The Essence of Care in clinical governance
The Authors
John Badham, CGST Board Team, NHS Clinical Governance Support Team, Leicester, UK
Debbie Wall, NHS Clinical Governance Support Team, Leicester, UK
Maria Sinfield, Essence of Care, Cheshire and Merseyside SHA, Warrington, UK
John Lancaster, Essence of Care, NHS Clinical Governance Support Team, Leicester, UK
Acknowledgements
The authors would like to thank Christie Hospital NHS Trust, Manchester and the Learning Disability Service at Chesterfield PCT for their consent to include case studies of their Essence of Care work.
Abstract
Purpose – To review progress of the Essence of Care Programme of Clinical Governance. To describe its development and highlight its achievements.
Design/methodology/approach – The background to the programme is outlined and the methods adopted by the Clinical Governance Support Team (CGST) and NHS personnel involved are described.
Findings – At the heart of commitment to improve quality of health care lies Essence of Care to which the fundamental needs and comfort of patients are paramount. This provides a benchmarking tool for national standards of practice across health and social care which is applicable across medical specialties and relevant to all health professionals involved in caring for patients. Fundamental aspects of care were identified based on concerns of patients and professionals; these include communication, personal hygiene, food and nutrition. Standards are agreed between patients, carers, user groups, health care professionals, professional bodies and NHS departments. Systems for feedback and monitoring ensure continual improvement. Wide dissemination has ensured that Essence of Care is embedded in the NHS.
Originality/value – This review summarises the aims, objectives and progress of the work of the Essence of Care Programme of Clinical Governance since its initiation.
Article Type:
General review
Keyword(s):
Clinical governance; Case studies; National Health Service.
Journal:
Clinical Governance: An International Journal
Volume:
11
Number:
1
Year:
2006
pp:
22-29
Copyright ©
Emerald Group Publishing Limited
ISSN:
1477-7274
Essence of Care in action
Patients attending Christie Hospital, England, for bowel investigations (colonoscopy) went directly to the theatre department. They were often older people with complex health needs. The two days of bowel preparation beforehand, and being “nil by mouth” on the day, meant some patients already felt weak and physically fragile when they arrived. By the end of their investigations, which included the additional impact of sedation, the Consultant, mindful of their condition, often admitted them to hospital. Planned as outpatients, they were in no fit state to go home.
A nurse from surgical theatres initially thought that being part of a multidisciplinary group focusing on food and nutrition benchmarking at the hospital(part of an Essence of Care toolkit for best practice in healthcare) was of no relevance to her department. However, following discussion with the group, it became apparent it was: A surgeon thought of a simple way to help alleviate the long term problem and shared her idea with the theatre nurse. The nurse representative told the group and they decided to put the proposal forward to the NHS Trust Board, which supported its implementation.
A £3 voucher for a hot drink, soup and a sandwich is given to patients having bowel investigations. After the procedure, patients can sit in the recovery room to get over the effects; time to have a bite to eat and get some strength back. This seems simple. It is, but it has made a huge difference to the hospital and to the patients. Figures showed that within a sixth month period there was a saving of approximately £8,000. More important for patients is that fewer are admitted to hospital after their colonoscopies and they can stick to their plans to go home afterwards.
The above case is one example of many improvements in patient care that have occurred across the NHS in England, and beyond, since February 2001, when Essence of Care was launched. “ Essence” is a benchmarking tool designed to help practitioners take a patient-focused and structured approach to sharing and comparing practice across health and social care settings, to improve the quality of patient care. It supports the measures to improve quality set out in A First Class Service (Department of Health, 1998). Indeed, it has been described as the bedrock of clinical governance, with clinical practice benchmarking connecting the concepts of quality, clinical effectiveness and evidence-based practice. The importance of Essence of Care, as a resource to support frontline professionals implementing clinical governance at local levels in NHS organisations was acknowledged in May 2002, when it was integrated into the NHS Clinical Governance Support Team's (CGST)[
The background to Essence of Care
The drive to promote consistent, high standards of care has been a major stimulus evident in recent healthcare policy and reform (Department of Health, 1998, Department of Health, 2000). These reforms clearly highlighted that there are fundamental aspects of care that are central to the patient's experience. The NHS Plan (Department of Health, 2000) reinforced the importance of “getting the basics right” and upholding principles that put patients at the heart of reforms.
