Measuring for quality improvement in physiotherapy - Wales
- Measuring for quality improvement in Wales is firmly rooted in the quality improvement agenda and a holistic vision of quality that looks at increasing efficiency and reducing waste, empowering the workforce and providing more integrated, citizen-centred care, all within the context of a tighter financial settlement
- The principles underlying quality assurance and improvement activity are around communication and collective action to drive up standards, improve patient safety and the patient experience
- The revised Healthcare Standards for Wales have just been released by the Welsh Assembly Government for consultation and are designed to support healthcare organisations to identify and work towards providing consistently higher standards of care
- The National Leadership and Innovation Agency for Healthcare (NLIAH) is the body that works with NHS Wales to address healthcare improvement through sharing of knowledge, expertise and resources and developing tools and techniques to implement and maintain quality improvements
- The newly published Annual Operating Framework for NHS Wales confirms a commitment to reducing variation, reducing waste and reducing harm. This aims to translate into pathways of care which are evidence based, founded on reliable systems and processes which enable professionals to do the right thing all the time
- Clinicians will be supported in collecting robust data which enables variation to be identified, analysed and understood and the introduction of Intelligent Targets is the first step in this journey and builds on the progress already achieved from the 1000 Lives Campaign
- Activity around improving patient safety in Wales is being led by the 1000 Lives Campaign which aims to reduce risks to patient safety by implementing life-saving interventions developed by clinicians in Wales
- Current activity around measuring for quality improvement is centred around national improvement measures and targets (so called 'intelligent targets') in specific pathways – stroke, cardiac, unscheduled care, and mental health
- Wales has also introduced a national reporting system around waiting times for AHP services
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Physiotherapists working in Wales need to be aware of the quality measurement and improvement initiatives impacting on the organisation in which they work. Where NICE guidelines and other robust evidence exist around clinical areas of practice in which physiotherapists are involved, it is essential that relevant recommendations and standards are identified, implemented and their impact demonstrated.
All physiotherapy service providers working in NHS Wales should be looking to identify initiatives that can be taken locally to drive up the quality of provision – particularly in patient pathways that are the focus of intelligent target work. The Healthcare Standards for Wales provide a framework for physiotherapy service providers to use when addressing the issue of quality improvement at a local level. Measuring the impact of any changes made will be crucial to demonstrate the contribution that physiotherapy makes to the performance of the organisation.
Clinicians should also be looking at the contribution that physiotherapy can make in the areas being considered within the 1000 Lives Campaign. Service providers should be working within their local organisations to get involved in implementing interventions within the identified areas and collecting data to measure impact.
Physiotherapists who have a responsibility for supporting others to get involved in measuring for quality improvement could find the NLIAH document Engaging clinicians in a quality agenda an invaluable tool.
News & Comment
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The values of many health service professionals in Wales reveal a strong commitment to public service and free, community-based, services. The Welsh system has thus been based on shared ideals (Greer et al).
The Welsh Assembly Government has stated its vision that the services provided by NHS Wales should be genuinely shaped by and meet the needs of the people it serves, at the same time as taking full account of the latest evidence on best clinical practice. This is to be achieved through putting democratic engagement at the heart of the NHS – voice, not choice (One Wales).
The National Leadership and Innovation Agency for Healthcare (NLIAH) was formed as an NHS Wales organisation to help address healthcare improvement in Wales through:
- sharing of knowledge, expertise and resources
- developing tools and techniques to implement and maintain quality improvements
The work of NLIAH operates under 5 main brands with the Quality Improvement Plan (QuIP) strand leading on the delivery of some of the key actions from the Healthcare Quality Improvement Plan (QuIP)published by theWelsh Assembly Government in 2006.
One key strand of this work is the 1000 Lives Campaign which aims to reduce risks to patient safety by implementing life-saving interventions developed by clinicians in Wales. The evidence-based content areas which have been developed by clinicians working together, involve work in the following areas:
- Improving Leadership for Quality
- Reducing Healthcare Associated Infections
- Improving Critical Care
- Improving Medicines Management
- Reducing Surgical Complications
- Improving General and Medical Surgical Care
- Reducing Harm from Hospital Acquired Thrombosis
Two development areas will also be tested during the Campaign: Transforming Care at the Bedside and Pressure Ulcers.
Trusts and Local Health Boards have the responsibility of introducing agreed interventions and commit to monitoring their impact and sharing data during the two year Campaign period. Support is provided to all organisations taking part through training, detailed information about each content area, expertise and implementation tools.
