1 Drafting a Standard n Establish the requirements n Agree the process n Draft the Standard n Test the Standard n Implement the Standard

2 Maxwells Dimensions of Quality n Access n Equity n Relevance to need n Social Acceptability n Efficiency n Effectiveness

3 The Donabedian Approach n Structure - includes the skills of the staff, the buildings and premises, and the equipment the organisation makes available n Process - the methods that are adopted by the organisation to provide its services, or in its production processes n Outcome - the combined results of the structures and processes of the organisation in the production of its products or services.

4 Donabedian in healthcare n Structure - the resources required to deliver care; the environment in which care is delivered; the facilities made available; the equipment e.g. bandages, linen, drugs, etc. made available; and the documentation of procedures, policies and guidance to staff. n Process - the actual procedures and practices implemented by staff in their prescription, delivery and evaluation of care; and the monitoring, evaluation and actions to adjust the provision of care n Outcome - the effect of care received by patients as a result of healthcare intervention; the benefits to staff as a consequence of providing this care; and the costs to the organisation of providing care.

5 A Donabedian Standard

6 The Wright Matrix

7 A Different Approach

8 Select an issue pertinent to your working environment. Use one of Maxwells dimensions and define an appropriate Standard and 3/4 relevant Criteria. Define an appropriate Standard and 3/4 Criteria for Donabedians Structure. Take approx. 15 minutes

9 Measuring Performance n Tangible hard outcomes may be measured quantitatively n Intangible soft outcomes may be measured qualitatively n Communicate the results to those involved n Graphic representation can be useful

10 Methods of Monitoring Consider:- n what should be monitored, and to what level of details n frequency with which monitoring should take place n cost of monitoring system n time taken to monitor n possible use of existing systems n who will be responsible for monitoring and acting on results

11 Standard: Care should aim to reduce the patients risk of developing pressure sores. Criterion 1 The patients pressure areas should be attended to every 2 hours. Criterion 2 The patient should be assessed using the Norton Scale at appropriate intervals, given the patients condition and mobility. Criterion 3 If the patient has an at risk score on the Norton Scale it should be recorded in the care plan. Construct the audit questions to measure this Standard.

12 Evaluation of the Results n There may be more than one cause of the problem and more than one possible solution n Analyse the processes to determine the causes of the problem using brainstorming, flow charts, fishbone diagrams or Pareto diagrams n Consider costs and benefits of potential changes

13 The quality of technical care is defined not by what is done, but by what is accomplished. And consumers are uniquely able to say what outcomes are to be pursued, what risks are to be accepted in return for what prospects of amelioration, and at what cost (Donabedian, 1992)

14 It can be argued that technical care not congruent with patient preferences has failed in quality… it follows that consumers define (or participate in defining) the quality of technical care by the simple expedient of specifying the goals it must serve. Only the technical means, and the skill by which they are implemented, remain for the clinical expert to govern (Donabedian, 1992)

15 In Consumer audit continuous improvement is only likely to be effective if patients are involved in the construction of the measuring instruments. This is essential for an accurate focus upon issues of patient concern.

16 However it is necessary to exercise a degree of caution before assuming that patient empowerment is a panacea to all the problems of service delivery. It is not necessarily paternalistic to argue that some patients may be happy to hand over complete discretion of their care to others.

17 Empowerment for some may mean disempowerment for others i.e. the articulate may receive a disproportionate share of resources and attention. A distinction needs to be drawn between empowerment at a collective level and empowerment at an individual level.

18 After the Audit n Opportunity to Progress –Research –Continuing system to suggest new areas –Quality Indicators –Improvement in patient care

19 Outlining an Audit Project It is possible to attempt to describe the features of any audit in advance. At this stage it will not be possible to define all the parameters, but consider the main elements required to describe an audit of the outcomes from an initiative titled Maintaining Healthy Weight in your Practice Population. Consider: Which staff group might lead the audit? Which staff may get involved? What would the objective of such an initiative be? How would potential participants be informed/chosen? What Standard(s) would be specified? Who would be involved in the initiative being audited? Who would be involved in determining the audit criteria? What could be measured/recorded to monitor progress? How would the (success of the) initiative be measured (that is how would it be judged that a Healthy Weight was now being maintained by a larger proportion of the practice population)? What data would be required to inform the initiative and from which sources? Consider whether there is (or could be generated) a willingness to Achieve a Healthy Weight within the practice population (and what information could be used to measure the commitment) How would the results of the audit be communicated, and to whom?

20 Further Reading