Do Quality and Safe Care Champions in community nursing teams positively impact on patients?

From 2015 onwards, a process to gain evidence-based assurance, known as the Quality Always (QA) Clinical Assessment and Accreditation Scheme (CAAS), was implemented in Derbyshire Community Health Care Services (DCHS) NHS Foundation Trust (Coope, 2018). CAAS was designed following learning from an acute trust nursing assessment and accreditation model called ‘safe clean and personal every time’ (Morris, 2012) and the NHS Change model (NHS England, 2018). Understanding the nature, context and complexity in delivering community nursing services (St John and Keleher, 2007) was a vital component in adapting the CAAS to be valued and respected as valid within a community trust.

One of the key and unique elements of the adapted process was the development and implementation of quality and safe care champions (QSCCs). These champions would be members of staff from patient-facing clinical teams in a variety of roles and backgrounds, from healthcare assistants, nurses, allied health professionals to medical professionals and, in some cases, non-medical staff who enable patient care. Champions are nominated in agreement with their clinical line managers for their interest or passion in a specific aspect of patient care. They are usually frontline staff working to advocate, embed and uphold best practice in their day-to-day interactions with patients and co-workers, as identified through the 15 QA standards in CAAS.

The network of champions would be developed across DCHS over 11 quality and safe care domains (infection prevention and control, tissue viability, continence, falls prevention, pain management, public health/lifestyle, safeguarding, nutrition and hydration, dignity and inclusion and patient experience, end-of-life care, and dementia), which were linked to the 15 QA standards. It is supported by specialist practitioner input, the QA team and a communications strategy that embraces MS Teams, the DCHS trust website and a dedicated, closed managed Facebook group.

A network of over 1200 champions has been established since 2015, which is approximately 25% of the organisation's workforce. The QSCCs were implemented alongside the QA processes that were developed by the operational, quality and clinical leads within the trust, led by the QA clinical lead. The developing QA processes drove the ambition to establish a network of champions for practical quality and safety at the patient interface.

Each service was expected to introduce and support champions. Engagement events and practical support for champions was introduced through the QA team via the quality-improvement lead role and associated professional expertise from specialist quality and patient safe care leads. Each champion signed up with their line manager to a contract that agreed time to undertake the role was protected. Each champion was registered by the QA team to build detailed knowledge of the network of champions and to communicate effectively and responsively with them.

Time and resources to implement and embed this approach were required and proof of the concept was requested from within DCHS to understand the return on this investment. An important question to ask now is whether or not the changes introduced by implementing champions led to improvements for patients (Deming, 1993).

Methods

In reviewing the benefits to the organisation, the authors applied the East London NHS Foundation Trust framework (Shah and Course, 2018) because it gave scope to consider the impact of champions across key areas, including possible cost efficiencies. However, it emphasised patient and family experience, as well as the benefits to staff. The areas the authors chose to focus on were cost avoidance, and patient carer and family experience outcomes.

The hypothesis was that as the number of champions and activities to embed quality and safety increased, this would be reflected in the ratings and attainments of the CAAS programme. To ensure that the programme benefited patients, the authors would consider key patient safety incidents such as pressure damage that had developed or deteriorated in care, and patient experience information in the form of concerns and complaints.

Clinical assessment and accreditation scheme

The CAAS is the assessment and accreditation process led by a senior clinician with a dedicated team of clinical assessors, who are all experienced Band 7 clinicians. The CAAS consists of a programme of visits to all clinical settings, including patients’ own homes, with assessment against previously set and agreed quality care standards (Table 1).

A red, amber, green (RAG) rating is awarded, and teams are revisited at intervals depending on the rating and the progress made against signed-off improvement plans (Table 2).

Each assessment is a Plan, Do, Study, Act cycle (Figure 1), as outlined in the Handbook of Quality and Service Improvement Tools (NHS Institute for Innovation and Improvement, 2013).

The aim is to achieve gold accreditation status, which is awarded by a panel of executives, non-executives and patient representatives after a team gains two consecutive green ratings. Assurance is gained that the team will preserve the quality standards.

After gold accreditation is achieved, teams are advanced to earned autonomy self-assessment, taking ownership of sustaining the quality of their services. The goldaccredited team's achievements are then triangulated with its self-assessment by the QA team after 12 months (Table 2).

What: the aim

In 2021, the QA Team decided to examine the CAAS history of one of the community service teams. This was in response to the DCHS request for proof of concept for the QSCCs and their impact in the community setting. The authors selected Team C that had been engaged with the QA process for 4 years. This timeframe provided ample data to review and experiences to evaluate, ensuring that the exercise was meaningful.