As part of its drive to raise the standards and quality of healthcare in Wales, the Welsh Assembly Government has recently revised and put out for consultation, the Healthcare Standards for Wales.
The standards are designed to support healthcare organisations to identify and work towards providing consistently higher standards of care. The integration of the Healthcare Standards for Wales into the Annual Operating Framework for NHS Wales signals the importance of service quality and governance arrangements to the NHS in Wales and brings them into the formal performance assessment framework. The revisions made to the earlier version of the standards have attempted to align them more closely to clinical and other professional standards and quality requirements. This is intended to facilitate their use by all healthcare teams, practices and departments - ensuring that the standards are met by all services consistently, wherever or whatever they may be.
The Welsh Assembly Government expects healthcare service providers to use the standards to:
- assess for themselves (or benchmark) how or if they currently meet them
- identify what they do well and should be shared
- identify what they do less well and need to put right themselves or which may need to be addressed at a divisional or corporate level
- map against their own professional standards and show how they complement and sit alongside them and
- make changes which contribute to overall quality improvement within their services
Within the document there is a clearly stated commitment to the provision of clinically effective care that is based on nationally agreed best practice and guidelines, including those defined in National Service Frameworks and by the National Institute for Health and Clinical Excellence (NICE).
More recently, the Annual Operating Framework for NHS Wales 2010/2011 has outlined a vision of quality in healthcare that is encapsulated as reducing variation, reducing waste and reducing harm. This translates into pathways of care which are evidence based, founded on reliable systems and processes which enable professionals to do the right thing all the time. Clinicians and healthcare professionals are expected to at the forefront of the drive for higher quality, working with patients and partners to plan and deliver services which transcend boundaries, using high quality data and information.
The Healthcare Standards for Wales is the framework that places patients at the centre of the way in which services are delivered and are seen to be key to driving continuous improvement. NHS Wales has committed to a closer alignment of the Healthcare Standard Improvement Plans (HCSIPs), the Annual Operating Framework standards and efficiency measures and the newly introduced intelligent 'targets' to give a considered assessment of the NHS organisation as a whole.
Activity around generating measures for quality improvement in Wales is being led by NLIAH, working with the Welsh Assembly Government, to facilitate the development of 'Intelligent Targets' in four distinct care areas: Stroke, Cardiac, Mental Health and UnscheduledCare.
These national improvement measures and targets are to be focused on improving the quality of care delivered and the outcomes for patients. The approach brings together clinicians from across NHS Wales to work on identifying, developing and more recently testing the application of clinically relevant targets for these care areas. The aim of the intelligent targets is touse clinically meaningful measures of improvement based on the most reliable and relevant scientific research and knowledge available.
Example: The All Wales Stroke Services Improvement Collaborative brings together multi-professional teams from across Wales to support teams to develop services resulting in improved patient experiences, better processes of care and improved early rehabilitation.
The introduction of measurement of quality around evidence-based standards ('intelligent targets') has enabled demonstration of improved patient outcomes. The first year report of the All Wales Stroke Services Improvement Collaborative (AWSSIC) demonstrates that improvement is taking place in stroke services in Wales and that more can be achieved by focusing on measurement and reliability.
The report provides excellent examples of how measurable improvements in patient care have been achieved through reliable implementation of evidence-based processes.
In addition to the work around the development of intelligent targets the Welsh Assembly Government is also addressing issues of quality around access and timeliness. The Referral to Treatment Time pathway sets a national target of 26 weeks total time from primary care referral to treatment by the receiving consultant in secondary care. Physiotherapy will be part of this pathway. In addition monthly national reporting is now in place on waiting times for Allied Health Profession services, with a national target set for a maximum of 14 weeks.
Currently, all NHS Wales physiotherapy service providers report monthly on waiting times and these are published on the Welsh Assembly Government website.
Quality assurance process
Healthcare Inspectorate Wales (HIW) will use the Healthcare Standards to underpin their assessments of the safety and quality of healthcare services. They will also continue to validate NHS organisations' self-assessments against the Healthcare Standards for Wales. HIW are currently revising their assessment processes in parallel to the revision of the standards to ensure that they meet the needs of the new NHS arrangements and the proposed alignment with the National Minimum Standards within the private and voluntary sector.
NHS Wales has produced a Governance e-Manual to support NHS organisations in Wales to develop robust governance and assurance arrangements that meet the standards of good governance set for all public services in Wales.