Planning and Monitoring Improvements to Quality Service in Healthcare

This report focuses on planning and monitoring improvements to quality service within a healthcare setting, specifically using St. Thomas Hospital as a case study. It begins with an introduction to the concept of quality in healthcare, emphasizing the importance of legislative and statutory requirements for delivering effective and efficient services. The main body of the report delves into relevant legislations such as The Health and Social Care Act 2012, the Care Act 2014, the Equality Act 2010, and the Health and Safety at Workplace Act 1974. It also examines statutory requirements like the Care Quality Commission (CQC) and the National Institute for Health and Care Excellence (NICE). The report then moves on to Activity 2, which discusses the planning and monitoring aspects of quality improvement, focusing on identifying areas for improvement within St. Thomas Hospital, such as staff acquisition and development. The report concludes by highlighting the significance of quality, safeguarding, and the promotion of diversity and inclusion within healthcare to ensure optimal patient care and employee well-being.

Planning and
Monitoring
Improvements to
Quality service in a
healthcare setting

Table of Contents
ACTIVITY 1....................................................................................................................................3
INTRODUCTION ..........................................................................................................................3
MAIN BODY ..................................................................................................................................3
CONCLUSION ...............................................................................................................................6
ACTIVITY 2....................................................................................................................................7
INTRODUCTION...........................................................................................................................7
TASK 3............................................................................................................................................7
P4 Carry out a review of one aspect of working practices in own setting to accurately identify
improvements that can be made to the current level of quality..................................................7
P5 Discuss why the aspect selected requires improvement using a range of different sources of
information..................................................................................................................................8
TASK 4............................................................................................................................................9
P6 Produce a detailed plan for a relevant quality improvement initiative in own work setting. 9
P7 Discuss potential or actual barriers to completing the quality improvement initiative.......10
CONCLUSION..............................................................................................................................10
REFERENCES..............................................................................................................................11

ACTIVITY 1
INTRODUCTION
Quality may be defined as the standard fixed for something which can be measured
against another thing of similar kind or may be meant as a degree of excellence for something.
Quality in health care may be referred to as the degree for which the services of health care for
the individuals and population increases the desired outcome of health and is consistent with the
current professional knowledge. It is important in this sector so that the patient is given treatment
in safe, affordable and effective manner so that an individual is able to recover from its problems
on time with effective and efficient services (Buttigieg, Gauci and Dey, 2016). If the quality
standards are maintained in the health care industry, it may result in worst consequences due to
any laxity or mistake. It may be ensured by analysing the data and its result, formulation of
targets, creating a balanced team and executable plans. Each health care centre has its fixed
standards which are utilised to provide services in appropriate manner so that efficient services
are delivered. The health care centre chosen for this report is St Thomas Hospital in London. It
specialises in cardiothoracic surgery, dermatology, children services, gynaecology and many
other. This report shall cover the legislative and statutory requirement in measuring quality and
impact on improving quality on different individuals.
MAIN BODY
Legislations are the rules, regulations, by laws, notifications, ordinance which are
required to regulate its working in delivering efficient services. As the manager of St Thomas
Hospital, the person is liable to follow certain policies and rules while treating any patient which
are enacted by the UK government. Foe the effective delivery of services, the following acts are
need to be complied by the hospital in order to ensure effective services are delivered to the
patients which are discussed as under-
The Health and Social Care Act, 2012 was designed to state the duties regarding health
inequalities. It formulated an independent board which are entrusted with a task of promoting
choice of patients and to minimise the administrative costs. It is aimed to strengthen the role of
care quality commission and to develop and monitor the activities which are being carried out by
the health care centres (Dollar and et. al., 2019). Another legislation is Care Act, 2014 which sets
the ways in which the people care and support for meeting and introducing the right for

assessment which comprises of the careers and in need support and self funders. This law makes
the health care centre like St Thomas Hospital liable for inspiring to make them use of the people
centred approach so that vulnerabilities are safeguarded. Equality Act, 2010 is designed to
legally protect the individuals from discrimination which might arise in the working environment
and wider society so that equality is promoted and equal opportunity is given to all. It
emphasises on fair treatment within all and this legislation is important for St Thomas Hospital
so that equality is promoted in the organisation and future growth is ensured. It also protects
people from harassment, discrimination and victimisation so that equal opportunity for all is
ensured. Health and Safety at Workplace Act, 1974 is designed to promote health, safety and
welfare at the workplace through the use of enforcement, regulation and encouragement. It states
the duties on employers to maintain and manage the safety at workplace so that safe working
environment is created for all (Glegg, Ryce and Brownlee, 2019). St Thomas Hospital must
ensure that safety of its employees are at their priority so that appropriate environment is given to
them for carrying out their responsibilities and activities.
Statutory requirements are the implied laws passed by the state or government
authorities. The managers and employers of St Thomas Hospital are liable to ensure the
maintenance and determination of these requirements within their healthcare organisation. Some
of the statutory requirements in context to St Thomas Hospital is discussed thereunder-
Care Quality Commission (CQC) is a non departmental public body which was
established in 2009 with an aim to inspect and regulate the services. In context to any service
sector or healthcare centre, this commission assist the hospitals in providing high quality service
to the patients so that safe and effective treatment is given to them and they are encouraged for
improvement in their health. In St Thomas Hospital, the managers have opted the total quality
management approach and continuous improvement. TQM denotes that the management has
formulated a system which is based on one principle that every member within their workforce
has been committed towards the service which are being offered to maintain higher standards in
respect of all aspects of the organisation (Granger, 2020). Continuous improvement refers to the
process which is ongoing for improving processes and services which are being delivered by the
healthcare centre. National Institute for Health and Care Excellence (NICE) is a non
department public body and a department of health in UK. It states the guidelines for four areas
which includes social care, clinical practice, utilisation of National Health Service and

