Quality improvement in social care - what's the best way to do it?

Managing quality in health and social care 

Implementing a process for managing and improving quality 

One of the best ways of managing quality in health and social care is auditing your services to see where they might be below standards and to identify where standards could be driven up further.

Before auditing your services, you should run a quick check on yourself. How do you see care audits? As a way of checking for problems? To generate evidence for the CQC or Care Inspectorate or RQIA? Or do you see them as a way to identify where and how you can make your care services better?

To make the most of audits you should be coming from the latter perspective. Because although care audits are indeed necessary to demonstrate to inspectors that you have proper oversight, at its core the audit is a Quality Improvement Process.

Methods of quality management in health and social care 

Various approaches to managing quality and improving it, often called Quality Improvement Methodologies have been developed, emerging from different countries, decades and sectors of the economy.

When it comes to health and social care, the Healthcare Quality Improvement Partnership (HQIP) have developed their own guide to the social care audit in practice. Their guide utilises a model very similar to the Plan-Do-Check/Study-Act (PDCA) framework, first popularised by W. Edwards Deming, who many consider to be the father of modern quality control.

Each of the four stages of this cyclical model have been adapted by the HQIP to fit to social care. For guidance when auditing, you may want to build in your regulators own measurements of what high quality care looks like. For example the CQC's Key Lines of Enquiry in England.

Incorporating these established measures into your quality improvement audit process will give you nationally recognised frameworks to assess your levels of care quality against, rather than relying upon internal conceptions of what high quality health and care looks like. 

An adapted Plan, Do, Check, Act cycle for quality management in health and social care

Stage 1: Plan & Prepare

Preparation for a care audit as part of an ongoing quality improvement cycle:

• Determine which quality problem you will audit, e.g. a known risk to people using services, or to staff, a high cost or high-volume activity, or incident or complaint trend
• Agree the criteria and standards of quality you aim to measure against
• Involve people who use services, and other interested parties, in setting your objectives, standards, and the processes you will use

Stage 2: Review Quality

Data collection to review quality may be quantitative, capturing numerical data, or qualitative, capturing people’s experiences, to check whether standards are being met:

• Determine the data you need to understand whether you are meeting the standards identified, e.g. to check nutritional care, one might use the criteria ‘All staff assisting people with their meals must have appropriate training to ensure people are given the time, help and encouragement they need to eat the food provided’
• Prepare appropriate data collection form or system, and pilot before use
• Collect the data
• Analyse the data, to determine whether or not you are meeting the standards set, and if not, why not

Stage 3: Improve practice

Understand where and why performance is not as good as it should be, agree how it can be improved, and develop and implement changes:

• Discuss the results with all those affected and develop a consensus on what needs to change, e.g. in the case of nutritional care, you might find that few staff have appropriate training and agree that the organisation should ensure staff are trained relevant to their role
• Agree how to address all issues identified, taking into account what is likely to be effective, feasible and affordable
• Prepare an action plan to address the issues, using a variety of methods designed to achieve better compliance – such as training, protocols, checking systems, e.g. in the case of nutrition, appetising food, provided in an environment conducive to eating well
• Identify those responsible for making sure that each required improvement action happens
• Implement agreed changes and ensure people take responsibility for the actions assigned to them in the plan

Stage 4: Sustain Improvement

Everyone with responsibility must ensure the changes they make lead to improvement, by reviewing changes over time in order to sustain them:

• Integrate approaches to sustain improvements in the way the team, department or organisation works
• Agree dates for further or ongoing review or data collection, considering how long it will take for changes made to impact upon people using services
• Review performance further when changes have been made and time has elapsed, repeating the review as required and appropriate for continual improvement
• Make sure the benefits of care audit are experienced by the people who use the services, e.g. in the case of nutrition, this might mean comparing people’s nutritional status after changes have been made, to that at the outset of the audit

 

Why should health and social care providers use this model?

This adapted PDCA framework is probably the one care providers should use.

Other generic quality management and improvement methodologies, such as Sigma Six, can be used instead of or alongside PDCA, especially by larger care providers who 1. May have more mature quality management processes already and 2. Have larger datasets to analyse.

The issue with using models like Sigma Six for social care audits, is that they inherit many characteristics of the industries they were born in – typically manufacturing. There the focus is on making repeatable processes more efficient, stable and effective. Therefore, models like Sigma Six focus on setting a benchmark, before spotting and correcting deviations from this.

The symbol commonly used for Sigma Six.

While this works on the assembly line, it is less applicable, or even desirable in social care, where the focus should be on quality, personalisation and individualised outcomes, with unavoidable variety between each person receiving and delivering care.

The future of care quality management and audits: easier, more reliable, more effective.

The development of cloud-based software is starting to pay dividends in the practice of quality improvement, including in social care.

One such tool; Access Care Compliance, closely mirrors the audit framework recommended by the HQIP. It also comes ready with a library of proven care audits, while still giving you the option to create your own audits too.

This audit library helps make Stage 1 and Stage 2 in the process above much easier, because it does the job of determining the audit and information criteria for you, in line with the Care Quality Commission’s Key Lines of Enquiry.

Another really valuable thing Access Care Compliance does is to use the information from your own audits to create specific action plans, so you know what needs to happen to drive quality improvement, what has been done so far and what is outstanding.

Further guidance on quality improvement in health and social care

The Health Foundation has published its own 'Quality Improvement Made Simple: What everyone should know about health care quality improvement'.

Alongside some of the practices we've discussed it talks about the importance of change management when implementing and maintaining quality improvement systems in health and social care. It also advises on solutions to some of the frequent challenges that research has identified in making quality improvement work and 'stick' in health and social care.