Quality management in general sense is a major area in all customer oriented businesses and any degrade in the quality would tamper the image of the organizations and definitely there would be a reduction in the customers. It is actually defined s the ability of an organization to satisfy the actual needs of the individuals and stakeholders at minimum cost of resources.
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This is an assignment mainly focused on the area of quality improvement in health and social care sector. In the perspective of health and social care sector, Quality is defined as the level of services in the health and social care enhances the outcomes of health. The regular changes and strategies that are introduced to improve the quality of health services is termed as the quality improvement and the various government legislations, guidelines and health programmes that are put into action are the agenda of quality improvement. The strategies have the main motto of improving the service quality in the health care for the patients and their respective families
Quality improvement agenda is the main subject discussed in the first section of the assignment which covers the details of almost all white paper publications, reports, bills and act. In the second part of the assignment, the author analyzes a nursing care organization in regard to the various improvements made according the quality agendas discussed in the previous section. In the final section, suitable theory and model are analyzed to overcome the quality defects in the organization and implement suitable efforts to improve the quality.
TABLE OF CONTENTS
Introduction
Consistent improvement in the quality of service is the most required component for businesses that are completely customer oriented particularly in health and social care. The customers or patients of all categories should be treated with utmost care and ensure that their needs are satisfied completely at right time (Protzman, Mayzell, & Kerpchar, 2011).
The recent economic downturn forces most of the businesses to respond with certain indiscriminate cuts. But the cost cutting technique is not suitable for the health care sector. Instead the health and social care organizations would adapt quality service and improvement to make the healthcare organization more efficient, safe, effective, timely service to the customers and patient centred. Therefore to meet the current trends the health departments of UK have developed new quality standards for NHS which necessitates certain changes in service and staff to promote continuous and dynamic quality improvement.
There is a crucial need for improving the quality service of health care sectors in the current environment. An assignment is planned to analyze the subject thoroughly using different models and theories and suggest suitable strategies to enhance the quality in the health and social care organizations. The assignment would be divided into three different parts.
The first section is an evaluation of quality and service improvement agenda in NHS, UK
The second section deals with the impact of quality and service improvement in one of the nursing and care organization
Analyze the relevant theories and models to produce necessary recommendations and suggestions in appropriate areas to improve the quality
But before analyzing the assignment, the author would like to bring clear definition for quality, quality improvement and quality improvement agenda.
Quality, Quality Improvement and Quality Improvement Agenda
Quality in the perspective of health and social care sector is defined as the extent to which the health services offered increases the probability of required health outcomes (Chisholm-Burns, Vaillancourt, & Shepherd, 2008) and maintains the consistency to the latest professional knowledge. Quality comprises six dimensions which are
Dimensions of Quality in HealthCare
Figure 1: Source: Made by Author (2013)
Safe: No harm is caused to the patients from the treatment offered to them
Effective: To offer services based on scientific knowledge that gives exact benefits
Person-centred: To offer necessary care appropriate to the needs and values of the individuals
Timely: To eliminate waits and delays (Caldwell, Butler, & Posten, 2009)
Efficient: To eliminate wastes
Equitable: To offer services equally to all regardless of income and wealth
Quality Improvement is defined as the systematic changes, methods and strategies implemented in the above mentioned dimensions to enhance the quality and ensure better patient experience and health outcomes.
Quality and Service Improvement Agenda according to this assignment is referred to the different policies, guidelines, health programmes, Government legislations and other improvement strategies implemented to improve the quality of service offered to the patients, their families and other related individuals in Health and social care sector (Turnock, 2008).
Development of the quality & service improvement agenda in health & social care – A critical analysis
The first task would be in a form of a literature review which thoroughly evaluates the working of National Health Service, the world’s leading publicly funded health service popularly referred as NHS and its agenda of quality and service improvement
Introduction to NHS
Established in 1948, National Health Service, NHS is the world’s largest publicly funded health service and has the main objective of providing good healthcare to all, irrespective of income and wealth.
National Health Service (NHS) is the name shared by four publicly healthcare systems such as National Health Service, England, Health and Social Care in Northern Ireland, NHS Scotland, and NHS Wales. Though all four systems are funded centrally from the general taxation they are managed individually (NHS, 2010).
Except for certain unique prescriptions, optical and dental, NHS services are totally free for UK residents. Any type of treatment from an ordinary coughs and cold up to a complicated heart surgeries and emergencies, NHS offers almost all advanced medical services. More than 62 million of patients have been treated so far.
