Quality, its definition and how we in healthcare measure it compared to patients' perception of their care could be addressed by using the ‘What matters to you?’ principle (What Matters to You?, 2020). Could this be the key to combining both objective and subjective metrics in ward accreditation programmes, which are designed to drive quality improvement? As more NHS trusts devise their ward accreditation programmes the impact on Care Quality Commission (CQC) ratings will be of interest to determine whether there is a correlation between having an accreditation programme and the quality of care delivered to patients.
The CQC (2021) has launched a new strategy, promising to move away from the traditional burdensome inspection model to a continuous cycle of monitoring using tools such as accreditation to inform their measurements. The strategy makes a commitment to publish new information about quality, use a clear definition of quality and define safety.
What is the driver behind ward accreditation? Is it to motivate improvement or is it to provide assurance or can it, in fact, be both?
Defining quality
As a Darzi Fellows Alumni, I'm drawn to Lord Darzi's definition of quality (Darzi and Department of Health (DH), 2008), which has three criteria: patient safety, patient experience and effectiveness of care. There are many other definitions of quality; however, it is linked to a person's perceptions and as such can lead to variations (Gottwald and Lansdown, 2014). Indeed, although hospitals can measure the quality of care based on clinical outcomes, patients judge the quality of their care based on their perception of the experience they encountered (Lee, 2004). Hanefeld et al (2017) suggested that the definitions of quality fail to address the complexity of perception.
Objective and subjective measures
I've long been intrigued by this difference between how we in healthcare measure quality using objective measures, in comparison to patients who judge quality based on a subjective measure of their perception of the care they received. Outcomes are objective measures whereas patient experience is subjective. Although outcomes are delivered by efficient teamwork, impressions are delivered by individuals and quality must therefore be measured on both objective and subjective indicators (Lee, 2004). Is there a large gap between the patient's subjective measure of quality and the NHS objective measures of quality? And, if so, how do we fill that gap?
‘I've long been intrigued by the difference between how we in healthcare measure quality, using objective measures, in comparison to patients, who judge quality based on a subjective measure of their perception of the care they received
Ward accreditation
It has been suggested that ward accreditation can drive quality improvement in patient outcomes, increase positive staff and patient experiences and have the potential to enable nursing- and midwifery-led improvements, shared learning and good practice (May, 2019). Ward accreditation is described by the Chief Nursing Officer for England as a set of quality standards that enables areas of excellence to be celebrated and areas for improvement identified using a structured quality framework. Several NHS trusts in England have implemented accreditation programmes, many of which are aligned with the CQC standards (May, 2019). It is implied that, by improving the quality of patient care through the accreditation process, a hospital's CQC rating could be improved as a result (Ingelsby-Burke, 2018).
New CQC strategy
To maintain and improve high standards of quality regulation by the CQC, it has been using pre-announced on-site inspections using a set structure to evaluate healthcare providers against a set of standards. This results in significant time and resources due to the intense level of scrutiny and is a costly means of assessing the quality of care that patients receive (Allen et al, 2019). In its new strategy, the CQC is moving away from the traditional inspection model to one that employs a continuous cycle of monitoring using tools and techniques such as accreditation (CQC, 2021). This approach will reduce the burden and improve the quality of the inspection regime. Accreditation is reflected in the ‘well led’ domain of the key lines of enquiry to evidence commitment to quality improvement and assurance. However, the CQC will only recognise accreditation schemes that meet key standards to assure quality and vigour, evidence of uptake among NHS organisations to enable benchmarking and schemes standards being mapped to the CQC assessment framework (UK Accreditation Service (UKAS) et al, 2019).
I welcome the commitment made by the CQC in its A New Strategy for the Changing World of Health and Social Care (CQC, 2021). It aims to publish new information about quality, use a variety of tools to measure quality, use a clearer definition of quality and reference what poor care looks like, agree, and establish a definition about safety. It is interesting that when defining safety, Darzi uses safety as one of the three domains of quality (Darzi and DH, 2008); however, it appears that the CQC are planning to define quality and safety separately.
What matters to the patient?
If objective measures of quality depend upon teamwork focused on the prevention of harm, then subjective measures require caring compassionate individuals. But how do we measure this? Often complaints are used to measure patient experience; however, this is a reactive response as they often are not reported at the time, thus preventing real time measurement and improvement. The friends and family test (FFT) is an attempt to capture a subjective measure of care; however, yet again this becomes an objective measure in using benchmarking responses and percentages rather than digging deeper into what matters to the patient. I often reflect on the Tom Peters (2012) quote:
‘The problem is never the problem, the response to the problem is the problem. Perception is all there is.’
How can we measure perception when this is inevitably different for each individual? It is not always the thing that went wrong that bothers people but how it was responded to. Should we be using this to measure patient experience by, for example, asking patients ‘When you reported a problem was it responded to appropriately?’ Could this be the link between objective and subjective measures of quality?
I have reflected on my time working at Moorfields Eye Hospital in London where the intravitreal injection clinic had high FFT recommendations. Although this was an objective measure, it stimulated my curiosity to discover why. I spent a day in the clinic with the clinical nurse specialist to discover he had created a classical music playlist to create a calm environment for patients during their procedure. What mattered to these patients was this small act, which had a huge impact on their experience and hence their perception of their care. This was an indicator of a subjective measure of quality. However, without me going that one step further it was just being captured as a quantitative metric. A proactive response such as this would allow hospitals to do more of the good that matters to patients.
The ‘What matters to you?’ movement is gaining traction across the NHS and I believe this could fill the gap between objective and subjective measures of quality.
Is ward accreditation the answer?
I wonder whether ward accreditation provides the answer to assessing the three domains of quality as per Darzi's definition? Currently, most scoring tools are based on the CQC fundamentals of care. I believe that ward accreditation scoring tools should include observations of care; however, there is an opportunity for patients to be part of the inspection as assessors, the National Patient Safety Strategy patient safety partner role is perhaps an opportunity for this, with discussions between staff and patients to inform the inspection as opposed to primarily being driven by data.
We must ask ourselves what is the driver behind ward accreditation? Is it an improvement tool designed to motivate leaders to aspire for the gold award or is it to provide assurance to the board? Or can it be both and how do we measure that?
In ward accreditation scoring tools, a commonly used indicator is patient falls. We can measure the number of falls, falls that cause harm, whether risk assessments are in place and the interventions used to prevent falls, which are risk averse approaches. Thus we are not asking patients how it feels to be in a bed with cot sides. Although cot sides could prevent them from falling, for some patients being in a bed with cot sides may be a negative experience and affect their perception of their care if they lose independence in being able to go to the toilet at night without calling for help.
Patient engagement and involvement in the design of ward accreditation standards should be considered. Could it be that we ask patients ‘What matters to you?’ to inform the metrics on each ward and to define the wider definition of quality? Quality is about what matters to patients as well as us as an organisation. We need both.
Ward accreditation is an improvement tool that assesses the quality of care received by patients in hospital. NHS trusts should consider the use of ward accreditation to improve the quality of care received by patients. We need to do more of the good and be proactive and use the ‘What matters to you?’ campaign to inform ward accreditation standards. There is an opportunity as more and more trusts implement ward accreditation to fill the gap between subjective and objective measures using co-production to design the standards. Better standardisation nationally would allow patients to be satisfied that the care they expect is delivered.