Quality

Key Points Background Implications News Resources Action Points References

Key Points

In recent years, the NHS has seen a shift in focus from increasing the quantity of care to improving the quality of care, as experienced by people who use its services.

During this period we have seen growing requirements for health professionals, including physiotherapists, to demonstrate the efficacy and quality of their service to a range of audiences.

This means that physiotherapists need to keep abreast of the health service quality agenda and understand how this translates to their daily work.

Quality in healthcare can be defined as: 'the total package of features and characteristics in healthcare service or product and the way in which it is provided, that bear on its ability to satisfy the agreed need of the consumer and the agreed requirement of the purchaser within the constraints imposed by professional judgement at lowest cost, and whilst minimising waste and losses.' ⁽¹⁾
There has been much debate about the key themes within which quality should be assessed and measured, and there is no definitive model of healthcare quality, although most versions have strong similarities. In this resource we use the model set by the Institute of Medicine in 2001⁽²⁾, which argues that the key six aims for improvement should built around the core need for health care to be:
- Safe – the provision of services that do not harm the patient or expose them to any unnecessary risk
- Effective – the extent to which an intervention is appropriate and produces its intended result, drawing on a strong evidence base underpinned by rigorous research
- Patient centred – healthcare delivered in partnership with patients and their families with compassion, empathy and responsiveness to individual needs, values and preferences
- Timely – the provision of services at the time they are needed, within the appropriate setting and without excessive waiting times
- Efficient – the cost-effective resourcing of systems to enable delivery of appropriate, efficient and coordinated services
- Equitable – services provided on the basis of clinical need, regardless of personal characteristics and circumstances and in such a way as to reduce differences in health status and outcomes across various subgroups.
Different authors and government policies identify different themes within quality, or use slightly different terminology or concepts. Each of the UK countries has agreed its own key indicators for quality improvement and clinical outcomes. These indicate what specifically needs to be measured within your services. (For more information see the individual country pages.) However, the broad principles of quality tend to be similar across countries and over time.
Today, across the UK, there is a strong emphasis on safe systems, a strong evidence base, and a positive patient experience.
Quality in healthcare is judged against standards in order to provide quality assurance. These specify what needs to be achieved, and to what level. They may apply to any activity of feature of health care that is important for quality. An example of a standard might be '95% of patients in an outpatient clinic are seen by a therapist within 10 minutes of their scheduled appointment time.'
Across the UK, quality and outcome measures are routinely collected to assess quality. Meanwhile, work is being carried out across the UK to provide practitioners with appropriate tools and indicators to enable them to measure the quality of their provision across a range of dimensions. For more information about this area of work, see the separate topic measuring for quality improvement in physiotherapy.

Resources

There are no related resources for this policy.

Implications

All physiotherapists have a professional duty to maintain and develop their competence, and through this, the quality of their service provision. Where national guidelines exist around specific clinical areas, physiotherapists must use these to support the development of their services.

Physiotherapists also have a role to play in influencing the quality agenda at commissioning level. Many commissioned services are designed to deliver outcomes based on key quality dimensions. Each of the six dimensions of quality highlighted in the key points has specific implications for physiotherapists:

Safety – All healthcare providers within the NHS are currently obliged to provide data on their success in tackling patient safety issues. Physiotherapists need to help improve quality measures around patient safety either indirectly, through reduced length of stay, or directly – for example, through falls prevention programmes. Patient safety standards and national audit programmes are key resources in benchmarking performance on patient safety in this area.
Effectiveness – Physiotherapists, like all healthcare practitioners, are increasingly required to demonstrate both the effectiveness of their interventions by using evidence-based practice, and their cost-effectiveness.
Patient centredness – A key aspect of quality involves meeting the needs of patients in a way that addresses the full extent of the patient's journey and experience and quality of life, measured through patient reported outcomes measures.
Timeliness – Physiotherapists need to be aware of their legal requirements, as well as any national or local initiatives to assess or tackle waiting times. This is an important aspect of access to healthcare, which has been a significant concern for many years (see the access to services topic), as has waiting times.
Efficiency – Quality will be substantially determined by the extent to which a physiotherapy service is adequately resourced and coordinated, and the efficiency with which the resources are deployed. Physiotherapy is relatively low cost compared with many other healthcare services, and can help reduce other costs through improved discharge rates and reduced readmission rates. Physiotherapists need to demonstrate these strong cost/benefit outcomes.
Equity – All UK governments have stated their commitment to address health inequality, and key audiences such as commissioners, planners and the public have an interest in what physiotherapists are doing to address inequities in health status or access to health services. Monitoring data around issues of access and health outcomes for specific groups in the community should form a key component of quality assurance and assessment in physiotherapy provision.

