Power to the people
With healthcare featuring prominently in the UK's general election earlier this year, never before have patients’ rights been so high on the agenda. And, as Emma Challans, clinical effectiveness manager at Sheffield south west Primary Care Trust (PCT), explains, the key to clinical excellence is handing back control to the end users – the patients themselves
The commission for health improvement’s (CHI), now the healthcare commission, clinical governance reviews indicate that PCTs in England demonstrate minimal patient involvement in how primary care services are delivered. In March 2003, CHI published ‘Nothing about us without us: what patient and public involvement means to CHI’. The document highlighted barriers to patient involvement such as lack of skills, resources and the opportunity to participate. Clinical audit is at the heart of clinical governance supporting services in delivering evidence-based medicine.
The right questions?
'Principles for best practice in clinical audit’ (2002) by the UK's National Institute for Health and Clinical Excellence (NICE) defines clinical audit as: ‘A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery'.
‘Working for patients’ (1989) defines clinical audit as: 'Improving the quality of patient care by looking at current practice and modifying it where necessary'.
But do we know what patients really want or expect from a service? Involving patients is key to developing services. They can tell us how we can respect them and their culture, whether we involve them in decisions and whether they trust us.
When designing and using patient questionnaires, are we asking patients the right questions? Would it be better if a patient completed a questionnaire with another patient? Recent projects indicate that a patient is more likely to tell another patient something that they would never mention to their health care provider.
Before involving patients it must be clear from the very start why we are doing so. Balogh et al (1995) stated that users can actually be genuine collaborators, rather than merely sources of data. Clinical audit assists and develops services in improving patient care - therefore, it seems only logical to create a clinical audit patient panel (CAPP).
Training the panel
To date, most audits have only had token patient input. For example, patients were asked to attend meetings for confirmation of a patient being involved whether they had the opportunity to contribute or not. A comment once heard was: 'Thank you for coming along today to listen to what we have decided to do’. The organization had already decided the outcome and patients were there as a mere token gesture only. A panel of trained patients can advise, support and improve clinical audit activity within a trust enabling service users’ and carers’ perspectives to be included in evaluating quality and to identify opportunities for improvement.
To ensure active involvement of the patients, it is essential that all panel members have a basic knowledge and understanding of clinical audit. Those involved should be aware of how audits are carried out, why they are done and what they can achieve if done properly. To ensure confidentiality, all trained patients wishing to become part of a panel must sign a confidentiality agreement.
When delivering training it is important to discuss the concerns and benefits of patient involvement from staff and patients. These may include a patient feeling that their views will not be taken seriously, that they won't understand the issues and that what they say or do may affect their future care. Staff may also feel that they are being criticised and that involvement undermines their role. All these issues should be discussed and those involved should be informed of the policy that patients will not work with their own GP practice or a service that they are currently accessing.
Case study: Sheffield PCT
A panel of ten members is currently available to work with PCT services and independent contractors in south west Sheffield. Members of the panel will have received the appropriate training and signed a confidentiality agreement. Panel members will either work alone or with others on an audit project. It is expected that they will work in pairs until their confidence and experience has grown. The process of involvement is as follows:
- The service will propose an audit project and request panel member involvement.
- The audit project and involvement of a panel member is confirmed.
- Panel member with specialist interest is contacted to be involved.
- Panel member accepts audit project (panel members can decline).
- Panel members meet with the service to discuss the audit project.
- Project is developed and taken forward with full panel involvement, for example: developing criteria/standards, creating a data collection tool and reporting feedback.
Some of the audit projects currently running are:
- district nursing: audit of patient records
- therapy services: patient questionnaire redesigned and implemented
- professional, panel member and patient. Here, patients were identified by secondary care and asked to participate. A set of questions was developed between the patient panel member and the health professional based on the evidence-based criteria used within the Sheffield care pathway for people with breathing difficulties. The patient panel member and health professional had the same questions to fill in based on feedback from the participating patient, and both made their own comments on the patient’s answers. The questionnaires are currently being analyzed.
- free nursing care policy and guidance - audit of clinical assessment including the grading level given to each patient by a member of the nursing team
Panel members also gave some valuable feedback. One member claimed the panel was ‘really useful’. Another said it allowed users to have ‘an impact on their care’ and one member felt like they were ‘really making a difference’.
About the author: Emma Challans AIQA is clinical effectiveness manager at Sheffield south west PCT. For more information contact e: Emma.Challans@sheffieldsw-pct.nhs.uk
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