1.2 Structure of NHS
The Secretary of State for Health is in the top hierarchy of the structure of NHS. This person is the Government minister of Health department and takes utmost responsibility for NHS and reports to Parliament. Next level is the executives of department of health and NHS responsible for strategic planning for NHS under which there are 28 Strategic Health Authorities responsible for planning the necessary healthcare for their appropriate regions. Health services are divided into Primary Care and Secondary Care. GPs, pharmacists, dentists, opticians and other regular services which are demanded often are categorized as Primary Care. On the other hand, certain specialized services that are used occasionally are termed as Secondary Care.
These services are offered by large number of NHS organizations called Trusts. The trusts providing secondary care such as hospitals, ambulance etc is known as NHS Trusts and those offering Primary Care are Primary Care Trusts (White, 2010).
Organizational Structure of NHS
Figure 2: Source: Made by Author (2013)
1.3 Past Developments in quality and service improvement agenda in NHS
The various studies that were made on NHS two to three decades back pointed out that there was lack of responsibility in the management in regard to the quality improvement and maintenance. The organization managers focused only on financial matters and performance targets. There were only very few attempts made to improve the quality during 1990s and it included
Doctors were ordered to participate in medical audit in 1989 which was not in practice earlier
The 1991 patients charter, the Government document which declared various rights for the patients of NHS in areas such as general practice, hospital and community treatment, ambulance services, optical, dental, pharmacy and maternity (Silver, 1997).
The various white paper publications and community care reports have analyzed the problems of NHS and had made relevant changes in the structural pattern and policies to enhance the quality in NHS in a very short time. The study of these publications and reports would assist to understand the developments made in NHS in regard to quality improvement. Some of the popular white paper publications and other government documents are discussed in the further sections.
1.3.1 The Griffiths Report: ‘Community Care: Agenda for Action’: 1988
This is a report prepared by Sir Roy Griffiths during the period when NHS faced various problems. Griffiths after an in-depth analysis came out with comments stating that NHS was lacking effective leadership management which was very essential for quality. Further to this the whole system of community care was analyzed by Griffiths and in 1988 a report was developed by him called “Community Care: Agenda for Action”. Griffiths proposed to sort out the area which included dependent groups such as older people, disabled and mentally ill (Tanner & Harris, 2008). The report had six recommendations to be put into action immediately:
Requirement of appropriate ministerial authority to implement the policy
Local authorities such as social work, service departments should have he responsibility to maintain long term and continuing care. On the other hand, the health boards should take responsibility of primary and acute care
Necessary grant from Central Government
The activities that have to be implemented by social service departments have to be specified after assessing the care needs of various localities.
Flexible packages have to be designed based on the care needs for the senior residents
Collaboration between social departments and voluntary/private sector of welfare
Social services should take the responsibility of registering the residential homes
1.3.2 Working for Patients: 1989
The proposal of clinical audit was introduced in the white paper “Woking for Patients: 1989”. The main aim of the proposal is to create appropriate conditions that would make the clinical audit a regular practice for professionals thereby leading to improvement in the quality (Parliament.uk, 2010). Nearly £218 million was spent during the period 1989-90 and 1993-94 for the purpose of introduction and development of clinical audit in NHS. An additional £61 million was funded again in the period 1994-95
1.3.3 White paper ‘Caring for People’ 1989
This white paper published in the year 1989 is a response for the report of Griffiths Caring for People and also a supplement for the Working for Patients as both had the same views which are:
State provision was inefficient
The purchaser and provider roles was separated
Decentralization of budgetary control
The white paper supported and followed the recommendations laid down by Griffiths report but recognized six different objectives
New funding structure
The responsibilities of agencies have to be clearly defined
The management of care and needs assessment should be developed (Renwick, 1996)
Domiciliary, day and respite care should be encouraged
1.3.4 The NHS and Community Care Act 1990
After the publication of the above mentioned white papers and reports, the UK government set out legislation to administer the health care and social of National Health Service. The legislation was laid down to assess the needs, conditions and requirements of the patients and provide appropriate care services. Additional to this, the act also established an internal market to supply the healthcare and make the state an enabler (Trauer, 2010). It was also pointed out that the local authorities should take the prime duty of assessing the people in regard to social care and support which would guarantee required services for those who require the community care or other service support. The results of the assessment of the needs and conditions assist the local authorities to identify whether the individual require care service or social service.
