Improving practice

The course follows the series of standards set out in “Best Practice for the Care of Patients with TB – A Guide for Low-Income Countries" (Union 2007). which was developed. Within a nursing context, it is useful to set standards for best practice to clarify what is to be achieved with regard to care being delivered to patients and those closest to them.
The Marsden approach to standard setting, which is used here, provides a framework that consists of the standard statement, rationale, resources, professional practice and outcomes (see table below). The standards follow the patient through diagnosis and treatment each one beginning with a statement regarding the desired standard of care. Most of the educational material and information is presented in the “Rationale” section of each standard, forming the basis for good quality care.

Having filed any gaps in their knowledge, people using the course are then invited to reflect on the “Resources” they have available to them and the level of “Professional practice” currently being reached in order to assess any gaps which need to be addressed. Once gaps have been identified it will be possible to plan how to make improvements according to the local situation. Specifying an expected “Outcome” enables users to assess whether or not they have reached the desired standard of care.

Table The framework for standard setting

Component	Definition
Standard Statement	A clear and concise statement outlining the level of care to be reached for patients with a defined problem or need
Rationale	What is required to meet the defined level of care? People knowledge and skills required by health care professionals availability of relevant training and education required members of the multidisciplinary team role and function of the management in relation to meeting the requirements. Equipment availability of specialist and non specialist items required availability of written materials for patients policies and procedures available to staff. Environment patient environment (e.g., privacy, possibility for isolation, etc.) staff environment (e.g., space for both clinical and administrative work; storage, etc.)
Professional Practice	Critical elements of assessment, planning, implementation and evaluation Highlighting of specific aspects of professional practice relevant to the patient’s problem/need Suggestions with regard to the identification of and referral to the appropriate care providers Documentation required in terms of patient records and for evaluation purposes
Outcome	Expected results of the planned intervention which can be assessed through patient satisfaction staff satisfaction documentary evidence

Key components of the Clinical Audit process

The first step to improving practice and thereby the quality of patient care is to look at the strengths and weaknesses of your existing service. Clinical audit provides a systematic approach to evaluating current practice against agreed standards and making changes with a built-in process for evaluation. As you work through this CD Rom you may discover that much of your practice reflects what is described in the standards. The aim of the learning activities linked to each standard and the clinical audit questions is to help you identify areas that could be improved and ask the following questions.
• What are the priorities for improvement?
• Which priorities present the best possibility for practice development under current circumstances, e.g., what capacity is there for change?
• What motivation is there to make a change?
It is important to assess a service’s strengths and build on these to motivate staff and support small changes that are likely to show improvements within a short period of time. This is the best way to achieve successful change in the first instance and give staff confidence and enthusiasm to look at other areas that need to be improved. Failure is more likely if expectations are unrealistic or the challenge is too great and failure can lead to poor motivation and demoralisation.

Clinical audit is seen as a cyclical process (Figure below) to emphasise the fact that practice development is a dynamic process and progress needs to be constantly re-evaluated.

Clinical Audit Cycle

Evaluation can often be challenging, especially if the outcome is different from what was predicted, but it is vital that it is carried out in order to see what works and what does not. Sometimes an unpredicted outcome can lead to a stronger intervention or service than initially expected. It may be tempting to introduce a particular intervention without planning to evaluate it because there is good evidence that it has been effective elsewhere. The problem with this is that the process of developing good practice through standard setting is context specific, and the intervention may need to be altered in order to become effective in a different setting.

In TB control nurses routinely collect data relating to case finding and treatment outcomes, which could be useful in evaluating a number of different practices, for example:

Quarterly cohort analysis gives regular feedback about overall programme performance and can highlight problems with regard to rates of sputum conversion, defaulting, etc. The Unit Coordinator responsible for undertaking the analysis can work through the outcome data with the relevant health-care workers in order provide a clearer picture about what is happening locally, including signs of service strengths and weaknesses.

Laboratory registers compared with TB registers can evaluate how many sputum smear-positive cases actually started treatment and within what time period.

Treatment outcome data can highlight monitor rates of default, failure or death.

Patient record cards can show treatment adherence patterns. If a problem is identified, a change in practice can be implemented and its impact measured using the same data as well as considering other means of evaluation, such as patient experience and staff reaction, depending on who is involved in the change.

Care prevention and management of tuberculosis