Introducing a ward accreditation programme

The trust had been placed in special measures by the CQC in October 2017 (CQC 2017), and one response to this had been to commit to introducing a ward accreditation programme, with the aim of encouraging a shift towards a safety culture across the organisation. The approach used to introduce the ward accreditation programme was similar to that described in the NHS Improvement (2019) guide in that:

The ward accreditation programme – known as the ASPIRE programme – was piloted on one ward and the evaluation was positive, which led to trust-wide roll-out. In the first year of the project, all 24 inpatient wards underwent the accreditation process. In the first round of assessment, two wards obtained the highest rating (‘gold’), while 22 wards obtained ‘silver’, ‘bronze’ or ‘red’ ratings. Each ward’s status was reviewed in further rounds of assessments at intervals determined by their status: wards that had obtained ‘gold’ were reviewed every nine months; ‘silver’ wards were reviewed every six months; for ‘bronze’ wards the interval was three months; and for ‘red’ wards it was six weeks. During the first 18 months of the project, several wards improved their ratings through shared learning and improvement activities aimed at addressing areas that required attention. Three wards that had obtained ‘silver’ status at first assessment achieved ‘gold’ and five wards moved from ‘bronze’ to ‘silver’. At the end of the 18-month period, no ward was rated ‘red’.

Positive feedback from across the organisation indicated that a shift towards a safety culture had started to occur. After the first year of action and improvement activities, some minor modifications were made to the accreditation programme to avoid the duplication of questions to staff and strengthen clinical documentation standards – areas that had been identified as requiring improvement.

Strengthening the accreditation process

Eighteen months after the start of the project, the trust’s senior nursing leadership team expressed concerns about the quality assurance delivered by the ASPIRE ward accreditation programme. These concerns were triggered by one ward in particular, which had experienced a series of safety incidents, and issues regarding its safeguarding and safety culture had been raised by external NHS partner organisations. For example, concerns had been raised regarding a lack of rigour in nutritional status and bowel care monitoring and in relation to the management of patients with dementia, and several suboptimally organised and communicated discharges of vulnerable older people had been reported. These incidents had occurred over the six months preceding the ward’s latest accreditation reassessment, in which it had maintained the ‘silver’ status it had obtained in the two previous assessments. A ‘silver’ rating was defined as: ‘Good overall evidence of improvement activity progressing the delivery of above-average levels of patient safety and quality standards’ (ASPIRE Ward Accreditation Leadership Group 2017).

The ward’s renewed ‘silver’ rating did not reflect the incidents that had occurred and the concerns that had been raised regarding the quality and safety of care it provided. The senior nursing leadership team recognised that the accreditation rating only provided a superficial feeling of reassurance that the ward was providing safe and effective care and that this was based on trust in the accreditation process itself, rather than on its outcomes.

Up until that point, the evidence used for ward accreditation had centred on a structured standard-based assessment that relied primarily on care standards and environmental standards. In March 2019, the National Institute for Health Research (NIHR) (2019) published a themed review about staffing on wards, which summarised existing research evidence across two themes: ‘shaping the team’ and ‘managing the team and the ward’. The senior nursing leadership team found that two strongly evidenced features of the NIHR themed review were missing from the ward accreditation programme’s metrics:

This led the senior nursing leadership team to question whether direct registered nurse care time data were used effectively in the accreditation process and how staff’s experience of teamworking was measured.

Two further quality assurance-related measures linked to the evidence base connecting workforce skill mix to patient safety (Griffiths et al 2019) were proposed:

A fifth element was suggested to complement the programme metrics: observation of care. Observed staff behaviours could be compared with the outcomes of the patient experience survey (an element from the original programme), enabling data triangulation and therefore strengthening quality assurance (NHS Improvement 2018b). The Quality of Interaction Schedule (QuIS) (Healthcare Improvement Scotland 2011) tool was used to conduct the observations of care. McLean et al (2017) identified that the QuIS is a valid tool in acute care, but that further research is necessary to explore the relationship between QuIS measures and reported patient experience.

Evaluating the revised accreditation programme

The action cycle of the Knowledge to Action Framework (Graham et al 2006) was used to implement and evaluate the revised ASPIRE ward accreditation programme on one pilot ward – the ward where incidents and concerns had triggered the programme’s revision. A small external ward accreditation team of four people – one team leader at head of nursing level and three team members at clinical matron, ward team leader or therapy team leader level – was formed. Box 1 details the Knowledge to Action Framework action cycle used to evaluate the revised ASPIRE ward accreditation programme.

The five new elements of the revised ward accreditation programme were combined with four elements retained from the original programme to form an assessment matrix comprising nine elements (Box 2).

