Are we providing quality care for patients and how are we measuring and assuring this?

How do we as nurses know we are providing the best care possible? We ultimately want to improve the patient healthcare journey. In 2010, Mandie Sunderland (CEO of the then Heart of England Foundation Trust) spoke to Irish nurse managers at a national conference about her worries in the provision of care by all her nurses in her Trust. She spoke of assuming care was okay unless told otherwise. She reassured high level managers that care delivered by nurses was up to the proper standards. After the Mid Staffordshire Report showed severe deficiencies of care in a neighbouring Trust, she felt she needed more than assuming care was meeting standards in her Trust and set about developing “metrics” to measure the fundamentals of care. Metrics highlighted improvements she needed to make immediately to support nurses to ensure care reached the required standards. When Mandie spoke to Irish nurse managers, she was candid in saying that the reality of care delivery was far from rosy.

This opened discussion for how we felt the standard of care was in Ireland. The Director of the Nursing and Midwifery Planning and Development Unit (NMPDU) in the North West (Anne Gallen) set about exploring metrics for her region. In 2011, a group was formed and local Directors of Nursing examined metrics developed by Mandie Sunderland and set about “irishising” them. This meant mapping all the metrics to Irish instead of NHS standards and ‘tweeking’ them to match priorities at that time in Ireland. This was done in Donegal for Older Persons Services and the acute hospital (Letterkenny University Hospital) originally and then other managers came on board and wished to use these metrics. Metrics were collected on excel spreadsheets but as more services came on board a more permanent solution was sought. In 2012, we went back to Mandie to ask for assistance on how best to collect and report on metrics. Mandie kindly introduced us to Testyourcare (TYC) used in the Heart of England Foundation Trust. To facilitate learning and sharing, she kindly agreed to set up the North West on TYC. This allowed more versatility and allowed greater reporting on the metrics.

At this stage, more services in Dublin and the North East wished to come on board. We took the existing metrics and worked with practice development groups and Directors to get collaboration on a core set of metrics across the 3 regions. (North West, Dublin North East and Dublin North). This was facilitated through the Nursing and Midwifery Planning and Development Units (NMPDU’s). With more resources, we could move into other nursing arenas and developed metrics for mental health, intellectual disability services, midwifery and children’s services and then into public health nursing services. Within TYC, the RAG Rating is used to illustrate standards (Red for below standard, Amber for needing improvement and Green for meeting the standard). Reports can be obtained which highlight where metrics standards were met or may need improvement. All standards measured were process driven to ensure that nurses and midwives adhered to standardised processes when delivering care. This approach was supported in some hospitals that collected outcome measures such as number of falls, number of ulcers etc. Another component of metrics is action planning. Action plans are put in place to assist managers and staff to reach the appropriate standards. Governance procedures are recommended to support managers in putting forward their action plans monthly for discussion and follow through.

The Metrics Initiative has steadily grown, year on year and more services wished to adopt them. At this point, it was agreed that services could adopt the existing set with a view to setting up a process to nationalise metrics, now called Quality Care-Metrics. In 2015, Quality Care-Metrics (QCM) were adopted and launched for seven workstreams (Acute, Mental Health, Intellectual Disability, Older Persons, Public Health Nursing, Children and Midwifery Services) by the ONMSD as a standardised measurement tool for the fundamentals of nursing and midwifery care.

Anne Gallen as National Lead for QCM in collaboration with the Office of the Nursing and Midwifery Services Director (ONMSD), engaged 3 colleges (UCD, UL and NUIG) to undertake research to develop a core standardised set of Quality Care-Metrics nationally. This involves undertaking a literature review to explore other metrics in use internationally and nationally and exploring what metrics could be developed that would be under the influence of nursing and relevant to the fundamentals of nursing.

Nurses and midwives are currently enrolling to take part in an edelphi process as part of this research across the country to shape the new metrics. It is aimed to have as many nurses and midwives involved in the research to obtain consensus agreement on what core metrics and indicators should be selected and measured nationally. It is hoped that in September 2017, a new national standardised set of Quality Care-Metrics will be made available to all HSE nursing and midwifery services. At present, more than 80% of acute hospitals are using the current set of QCM. Within Midwifery Services 84% of services are engaged with QCM. At present 74% of Children’s services use QCM. Mental health, Intellectual Disability, Older Persons and Public Health Nursing Services are also using QCM but adoption is slower in these disciplines. It is hoped that when nurses and midwives have participated in the development of the national set, engagement will increase and be more widespread. Ireland would be the first country internationally to achieve a national standardised set of metrics for nursing and midwifery across disciplines nationally.

The Office of the CIO (OoCIO) supports the project in several ways. As part of QCM, a government to government initiative has been agreed with the OoCIO to facilitate Testyourcare (TYC) provided by the Heart of England Foundation Trust as the current national platform for collecting and reporting on QCM. OoCIO have also assisted in the implementation of ICT Tablets for the point of care collection of data. Over 200 tablets were enabled for data collecting and reporting across services. The OoCIO are also supporting enhanced reporting and analytics on the data from TYC. Using Qlikview (Visual analytics tool), Eoin Darcy, OoCIO is spearheading the development of a quality dashboard for managers to highlight trends and to flag metrics that may need improvements to maintain appropriate standards. A visual display highlighting the key information and trends forms the basis of this dashboard and is being offered to high level nurses (Chief Directors of Nursing and Midwifery) in the first instance with a plan to devolve it down to senior managers in acute hospitals.

To facilitate education of nurses and midwives in the collection and reporting of QCM and the use of TYC, a QCM Hub is being developed on HSELanD. This will support nurses and midwives at the coalface to learn more about metrics and how to collect and measure them. It offers great learning in the action planning phase where true change can be brought about by following the ‘plan do check act’ cycle (PDCA).

With QCM, nurses and midwives become familiar with standards and their role in maintaining them. The current QCM set facilitates national collection of a standardised set of core metrics. TYC provides a mechanism for collecting and reporting on metrics and supports action planning to bring about changes and improvements where needed. For more information on QCM, go to the HSE ONMSD webpage on Launch.html.

To find out information about participating in the Quality Care-Metrics research eDelphi process to shape a new national standardised set of QCM, go to the following HSE Page for more information: Study.html.


Paula Kavanagh

About Paula Kavanagh

Paula is a Nursing and Midwifery Development Officer covering Donegal, Sligo, Leitrim and West Cavan. She has a key interest in developing initiatives to help people engage with health services electronically and in clinical dashboards and bringing useful data to nurses and midwives to assist in decision making.

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