Ward accreditation is fundamental in contemporary healthcare delivery. One NHS trust in southwest England that had been placed in special measures introduced a ward accreditation programme – known as the ASPIRE programme – but the trust’s senior nursing leadership team raised concerns about the level of quality assurance provided. Therefore, the trust revised its newly created ward accreditation programme, referring to the evidence base to re-evaluate the metrics used for assessment. Five new elements, including direct registered nurse care time and ward climate, were introduced in the accreditation process. The revision improved confidence in the quality assurance provided by the programme, which became central to the trust’s overall improvement plans.
Nursing Management. 27, 5, 35-40. doi: 10.7748/nm.2020.e1957Correspondence
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Frazer Underwood participates in the National Institute for Health Research (NIHR) Senior Nurse and Midwife Research Leader Programme. The views expressed in this article are those of the authors and not necessarily those of the NIHR or Department of Health and Social CarePermission
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Published: 24 September 2020
Care Quality Commission - healthcare inspection - management - patient safety - patients - professional - quality assurance - service improvement
QUALITY AND safety of care commitments are embedded in the NHS Constitution for England (Department of Health 2015), which states that patients ‘have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality’.
Delivering this legal right to the public requires a considerable and continual focus on behalf of the workforce every day. Reducing patient harm and patient mortality are further drivers for robust safety and quality measurement, as well as for effective reporting processes across healthcare organisations (Morris 2012).
Over the past decade, nurse managers have made significant efforts to use improvement methodology to translate knowledge into action and deliver measurable assurance of quality and safety of care. The structures put in place are now becoming pillars of trust board assurance frameworks. One such structure is ward accreditation programmes, which are promoted by the chief nursing officer for England in the Guide to Developing and Implementing Ward and Unit Accreditation Programmes (NHS Improvement 2019).
This guide is targeted at chief nurses and those in other senior nursing and midwifery roles, and provides examples of established accreditation programmes, some of which were created more than ten years ago. All of the examples included are from trusts with high Care Quality Commission (CQC) ratings for quality and safety, and all programmes use the CQC’s (2018) five key lines of enquiry, which ask whether services are safe, effective, caring, responsive and well-led.
This article presents a case study from a trust in the southwest of England, describing how it has enhanced its quality assurance framework by revising a ward accreditation programme that had been introduced in response to the trust’s placement in special measures (NHS Improvement 2018a).
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 programme harnessed what the trust was already doing well, focused on priority areas for improvement and drew on established ward accreditation programmes.
» The project was led by an engagement and leadership group that comprised ward staff.
» Time was invested in developing and training the assessment teams.
» Executive sponsorship and project leadership support were essential.
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.
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:
» Direct registered nurse care time (the proportion of time that registered nurses spend providing direct care to patients). This has been shown to be strongly associated with safety and quality (Griffiths et al 2019).
» Ward climate – patient experience has been shown to improve in line with staff well-being, and it has been identified that there is a link between the team’s behaviours and cohesiveness and the ward’s safety culture (Maben et al 2012). 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 rostering efficiency dataset, Safe Effective Rostered Fairly (SERF), obtained through the HealthRoster software (Allocate 2020).
» A ward-to-board data reporting tool on ward quality and safety triggers, the Quality, Effectiveness and Safety Trigger Tool (QuESTT) (NHS South West 2011).
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.
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.
Identify the problem
The problem identified was that the ward accreditation programme did not provide trustworthy and reliable quality assurance of ward safety practice and culture
Adapt knowledge to local context
Several features of the National Institute for Health Research (2019) themed review about staffing on wards were adopted to strengthen the accreditation process. Five new elements were introduced:
» Direct registered nurse care time
» Ward climate
» Observation of care
» Ward quality and safety triggers
» Rostering efficiency
Assess barriers to knowledge use
The ward accreditation team were familiar with four of the five new data collection tools that were to be used. The fifth tool – the Quality of Interaction Schedule tool used for observation of care – had a clear user guide. The fact that the evaluation was led by a small ward accreditation team simplified knowledge acquisition
Select and tailor interventions
The ward accreditation team was involved in informing and developing the revisions to elements of the previous programme, with the aim of simplifying standard-based assessments
Monitor knowledge use
This was the testing phase in the pilot ward. The ward accreditation team used the new and retained metrics to obtain data. They also collected feedback on the revised accreditation process, including staff experiences of the ward climate survey and how the ward accreditation team felt about the new questions and the observations of care
A tabletop exercise was undertaken to review the data obtained and to develop a revised assessment matrix, in which all data regarding the nine elements of the revised accreditation programme were drawn together
Sustain knowledge use
Information collected during the pilot was used to develop a manual describing the structured approach of the revised programme and containing guidance on how to conduct assessments
The revised programme was tested in three other wards before trust-wide roll-out. The programme manual is being regularly revised as learning continues
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).
» Direct registered nurse care time – data extracted from the quarterly ward assessment of registered nurse time spent providing direct care to patients
» Ward climate – an independently distributed and anonymous survey of ward staff measuring team cohesiveness, whereby the team is rated ‘functional’, ‘cold’, ‘cosy’ or ‘dysfunctional’ (West 2012)
» Observation of care* – three 20-minute observations of care evaluating whether the care observed has a negative, neutral or positive effect on patients
» Quality, Effectiveness and Safety Trigger Tool (QuESTT) – data extracted from the ward-to-board data reported by clinical matrons each month
» Safe Effective Rostered Fairly (SERF) performance – data extracted from the rostering efficiency dataset
» Environmental standards assessment* – combination of observation of the physical environment and observation of practice in that environment, for example equipment cleaning practice
» Care standards assessment* – series of structured questions assessing staff’s knowledge of a range of practices and clinical topics, for example end of life care practices
» Documentation audit* – comprehensive audit of clinical records, including medicines records
» Patient experience survey* – data obtained from ten questionnaires completed by patients
*Conducted during an unannounced four-hour accreditation visit
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.
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’.
» Gold – strong evidence of improvement activity and achievement of consistently high patient safety and quality standards. The team working on this ward is recognised as significantly cohesive and focused on obtaining positive patient outcomes
» Silver – good overall evidence of improvement activity progressing the delivery of above-average levels of patient safety and quality standards. The ward team is working well together, producing overall positive patient outcomes
» Bronze – safe ward with evidence of targeted improvement activity progressing the delivery of patient safety and quality standards. The ward team is working together to deliver a good level of patient experience
» White – safe ward with limited improvement activity progressing the delivery of patient safety and quality standards. Team leadership and team working are areas identified for improvement to fully enhance patient experience and safety
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.
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 south west 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.
• Nurse managers have made significant efforts to use improvement methodology to deliver measurable assurance of quality and safety of care. One structure that has been put in place is ward accreditation programmes
• In one trust, the senior nursing leadership team expressed concerns about the quality assurance delivered by the ward accreditation programme. These concerns were triggered by one ward in particular, which had experienced a series of safety incidents and issues that were not reflected in the ward’s accreditation rating
• In response to these issues, the trust enhanced its quality assurance framework by revising the ward accreditation programme using the evidence base
• The revised 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
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