Essence of Care was developed from a commitment in the national nursing, midwifery and health visiting strategy, Making a Difference (Department of Health, 1999). This put clinical governance at the centre of its plans for quality improvement. The document highlighted an example of clinical practice benchmarking in the North West of England, where it was successfully used to compare and share practices across paediatric care. Exploring the benefits of benchmarking was cited as one way in which the nursing, midwifery and health visiting professions could re-focus on the fundamental and essential aspects of care; making standards explicit; monitoring practice and seeking to improve quality. Following publication of the report, patients, carers and professionals worked together to agree and describe good quality care and best practice, identifying a range of “aspects of care” benchmarks, fundamental to the patient's experience.
Developing the “aspects of care”
The Essence of Care identifies nine “fundamental aspects of care”, each with its own set of benchmarks: the most recent (April, 2003) focuses on communication between patients and or carers and healthcare personnel:
The fundamental aspects of care[
- communication;
- continence and bladder and bowel care;
- personal and oral hygiene;
- food and nutrition;
- pressure ulcers;
- privacy and dignity;
- record keeping;
- safety of clients with mental health needs; and
- principles of self-care.
Concerns around these interrelated aspects of care were initially highlighted through patient complaints, ombudsman reports and professional concerns.
The evidence used to establish the benchmark standards included:
- consensus agreement involving over 2,000 patients, healthcare professionals and user group representatives;
- patient stories derived from the Leading an Empowered Organisation (LEO)/Royal College of Nursing Leadership Programmes;
- Allied Health Professionals Leadership Programme development;
- lessons learnt in relation to humanity of care, from Commission for Health Improvement clinical governance reviews; and
- national guidance and policy.
Patients' and carers perspectives were paramount to the process of identifying the benchmark standards: availability of the evidence was balanced with their expectations about what constituted “best practice” and what aspects of care were fundamental to them. As such the benchmarks, and their continued development, reflect those areas of care that actually matter to patients and their carers.
What's in the toolkit?
The Essence of Care toolkit contains the following:
- an overall patient-focused outcome for each of the nine aspects of care (see above); and
- a number of factors that need to be considered in order to achieve the overall patient-focused outcome.
Each factor consists of:
- a benchmark of best practice for each factor;
- a continuum between poor (E) and best practice (A);
- indicators for best practice that support the attainment of it;
- guidance section on how to use the benchmarks; and
- forms to document and chart activity.
In the context of the food and nutrition aspect of care (the focus of the two case studies in this article) the patient-focused outcome is:
… patients are enabled to consume food (orally) which meets their individual needs.
Food and nutrition has ten factors which include, for example, “Factor 9 – Monitoring”. The benchmark for this has a continuum from E to A (see Figure 1).
The set of indicators for best practice include, “patients, carers, practitioners or professionals complete the food and fluid chart.” Discussion can be stimulated around the evidence produced to support the indicators, and experiences of different groups can be compared. Additional indicators can be added to reflect the uniqueness of particular patient or client groups. This process allows healthcare practitioners to review aspects of care, identify where to focus practice development, and plan what they need to do to their service to reach the highest standards.
Communication and dissemination
During 2000, in preparation for the launch of, what were then “new” aspects of care benchmarks, eight regional facilitators were trained to use the initial Essence of Care toolkit. These regional facilitators supported local facilitators in each NHS acute and primary care trust to take training forward in their own organisations. Copies of the toolkit were then sent to each regional office across England in February 2001 (Department of Health, 2001).
Essence of Care has always been subject to ongoing review and amendment in line with users' comments. For example, whilst “communication” was an integral part of each of the initial eight aspects of care, it was felt important enough to merit inclusion as a stand alone “aspect” in a revised 2003 Essence of Care. This move was a direct response to requests from participants involved in using the first version of the toolkit (Department of Health, 2001). In addition, the format of the original benchmarks was simplified because users had difficulties in applying it to their local, variable, circumstances: intervening steps on the E (poor practice) to A (best) continuum were removed. The focus shifted therefore from rating practice, towards more emphasis on stimulating discussion among the benchmarking comparison group.
