Introduction: Care delivery should be safe, patient-centred, compassionate, effective and efficient. Nurses and midwives deliver clinical care around the clock yet measuring this care and its effectiveness has been seen as a deficit. Quality Care-Metrics (QCM) are “a measure of the nursing and midwifery clinical care processes, in healthcare settings in Ireland, aligned to evidenced based standards and agreed through consensus” (1). Measuring the degree to which nurses and midwives adhere to fundamental care processes assures the quality of care delivered to patient and clients.
The HSE Office of Nursing and Midwifery Services Director (ONMSD) introduced the care quality measurement in 2015. Currently, more than 80% of acute hospitals, incorporating Midwifery and Children’s Services undertake QCM collection. There is a growing penetration of QCM also in Community Services, public health, mental health, intellectual disability and older person’s settings.
Practice Change- The ONMSD provide a national standardised tool to measure nursing and midwifery care processes. This involves developing national standardised Metrics measuring the fundamentals of care and the provision of an electronic data collection and reporting system to facilitate easy data entry and reporting for staff on the ground.
Many services collected local audits which lacked consistency between what was measured. QCM is bringing about that change and assisting staff to become more familiar with standards measured each month.
Aim and Theory of Change Objectives include to:
provide a national standardised approach to care quality and measurement collate and report on all results in a standardised format
provide real time data to nurses, midwives and their managers on delivery of safe, quality care
Measuring the quality of care is deemed critical by the Health Information and Quality Authority who stated:
“Unless we actually measure the quality and safety of care, we cannot determine if improvements are being made” (2).
The National Clinical Effectiveness Committee (3) defines a standard as a definable measure against which existing structures, processes or outcomes can be compared. Donebedian (4) highlights structure, process and outcomes as three essential components of measuring good quality care. QCM focuses on ensuring the process measures adhere to standards.
Targeted Population and Stakeholders: The project initiated in Donegal and grew expansively into a national initiative. QCM is now integrated nationally across nursing and midwifery services: Acute, Mental Health, Children, Midwifery, Older People, Public Health Nursing and Intellectual Disability Services.
Timeline: The project commenced in 2012 involving two community hospitals in the North West. In 2013, it expanded to 2 acute hospitals and 9 community hospitals. In 2014, it expanded to Mental Health services, Intellectual Disability services, Midwifery and Children’s services and into two further regions of the HSE (Dublin North and Dublin North East).
In 2015, the ONMSD took on the initiative as a national project and 30 acute hospitals around Ireland were involved. In 2016, 81% of acute hospitals are now collecting QCM (5).
Highlights: QCM has resulted in more staff awareness of metrics and standards. Patient care has improved through greater adherence to standards. Documentation has improved in recounting care delivered. A standardised approach has led to positive measurement across services.
Sustainability: The project has been built for sustainability through the ONMSD.
Transferability The project has proved to have a high transferability factor. Expressions of interest have been made by other health care professionals and other services outside of nursing with a view to following this approach.
Conclusion: QCM has been an exciting and invigorating project to participate in. It has given nurses and midwives a real method for measuring and improving care delivery.
Lessons learnt: There has been great learning on this project. The benefits of the bottom up approach were evident as QCM grew exponentially. The top down approach is now in use to standardise across all services, managed centrally from the ONMSD. Guiding and keeping all stakeholders engaged at different stages (some beginning the journey, others well established) has been a crucial element.
Compromise and negotiation have been key in order to ensure ownership by stakeholders is recognised. Many early adopters had to let go of metrics they used in order to standardise with other services.
Ensuring services were using and understanding the same terms so that QCM was measurable across services.
1- HSE. Guiding Framework for the Implementation of Nursing and Midwifery Quality Care-Metrics in the Health Service Executive Ireland. HSE: Dublin. 2015.
2- HIQA. Guidance on Developing Key Performance Indicators and Minimum Data Sets to Monitor Healthcare Quality. HIQA: Dublin. 2013:2.
3 DoH. National Clinical Effectiveness Committee (NCEC) Standards for Clinical Practice Guidance. 2015.
4 Donebedian, A. The Quality of Care- How can it be assessed? JAMA 1988;260(12):1743-1748.
5 Gallen, A. Quality Care in Nursing and Midwifery, World of Irish Nursing and Midwifery, 2015;23 (9):61-62.