Each of the UK countries has agreed its own key indicators for quality improvement and clinical outcomes. For more information, see the section for your country.

There is an argument that quality of care and quality of workforce are strongly linked – in other words, that workforce training, health and satisfaction all contribute to the quality of care provided. For more information see the work health policy topic.

News & Comment

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NHS Atlas shows variations in healthcare

1 year ago
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Government backs 'transparent' GP commissioning

1 year ago
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Working together to reduce health inequalities

2 years ago
News item

CSP reaction to publication of 'NHS 2010-2015: from good to great'

2 years ago

Background

Improving the quality of healthcare in the NHS is high on the agenda in all four countries within the UK. This agenda is being driven by a number of challenges facing healthcare providers across the UK, including increased patient expectations, improved information and connectivity, advances in treatments, concerns around patient safety, and the embedding of evidence-based guidelines into clinical practice. Quality is measured on a range of outcomes such as the 18-week wait in England and self-referral in Scotland.

These changes are taking place within a context of financial insecurity and increasing budgetary constraints, which result in greater need than ever before to demonstrate value for money in the shape of clinical effectiveness and patient outcomes. Healthcare professionals need to be able to provide the evidence to demonstrate the quality of the service they provide to commissioners, regulators and patients. They will find themselves under increasing pressure to do this, in an increasingly demanding healthcare environment.

Quality is a complex concept for which there is no single, definition. It is a term frequently used within the policy and political context, but means different things to different people. For a physiotherapist it could mean the use of cutting-edge treatments, while for a primary care trust it could mean high patient satisfaction. For a commissioner it may relate to set standards having been met.

Each authority on the subject has proposed a different definition. In 1966, in his seminal work Evaluating the Quality of Medical Care(3), the public health pioneer Avedis Donabedian defined the three distinct aspects of quality in health care as outcome, process and structure. These initial ideas were later developed by figures such as Øvretveit(4), Maxwell(5) and Wright and Whittington.(6) Each government initiative favours a different model, focusing on different themes.

For example, in 1984 Maxwell identified 'access, relevance, effectiveness, equity, efficiency, economy and social as key areas of quality. Meanwhile, the 2004 English document Standards for Better Health(7) identifies safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, care environment and amenities, and public health'.

The model used in this topic, set by the Institute of Medicine in 2001(2), is currently used by the Scottish Executive.

Even the term 'quality' has been referred to in different ways over the years. In the 1970s there was much talk of 'quality' and 'quality assurance', but by the late 1990s there was more emphasis on clinical governance – a related area, with different definitions and sets of values. Today's interpretation of quality in healthcare focuses not only on the impact of a specific intervention on the health status of a patient, but on the quality of all aspects of the patient experience, drawing on qualitative as well as quantitative data.

Each of the UK countries has made its own commitment to use evidence-based clinical guidelines to define quality in terms of effectiveness. All four governments talk of quality improvement as a key driver, and there is increasing agreement about what is meant by quality in healthcare. However, there are differences between the countries, and a wide range of approaches to measuring quality and quality improvements, due partly to the various national values and principles underlying the development of health policy.

Nevertheless, in the past decade there has been a growing consensus internationally about the key dimensions of quality in healthcare, and how to assess performance in these areas.

Action Points

Familiarise yourself with how the quality agenda is developing within your country, the key quality themes, and which frameworks relate to your work. (See the page for your country for more details.)
Take some time to understand the specific government drivers in this field and how they impact on physiotherapy in your area: see the page for your own country for details.
Identify what this means for your practice.
Look for local initiatives that can drive up the quality of provision, and identify the impact of these changes to demonstrate the contribution that physiotherapy can make to quality improvement within your organisation. Look at the NHS Quality and Productivity library for examples of good practice.
Use our action planning tool to help you get started on producing quality metrics for quality improvement.
When you are in contact with commissioners, think about how you could draw on your specialist knowledge to influence the way they measure and assess quality.
Look for local initiatives that can drive up the quality of provision, and identify the impact of these changes to demonstrate the contribution that physiotherapy can make to quality improvement within your organisation. Visit the NHS Quality and Productivity Library for examples of good practice.
Refer to the CSP's Core standards of physiotherapy practice to determine the quality of service you should provide.