The main objectives of the act are as follows:
To restructure the NHS
To improve the quality in health care and services
To improve the health through health promotion and diseases prevention programs (White, 2010)
Provision of more information to users
Signing of contracts with GPs, opticians and dentists
To bring up individual care plan for patients and other users
The act and NHS together modified the structure and divided the role of local and health authorities. This was done to evaluate the needs of the local population and then make intend to purchase the services from providers. The health organizations to develop as providers should become NHS trusts. The community care act has given along term care for the people either in their own place or residential homes
1.3.5 The new NHS: Modern and dependable – White paper
In 1997, the new Labor Government brought new changes and amendments of NHS and announced through a white paper, The New NHS: Modern and dependable which specified a modernized strategy to bring improved quality of patient care in NHS for a period of ten years (Gralton, 2000). The paper also elucidated that each and every staff of NHS should take utmost responsibility in improving the quality. This white paper also introduced a new concept called Clinical Governance.
Clinical Governance is a key component in the health and social care organizations which ensures that quality is at the first step of organizations’ objective. It is referred as a systematic approach to enhance and maintain the quality of care within the health system. Formerly the approach was developed by National Health Service, UK defining it as a structure through which the different organizations of NHS are responsible to ensure continuous improvement in the service quality and maintain high level of standards and create excellent clinical care environment.
Attributes of Clinical Governance
Figure 3: Source: Made by Author (2013)
Adding to the above, the white paper included six major aims declared by the department of Health. They are
The NHS should be renewed as genuine national service where the patients would get the consistent and best treatment of highest quality at right time
Doctors and nurses should deliver the services according to the latest standards (Blaber, 2012)
NHS should work in partnership by developing links with local authorities to eradicate the barriers that hinders the quality improvement
NHS should adapt rigorous approach to drive efficiency
NHS should re-establish the public confidence
1.3.6 A first class service: Quality in NHS
The following year after the publication of White paper The new NHS: Modern and dependable, another consultation document “A first class service: Quality in NHS” was defined and pointed out that there would be consistency in the quality set by the standards through National Service Frameworks and National Institute for Clinical Excellence (NICE)
1.3.7 The NHS Plan: A plan for investment, A plan for Reform
This is a document published in July 2000. A team headed by Tony Blair developed a work of Modernizing and reforming the NHS and this was included in the document. The document included certain major policies and they are:
To ascertain that the number of doctors, nurses and medical students are increased
The consultant should put seven years of their service with NHS
To take a commitment of expanding the health care services by opening 100 new hospitals and adding 8000 bed spaces by another 10 years
Patients should be able to access GP’s within 48 hours
Waiting Lists proposals should be replaced as Booking Systems
To create a new level of primary care trusts to bring about effective relationship between NHS and Social services (Department of Health, 2010)
The policies laid down by the document modernized the NHS by increased strength of staff.
1.3.8 Care Standards Act 2000
Passed in July 2000, this is an act of parliament that brought certain modifications in Registered Home Act, 1984. The major aim of the act is to examine thoroughly whether the services are delivered with utmost care. Another objective of the act is the registration of children’s homes, independent clinics, care homes, and other bodies offering health and social care services (Dening & Milne, 2011). The act to accomplish the above objectives incorporated certain changes.
Local authorities should operate the functions with the same level of private healthcare service providers.
Setting up of National Care Standards commission to monitor the functioning of nursing and care homes.
Launch new standards for National Minimum care
Effective coordination between the Institution of Social Care Council and individuals of social care
The setting up of standards, extension of regulatory functions and registration of care homes implemented in the act brought tremendous quality improvement.
1.3.9 Delivering the NHS Plan – Next Steps on Investment, Next Steps on Reform
This is a policy document supplementary to the 2000 White Paper The NHS Plan and summarizes the necessary steps to be taken to deliver the various reforms planned in the white paper. The document addressed various issues and suggested appropriate reforms to eradicate the issues.
Reduce the waiting time for surgeries
Decrease in deaths due to cancer and cardiac problems
Employ additional staffing
Stress the importance of training for staff
Motivate the trusts by offering incentives
Setting up of NHS Foundation trust for better flexibility in the management (Crisp, 2011)
Improve the relationship between health and social services especially the care homes of senior citizens
Setting up of one independent inspectorate to manage and control NHS and private organizations
1.3.10 Health and Social Care (Community Health and Standards) Act 2003
The act put an end to National Care Standards Commission and Commission for Social Care Inspection (CSCI) was replaced. The act made changes and improvements to Care Standards Act 2003. The act described appropriate functions and powers for CSCI. Additional to these, the act also dealt with various functions of boarding schools, colleges and training centres. The different grievances on social care were dealt and provided relevant regulations to handle the complaints.
