Background
Methods
Setting
Ethical considerations
Participant sampling and recruitment
Hospital ID | Role | Interviewee Abbreviation |
---|---|---|
H1 | Matron |
H1_Matron
|
H1 | Consultant |
H1_Consultant
|
H1 | Sister |
H1_Sister
|
H1 | Consultant |
H1_Consultant
|
H1 | Matron |
H1_Matron
|
H2 | Falls Lead Nurse |
H2_Falls Lead Nurse
|
H2 | Assistant Director of Nursing |
H2_Assistant Director of Nursing
|
H3 | Nurse |
H3_Nurse
|
H4 | Consultant |
H4_Consultant
|
H5 | Matron |
H5_Matron
|
H5 | Patient Safety Lead Nurse |
H5_Patient Safety Lead Nurse
|
H5 | Consultant |
H5_Consultant
|
H5 | Matron |
H5_Matron
|
H5 | Consultant |
H5_Consultant
|
H6 | Falls Lead Nurse |
H6_Falls Lead Nurse
|
H6 | Practice Development Physiotherapist (supports falls lead nurse) |
H6_Physiotherapist
|
H7 | Falls Lead Nurse |
H7_Falls Lead Nurse
|
H7 | Consultant |
H7_Consultant
|
Data collection
Data analysis
Results
Report features, local feedback characteristics and actions undertaken following the feedback
a. Report
|
a.1 Benchmarking of performances |
a.2 Simple visual representation |
a.3 Case studies and recommendations |
a.4 Representativeness, credibility and reliability of audit data |
b. Feedback
|
b.1 Different formats (e.g. verbal vs. written) |
b.2 Different professional groups involved (in particular front-line healthcare professionals) |
b.3 Use of graphical tools / visual representation in the presentation and dissemination of feedback |
b.4 Feedback communication simple and straight to the point |
b.5 Encouraging wording and open discussion |
b.6 More frequent or continuous feedback of performance data |
b.7 Feedback reach |
c. Actions undertaken
|
Using data to drive improvement
|
c.1 Use of other relevant data sources |
c.2 Use of continuous monitoring tools (e.g. use of QI tools such as Run Charts) |
Undertaking QI initiatives
|
c.3 Staff engagement and motivation |
c.4 Ownership and clear responsibilities |
c.5 Leadership and communication at different organisational levels (team, ward, Trust) |
c.6 Training |
c.7 Staffing level and turnover/ Resources |
c.8 Organisational culture |
c.9 Senior and operational management support |
c.10 QI skills |
c.11 Supportive QI networks/ collaboratives |
“I thought the comparison of different trusts was very, very helpful. It makes it a bit more of a competition […] It’s quite a nice healthy competition to improve on your previous results, but also to be better than your neighbours.” H1_Sister.
“It was helpful to have a comparison where we put the national average, I think it was a chance for us to sit down and try to reflect what we are doing well and what we are not doing well. It was a trigger to change […] it was a way to reflect on our practice and change something.” H5_Consultant.
“I liked the way the ratings were […] You know the RAG rating: the red, amber, green rating. The sparkline bit of the documentation, I think, was also quite novel because it gave you an idea of where the gaps were, and it sets about how we understand benchmarking with our regional colleagues and our local colleagues. So that was extremely helpful” H5_Consultant.
“I think the summary sheet of the 2017 audit report was useful because it was easy to read, […] was really easy to use and to see at a glance where things could be improved.[…] I suppose I just opened it up and I could find exactly what I wanted to see immediately”. H1_Consultant.
“It was useful to have the list of recommendations that you can take away when you’re transferring them into the care that you provide.” H1_Matron.
“Maybe some examples of people with good practice would be helpful. […] It would have been nice to have some indication of why some centres appeared to have got it all organised better than we managed.” H1_Consultant.
“I’ve got some doubt about this because it was only a snapshot for only one week and there were only 13 patients, so probably I will have some doubt that it was really representative […] I think probably everyone realise it was a little bit too snapshot!” H5_Consultant.
“Well, I felt our data was, I was very confident, because we had a consensus about how we were putting it in and we followed the guidance very closely.[…] I felt we answered it very honestly, I know that, so I’m confident our data was.” H1_Consultant
“I think the RAG rating is brilliant because they actually give you a colour scheme. […] Giving you numbers and percentages as well is actually quite appropriate. […] It’s also easy to communicate, so when you’re actually putting that on a PowerPoint slide, you’ve got your particular region - so H5 is - and then you can see how you compare to your neighbouring hospitals.” H5_Consultant.
“I like the infographics.[…] Things that you can easily print out and use for other people who don’t necessarily have a big interest in it, but it still makes them understand what the audit’s about and what’s been found.” H7_Consultant.
“We have a very relaxed atmosphere at clinical governance meetings, and everybody, whoever they are, feels that they can speak out […] this helps to identify where change needs to happen” H3_Nurse.
“It would be also good to have ongoing information, perhaps quarterly, feedback rather than just yearly.” H2_Assistant Director of Nursing.
“it would be useful to get a feedback to all the nursing staff, but that is difficult to do, obviously, because of timing. Getting people off the ward, and that kind of stuff.” H3_Nurse.
“it [falls prevention]’s always seen as an elderly care problem, even though it’s a hospital-wide issue. I’ve struggled with this every time to get people from other departments and more senior management to be involved in the audit. Everybody feels it’s somebody else’s job.” H1_Consultant.
“All our reported falls data is obviously taken into account, which is where we picked up that falls were happening at certain times of day, or increased falls at certain times of day. So we use our instant reporting data as well.” H2_Assistant Director of Nursing.
“I think Run Charts are quite important because it gives you continuous data interpretation as you’re going along.” H5_Consultant.