The revised 2003 Essence of Care was sent out to all NHS organisations; copies were also sent to universities, prison healthcare services and to key stakeholders. Since then the regional and local facilitators have worked in partnership with practitioner leadership programmes, the CGST and the wider NHS Modernisation Agency, to embed it within NHS organisations' clinical governance arrangements across the country.
To satisfy demands for this revised toolkit from the UK and beyond, a downloadable version was posted on the Essence of Care programme pages on the CGST web site (www.cgsupport.nhs.uk).
In Essence, what are the benefits?
The benefits of the toolkit include:
- It is a multidimensional tool with a generic format that can be used in different healthcare settings, with patient and/ or carer groups, and regardless of clinical specialty.
- The focus is on the patient and the patient's journey rather than on any one professional perspective.
- There is an opportunity to collaborate through integration of organisational, management and professional approaches to delivering quality of care.
- It provides a forum for practitioners to take part in informal clinical supervision where participants can discuss issues beyond the benchmarking area being considered.
- Professional development: practitioners have integrated their activities into professional portfolios, demonstrating the effectiveness of an underlying philosophy which sets out to share and develop best practice.
- The benchmarking process can lead to improvements in other related areas, emphasising, for example, the importance of ensuring systems are in place to address the needs identified, and the necessity of connecting work into local, regional and national strategies (for example National Service Frameworks) to ensure synergy with delivering clinical governance.
The example below demonstrates another potential benefit from working through the Essence of Care process: staff who are well supported and empowered to look at their own practice, are more likely to identify the solutions and take ownership and responsibility for making changes.
Ensuring what you want is what you get ConcernsA learning disabilities team from Chesterfield PCT reviewed their service by working through the Essence of Care Food and Nutrition benchmark. They were concerned about patients who misunderstood menus and were unable to communicate what they wanted to eat. When meals arrived, they were not always what the patients expected; sometimes there was food they didn't like.ActionTwo care support workers came up with an idea to improve the care of these patients. They used pictures of real food (e.g. peas, carrots) to build up a visual menu, cutting out and laminating each picture and sticking Velcro on the back. Then the pictures were divided into sections in a file i.e. soup page, main course, vegetables, pudding page, fruit page, etc. Finally, strips of Velcro were added to plastic plates.ImprovementA patient ordering food can show what s/he wants by selecting pictures from the file and “sticking food on their plate”, to build up a meal. Patients are happy, as they know what they are getting. They no longer have the frustration of trying to communicate what they want, only for this to be misunderstood.The “picture plates” idea has spread to other departments: it is being used for stroke patient care; in older people's services; and to aid other patients with communication problems. There is huge potential for helping any patient who experiences language difficulties.
The above example also shows, in a small way, the value of sharing good practice beyond one's own specialty or service, as so often ideas from one area are transferable to others. Internal benchmarking therefore, can also encourage inter-departmental networking: this is particularly important where staff in specialist areas feel isolated. Spreading this benchmarking exercise further afield can allow for a “compare and contrast” of current practice across different types of organisations (e.g. between mental health and acute trusts). Sharing good practice and learning from the examples of others is something that NHS organisations have not always been good at (Commission for Health Improvement, 2003), but that Essence of Care benchmarking encourages.
Supporting success
Integrating Essence of Care into the work of the Clinical Governance Support Team was a crucial step in ensuring that fundamental care was addressed in all NHS organisations, and with the advent of commissioning, in private sectors of care.
Healthcare practitioners have been able to identify a critical path of sustained improvement; from the point of contact with patients and their carers, through to the boardroom, ensuring that addressing fundamental care issues is not only on NHS Trust Boards' agenda but is visible within Board Directors' objectives and those who have responsibility for the delivery of high quality care.