The major amendments made by the act are:
NHS Foundation Trusts were created
Independent health care regulator for set up
Establishment of Commission for Health Care Audit and Inspection (CHAI) and Commission for Social Care Inspection (CSCI) (Health and Social Care , 2003)
Legislation for compensation payment
Proviso for altering Welfare Food Scheme
The proposal accelerated the standardization of practice and service in Health and Social Care. The concept of self-government in Foundation Trusts was initiated and privatisation, marketing and variability of service were encouraged.
1.3.11 The NHS Improvement Plan: 2004
This is a document published by the Government in 2004 which laid stress on the treatment of chronic diseases, enhance the public health and develop projections for the future.
The patients would be given choice of five hospitals by 2006 (Murphy, 2004)
The choice would be extended as limitless by 2008
The private service providers also would be allowed to participate
To reduce the waiting time for treatment and the limit was set as maximum of 18 weeks by 2008
BY 2005 Cancer patients would not be allowed to wait for more than 8 weeks
To introduce electronic booking and prescription by 2005
The proposal was praised as a worthy one in terms of choice and waiting time and this improve the quality experience of the customers. The participation of private service providers was also a major improvement which improved the efforts of reducing the morbidity rates.
1.3.12 Our Health, Our Care, Our Say
The white paper Our Health, Our Care, Our Say was published in 2006 to develop a new direction for community care. The whiter paper describes the various developments and improvements that the Government is planning to implement in health and social care sector and also gives the valid reasons for making the necessary changes and appropriate steps that would be taken to implement the action plan. The white paper sketched the plan for the next five years. The main goals of the white paper are:
Earlier support for prevention services
Launch of new NHS “Life Check” program for people to make healthier choices (Davies, 2007)
Extended support for mental health and well being
GPs to give convenient appointments
To achieve the above goals, some of the major amendments mentioned in the white paper are:
Transfer for funds from hospitals to community care services to prevent ill health
To encourage community hospitals to operate for comprehensive solutions
To rearrange the specialists like GPs, opticians, orthopaedics, dentists etc to the closer reach of the communities
Enhance public health through prevention measures
Expert Patient Programme to persuade the individuals to take more care of their health
Motivate GPs for providing amiable and convenient appointment timings
Though these objectives would improve the community care but requires larger capital in regard to facilities and training.
1.3.13 A new NHS review and Darzi reform
Our NHS, Our Future: 2007, an interim report and High Quality Care for All: 2008, a final report were submitted by Prof. Lord Ara Darzi and the report was a complete review of NHS.
The interim report had the following recommendations:
Emphasis on GP surgeries and Health Centres and was suggested for necessary investments
Flexibility in operational times of GPs.
Setting up of Health Innovation Council
Setting up of Patient Safety Direct (Tingle & Bark, 2011)
Planning of rigorous audit regulator of Health and Adult Social Care
Launch of Care quality commission
On the other hand, the Final Report comprised the following recommendations:
Providing control and choice for the individuals in regard to their health care treatment
Launching different health campaigns
Curtailing down the vascular diseases
Enhance the choices for the GP
Launch of new service Direct Payment into health care (Glasby, 2011)
Development of person-centred care plan for individuals having chronic problems
Apart from the above recommendations in service delivery, the major achievements of the proposal assisted the establishment of Care Quality Commission (CQC).
1.3.14 Health and Social Care Act 2008
The Bill for this act was laid down in 2007 which included the following changes:
Setting up of Care Quality Commission (Healy, 2011)
Managing the health care professional for safe and ethical practice
Necessary steps to bring an end to infectious and contaminated diseases
The bill came into existence in 2008.
1.3.15 Equity and Excellence: Liberating the NHS: 2010
This is a white paper published in 2010 which specified the long term idea of the Government about the future of NHS. The objectives are:
To put patients at the core of all activities of NHS
Emphasis on continuous improvements on areas concerned with patients healthcare
Authorize and allow clinicians to take full freedom to take decisions on new innovations and improve the quality of healthcare (Department of Health, 2010)
1.3.16 The Health and Social Care Bill: 2011
The bill passed by the Government in 2011 recommended various changes for the NHS, England.
Transferring certain responsibilities of Department of Health to the new independent NHS Commissioning Board
Formation of economic regulators who are given permission to ensure complete protection against anti-competitive practices
Real budgets allocated to GPs, clinical commissioning groups and other professional to buy care for their local communities (Gabe, 2009).
