Case Study 3 - Breaking it down

Quality of care review guidance
Healthcare Improvement Scotland

Managing capacity and resources while assuring high quality care

Julie Campbell, Lead Nurse for Patient Safety and Care Assurance, NHS Borders

Facing the challenge of assuring care quality amid stretched capacity and resources, NHS Borders navigated these challenges using the Excellence in Care (EiC) Quality of Care (QoC) Review guidance. Prior to using the QoC guidance, NHS Borders had tried to remobilise their care assurance standards post-Covid and had tried alternative approaches but had found they did not meet their needs. 

Without a preferred care assurance approach, NHS Borders participated in testing the QoC Review guidance EiC Framework. After initial testing, the tool received support from the Associate Director for Acute Nursing, leading to its integration into their governance structure. Local staff also viewed the new approach positively. Although initially nervous, the identification of good practice in addition to areas needing improvement helped staff become more comfortable with the process. Senior Charge Nurses (SCNs) also appreciated the practicality of the tool.

“I think as the EiC framework [EiC QoC Review guidance] is a QMS it is more practical tool. Elements such as workforce or wellbeing could easily have been missed using other tools, on a regular basis. Previous tools were also repetitive on a monthly basis.”

The approach was also recognised as a valuable resource for inspection preparation allowing teams to share their knowledge and improvement plans.

“Implementation of the QoC Review guidance locally provides assurance that we are prepared and consistent across all inpatient areas. It also provides SCN’s autonomy to identify improvement initiatives following a CAV, SAER or complaint.”

Managing resource whilst assuring care

Despite the generally positive reception of this new approach to care assurance, there were concerns over the amount of resource required to embed this resource into their care assurance standards. To address this, the NHS Borders Patient Safety and Care Assurance team asked acute wards to conduct partial Care Assurance Visits (CAVs) monthly.  

The CAV tool was broken down into its constituent parts to make it more manageable, enabling staff to prioritise relevant elements.

“Our Care Assurance Structure requires SCN and CNM to perform monthly CAV’s, applying 2 elements from the framework each time, taking approximately 1.5 hours.”

Clinical Nurse Managers (CNMs) and Senior Charge Nurses are expected to lead their areas CAVs, leveraging SCNs’ in-depth knowledge and CNMs’ governance oversight and QI experience.

While monthly CAVs will be led by senior team leaders, additional senior leadership will join the CAVs biannually. Ultimately, these CAVs are intended to feed into an annual Quality of Care review in each inpatient area.

In addition to the planned annual QoC reviews, NHS Borders will conduct ad hoc QoC reviews in response to identified care quality concerns. For example, a QoC review was commissioned in one department following a CAV that identified limited assurance of an element. This involved setting up a designated day with multi-professionals, using data from local Safety and Quality dashboards, and developing a learning improvement action plan. Senior Charge Nurses can now use the CAV template to report back to their senior clinical management teams monthly whilst these plans are implemented.

They have since used the CAV tool in a variety of care contexts including the medical assessment unit, emergency department, and maternity services. Initially focused on acute services due to care quality concerns, efforts have begun to embed this more widely within the Board’s care assurance governance structures and with allied health professionals.