The healthcare agenda is dominated by ‘quick fix’ solutions. As a result, the complexity of issues involved and the amount of time it takes for real and enduring change to occur is often underestimated. Consequently the ‘little things’ that define the quality of the environment in which patients receive care and in which staff provide care can be overlooked. According to West et al (2014), if organisations want to provide compassionate and safe care, they must focus on nurturing appropriate cultures. Francis (2015) highlighted the need for a culture of safety and learning, where staff feel safe to raise and discuss concerns.
In 2018, in order to assess organisational culture, an engagement exercise/cultural gauge was used within Kettering General Hospital (KGH). This revealed that many staff did not feel engaged with Trust strategic developments. Furthermore, they did not always understand the standards of care expected of them and did not think everything was changing for the better. These findings were also reflected in the Care Quality Commission (CQC) report and staff survey. Staff were disenchanted with failed ‘quick fixes’. It was time to focus on a quality improvement plan that staff believed in and that would provide sustained change.
Excellence in Care Ward Accreditation (WA) is a local quality improvement process for nurses, which focuses on sustainable change over time (KGH, 2018). It concentrates on all the ‘little things’ that contribute to standards of care and the culture on a ward. It involves a comprehensive review of nursing standards, which encompasses observational standards, documentation audits and interviews with staff and patients. Additional data sources are used to triangulate and populate the report to ascertain the overall rating of gold, silver or bronze. There are 14 standards, which include leadership, safeguarding, nutrition, falls, pressure ulcer prevention and infection prevention.
WA is not a quick fix solution; it needs to be locally developed, implemented and embedded. Although the key nursing standards were based on KGH nursing and midwifery quality strategies and CQC findings, each area developed its own additional specific standards. The process started with a self-assessment—staff are encouraged to speak openly about any safety issues and share their learning. In addition, the self-assessment served as a means of clarifying the standards expected of ward teams.
Following the initial self-assessment, cycle one involved three further quality assessments by the WA team, at 4-month intervals. The WA results were impressive. The percentage of wards rated as bronze decreased from 62% to 10% at the end of the first cycle. There was a positive shift within the silver range, but only one ward was rated gold—anticipated as gold status at this stage is aspirational.
What has developed over time is a certain amount of healthy competition between wards striving for gold status. Alongside this, supporting systems such as ‘share and learn’ events allowed teams to share good practice and learn from any care concerns they may have. What has been valuable is that senior nurses now have a validated view of their ‘worry wards’ underpinned by current data rather than a sometimes unfounded reputation.
Despite the pressures on the wards due to COVID-19, the director and deputy director of nursing have supported the commencement of the second cycle of WA. Cycle two has started with a self-assessment followed by quality assessments by the WA team. The infection prevention standard was enhanced to include COVID-19 measures. When the COVID-19 crisis is over we plan to repeat the cultural assessment exercise to ascertain the effect of WA on organisational culture. In the meantime, however, we are planning to collect data and upload evidence such as photographs of the ward environment electronically. And due to the success of WA in nursing the Trust is keen to develop a multidisciplinary WA process.