Team C was a community nursing team consisting of four smaller teams lead by a Band 6 community sister/district nurse, under the overall management of a Band 7 integrated community team lead. Located in an urban area of Derbyshire's ex-coalfields, Team C comprised five GP practices with a population of ageing, frail adults and a number of care home/local authority beds facilities requiring community nursing visits from the nursing team to support people in residential care. The team had seen nine leadership changes: six instances of experienced district nurses retiring or moving roles, and three instances of nursing staff transferring into district nurse training posts. The replacements for these leadership roles were not always with a qualified district nurse.

There are recognised challenges in communicating and influencing evidence-based practice within community settings (van Bekkum and Hilton, 2013). In this case, the geographical spread of community staff across the county, the fact that the four smaller teams comprising Team C were not all located with each other or with their leaders meant that communication, sharing ideas, professional support, team meetings and supervision (both of caseloads and clinical supervision) were fragmented and not implemented effectively. The use of digital communication was not established in the locality for training events or team meetings. This meant that travel to a variety of sites to access training or meetings was a significant time pressure and affected the capacity of the team members to attend and balance clinical workloads.

Specific challenges identified with Team C were the limited collective response to quality-improvement actions, potentially due to the inconsistent leadership experienced by Team C (Langley et al, 2009). There are three key stages necessary for accreditation to affect quality within a team. Coherence is established when a team and its staff perceive that accreditation aligns with the team's beliefs, context and model of service delivery. Team buy-in is established when there is both a conceptual champion and an operational champion, and is influenced by both internal and external contextual factors. Quality improvement would occur when Team C took purposeful action in response to observations, feedback or self-reflection that had resulted from the accreditation process (Desveaux et al, 2017).

These factors were drivers in the strategy that led to the implementation of the QSCCs network to align with CAAS, in order to mitigate these specific challenges in community settings. Team C would represent the community teams in DCHS and assist understanding around influencing how evidenced-based patient care and quality experiences were implemented. The ambition for the QSCCs network was that community teams would recognise and make sense of an approach (CAAS), engage and participate in it to share best practice and evaluate patient quality improvements.

How: data assessed

The QA quality improvement lead, who was a Band 6 nurse dedicated to implementing the QSCCs programme, led the investigation into Team C. The investigation used data available to the QA team via the QA dashboard and reporting tool. This is a business intelligence tool that is accessible from team to trust board level. The QA dashboard analyses all historical and current CAAS outcomes and presents the findings in a narrative and graphical data format. This enables the user to understand data from assessments and improvement plans, and make informed decisions regarding patient safety and quality improvements.

The QA dashboard and reporting tool has been invaluable to the QA team and DCHS in providing detailed assurance reports from ‘ward to board’, as well as enabling analysis of attainments against safe patient care standards, assurance data, themes and trends of CAAS in detail.

The quality-improvement lead set out to identify the engagement of QSCCs within Team C, and their influence on the outcome of CAAS by analysing data within a 4-year period (2016–2021). This data focused on the activities of QSCCs relating to the 15 QA standards.

Further data about a particular question in the Patient Safety standard concerning the QSCCs was analysed to correlate QSCCs’ engagement with assessment outcome. The question was ‘Does the team have QSCCs who keep up to date via trust-wide networks and are aware of the “sign up to safety” pledges, including working to embed best practice and provide evidence of improving patient safety and care?’

The Sign Up To Safety pledges were part of a national campaign by NHS England, which has since been updated by the NHS Patient Safety Strategy (NHS England, 2019). These pledges included: putting safety first by committing to reduce avoidable harm in the NHS and make public locally developed goals and plans; collaborating by consulting the workforce and nurturing an open attitude to health and safety issues; continually learning to be more resilient to risks by acting on feedback from patients and staff, and by constantly measuring and monitoring how safe DCHS services are; being supportive, open and transparent about patient safety; and ensuring a patient safety culture where serious harm is minimised and preventable harm in healthcare is eliminated. These aims are at the heart of QA.

The question on which further data was analysed provided insight into the impact of QSCCs on the outcome of the process. Specifically, it was important in gauging QSCCs’ advocate role and their proactive approach in providing evidence of actions taken to improve patient care.

