Title: Measuring quality in community nursing: a mixed methods study
Funder: Department of Health (England)

Abstract: The NHS needs to reduce avoidable hospital admissions contain costs and improve or maintain quality. Community nursing services (e.g. district nurses community matrons) are crucial in offering alternative provision to acute services and serve some of the frailest in society. Care provided by community nurses is largely invisible to health service planners and managers is poorly understood and research is limited. For these reasons quality measures in community nursing is the focus of this study. Measures of health care such as quality indicators can be used for service improvement purposes and enable commissioners provider organisations and users to judge service standards. An example of a community nursing quality indicator is ‘Each patient with a leg ulcer should have a formal record of ulcer size documented at first presentation and at least 4–6 weekly intervals thereafter. There are over 150 providers of community health services across the country and each has a bespoke quality indicator scheme made up of a mixture of nationally and locally selected indicators. Due to the substantial variability across community quality indicator schemes comparison both within and between organisations is difficult. Millions of pounds are spent directly and indirectly on quality indicators yet we have little information about them. The estimated spend on Community Commissioning for Quality and Innovation (CQUIN) (a pay-for-performance quality indicator scheme) in 2012/13 was £275 million and this is set to increase with the introduction of quality premiums in 2014/15. This research will study the selection application and usefulness of quality indicators for measurement of community nursing quality. The aim is to identify what works for whom and in what circumstances to ensure that quality indicator schemes achieve their intended goal of improving the quality of patient care. A mixed methods design utilising an integrative approach of connecting quantitative and qualitative data rather than merging or embedding will be used. Mixed methods will be employed sequentially to provide breadth and depth of description of quality indicator use in community nursing. First a national survey will provide quantitative data describing the range of quality indicator and incentive schemes in use for community nursing in England and current providers of community nursing services. Data from the national survey will be analysed descriptively to map the location provider type (NHS non NHS: private independent voluntary sector) quality indicator type (structure process or outcome) derivation (national regional or local) goal (e.g. end of life care) and source (e.g. NICE NHS Health and Social Care Information Centre) of quality indicators currently being utilised in practice. Second a qualitative case study will identify and probe the processes of selection and application of quality indicator schemes for community nursing to provide an in depth understanding of the relationship between national and regional policy directives and broader influences such as the context of social care on local implementation. Five case sites will be chosen based on 1) variation and number of quality indicators 2)nursing service provider type (NHS and non NHS) and 3) geographical location with no two sites being within a the same former Primary Care Trust area. Commissioners and provider managers eligible to take part in the case study are those directly responsible for agreeing and implementing quality schemes for community nursing services. Service providers may be NHS or independent organisations. Community nursing services will provide nursing support to people in their own homes prevent unnecessary hospital admission or support patients on discharge from hospital. Patients will be aged over 18 and receiving care from community nurses in their own home.Data collection for the case study will follow the annual commissioning cycle and comprise: 1)Interviews and observation of meetings with provider quality and performance managers and commissioning leads in local regional and national organisations to find out why particular indicators are selected how they are introduced to the community organisation and their usefulness in assessing service delivery and influencing commissioning; 2. Interviews and observation of frontline clinical teams to learn how the indicators are applied in practice which ones are useful and how the data are collected;3. Mapping and analysis of quality indicator datasets for completeness and data quality to assess their robustness; 4. Interviews with service users to learn the extent to which the quality indicators match their priorities and the reflect quality of community nursing services.The study will generate multiple sources of qualitative data including interviews with service users local quality implementation leads and senior local regional and national quality leads focus groups shadowing of frontline nursing staff and observation of meetings. Data will be audio-recorded except during shadowing of frontline staff where contemporaneous notes will be used transcribed verbatim anonymised and entered onto a qualitative data management computer programme. drawing on constant comparison techniques data analysis will proceed with and inform subsequent data collection. Data will be open coded initially to generate concepts that will be further analysed to determine their attributes and dimensions resulting in a thick description of the selection application and usefulness of quality indicators in case study sites. To help explain our conceptualisation a previously used theoretical framework incorporating the contextual determinants that can influence attitude and behavioural factors affecting implementation of policy in health care settings will be utilised.The overall project design incorporates a dissemination strategy based on linkage and exchange the principles of which are that researchers work with research consumers (eg health service commissioners professionals and users) at every stage of the research process. We will test our analyses and interpretation of evidence from the case sites in workshops to which local commissioners community nursing providers and user groups will be invited in a further ten sites nationally to improve the dependability and transferability of our findings. Outputs from the project will be a national picture of quality indicator schemes for community nursing an understanding of how quality indicators and penalty or incentive schemes are used in the context of community nursing identification of benefits or drawbacks of using quality indicator schemes to meet the quality priorities of service users commissioners and providers and good practice guidance and transferable practice recommendations to improve indicator selection.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE