1. Drafting a Standard Establish the requirements Agree the process
Draft the Standard
Test the Standard
Implement the Standard
1. Establish customer requirements - ie ask patients, staff what they want
2. Who will draft the standard
who else will be consulted
whose agreement is needed
3. Make sure it is SMART
4. Ask clients if it accurately reflects their requirements
ask other staff if it is realistic and helpful
implement the standard on a trial basis to see what changes result
revise , if necessary
5. Monitor and review standard and need to revise again as client requirements change

2. Maxwell’s Dimensions of Quality
Access
Equity
Relevance to need
Social Acceptability
Efficiency
Effectiveness
Access - patients are not disadvantaged in their access to services through constraints such as distance, waiting times, design of buildings or language barriers. They have adequate information to be able to find and make contact with the service when they need it.
Equity - Each service has equal claim to the resources available and is distributed proportionately between the different groups of patients using it.
Relevance to need - The kinds of service provided reflect health needs and the volume of service provided is representative of those needs.
Social acceptability - The services provided satisfy the reasonable expectations of patients in a way that is socially acceptable to them and does not conflict with their social values.
Efficiency - The service uses the available resources advantageously and is cost effective and appropriately staffed.
Effectiveness - Appropriate care is given, the service produces the intended or desired results and patients show and report beneficial results from the service.

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

4. Donabedian in healthcare
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.
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
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.
Structure - the physical and organisational properties of the settings in which care is provided. - physical environment, equipment, staff, information, organisation
Process - What is done for patients - the healthcare worker assesses, records, does, reviews etc.
Outcomes - What is accomplished for patients - the patient is, does, states etc, observable, measurable behaviours,

5. A Donabedian Standard

6. The Wright Matrix

7. A Different Approach

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

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

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

11. Standard: Care should aim to reduce the patient’s risk of developing pressure sores. Criterion 1 The patient’s 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 patient’s 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.
Measuring C1
Have the patient’s pressure areas been attended to every 2 hours?
Measuring C2
has the patient been assessed using the Norton scale?
Given the patient’s condition and mobility at what intervals should the patient be assessed?
Has the patient been assessed using the Norton Scale within the appropriate intervals identified in audit question 3?
Measuring C3
Has the patient had an “at risk” score recorded in the care plan?
In your opinion would the patient have an “at risk” score on the Norton Scale at the moment? Is there a difference between the answer in audit question 5 and audit question 6?
The person completing AQ 3&6 will need to be competent in assessing patients using the Norton Scale. If there is no record of an “at risk” score this may be because there has been no assessment of the patient, the patient may never have been “at risk”, or the patient may have had an “at risk” score that was not recorded. AQ6 is designed to assess whether there should currently be a record of the patient being “at risk”.

12. Evaluation of the Results
There may be more than one cause of the problem and more than one possible solution
Analyse the processes to determine the causes of the problem using brainstorming, flow charts, fishbone diagrams or Pareto diagrams
Consider costs and benefits of potential changes
2. Fishbone - “cause and effect diagrams”, give an overview of all the factors that affect the task.
Pareto diagrams are based on the principle that 80% of problems result from 20% of causes. If you then tackle the 20% of causes you will make the greatest impact on the problem. List all the factors and how often each occurs. The most important, most often reason can be clearly seen as the one to be tackled.
3. Costs and benefits:
financial implications
staff time and morale
impact on clients
management attitudes
organisation’s image
any other aspects
use pay-off matrix - a box that compares the probability of success - high, medium or low against the pay-off - high, medium or low
or force field analysis 2 columns line in middle = status quo
on one side are forces for change on other forces against change. The weight of the arrows show how important each force is.

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)
Donabedian has now explicitly acknowledged the role of the consumer. On a remarkable endorsement of the role of the patient as a co-producer of healthcare, Donabedian has advanced from his previous formulations to a point at which he advocates a much greater role for patients than many other theorists.

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)
Donabedian terms this “Collaborative consent”.

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
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.
Empowerment for some may mean disempowerment for others i.e. the articulate may receive a disproportionate share of resources and attention.
The principles enunciated by Maxwell (1992) of equity and access may well be threatened if empowerment is interpreted to mean acquiescence in a request for further treatment which the relevant professionals estimate have a high probability of failure.
A distinction needs to be drawn between empowerment at a collective level (ensuring that systems are in place for the patient’s voice to be heard) and empowerment at an individual level (arguing for particular forms of intervention for oneself or one’s relatives).

18. After the Audit 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