Policy responses and statements

Name of organisation:

NHS Quality Improvement Scotland

Name of policy document:

NHS QIS Stakeholder Consultation - our direction and work

Deadline for response:

16 October 2008

Background: In 2006, NHS Quality Improvement Scotland commissioned an independent evaluation into its work, which found that NHS QIS has made a positive impact on NHSScotland but needs to be clearer about why it does what it does and the way that it does it. NHS QIS also needs to strengthen its engagement with frontline clinicians and with primary care to be of even greater value to the NHS.

As a result, over the last year, NHS QIS hosted a series of stakeholder meetings with health professionals, NHS managers, patient representative groups and policy makers. In the light of their views, and discussion with its Board and staff, NHS QIS clarified its vision, purpose, role and objectives.

The next step was to engage with stakeholders on its future work. NHS QIS prepared consultation documents to give the College and other stakeholders an opportunity to play a part in shaping the future work programme of NHS Quality Improvement Scotland. The booklet provided information on the strategic direction and the processes for determining what work NHS QIS undertakes. Stakeholders were invited to:

• comment on these processes, and
• identify the most pressing quality and patient safety issues to which NHS QIS should contribute

Stakeholders were asked to fill out as much or as little of the questionnaire as was relevant to them.

COMMENTS ON
NHS QUALITY IMPROVEMENT SCOTLAND
NHS QIS STAKEHOLDER CONSULTATION –
OUR DIRECTION AND WORK

The Royal College of Physicians of Edinburgh is pleased to respond to NHS Quality Improvement on the NHS QIS Stakeholder Consultation - our direction and work.

In order to lead quality improvement in healthcare effectively in Scotland, NHS QIS requires a strong strategic direction with a clear emphasis on achievable medium term goals.  The College fears that the breadth of responsibilities given to NHS QIS has diluted its impact with clinicians and the wider public – it has yet to make its mark.  Previous work programmes may in themselves have raised standards, but this has been within tightly defined areas and may be lost on many patients and, in our view, is lost on most healthcare professionals and certainly most physicians.  Indeed, there remains a perception within the clinical community that the emphasis to date has been on establishing quality initiatives in areas where measurement is easy and avoided areas where measurement is more difficult but possibly more meaningful.

NHS QIS needs to ensure there is a strong quality culture embedded within local healthcare systems, and teams must be supported to address their own service and clinical weaknesses. Addressing those aspects of healthcare that cause complaints and influence clinical outcomes irrespective of “theme” is critical.  Only then will patients and healthcare teams appreciate the impact of nationally-led quality improvement initiatives and NHS QIS will earn the leadership role it has been given by government.  Exemplar projects including specific national audit must be balanced against infrastructure and process support to drive local quality solutions and wider implementation.

The College believes there is much to be gained from open consultation on the future direction and planning processes for NHS QIS and congratulates NHS QIS on this mature first step.

Question 1:  Is the concept of the strategic planning cycle as proposed for NHS QIS appropriate?

From the outline information in the consultation document, the College has a number of questions which may stimulate further refinements of the NHS QIS model.

1. Does each theme need its own cycle? 

         The strategic planning cycle implies a standard progression for individual projects accepted for inclusion within pre-determined clinical and social themes.  This suits individual clinical programmes well, but is unlikely to be effective in supporting how these are accepted within an overall quality strategy for Scotland.  Would the model benefit from adding a third dimension, giving each theme its own “disc” within which topics can be suggested, screened, approved, implemented, evaluated and proposed? This would allow for cross referencing between the themes and greater understanding of how the discs fit together (if at all) and where partner organisations can add value.  It may be that the cross cutting issues eg basic nursing care, effective communication or infection control are the issues that carry most direct impact with patients and health care professionals.

2. Who selects the work programme?

Clearly, the diversity of the quality agenda forces choice and priorities - hence the selected themes which reflect the clinical priorities of the Health Department.  However, this top down policy approach sits uneasily against a more patient-centred NHS in Scotland.  Can NHS QIS find a way to analyse the experiences of patients and front line staff across Scotland to prioritise the service and clinical standards work that will bring most benefit?  This should reflect how patients access healthcare services and take account of the confusion, dissatisfaction and disparate outcomes that can result from the local adoption of different patient pathways.  The analysis should include patient complaints, clinical errors and clinical audit, linking the patient safety and clinical governance programmes to real experience.  Health Boards should be required to identify their own priorities for quality improvement within a national quality strategy and build a balanced programme of national work (supported directly by NHS QIS) and local projects (supported indirectly with standard setting, training, audit etc). 

3. Does the strategic planning cycle apply to all 3 key functions?

         The College can appreciate the relevance of the cycle for standard setting, effective clinical practice and implementation projects, but it may be less relevant for performance assessment responsibilities.  This, perhaps, signals the need to put greater distance between the facilitator/developmental roles of NHS QIS and its assessor/judgemental responsibilities.  There is little doubt that local quality improvement resources are hijacked by national priorities in the NHS QIS work programme and the quality assessment visits.  The strategic plan should take account of these tensions and may need to handle the quality assessment programme separately.

