QUALITY ASSURANCE AND DEVELOPMENT OF STANDARDS

8. QUALITY ASSURANCE AND DEVELOPMENT OF STANDARDS

Practice guideline programmes, are one of many types of quality programme, which are increasingly being used to improve the quality of care (Ovretveit and Gustafson, 2003). One of the key components of a guideline programme is identification of or setting of key standards and criteria for audit. These clini- cal standards, based on existing evidence, would be used subsequently as the criterion for evaluating the quality of care provided by an organisation or indi- vidual unit or department. Such quality assurance may be undertaken through an internal or external peer review or through an accreditation process (Del Mar, 2001; Steel, 2001). In the United Kingdom, as in Australia, guidelines and clinical standards underpin much of the quality, or more recently, the clinical governance agenda (Scally and Donaldson, 1998). This process aims to make it a statutory responsibility for each organisation to be accountable for ensuring the monitoring and improvement of the quality of healthcare it provides (Scally and Donaldson, 1998).

Clinical standards primarily enable identification of the essentials that need to be right in the treatment of particular conditions if outcomes for the patients are to be optimised. Standards can be set at several levels: minimal, normative, and exemplary or may be deemed essential or desirable (Del Mar, 2001). It is important to recognise which level should be applied to any stan- dard as minimal standards are primarily aimed at promoting basic levels of care by identifying those areas or professionals who perhaps require remedial, or in rare cases even punitive action. Outcome-related standards are deemed as the “gold standard” of performance measurement but in reality they are diffi- cult to capture, particularly in the short term (Davies and Crombie, 1997; Goddard et al., 2002). Increasingly, process or to a lesser extent structure mea- sures are deemed more attractive especially if they are linked through evidence to outcomes (Crombie and Davies, 1998). Indeed, guidelines or care pathways will outline intervention or processes of care that lead to a desired outcome (Nathwani et al., 2001). The timely (within 4–8 hr of admission) administra- tion of appropriate intravenous antibiotics for patients with severe CAP is

30 Dilip Nathwani regarded as a key quality indicator (Nathwani et al., 2001, 2002). This inter-

vention is regarded as an important, validated, credible, consistent, simple, and measurable process standard based on evidence that is valued by clinicians, quality administrators, and patients (Nathwani et al., 2002). A CAP audit in Tayside used this as one of the key performance indicators in prospectively evaluating pneumonia care. This study revealed that a significant 39% of patients admitted with severe CAP did not receive antibiotics within the appro- priate timeframe. Indeed, 29% did not receive intravenous antibiotics within

24 hr of hospital admission (Marrie et al., 2000). Poor performance on a process measure gives a clear indication of the remedial action that is required and this can be linked to an incentive to bring about positive change. This audit in Dundee stimulated broad educational feedback and the development and implementation of a care pathway for CAP (Marrie et al., 2000) which will be subject to further evaluation (G. Barlow, personal communication). The path- way implementation is supported by a number of proactive educational and feedback interventions. On the other hand, a commonly used crude outcome marker of death is more difficult to interpret as it is insensitive to the quality of healthcare received and can be influenced by a range of other factors (Mant and Hicks, 1995). In our CAP audit (Nathwani et al., 2002), compliance with the unit protocol did appear to correlate to a reduction in mortality but the association was by no means robust.