Findings from the evaluation

The pilot ward evaluation found that that registered nurses spent 40% of their time providing direct care to patients, which was below the trust’s target level of 60% direct registered nurse care time. This partly reflected the high registered nurse vacancy rate on the pilot ward, since working on shifts with an inadequate number of other registered nurses meant their time was increasingly spent on activities away from patients, such as administrative tasks.

The findings from the ward climate survey revealed that the team had low cohesiveness, with suboptimal communication and inadequate leadership support. The senior nursing leadership team immediately responded to these issues, with support from a senior member of the human resources team.

The observations of care identified a positive patient experience of care, as exemplified by the following statement by one of the ward accreditation team members:

‘[The] healthcare assistant made a positive person-centred intervention to de-escalate a potentially verbally aggressive situation with another patient – [they] reseated them in the bay, initiated a discussion relating to their former hobby and introduced some magazines from their locker for distraction. The patient continued to engage well for the period of observation’ (ASPIRE Ward Accreditation Observation of Care Response 2019).

Most of this personalised care was delivered by non-registered staff, reflecting the low direct registered nurse care time. The outcomes of the observations of care correlated with findings from the patient experience survey.

The outcomes of the QuESTT triggered an alert that the ward required attention and support from the senior nursing leadership team. Elements triggering safety concerns included that the ward had a new leader and a high registered nurse vacancy rate, that several recent serious events had occurred and that several formal complaints had been made.

The SERF performance report identified concerns regarding staffing levels on the ward. The environmental standards assessment, care standards assessment and documentation audit identified a combination of effective practice, compliance and areas that required attention and improvement. The findings from the patient experience survey showed high levels of patient satisfaction, which correlated with the outcomes of the observations of care.

Revised accreditation ratings

From the data drawn together in the revised assessment matrix, a final percentage score was calculated and translated into revised accreditation ratings (Box 3), reflecting the importance that the accreditation process gives to ward team cohesiveness. The top three ratings remained ‘gold’, ‘silver’ and ‘bronze’, but the lowest rating was changed to ‘white’, which was considered to be a more neutral term than ‘red’.

The pilot ward was reassessed using the revised assessment matrix, and obtained the lowest rating of ‘white’.

Rolling out the revised programme

Strengthened by the use of the evidence base, the revised ASPIRE ward accreditation programme was rolled out across the trust. Through feedback from the team leaders, it was identified that ward teams felt positive about the changes that had been made to the programme and had greater confidence in the quality assurance it provided. There was a strong commitment from the senior nursing leadership team and the team leaders to the strengthening of the programme and they had confidence in the revised accreditation ratings.

It was important that the changes were communicated to the ward team and the trust board. The team leaders reported that they understood that the previous accreditation ratings had been based on a different assessment framework, but they initially found the changes challenging to communicate to their team members. Therefore, presentations and question-and-answer sessions were delivered to the team leaders to communicate the evidence-based changes made to the programme. The senior nursing leadership team responsible for the pilot ward explained the accreditation process, its outcomes and the subsequent improvement plan. Team leaders found this useful for communicating the changes to their teams. The director of nursing, midwifery and allied health professionals explained the evidence-based changes to their trust board colleagues, explaining the reasons for the revision and enhanced quality assurance provided by the revised programme.

As the first ward to go through the revised assessment process, the pilot ward experienced significant challenges, notably in adjusting and responding to its lower accreditation status. However, the ward team and new leader were keen to focus on areas for improvement, which required team cohesiveness. Organisational learning concentrated on new approaches to rapidly respond to teams with low cohesiveness and suboptimal leadership. Prompt intervention from the senior nursing leadership team, open discussion of accreditation results and exploration of areas for improvement were all beneficial. The revised programme was assessed by team leaders in non-ward areas and was deemed suitable for transfer to other areas, including children’s services and outpatient services, without modifications.

The trust came out of special measures in April 2020, two years following the introduction of the original ward accreditation programme and six months after its revision. The revised ASPIRE ward accreditation programme has been adopted by the local community partnership trust in its community hospital inpatient services.

The case study detailed in this article is descriptive and there are several opportunities for further research, notably an evaluation of the longitudinal effects of the revised accreditation programme on quality standards and the safety culture within the trust.

Conclusion

Ward accreditation is fundamental in contemporary healthcare delivery. To deliver the quality and safety of care commitments in the NHS Constitution for England (Department of Health 2015), one NHS trust in southwest England revised its ward accreditation programme, which had been introduced in response to being placed in special measures. The senior nursing leadership team referred to the evidence base to revise the programme, using findings from an NIHR (2019) themed review to address the need for enhanced quality assurance.

The ward accreditation team’s experience in rolling out the revised programme throughout the trust demonstrates that evidence-based changes can be relatively straightforward to implement. The revised ASPIRE ward accreditation programme appears to be highly effective in identifying areas that require attention, with the aim of improving safety culture and team cohesiveness on inpatient hospital wards.