Quality services and quality improvement processes

Introduction 

Quality healthcare can be defined in many ways. The STEEEP framework is currently adopted within the NHS and other health care systems globally to guide, assess and improve the quality of health care services. STEEEP has six domains which stand for Safe, Timely, Effective, Efficient, Equitable, and Patient-centered. 

• Safe  – avoiding harm to people for whom the care is intended 
• Timely - providing care without harmful delays for example reducing waiting times so intervention is provided at the optimal time for the person/their diagnosis/situation so avoiding potentially harmful delay
• Effective - providing evidence-based healthcare services  
• Efficient - avoiding waste and getting maximum benefit from available resources
• Equitable – providing care that is consistent and does not vary in quality based on protective /personal characteristics such as gender, ethnicity and socio-economic status or geographic location
• People-centred –  providing care that is respectful of and responsive to individual patient preferences, needs and values. 

The World health organisation includes the additional domain of integrated providing care that makes available the full range of health services throughout the life course. See World Health Organization. 

There are several aspects to a quality service to keep in mind when you are either planning or improving a service outlined in Table 1. Services should consider how these link to the HCPC, professional and clinical standards.

Table 1

Quality improvement 

Quality improvement (QI) is an approach encouraged in healthcare in the UK where ‘the duty of Quality’ signifies a legal and ethical obligation of all NHS organisations to continuously improve the quality of services they provide. According to the health care foundation quality improvement QI involves a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement.  Quality improvement often involves the implementation of evidence-based approaches in local practice with careful evaluations of their impact (See Health care improvement). 

QI projects offer discrete ways to engage in QI and are designed to help staff on the ground tackle local problems in a methodical, incremental way. They usually focus on the process of making healthcare more safe, timely, effective, efficient, equitable and patient-centred. Their general aim is to embed QI thinking in everyday practice, not just apply it to specific projects.  

As a result, QI projects are often concerned with some aspect of demand and capacity within the system and patient flow through the system, with careful consideration of outcomes, people’s experience, and the cost of healthcare provision.   

QI approaches might emphasise the everyday, ongoing work of healthcare as an opportunity to get things right first time for patients and staff (e.g. Total Quality Management; Continuous Quality Improvement). They might use the PDSA cycle (e.g. Plan-Do-Study-Act cycles ) to encourage practitioners to plan, conduct and reflect on small tests of change. They might examine processes of patient care with a view to having the least wasted time, effort and cost (e.g. Lean or just-in-time thinking) or seek to improve reliability and reduce variation in care processes (e.g. Six Sigma). 

NHS Trusts encourage QI projects and will usually have QI/audit teams to support projects, provide training, share learning and maintain a register of those projects in progress/completed. These can be a useful resource for SLTs involved in QI. 

The Flow Coaching Academy also provides useful resources for health care staff on how to participate/lead continuous improvement within services.

QI initiatives are increasingly supported by collaboratives or communities set up around a QI package, a healthcare organisation or group, or at a local, regional or national policy level. One example is  The Health Foundation’s Q Community  but there are many more.  

For a more detailed review of healthcare improvement approaches please see RCSLT’s healthcare improvement information. 

Planning, monitoring, audit and evaluation 

Monitoring, auditing and evaluation are essential parts of the quality improvement process. They improve care standards and outcomes, through systematic review and enable the implementation of change. 

Consistent action is required locally to ensure that: 

• national standards and guidance are reflected in the provision and development of local services. Services are reminded of the importance of consideration for HCPC standards and evidence-based practice when engaging in these activities.      
• local patient and public views are an integral part of reflection on and development of services to meet local needs. (see assessing needs of Local population). 

That action is guided by a system of governance and is backed up through lifelong learning by staff, professional self-regulation and external inspection. 

What is governance? 

Governance is a framework through which organisations are accountable for continuously safeguarding standards of service provision and for continuously improving the quality of services. 

Standards will be assured through: 

• external monitoring 
• an internal system of governance covering all service functions. 

External monitoring 

Inspectorates across the four UK countries use different frameworks to monitor the quality-of-service provision. However, there is a general trend towards emphasising outputs and outcomes rather than structure and process. 

See clinical guidance topics A- Z for guidance for specific client groups. 

Internal monitoring 

Services will wish to monitor service performance in line with the requirements of external monitoring systems and service governance. 

Performance across quality domains may be evidenced through: 

• a range of clinical and service data, with an increasing emphasis on outputs and outcomes 
• detailing of policies and procedures across a range of domains. 

Services should have available relevant, easily accessible and comprehensible information to support decision-making at service and commissioning levels.  

Speech and language therapy leaders will need to make decisions and implement change based on good evidence; be it clinical practice, service-base, patient safety and/or experience of care. Connecting with your local patient safety/quality improvement/governance teams and networks is a great place to start. 

Clinical audit, research and service review

Clinical Audit, research and service review/evaluation are different processes/events with different aims and producing different results. The health care improvement partnership provides a useful guide to support clinicians to differentiate between them available from Healthcare Quality Improvement partnership. 

A further table from the Health Research Authority (2022) defines the key characteristics of research, service evaluation, audit and health surveillance projects to determine what sort of evaluation should carried out for different purposes and how a project should be managed. 

Services should be clear about the questions they are seeking to answer to determine whether clinical audit, research or service review/evaluation is required. 

Consideration should be given as to whether a mix of approaches is appropriate; for example, a local audit evaluating the impact of applying standards identified via research will make use of the latest research evidence and provide insight into application and effectiveness locally.  

What is a clinical audit? 

