Fulop, N;
Capelas Barbosa, E;
Hill, M;
Ledger, J;
Ng, PL;
Sherlaw-Johnson, C;
Rolewicz, L;
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(2020)
Rapid Evaluation of the Special Measures for Quality and Challenged Provider Regimes: A Mixed-Methods Study.
National Institute for Health Research: NIHR Journals Library.
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Abstract
Background: Healthcare organisations in England rated as inadequate for leadership and one other domain enter Special Measures for Quality (SMQ) to receive support and oversight. A ‘watch list’ of challenged providers (CPs) at risk of entering SMQ also receive support. Knowledge is limited about whether the support interventions drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. Objective: Analyse trust responses to the implementation of a) interventions for SMQ trusts and b) interventions for CP trusts to determine their impact on these organisations' capacity to achieve and sustain quality improvements. Design: Rapid research comprising five inter-related workstreams: 1. Literature review using systematic methods. 2. Analysis of policy documents and interviews at national level. 3. Eight multi-site, mixed method trust case studies. 4. Analysis of national performance and workforce indicators. 5. Economic analysis. Results: SMQ/CP were intended to be “support” programmes. SMQ/CP had an emotional impact on staff. Perceptions of NHSI interventions were mixed overall. Senior leadership teams were a key driver of change, with strong clinical input vital. Local systems have a role in improvement. Trusts focus efforts to improve across multiple domains. Internal and external factors contribute to positive performance trajectories. Nationally, only 15.8% of SMQ trusts exited within 24 months. Relative to national trends, entry into SMQ/CP corresponded to positive changes in 4-hour waits in Emergency Departments, mortality and delayed transfers of care. Trends in staff sickness and absence improved after trusts left SMQ/CP. There was some evidence that staff survey results improve. No association was found between SMQ/CP and referral to treatment times or cancer waiting times. The largest components of NHSI spending in case studies were interventions directed at 'training on cultural change' (33.6%), 'workforce quality and safety' (21.7%) and 'governance and assurance' (18.4%). Impact of SMQ on financial stability was equivocal; most trusts exiting SMQ experienced the same financial stability before and after exiting. Limitations: The rapid research design and one-year timeframe precludes longitudinal observations of trusts and local systems. The small number of indicators limited the quantitative analysis of impact. Measuring workforce effects was limited by data availability. Conclusions: Empirical evidence of positive impacts from SMQ/CP were identified, however, perceptions were mixed. Key lessons: • Time is needed to implement and embed changes. • Ways to mitigate emotional costs and stigma are needed. • Support strategies should be more trust specific. • Poor organisational performance needs to be addressed within local systems. • Senior leadership teams with stability, strong clinical input and previous SMQ experience helped enact change. • Organisation-wide quality improvement strategies and capabilities are needed. • Staff engagement and an open listening culture promote continuous learning and a quality improvement ‘mindset’, critical for sustainable improvement. • Need to consider level of sustainable funds required to improve patients’ outcomes. Future work: Evaluating recent changes to the regimes; role of local systems; longitudinal approaches. Study registration: Review protocol registered with PROSPERO (CRD: 42019131024). Funding: The National Institute for Health Research Health Services and Delivery Research programme (16/138/17 – Rapid Service Evaluation Research Team).
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