Over the past five years, the CGST has learnt that NHS Trust Board commitment is essential to effective delivery of clinical governance. It has proved an essential part of the Essence of Care process; the Board can not only reinforce the value of delivering the fundamentals of care, but directly address issues or concerns raised by key stakeholders through benchmarking activity, ensuring that issues are taken to the right people across the organisation. Board teams have also come to understand that effective use of the tool can provide evidence that the established standards for NHS care provided for patients in England are being met (Department of Health, 2004a)
The 28 Strategic Health Authorities across England have also been supportive in facilitating “celebrations of good practice”, a sharing of knowledge, and approaches to improvement at local level regarding the nine benchmarks covering the fundamental aspects of care. This has culminated in NHS staff being recognised in Nursing Times awards for their approach to Essence of Care and the impact it has had on patient care at a local level (Davis, 2002 and Sandiford, 2004)
Conclusions
Nationally, organisations in NHS primary, secondary and tertiary care, and across the private sector, have embraced the principles of the Essence of Care as fundamental to the implementation and delivery of good clinical governance. The application of the benchmarks to practice can result in a real difference to the quality of patient care delivered (Oxtoby,2003 and 2004; Gilbert, 2005; Harvey, 2004)
Contrary to the history of Essence of Care, the toolkit is not “just for nurses”: it is relevant to all healthcare personnel to explore the benefits of benchmarking activity, undergoing a process by which best patient–focused practice is identified and continuous improvement sought through comparison and sharing.
Development of the Essence of Care benchmarks has provided a valuable opportunity to challenge and break down traditional boundaries between professional groups, organisations and sectors and replace them with an integrated patient focus. Good leadership however, is critical to maintaining the drive and direction of healthcare teams that seek to deliver practice improvements using the benchmarking process. Such teams also have to balance the drive to demonstrate evidence-based practice, with the demonstration of care practices that patients and carers have identified as “of the essence”.
With the appointment of a successor organisation to the NHS Modernisation Agency, of which the CGST has been a part, and the launch of a new national organisation to support the implementation of clinical governance in 2005 and beyond, Essence of Care is to continue its contribution to NHS improvement and modernisation by being locally rather than centrally based. This move will facilitate regional ownership and continued evolvement of the benchmarking tool, ensuring it remains relevant and practical to local communities. Underpinning this is the message, delivered by agencies such as the National Patient Safety Agency (NPSA) and the Healthcare Commission (Healthcare Commission, 2004), both of which recommend using Essence of Care, stressing its relevance and value as a key mechanism for driving continuous quality improvement in patient care.
Figure 1Factor 9: monitoring
References
Commission for Health Improvement (2003), Getting Better? A Report on the NHS, The Stationery Office, London, .
Davis, C. (2002), "Biting changes", Nursing Times, Vol. 98 No.45, pp.44-5.
Department of Health (1998), A First Class Service: Quality in the NHS, The Stationery Office, London, .
Department of Health (1999), Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare, Department of Health, London, pp.49.
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Gilbert, R. (2005), "Using Essence of Care benchmarking to develop clinical practice", Nursing Times, Vol. 101 No.2, pp.54-9.
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Oxtoby, K. (2003), "Nutrition: the big challenge", Nursing Times, Vol. 99 No.37, pp.20-3.
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Sandiford, R. (2004), "The essence of teamwork", Nursing Times, Vol. 100 No.50, pp.24-5.
Further Reading
Ellis, J. (2001), "Benchmarking: a way of universalising the best?", Nursing Times Research, Vol. 6 No.2, pp.566-7.
Ellis, J.M. (2001), "Introducing a method of benchmarking nursing practice", Professional Nurse, Vol. 16 No.7, pp.1202-3.
NHS Clinical Governance Support Team (2003), Essence of Care Programme and Toolkit, available at: www.cgsupport.nhs.uk/Programmes/Essence_of_Care_Programme, .
NHS Modernisation Agency (2004), Good Practice in Paediatric Continence Services – Benchmarking in Action, NHS Modernisation Agency, London, .
Nolan, M. (2000), "Skills for the future – the humanity of caring", Nursing Management, Vol. 7 No.6, pp.22-9.
Corresponding author
Debbie Wall can be contacted at: debbie.wall@ncgst.nhs.uk