Evidence from quality summit discussions held with Team C following assessments, and the actions and recommendations based on assessment findings, indicated that Team C was unable to attain a green CAAS rating in the assessments from 2016 to 2021, despite quality-improvement plans being in place for the 10 assessments that took place during this timeframe.

Answering yes or no to the selected question would provide evidence about the number of QSCCs in a team and their proactiveness in sharing best practice. Answering yes indicated that the team was working to implement champions to positively impact on safe patient care. Answering no meant the team was not meeting the aim by introducing champions. The team was also measured by evidence shared by champions on the DCHS QA closed Facebook page and the DCHS QSCCs hub, meetings attended by champions (Nutrition and Hydration Strategy Group, End-of-Life Quality Improvement Group, Wound Improvement Group, and other training meetings).

Assessment reports from 2016–2020 were analysed in full for evidence of QSCCs’ activity on the ground and engagement with the QA process. Other data analysed included the QSCCs register held by the QA team, which collated details of the completion of champions’ training and champions’ engagement with the process, in terms of the support accessed through the quality improvement lead for Team C and the QA Facebook group posts for Team C.

The QSCCs register, designed by the QA team, to support champions, was used to give evidence on the total number of champions in Team C, their domain type, job role, contact details, team name, and locality. This register has been a vital element in developing the network of champions and keeping contact information and attendance at events up-to-date and accurate, and it is managed by the quality improvement lead and a QA coordinator. A closed DCHS QA Facebook group governed by the QA team in conjunction with the Trust Communications lead role is exclusive to QSCCs. It is a social media communication tool that allows champions to collaborate, connect and share best practice. Posts on Facebook include best practice on nutrition and hydration, tissue viability, pain, lifestyle, end-of-life, continence, dementia, dignity and inclusion, safeguarding, falls, infection control and prevention, including activities for national campaigns.

Results

CAAS is an evidence-based process of assessments, including face-to-face clinical visits to observe patient care, a review of agreed performance measures, safety metrics and patient experience outcomes set within the 15 QA standards relating to aspects of care delivery, the care environment and leadership. These are aligned with Care Quality Commission's key lines of enquiry (KLOE). A series of assessment questions (elements) are asked to gain assurance in each of the subject areas covered by the standards (outline in Table 1). Teams are scored red, amber or green (RAG), as in Table 2.

The quality improvement lead identified that Team C had 11 assessments over a period of 4 years from 2016 to 2021 (Table 3). The team had four red and six amber ratings. Detailed reports of each assessment were analysed alongside 4 years’ worth of the QSCCs register activity and Facebook posts.

After 10 CAAS assessments and in April 2021, Team C achieved its first green rating, scoring green for 13 standards (protection of vulnerable people; pain management; patient safety; environmental safety; nutrition and hydration; end-of-life care; medicines management; person-centred care; tissue viability; elimination; communication and patient experience; infection control; and public health) and two amber ratings (organisation's management of the clinical area; and clinical effectiveness).

Each CAAS assessment can be viewed as a Plan Do Study Act cycle (Figure 1), as outlined in the NHS Institute for Innovation and Improvement's Handbook of Quality and Service Improvement Tools (NHS Institute for Innovation and Improvement, 2013).

Discussion

The quality improvement lead recognised that there was insufficient effective QSCCs engagement with QA processes and the attainments against the patient safe care standards from December 2016 to September 2020, when real progress began to be achieved. This indicated there was limited ability for Team C to commit to the process and triggered a quality summit and three tabletop reviews, to understand the barriers to progress in improving patient care.

The outcome of these reviews highlighted challenges with recruitment and staff turnover in the locality that was affecting leadership which, in turn, was impacting on the effective provision of patient care standards. Within a period of 4 years, Team C had experienced nine changes of leadership. Gaining traction against the QA standards had been difficult as the teams were not consistently stable across the locality. It was emphasised that focus should be placed on engaging and promoting the QSCCs’ roles with Team C and its Band 6 leads.

There was no consistency in the champions keeping up-to-date via trust-wide networks and there was little or no awareness of the Sign Up To Safety pledges. There was also little or no awareness among champions of working to embed best practice and to provide evidence of improving patient safety and care. There were concerns involving the attainment of the patient safety standard in relation to inadequate assessment of risks to the patient's safe care, including recognising the deteriorating patient, record keeping and implementing effective hand hygiene, as well as issues with safe staffing levels, the high number of Datixes (patient safety incident reports) relating to medication errors, pressure ulcers and caseload management in the four smaller teams comprising Team C.