supervision for the public sector. This regulation aims to improve the results for the individuals
when making utilisation of public health, social or NHS care service. This may be attained by the
guidelines which are evidence based and advices which are rendered or different practitioners
along with the development of quality standard and performance metrics (Watters, 2019).
Apart from the legislations, these statutory requirements will help the employers of St
Tomas Hospital in giving affirmative environment to its staff so that they can provide the
services as required by the standards and quality shall be maintained in the services which are
being delivered.
Diversity and inclusion practices can be promoted within the healthcare centres which
will lead the employees to feel that they are being valued and will be delivering their
responsibilities in the best way. The managers of St Tomas Hospital has gained the advantage of
promoting diversity and inclusion practice through distinct perspectives which can lead them to
have clarity in what they have done and employee engagement shall be enhanced and problems
of patients can be solved on time (Grol and Wensing, 2020). This will help in motivating the
employees as it will create a positive impact on the ways in which services can be offered to the
patients and the employee will become aware of their basic rights which are required in the
workplace.
Safeguarding can be referred to as the term for protecting the human rights, health and
well being of the people that will help children, young people and vulnerable adults to live a life
free from neglect, harm and abuse. In order to protect them from unfair practices, the UK
government has enacted several laws and published various guidelines. The employers and
managers of St Thomas Hospital is liable to ensure that the people who are being treated in the
hospital are free from any kind of abuse or neglect. Children and disabled people are more
subject to abuses like emotional , mental or sexual and neglect as they do not have voice and
cannot stand for themselves (Guzman, 2018). So the managers of St Thomas Hospital are
entrusted with a duty to ensure that no employee in their centre are subject to any criminal record
so that its patients and attendee are being treated in safe environment.
Safeguarding Vulnerable Groups Act (SVGA), 2016 is designed to avoid risk of harm
to people by preventing the individuals who are unsuitable for working with the vulnerable
children and adult as they may be accessed to them through work. It is very important to protect
the service users as this is their basic right and for ensuring this, the managers of St Thomas

Hospital has decided to comply with the Human Right Act so that a safe environment is given to
them and they are being treated without any discrimination and inequality. Quality and
safeguarding are associated with each other directly because if quality service is delivered to the
user, its rights will be protected as quality implies the delivery of services which are standardised
so that satisfactory service is rendered to all (Hansson, Höög and Nyström, 2017).
CONCLUSION
From the above activity, it is concluded that quality are the standards which are being
formulated by the companies in order to render services so that enhanced level of satisfaction can
be taken by the customers. In context to healthcare sector, different legislations and statutory
requirements can be opted by this industry so that both managers and consumers can feel safe
and secured while availing services. Apart from this, it is important for the employers to ensure
that they promote diversity and inclusion practices in their service so that the consumers can be
treated as per the quality and requirement they are being looking for. Hence, it clearly shows that
it is important to safeguard the vulnerable groups from any kind of discrimination or inequality
so that they do not feel abused or neglect which may cause negative effect on them.