“Clinical audit is a way to find out if healthcare is being provided in line with standards and let’s care providers and patients know where their service is doing well and where there could be improvement. Clinical audits can look at care nationwide (national clinical audits) and local clinical audits can also be performed locally in trusts, hospitals or GP practices anywhere healthcare is provided.”  – NHS England

Services may wish to reflect on HCPC standards and clinical evidence base when planning or implementing clinical audit. A clinical audit cycle includes the following steps: 

• observing current practice and identifying areas for improvement  
• setting or defining standards of care 
• collecting data / measuring practice   
• comparing practice to standards and feedback results   
• agreeing changes needed to implement change 
• allowing time for changes to be imbedded  
• re-auditing and providing feedback on any changes/improvements.

This is a continuous process which allows for incremental changes to be implemented as part of ongoing service improvement.   

Models that could be used to complete audits are set out in NICE guidance.  

What is research? 

Research is systematic approach to deriving new, rigorous, robust, and/or trustworthy knowledge. Within quantitative research, statistical approaches are often used to consider how confidently this knowledge can be generalised. As such, the aim of research is often to explore questions and develop solutions that can be applied broadly, not just in one local service. Many research methods can be used in any type of evaluation (e.g. careful data collection, formal approaches to data analysis), but the focus and the scale of resources maybe different, along with the level of skills and knowledge required. 

The RCSLT and others provide a number of resources to help SLTs (and other health and social care professionals) develop research knowledge, skills, and experience. Please see the RCSLT’s Research webpages for more information. 

What is service evaluation? 

It is a structured process concerned with making an assessment, judging an activity or a service against a set of criteria. 

Evaluation is useful for looking in detail at service practice to see: 

• whether the service is meeting the needs of service-users 
• whether the service can be improved 
• what happens to individuals after an intervention is finished 
• whether resources are being used to the best advantage by providing care in a particular way whether the service should continue. 

Continuous service review allows for incremental changes to be implemented as part of ongoing service improvement. Service evaluation is designed to have a greater degree of impact and may involve radical changes to service provision. 

Some changes to service provision may be implemented within current resources, whilst other larger-scale changes may be classed as service development and require additional resources to be implemented. 

Please refer to Table 1 in the Introduction section of this page for examples of information that services may wish to audit to evidence quality and quality improvements over time. 

Speech and language therapy practitioners should be aware of the criteria that will be used to examine the therapy they provide will be examined. They will need to know about the policies, procedures, standards (including HCPC and clinical guidelines) and performance measures set at national and local levels, and in use within their working context. 

Tips for service/clinical leaders to consider when facilitating service improvement

• Identify regular opportunities available for the team to reflect, learn from events and concerns raised.  
• Invest time in planning and thinking things through to enable the team to explore the problem and come up with meaningful and impactful possibilities /solutions. This can often help to identify problems in the system and identify support required.  
• Identify what support is available and how it can be accessed. Support may come from peers, managers, leaders, or others in or outside your organisation. Your organisation’s governance, quality improvement, research and development teams where applicable.  
• Identify key stakeholders who should be involved (stakeholder mapping may help) and constantly review if the right people are in the room.   
• Think carefully about what type(s) of data you will collect, and how. Data can help to assess the system and also make sure that the change made has resulted in an improvement. Contact your organisation’s IT/ data teams for further support.  
• Identify areas for improvement that fits with the priorities, goals or vision of your department, directorate or organisation. Be selective and start with something which is achievable and scale up with future QI cycles.  
• Identify roles and responsibilities. When agreeing actions, also agree who is going to carry them out and how they will be monitored. 
• Ensure that measures are in place to monitor that changes are improvements and that any unintended consequences (desirable or undesirable) are addressed.  

Related RCSLT topics

• Service planning and responding to proposed changes 
• Workforce planning, staffing and resourcing 
• Meeting the HCPC standards 
• Delivering quality services  
• Clinical guidance  
• Research  
• Leadership resources  
• CPD and life-long learning 

Further reading and resources

• The Health Foundation – The Improvement journey: Why organisation-wide improvement in health and care matters, and how to get started 
• US agency for healthcare research and quality – The six domains of health care quality  
• NHS England – Health and Safety Policy (2017) 
• NHS England – Quality improvement e-learning platform – provides a range of free learning programmes. 
• NHS Education for Scotland Quality Improvement (QI) 
• NHS England (Improving Patient Care Together) NHS Impact 
• Department of Health – NHS internal audit standards (2011)  
• Healthcare Quality Improvement Partnership (HQIP) – National quality improvement programmes  
• Government guidance on Clinical audit: descriptive studies  
• BMJ – How to get started in quality improvement (2019) 
• Evidence-based Communication Assessment & Intervention – Issue on implementation science (2017)   
• The Health Foundation – Q Community 
• NHS England – Improvement tools  
• Advancing Quality Alliance – Quality, service improvement and redesign (QSIR) Tools 

Contributors

Lead Author 

• Maria Luscombe FRSCLT 

Supporting Authors 

• Jo Bradburn, Deputy Director of Allied Health Professions and Speech and Language Therapist 
• Natacha Capener, Lecturer and Speech and Language Therapist 
• Nicola Holmes, Chair of ASLTIP 
• Wing yee Lam, Practice Development Speech and Language Therapist 
• James Martin, Highly Specialist Speech and Language Therapist (Head & Neck) 
• Katie Masters, Specialist Speech and Language Therapist 
• Claire Matheson, Service Lead Adult Learning Disability 
• Rosalind Gray Rogers, Programme Director for Speech and Language Therapy 
• Jo Taylor, Speech and Language Therapist 
• Paula Walker, Highly Specialist Speech and Language Therapist