During the 4-year period investigated, the question ‘Does the team have QSCCs who keep up to date via trust-wide networks and is aware of the “sign up to safety” pledges, including working to embed best practice and provide evidence of improving patient safety and care?’ was answered yes only three times out of the 11 assessments (Table 4). One of the positive responses was noted by December 2018 and the next two were in the assessments in 2020 and 2021, as the number of QSCCs and their engagement increased.

Cited in some of the assessment reports were QSCCs’ activities, which were limited in their scope, implementation and impact on the patient safety standard. Team C stated this was due to the high turnover of staff and some of the new starters who were not aware of the champions’ role. From the records of the quality summits with Team C, it was recognised that steps were taken by the team to continually develop the other nursing roles, such as nursing associates, nurse apprentice and support staff completing their registered nurse training. It was hoped this would improve staff retention and to begin to introduce and embed understanding of the champion roles in these new members of staff.

QSCCs were not regularly collecting evidence of best practice to disseminate within the team, and it was noted that champions were not aware of the summary or detailed report of the team's CAAS assessments, or rating outcome. To mitigate this situation, the quality improvement lead supported QSCCs within Team C in collaboration with their leaders, by conducting monthly meetings, completing CAAS self-assessment and participating in self-evaluation and internal audits on champion activities (for example, in the areas of infection prevention and control, safeguarding training completion and pain management).

The four assessments that were carried out between 2016 and January 2018 that received two red and two amber ratings emphasised that the team had no nominated QSCCs to support patient care standards (Table 4, Figure 2). Improvement actions plans were generated after every assessment. However, because QSCCs in Team C did not have cohesion, the team failed to engage with the process. Despite this, Team C was reassessed within the stipulated timeframe of CAAS reassessment and the outcome remained either amber or red.

The number of champions began to increase within team C from April 2019 to September 2020 (amber rating). There were five champions by the September 2020 assessment. This was due to improved staff retention, which enabled increased contact with the quality improvement lead, and activity was noted from October 2019 to September 2020 on the various QSCCs communication platforms.

There was poor attendance on QSCCs’ training, according to data analysed from training registers resulting from no engagement with QA. The quality-improvement lead began to support Team C in January 2019, with group and 1-2-1 meetings. Drop-ins were also offered. Initially, uptake was limited. Through consistent support from the quality improvement lead, introducing virtual working and engaging with Team C's leadership, by April 2021 there was a quality and safe care champion nominated and actively engaged in every domain. Team C progressed to achieve its first green rating at this point and there was a significant improvement in completing risk assessments for patient safe care, clinical observations and patient care documentation.

From the findings discussed, it was evident that the increase in champion numbers and their activities was directly linked to safe delivery of care, as assessed and reviewed by the CAAS process and indicated by the improved RAG rating. It was noted that as the numbers of nominated QSCCs increased and they became more engaged with the process, the RAG rating began to move from red in 2016–2018, to amber in December 2018 and to green by April 2021, through collaborating, connecting and a coordinating the sharing of best practice.

There was no direct correlation noted in the domain of QSCCs and improvements, so engagement with one domain was no more effective than another. However, the more engaged the champions were across the board and the more they were active within Team C, the more the CAAS RAG rating improved.

The review also considered two key areas of patient care and experience as delivered by Team C within the timeframe. The review triangulated the results from assessment and the information gathered by the quality improvement lead in relation to Team C's engagement with spreading and sharing information and championing their specific areas of clinical practice. These key aspects of care would also underpin the researcher's ability to identify whether there were any benefits of the QSCCs in terms of avoiding costs and improving patient/care experience outcomes.

Patient safety incidents: pressure damage

The data from the Datix patient safety incident reporting system was reviewed from the beginning of 2017 through to the end of 2020. Any reports from Team C relating to pressure damage that had developed or deteriorated in care of any category (2–4) were included. Overall numbers of incidents were also considered, to ensure that reporting patterns were consistent across the time period and there were no deviations. On average, 127 patient safety incidents were reported each year between 2017 and the end of 2020. The highest incidents were related to pressure damage. In 2017, there were 125 reports, in 2018, there were 114, in 2019, there were 95 and in 2020, there were 70 incident reports; a reduction of 56% over the timeframe.