ACTIVITY 2
INTRODUCTION
Monitoring and planning are the main aspects which are to be considered when
delivering the effective service. Planning can be defined as the process which provides the
outline as to how activities are to be carried out so that desired goals and objectives can be
achieved. It states the analysis of both business opportunities and constraints. On the other hand,
monitoring can be refereed to as the process which is systematic in nature for collection,
analysation and using the information so that progress can be tracked in order to achieve
objectives of the program (Rose and et. al., 2020). This report shall cover the quality
improvement requirements, and the plan and monitor improvements to quality in context to St
Thomas Hospital, London which delivers services relating to healthcare.
TASK 3
P4 Carry out a review of one aspect of working practices in own setting to accurately identify
improvements that can be made to the current level of quality.
In order to deliver effective service to the consumer, it is important to monitor the
activities and they ways in which it is being carried out so that targets and objectives can be
achieved as per the given required standards and the customer loyalty can be assured. For a
healthcare sector, it is important to serve the consumers which creates an impact to them by the
quality of service provided to them (Jensen-Doss and et. al., 2020). Therefore, in order to prevent
the decline in their actions, it is necessary to identify the factors which led to its decline so that
improvement can be made as soon as possible. The managers of St Thomas Hospital is entrusted
with a duty to ensure that all demands and pressure are improved from retention of staff to the
overall result of the healthcare industry. For improvisation, evidence based practices will help in
improving the capacity of the hospital within the selection, development and deployment which
can be best supported by furnishing the services. So it is essential for the managers of St
Thomas Hospital to timely identify the factors which led to its decline in services.
The major practices include staff acquisition, organisational engagement, leadership
alignment along with development and front line empowerment. In context to St Thomas
Hospital, it is required to improve its staff acquisition and development. This can be referred to
the process of getting the human resources which are necessary for assigning and working on the

projects. In simple words, it is the process of recruiting and retaining the high quality staff within
the organisation. An instance can be taken in order to understand the impact of the staff on the
ways in which services are delivered. Suppose a patient comes to get treatment or for a check up
and the doctor replies to him that its working hours are over and he should come tomorrow. This
shows that instead of serving the humanity, the doctor's personal life is more important. This can
be improved when the employees feel that their work is more important and is at utmost priority
when it comes to save the life of someone. Technology also plays an important role in rendering
effective service as it creates an affirmative impact on the way service is to be rendered. For
instance, due to lack of knowledge, the nurse or other staff increases the intensity of the laser
beam during the operation which created pessimistic impact on the patient and the St Thomas
hospital. This shows that technology can be used in order to provide efficient training to the staff
so that improvements can be made in their work which will result in smooth functioning of
operations (Jones and et. al., 2019). This shows that it is an important aspect for enhancing the
quality service of St Thomas Hospital so that it can build its goodwill. This can be assured by the
external recruitment and making job platforms so that skilled and qualified employee can be
recruited.
P5 Discuss why the aspect selected requires improvement using a range of different sources of
information.
Staff acquisition and development is an important aspect as it creates both positive and
negative impact on the overall performance of the company. In respect of healthcare sector, any
single mistake or carelessness may result in taking the life of someone which is necessary to be
prevented. So it is necessary to understand that an effective staff creates a strong impact on the
firm which delivers services. But this cannot contribute alone in improving the quality. It is
important to provide timely training to the workforce with the help of evolving technology so
that services can be rendered effectively (Khalil, Byrne and Ristevski, 2019). For example, in
context to St Thomas Hospital, it has an energetic staff with experience. It does not imply that if
the technology is brought by the hospital then all staff can work with it because it is not possible
for an individual to acquire all knowledge within this field for instance, a child specialist can
only handle the case of child rather than a cardiologist or an X Ray expert cannot work with
same expertise in taking MRI. So it is important for the development of staff to use technology
but training is required to be given in order to get expertise in one aspect.

This perspective is important to be improved as without an appropriate staff, quality
service cannot be offered or delivered. Therefore, it is important for the manager of St Thomas
Hospital to formulate policies and strategies so that quality service can be ensured. An efficient
and effective workforce is the one who carry out their roles and responsibilities in the most
appropriate manner and in case of any emergency, innovative ideas can help in assisting the
solutions for that (Ortmann and et. al., 2018). On the other hand, development will help in
providing the strong base as training will improve the skills which will contribute in improving
the services and activities.
TASK 4
P6 Produce a detailed plan for a relevant quality improvement initiative in own work setting.
Staff acquisition and development not only includes what has been filled for the future
which will render an opportunity so that skill gap and goals can be aligned within the recruitment
process. So it is necessary to formulate an effective strategy plan which shall involve position to
be filled, recruitment calender, assessment, budget and tracking tools with other details. The plan
which shall be formulated by the managers of St Thomas Hospital is discussed below-
 Analysation of recruitment needs and skill gap- The fist step towards this plan is to
identify the needs of hiring together with skill gaps in existing employee. This can be
done through visualising the growth of the hospital in terms of number of visit of patients
and the turnover rate of staff.
 Creation of hiring plan and recruitment calender- This step requires to estimate the
number of employees needed in each division and the time when they are needed. The
manager of St Thomas Hospital will get a lead as to anticipate the future needs.
 Identification of tools- This step includes identifying the tools required for bringing the
plan into action like screening tool, applicant tracking system, etc.
 Identification of each job role's need- This step requires to identify the characteristics
and skills which are to be possessed by the person for any specific position.
 Budget- The last step involves formulating the budget where training and development
can be rendered to the employees so that they can get familiar with the work culture and
become aware about how to deliver the services (Murki and et. al., 2018).

