Around this time of year NHS Hospital Trusts will be preparing their annual Quality Accounts (QA). These are public documents aimed at enabling professionals and the public alike to be informed about the quality and safety of services provided across the organisation. Introduced in 2010 by the Department of Health, QA’s are part of the national drive to increase transparency of NHS health service providers in England.
Are QA’s any better that previous ways of improving quality and safety of nursing care? A look back over the history of nursing may help to answer that. Florence Nightingale gave the profession a great start by using statistics to evaluate patients’ progress. The shocking death rate of young soldiers in hospitals during the Crimean War prompted her to compile monthly statistics on the causes. Six months of figures revealed that almost three quarters had died of illnesses they acquired in hospitals, far more than from wounds. Her campaign for reform began, underpinned by systematic data collection to identify root causes of deaths. Some causes lay outside the hospitals’ control, namely unsanitary water supplies due to contamination from animal carcasses and blocked sewers. Once these were remedied the mortality rate from disease dropped sharply.
Over a century later, in 1972, a landmark change in nursing was brought about by the Briggs Report which put nursing onto a ‘research-based” footing from which it has become increasingly evidence-based, to the undoubted benefit of patients. The learning from Florence Nightingale was clear – that statistics brought about positive changes in social policy. Similarly, the change to being a research-based profession ensured that patients would be no longer subjected to ‘traditional’ ineffective (or worse, harmful) methods of care.
Since then, awareness of the influence of nursing politics has increased. Two books, The Politics of Nursing (1985, Jane Salvage) and Nurses: Power and Politics (1987, Trevor Clay) pointed out the key role of nurses in leadership positions in creating environments in which good nursing care can flourish. Both authors emphasised the need to have patients’ feedback at the heart of any service developments. In contrast with this ethos, the top-down nature of targets and funding streams in the NHS over two decades means that financial management has dominated all else, as is aptly described in a book NHS SOS published last year (Ed Davis J, Tallis R).
QA’s can reveal annual data on patients’ experience and outcomes of care in hospital. This presents a real opportunity for nurses, or anyone else interested, to see factual evidence on selected aspects of care in their local hospital. Priorities for improvement are decided by an inclusive process involving staff, patients, key stakeholders and the public. Common priorities for improvement include pressure ulcers and complaints. The Francis Report recommended that QA’s “..should no longer be confined to reports on achievements as opposed to a fair representation of areas where compliance has not been achieved.” As regards complaints, he points out that the nature and detail of complaints is more important than numbers alone.
A real strength of QA’s is that they are open to scrutiny by Local Authority Overview and Scrutiny Committees, Clinical Commissioning Groups and Healthwatch Groups which can see the draft version of QA’s, and to make comments which are then included in the published version. While there is some way to go in achieving ‘the perfect QA’, evidence is emerging that requests and comments from Scrutiny Bodies are being taken on board. Examples include increased clarity and jargon-free reports, and a change of emphasis in dealing with complaints to encourage increased reporting by patients, but with the aim of having lower levels of severity of patient harms.
Such improvements reflect well Florence Nightingale’s search for “facts not impressions”.
References
Clay T, Dunn A, Stewart N (1987) Nurses Power and Politics
Salvage J (1985) The Politics of Nursing, Heinemann, London.
Tallis R and Davis J (2013) NHS SOS: How the NHS Was Betrayed – and How We Can Save It.
A shorter version of this article is published in Nursing Times