Assigning all NHS trusts the status of Foundation Trusts
1.3.17 Health and Social Care Act of 2012
The White paper Equity and Excellence, liberating the NHS, published in 2010 contained the following recommended changes in NHS
Closure of PCTs and SHAs and set up new Health and Wellbeing boards
The Clinical Commissioning Group set up comprised 500-600 GP group which had to take the responsibility of directive from PCTs (Ham, 2012)
New regulatory body for all NHS services
To set up a body Public Health England to merge the activities with Local authorities to enhance the health of the communities
Subsequent to the white paper, a bill was published in 2011 which expressed the apprehension about the reforms. It was about the support extended for the participation of qualified providers that would lead to competition resulting to privatisation of NHS. Contrary to this, the Government expressed that the changes would guide to local partnership.
As there was heavy opposition for the changes, the Government conducted various consultations and suggested more than 2000 amendments, the main being the eradication of promotion of competition and a bill Health and Social Care regarding this was passed in 2012.
Quality and service improvement agenda in Nursing and Care
This task of the assignment evaluates the Quality and Service improvement agenda in one of the Nursing and Care service in London. The organization taken by the author taken for the case study is a popular nursing and care service for senior communities. The care home has spread its branches in nearly 27 communities and nearly 40000 senior residents are taken care. Residential care, nursing care and dementia care are the various person-centred services offered here.
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The service is a registered nursing care functioning in an exceptional environment setting comprised of highly qualified and experienced nurses who are much committed to their prime duty of taking care and maintaining the health, wellness, and self-esteem of each and every resident. All 27 residential nursing care operates on customized and person-centred programmes which offer the care exact to the needs of the residents. The most favouring element of the nursing care is each resident have been given dedicated care takers to provide round-the clock and best quality of nursing care. The high quality of nursing care makes the resident to live without fear in all aspects and have a feel at home.
Further to this, the author would analyze the working of the nursing care service in regard to the various quality service improvement agenda discussed in the above section.
2.1 Registration of Nursing care
From the earlier discussion of various white paper pubslications, reports, Government Bills and relevant Government Act, the author has stresses a major point that most of the publications, reports and acts such as Care Standards Act 2000, Health and Social Care 2003/2008 have insisted the mandatory registration of Nursing care services. i.e. all organizations that offer the care services should be registered, re-registered and regulated by National Care Standards Commission, Commission for Social Care and Care Quality Commission (Bernan, 2009).
The organization mentioned here in the case study has effectively completed the necessary registration process and submitted to the relevant bodies.
2.2 Quality improvements in the organization
The efforts that were taken for more than three decades in the past have brought out tremendous improvement in the author’s nursing care organization
The introduction and implementation of Clinical Governance in 1997 white paper lessened the inefficiency that prevailed and brought in various positive outcomes in the organization in regard to the nursing care
Improved accountability of clinicians and managers and slowly eradicated all the major issues in quality.
There was improved involvement in decision making from the residents and staff
There was change in culture that led to open and collaborative working
More focus on nursing care improved the health outcomes
Personalized care plans and direct payment option ensured flexibility to the residents
The CRB and ISA of Safeguarding Vulnerable Groups Act 2006 allowed the author’s organization to employ those individuals with good references without any history of crime or abuse which is very essential qualification to work in nursing care (Hannon & Clift, 2011).
Theories and model recommendations for improvements in a specific area
Theory of Nursing as Caring
The theory was developed by Anne Boykin and Savina Schoenhofer which provides a theoretical structure with related practical suggestions in Nursing and Care. The major assumptions of the theory in the perspective of Nursing and Care are:
Caring is the basic attitude of a common human being
The profession of nursing should have appropriate combination of the activities of discipline and profession which would help the nurses to understand the concept of caring and nurturing (Zaccagnini & White, 2011)
The theory pointed out that the caring lead up to various modifications in nursing practices and revealed the value of nursing in the modern nursing care environment. The theoretical connection are recognized and related to the suitable indicator to maintain consistency in nursing care. This advances the professionalism and also improves the quality of nursing care in the organization
PACE Model for improvement in Nursing and care
As the objectives of author’s organization is mainly concerned with the nursing and care for senior residents the Program of All-inclusive for the Elderly (PACE) model would be the best approach for betterment in the organization and promote well being of the seniors and the families. This is the best model identified for the nursing and care for senior residents who are above 55 needing nursing care. The model would ensure that the organization provides the senior residents a safe living in the community. The various services identified and recommended by the model in nursing and care which would improve the quality are:
To deliver the required medical services and provide the complete range of care to the seniors (Ehrman, 2009)
Care services of the PACE model includes adult day care with nursing facilities, therapies like physical, occupational etc, meals, personal care and nutritional advices
Appropriate medical care according to the needs of the seniors
Supply of all prescribed drugs
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