P7 Discuss potential or actual barriers to completing the quality improvement initiative.
The barriers are the roadblock which creates hurdle in the process of work. In context to
quality improvements, the following barriers impact the staff acquisition and development in the
St Thomas Hospital which are discussed thereunder-
 Employee resistance to modification- Due to evolution of technology, there has been
changes in the way nowadays services are being delivered. And if the employees resist to
make changes in themselves or in the environment so it will be difficult for the managers
of St Thomas Hospital to cope up with the new needs of the environment which may
trouble the humans.
 Short term focus- There has been a universal perspective for the employees that if they
see something better, they work towards switching it and this act as major brrier for the
companies to look for new staff. So the managers of St Thomas Hospital must work
towards motivating the staff so that they can render the service with adequate standards
and can have some sort of benefits (Nwabueze, 2016).
CONCLUSION
It is concluded from the above report that it is very important to identify such factors
which affect the performance of the organisation. It may include the practices which are being
delivered to the people or the ways in which it is done. Apart from identification, it is necessary
to find out the reason behind such factor so that it can lead to alteration in an appropriate manner.
Further a plan has been formulated so that it can be quality improvement initiative can be taken
and affirmative result can be generated. While this process is carried on, there are many barriers
which may arise to create a strong resistance in completing the process of quality improvement.
So it is very important to formulate such strategies in order to prevent the problems from
occurring.

REFERENCES
Books and Journals
Buttigieg, S.C., Gauci, D. and Dey, P., 2016. Continuous quality improvement in a Maltese
hospital using logical framework analysis. Journal of health organization and
management.
Dollar and et. al., 2019. Steps for implementing measurement-based care: Implementation
planning guide development and use in quality improvement. Psychological Services.
Glegg, S.M., Ryce, A. and Brownlee, K., 2019. A visual management tool for program planning,
project management and evaluation in paediatric health care. Evaluation and program
planning, 72. pp.16-23.
Granger, B.B., 2020. Six Simple Steps to Sustainability: A Checklist for Ongoing Monitoring of
Clinical Practice Improvements. AACN Advanced Critical Care. 31(2). pp.203-209.
Grol, R. and Wensing, M., 2020. Effective implementation of change in healthcare: a systematic
approach. Improving Patient Care: The implementation of change in health care, pp.45-
71.
Guzman, A., 2018. Case study: Reducing preventable maternal mortality in Rwandan healthcare
facilities through improvements in WASH protocols. Journal of Patient Safety and Risk
Management, 23(3). pp.129-134.
Hansson, J., Höög, E. and Nyström, M., 2017. Action research for multi-level facilitation of
improvement in health and social care: Development of a change facilitation approach
for a local R&D unit. Action Research. 15(4). pp.339-356.
Jensen-Doss and et. al., 2020. Measurement-based care as a practice improvement tool: Clinical
and organizational applications in youth mental health. Evidence-Based Practice in
Child and Adolescent Mental Health. 5(3). pp.233-250.
Jones and et. al., 2019. Evaluation of a health care transition improvement process in seven large
health care systems. Journal of pediatric nursing, 47. pp.44-50.
Khalil, H., Byrne, A. and Ristevski, E., 2019. The development and implementation of a clinical
skills matrix to plan and monitor palliative care nurses' skills. Collegian, 26(6). pp.634-
639.
Murki and et. al., 2018. Quality improvement collaborative for preterm infants in healthcare
facilities. Indian pediatrics. 55(9). pp.818-823.
Nwabueze, U., 2016. Organisational improvement: one hospital's experience of implementing
TQM. International Journal of Business Performance Management. 17(4). pp.466-487.
Ortmann and et. al., 2018. Quality control and improvement of cancer care: what is needed? 4th
European Roundtable Meeting (ERTM) May 5th, 2017, Berlin, Germany. Journal of
cancer research and clinical oncology. 144(6). pp.1097-1102.
Rose and et. al., 2020. Promoting Pediatric Preventive Visits Through Quality Improvement
Initiatives in the Primary Care Setting. The Journal of Pediatrics.
Watters, R., 2019. Translation of evidence-based practice: quality improvement and patient
safety. Nursing Clinics. 54(1). pp.1-20.

APPENDICE
SMART GOALS
Specific Measurable Achievable Realistic/
Reliable
Time frame
To hire efficient
staff for
maintaining and
improving the
quality in the
hospital.
To hire at least 10
employees in the
organisation so
that proper
treatment can be
given to the
patients and there
is no compromise
in the quality.
To contact the
recruitment
agencies in order
to hire efficient
staff and also
advertisement in
newspaper will
help in achieving
this goal.
The recruitment
agencies must be
reliable so that
efficient
candidate is hired.
The time required
to achieve this
goal is 4 weeks.