and disadvantages--see Table 4. In general, if one service is to be shown to be more effective, appropriate or efficient than another then a comparison study is needed, and the most rigorous design is the randomized controlled trial. However, time-series, geographical comparisons, etc. are useful when this design is not possible, see Table 4. Descriptive studies are of great value in assessing quality--specially if these are used to demonstrate for which patient groups care is most effective or to demonstrate failings in the quality of care. 4. Changing practice Defining quality standards is much easier than bringing about changes in clinical practice to improve quality (Black & McKee, 1998). Results of evaluations have often not led to changes in practice--for example during the Confidential Enquiry into Peri-operative Deaths in only 4--5% of deaths investigated did the clinicians involved express any interest in finding out the result of the enquiry (Black & McKee, 1998). Very basic quality standards can be enforced by included financial penalties for services which do not perform up to an agreed standard and the incorporation of quality items into the contract between those purchasing and providing the service. FUTURE RESEARCH Evidence from the evaluations to date has demonstrated a degree of effectiveness, humanity and acceptability of care for elderly people with mental health problems. Specialists in psychiatry of old age have pioneered many of the improvements in care. However, care is provided by various professionals, in multiple settings, amidst a complicated network of patient and family variables, and have closely interrelated goals. Given the wide variety of services, we need to know for which patients care is of highest quality and which models of care work best. The most significant questions. would seem to be what kinds of interventions, in what combination, form and amount, for what kinds of patients and families, and with which types of concerns work best under a particular set of circumstances. A further area of work, which can be undertaken locally, is to assess failing in local services and to seek to improve these through audit and quality assurance programmes. However, to assess care suitable measure of process and outcome are needed, and although a wide variety of health status and quality of life measures are available, these do not always provide goals for patients and families, and are not responsive to changes (Fletcher et al., 2002; Jenkins, 2000). The testing of generic measures for validity, sensitivity and reliability in this setting is urgently needed, along with further work on specific outcome measures. In the field of palliative care, it has been possible to develop outcome measures which cover the main domains of care identified by patients and professionals, and then use these to measure the effectiveness of care. Read More