When reviewing this data in relation to QSCCs activity, it was noted that there were no tissue viability champions in Team C in 2017, one tissue viability champion was registered to Team C in 2018, two in 2019, increasing to four in 2020. Activity of the QSCCs improved by 2020 and correlated to the reduction in patient safety incidents relating to pressure damage. Team C produced an evidence-based poster on tissue viability information for Team C colleagues in 2020, which it shared on the DCHS QA Facebook page. Tissue viability champions for Team C were winners for the Stop The Pressure campaign display board competition in 2020. They were attending wound improvement groups and carrying out audits of clinical records. In 2019, they shared on the QA Facebook page an SSKIN poster that they were using to remind staff of the principles of the SSKIN tool.

Treating pressure ulcers costs the NHS more than £1.4 million every day, resulting in an estimated 1.6 million district/community nurse visits, as these types of wounds are predominantly managed by primary care practitioners and district nursing teams (Guest et al, 2017). Analysis of community nursing caseloads in the trust over the time period included in the study indicated that 50% of their time was taken up with tasks related to wound care. Any reduction in the numbers of pressure ulcers would lead to lowering the costs of community nursing time and the associated costs of dressings and equipment.

Pressure ulcers are unpleasant and painful wounds (Fox, 2002). The indignity of the treatment and the risk of developing sepsis and other complications have a negative effect on patient wellbeing. Effective safe patient care should prevent skin damage and pressure ulcers from developing, which ensures improved quality of life for patients, increased quality of the care experienced, and reduced impact on family or paid carers.

This review of the incidents of pressure damage revealed that as the QSCCs became more proactive in activities to support improvements in safe care risk assessments and understanding how to prevent harms, the incidents of reported damage decreased. A correlation was seen between QSCCs and the avoidance of patient harms, related costs and an increase in patient experience outcomes.

Patient experience feedback

Complaints and concerns data for Team C was reviewed between the beginning of 2017 and the end of 2020. Some 10 concerns or complaints were received by/reported to the DCHS Patient Experience Team.

Of these, nine were classed as type 1 concerns, which were all locally resolved to the complainant's satisfaction without a full investigation. One was a type 2 complaint which underwent an investigation and was concluded satisfactorily from the patient's point of view.

The complaints were divided into issues relating to staff attitude (four) and those to a delay resulting from system failure (five). The only year there were no complaints relating to staff attitudes was 2020.

Community QSCCs experience

By April 2021, Team C had a total of 33 out of 50 staff that were nominated champions who kept up-to-date viatrust-wide networks and promoted best practice and sharing of information with good evidence of activities. There were some innovative ideas in place to counter the remote nature of working practices encountered in the community exacerbated by COVID-19 infection risks, such as a virtual notice board for QSCCs shared across the community nursing teams to ensure everyone received the information. Hand hygiene audits from the most recent assessment had a score of 99% and the QSCCs for tissue viability from Team C won a prize in the DCHS Stop the Pressure competition.

Conclusion

The close correlation between when QSCCs activity began to increase in Team C and their attainments against the quality and patient safety standards assessed via the CAAS process suggested that QSCCs played a role in improving the quality of their patients’ safety. The patient safety data relating to the reduction of pressure damage incidents from 2017 to 2020 linked to the activities of tissue viability champions provided further indication that champions have a significant impact on improving the quality and safety of patient care. This supported the original hypothesis and provided evidence of avoiding costs and improving patient outcomes.

The patient experience data was less conclusive, as no significant reduction in complaints was seen, although for 2020 there were no complaints about staff attitude, which was the first time in 4 years this had been the case. The impact of champions in this matter is not clear, although the facts would have been positively noted in their assessment ratings at that time.

The review of Team C's CAAS history and the learning gained from their achievements against the QA standards has demonstrated that community nursing teams can make effective use of QSCCs and the QA process, but they need to be supported by consistent and stable leadership, accessible resources, including virtual/digital platforms and professional support/advice from quality leads and specialist practitioners in order for the champions to be able to engage with initiatives that lead to improvements for patients in the community setting. There are benefits to the patient, team and organisation of using this approach, combined with an assessment and accreditation process. This is a return on the investment of time to support and enable community nursing champions.

Key points

• Quality improvements can be effectively introduced by quality and safe care champions within community settings
• Quality and safe care champions have a direct positive effect on the quality of patient care in the community setting
• Quality and safe care champions need tailored support, time and resources to sustain quality care for patients in the community
• Benefits were realised in the review: cost reduction costs were not avoided and patient experience outcomes.

CPD reflective questions

• Would you consider becoming a quality and safe care champion for your team and, if so, which patient care area might interest you?
• How do you think community nurses can be supported to access training and development?
• What initiatives have you been involved with to improve patient care in your community setting?