4. Should there be greater emphasis on implementation?

This is (rightly) signalled as one of the key functions of NHS QIS and the strategic planning cycle would be strengthened by greater emphasis on implementation within the evaluation stage.  Projects incapable of implementation or with no exit strategy (see later) should be subjected to careful scrutiny at the selection stage

Question 2:  Could the process for developing our work programme be improved?

1. The challenge of choice in a resource limited programme

This links to the above point on ensuring the wider clinical and patient community benefit from the activities of NHS QIS (1b).  It is important that the programme includes broader topics and/or cross cutting issues and that audit and outcomes projects do not shy away from difficult areas.  New ways of selecting topics for prioritisation could be developed that may include multi-professional specialty groups working with patients under the broad umbrella of NHS QIS.  Such an approach could facilitate the incremental development of standards in the many areas of healthcare where few exist currently.

As physicians (as opposed to surgeons), the College understands the difficulties associated with auditing the medical specialties and deriving meaningful outcome data. However, revalidation will become a key component of clinical governance systems and Scotland will need to produce reliable outcome data for physicians.  The College has started discussions with colleagues across Scotland to explore options to apply the principles of SASM to acute medicine, and this may help but will require national support.  We would hope that, in the future, not all NHS QIS resources will be applied to national clinical priorities with the result that some teams feel excluded from the quality agenda.  NHS QIS should collaborate with Royal Colleges and other recognised standard setting organisations to commission national standard setting projects rather than delivering them in-house.  This will support “buy in” from the clinical community and introduce an element of independence that will appeal to patients.

2. Transparent decision taking 

If the public and healthcare communities are to be invited to make proposals for the work programme, it is essential that the decisions are taken in a transparent manner and reasons given for projects that are rejected or postponed.

3. Can you guarantee effective exit strategies for projects?

Finding a suitable exit strategy is a common problem for quality initiatives.  Are programmes within themes to be wound up once key lessons are learned, or is the output sufficiently valuable to require integration into routine service delivery?  The consideration of an exit strategy should be an essential component of the selection process, along with early anticipation of data and IT requirements.  Only then can limited resources be diverted in the future to cover emerging projects, including smaller clinical specialties seeking support outside national clinical priorities.  However, the College accepts that, for some themes, the defined clinical quality standards must be retained within the national programme in the best interests of patients.

4. Impact of outputs on the work of others

Given the importance to NHS QIS of working with partner organisations, it is important to maintain clear communication channels within the themes as projects progress.  There will be early lessons for others including clinical teams, planners and those in charge of the IT strategy for Scotland.  The model should include an explicit requirement to disseminate interim and final results with a parallel mechanism that reviews continuing and long term results where appropriate.

Question 3:  Are the factors for inclusion in the NHS QIS work programme appropriate?

1. Selection of Topics

The College agrees that clinical teams will be more engaged in the work and direction of NHS QIS if topic selection is more transparent and there is an opportunity to influence specific work programmes within a quality strategy for Scotland.  There must, therefore, be a real perception generated across the breadth of healthcare providers within Scotland that the NHS QIS work programme and standards come from the patients and healthcare professionals at the front line, and are not simply handed down for implementation.

2. Factors to assess proposals

• Factor 3.  The College believes it would be helpful for NHS QIS to consider and publish the reasons why NHS QIS is the correct organisation to be undertaking the work selected for the programme (or not).
• Factor 4.  The College believes it may be difficult to assess topics/proposals against the strategic direction if this is not more clearly defined (even if time limited).  At present, it appears largely as a list of themes or priority areas and cannot reflect the generic failings which so often influence patient perceptions of care.
• Factor  6.  Any list has an implied hierarchy, and the College suggests that the likely outcome in terms of improved quality should feature higher up the list and certainly before factor 2 (timing) or factor 5 (follow on from previous work).

The College suggests adding the strength of the existing evidence base to the 8 factors already listed in line with procedures for selecting SIGN guidelines.  Areas with a weak evidence base may still feature in the programme but will flag up areas for attention to the research community and the office of the chief scientist.

Question 4:  Do you anticipate responding to our call for suggestions?

The College is refining its own approach to standard setting within its developing work on revalidation and would be keen to work cooperatively with NHS QIS over topic selection, programme definition and standard setting.  Our recent experience developing audits in community acquired pneumonia and epilepsy has delivered valuable procedural lessons on national audit and cross sector audit, particularly in relation to data capture - we would be happy to share these more widely.  Also, we are about the publish guidance on transition from paediatric to adult care – a clear national priority and which demonstrates the breadth of experience that can be accessed through College networks.

The College is aware of a number of areas associated with “physicianly” activity where the present standards are not well defined or are inadequate.  These are extremely important to patient care and experience, and include the broad area of acute medicine and unscheduled care.  We are holding a consensus conference on this theme on 13 and 14 November this year, and we hope this will start to deliver clarity and that it may inform a future work stream on acute and unscheduled medical care.    

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[15 October 2008]