“We do use various Run charts and tables which shows the amount of falls that we have every month, and the level of harm from every fall, so we can obviously see if we are improving by doing the work we are at the moment.” H6_Falls Lead Nurse.
“Run charts… It just demonstrates the fluctuations, there’s a good time, there’s a bad time […] rather than anything else more useful […] So that Run chart’s open to different interpretations, and different interpretations will lead to different meaning.[…] So that’s just demonstrate a variation of the same statistic.” H4_Consultant.
“I think it [improvement] ‘s centred around engagement of staff, isn’t it? So if the staff can appreciate the importance of falls, they’re going to do something […] So staff engagement is a huge barrier. If they’re well engaged and they understand the process, patient care improves overall.” H5_Consultant.
“Staffing levels is always an issue and continuity of our staff that we have here. […] only 27 per cent of the staff that work here are permanent and we’re having different nurses coming in every day. So any continuity of any initiatives is going to be very difficult to maintain”. H3_Nurse.
“This audit is one of the many national audits. I don’t think that’s, in terms of the trust’s priority, that isn’t something that is, anyone pay a lot of attention, other than myself or three or four people in the falls team. In terms of the general, that becomes just one of the many audits that we do in a year.” H1_Sister.
“It’s a very transformational space, supportive, very proactive culture in this hospital[.]. They have an open-door policy where, if you have any significant issues regarding anything that’s highlighted in our Clinical Governance meetings they’re very encouraging in the sense that they want staff to highlight areas where we feel need to be improved and they will help facilitate the improvement […] So that’s one of our mottos, really - collaborative working and working together, facing the future, etc. - as part of our logo of the hospital there.” H5_Consultant.
“There is the expectation you do the clinical audit but it’s very much left to the local team to decide what’s happening.” H1_Matron.
“In terms of quality improvement, I just don’t really see there was a big culture around it.[…] I just felt that it’s a little bit detached with the daily work, if that makes sense.” H4_Consultant.
“I think there should be people nominated from each area, […] a representative from each kind of speciality and not just elderly department.” H1_Matron.
“I think somebody who could head the initiative and the audit process and communicate a little bit better would definitely improve awareness and might actually implement change. I think somebody needs to take ownership of the work. I’m not sure who has done that, but they’re not communicating particularly well by the sounds of it.[…] I think somebody needs to take ownership of this for our advice and communicate how we’re doing, and actually get people involved.” H3_Nurse.
“We know some of the best work that goes on about preventative work is where you’ve got one individual or a team of individuals who are enthusiasts for the area and keep the pressure on all staff, all healthcare professionals.” H1_Consultant.
“I think that could help looking at just basic stuff like the action plans and monitoring, are we meeting the deadlines? If not, why not?” H5_Matron.
“I think there’s a real need to get all medical staff looking at falls in terms of medications and understanding blood pressures. So there’s a bit of education needed where we need to empower everybody, not just geriatricians to be thinking about screening people who have fallen, either before hospital or as inpatients.” H1_Consultant.
“It’s also making people more aware of the frail elderly, the risk of them falling, the impact of what a fall has on a particular individual, their quality of life, their psychological wellbeing, their health, the level of care and support that they need, the walking aids that may require afterwards; and then the impact it has on the hospital regarding length of stay, the impact on the staff looking after those patients, the impact on the resources used, but also some people after a significant fall won’t be able to get back home.” H5_Consultant.
“I didn’t really consider any [QI] methods on that, I think I probably did it by default. For instance, when you’re doing any change you do things that is a quality improvement tool without realising it.” H5_Matron.
“No, we didn’t [do any training on QI methods], although that would have been useful as knowledge of these methods in our team is poor.” H2_Falls Lead Nurse.
“They [the use of QI methods] were supported by the falls collaborative to find out if that [improvement idea] was working, using the PDSA (Plan-Do-Study-Act) tool.[…] I think some areas were very reluctant to use the tools. They felt that it wasn’t relevant, but once they’d been persuaded in the right direction to use the tool, it was then much easier to see which changes worked, and which didn’t.” H1_Sister.
“I don’t think it’s going to be helpful for me to continue doing this audit. The reason being that 2017 and 2015, the result hasn’t really shown any difference. I didn’t feel that there was lots of changes, so I’m quite happy with what we’ve done with the audit, but I don’t think it is useful to keep repeating the same thing.“ H4_Consultant.
Reported changes in local practice following the NCA feedback
“I think there’s more ownership, ward-based […] I think there’s a better understanding, it’s everybody’s problem, but also the importance of why we’re trying to reduce falls, and it’s not just another audit.” H5_Matron.
“I think there’s more awareness on the wards and kind of the ward level staff about falls. I think people are more aware of the potential consequences […] I think people talk more about falls and trying to prevent them within the hospital.” H7_Consultant.
“So I think it highlighted areas where we weren’t doing too well in, and […] it made us concentrate on seven aspects. People were able to focus on those seven different areas, and that translated into less falls and less harm for the trust and for patients.” H5_Consultant.
“We have - we are trying - involvement with patients in preventing falls rather than giving information after a patient has fallen, actually making sure all at-risk patients and relatives have got a leaflet and information that they can use.” H2_Assistant Director of Nursing.
“I don’t feel just continuing looking at this is going to bring too much value, but I feel that looking at a different group of patients, say patients admitted like after a week, that would be more helpful to me. […] just repeating the same admissions audit I just felt is not that really going to be useful.” H4_Consultant.
“So although we’d put an initial changed programme in, it got impacted on when we went into an electronic patient record. So that’s been affected by a bigger change that happened across the whole organisation.” H1_Matron.
“I don’t think the local teams really changed very much as a result of the audit. […] I guess there was other priority from the safety boards, or from the trusts.” H4_Consultant.