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Transcript of Sharing the evidence: clinical practice benchmarking to improve continuously the quality of care
Sharing the evidence: clinical practicebenchmarking to improve continuouslythe quality of care
Judith Ellis MBE MSc BSc(Hons) RGN RSCN PGCE RNT
Principal Lecturer, University of Central Lancashire, Preston, Lancashire2
Accepted for publication 27 October 1999
ELLISELLIS JJ. (2000)(2000) Journal of Advanced Nursing 32(1), 215±225
Sharing the evidence: clinical practice benchmarking to improve continuously
the quality of care
It is unacceptable for health care professionals to acquiesce quietly to incon-
sistencies in the quality of health care received by patients. In the United
Kingdom, the introduction of clinical governance has formalized the expecta-
tion that professionals' practice will meet recognized standards of care consis-
tently. It is being stated that all available evidence is being used to identify
national standards of excellence. This will inform professionals not only of
expected outcomes but of also the structures and processes that need to be in
place to support the attainment of such outcomes. Clinical practice bench-
marking is one continuous quality improvement approach, which is being used
by paediatric units in 27 National Health Service Trusts in the north-west of
England to promote the utilization of available evidence in to practice. The
evidence base for benchmarks of best practice is considered continuously using
a hierarchy of evidence. This clari®es the different evidence available, upon
which benchmarks or standards of excellence can be based, but reinforces the
kudos awarded quantitative research evidence within health care. Once
benchmarks have been agreed, benchmarking activity supports practitioners in
a continuous cycle of comparison and sharing that is aimed at ensuring that
children and their families receive evidence-based care, wherever they are
admitted in the north-west of England.
Keywords: quality, improvement, patient focused, clinical practice
benchmarking, comparison, sharing good practice, evidence base,
consistent service provision, children's health services, paediatrics
INTRODUCTION
The north-west paediatric practice-benchmarking project
was established in the north-west of England in 1994.
Now, in 1999, membership includes paediatric nurses
from 27 National Health Service (NHS) Trusts and
academic staff from ®ve universities.
The group was formed in response to members'
concerns that there appeared to be inconsistencies in the
quality of care being received by children and their
families across the north-west of England. In addition,
resources were being wasted through repetition of effort as
practitioners in all areas strived independently to ensure
delivery of evidence-based care in the same areas of
practice, e.g. paediatric pain control.
The origins of benchmarking are from within industry,
where it is now accepted as providing a structured
approach for the compilation of comparative data betweenCorrespondence: Judith Ellis, NHSE, Quarry House, Quarry Hill,
Leeds LS2 7UE, England. E-mail: [email protected]
Ó 2000 Blackwell Science Ltd 215
Journal of Advanced Nursing, 2000, 32(1), 215±225 Nursing and health care management issues
organizations, which can then support realistic develop-
ment (Codling 1992, Zairi & Leonard 1994). Within the
health service, benchmarking data gathered have also
tended to concentrate upon organizational issues, e.g. the
reduction of waiting times, staf®ng ratios, etc. (Mitchell
1996, Aspling & Lagoe 1996, Phillips 1995). This however,
means that members are always copying the best actual
practice identi®ed, which as Harrington (1996) highlights
can only ever make the copier second best.
The north-west group has adapted benchmarking
principles from industry to support the development of
clinical practice, but comparison is not limited to the
actual practice of benchmarking partners. In clinical
practice, the benchmark against which practice is
considered can be de®ned as professional consensus of
best possible achievable practice (Ellis & Morris 1997).
Rather than comparison with actual best practice, clin-
ical practice benchmarking ensures utilization of all
levels of evidence in the identi®cation of standards of
excellence, with benchmarking activity supporting struc-
tured comparison and sharing (Ellis 1995, Ellis & Morris
1997).
Figure 1 illustrates the stages involved in a clinical
practice benchmarking cycle for continuous quality
improvement towards best possible practice.
The experiences of the paediatric benchmarking group
will be referred to in this paper to support consideration of
the possible value of clinical practice benchmarking
activity in relation to:
· Continuous development of quality health care.
· How best practice in structures and processes supports
the attainment of required patient-focused outcomes.
· Use of all sources of evidence in the compilation of
evidence-based benchmarks of best practice.
· Practitioner and multidisciplinary involvement at all
stages of benchmarking activity.
· Impact of benchmarking upon consistent quality health
care.
QUALITY HEALTH CARE
The National Health Service (NHS) in the United
Kingdom (UK) is being encouraged to ensure uniform
Figure 1 Practice bench-
marking cycle (Ellis 1999).
J. Ellis
216 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225
provision of high quality health care (Department of
Health, DOH 1997). The concept of quality as it relates
to health care has seldom been de®ned and it has been
widely accepted that it is a complex multidimensional
concept in constant need of analysis and clari®cation
(Attree 1993, Gillies 1996). Undeterred, the modern
health service has extended the requirements for assured
quality care. For example, the recent introduction of the
notion of clinical governance (Department of Health
19984 ) suggests that quality can be identi®ed, evaluated
and managed (Attree 1993, National Health Service
Executive, NHSE 1998). It is suggested that clinical
practice benchmarking may be one approach that may
provide a quality assessment and continuous quality
improvement approach that supports the development of
quality care (see Figure 1) (Ellis 1995, Ellis & Morris
1997).
QUALITY ASSESSMENT AND IMPROVEMENT
Quality assessment can be used to prove the level of
service being delivered but it is of no bene®t unless
undertaken in conjunction with quality improvement.
For example, national indicators (e.g. national compar-
ative data in the United Kingdom available from the
National Institute for Clinical Excellence (NICE) and in
National Service Frameworks (Department of Health
19985 ) tend to concentrate upon mortality and morbidity
®gures, the measurable outcomes. The utilization of
such assessment information to develop quality practice
is vital but seldom forthcoming (Gillies 1996). As
Nightingale demonstrated in the Crimean war, knowing
about abysmal outcomes for patients is only useful if it
is used to improve the structures and processes which
transform the outcome for the patients (Woodham-
Smith 19506 ).
Clinical practice benchmarking acknowledges the
need in health care to consider best practice not only
in attaining a required outcome, but also as suggested
originally by Donabedian (1966) and later by Bond &
Thomas (1993), within the structures and processes that
need to be in place. It is suggested that clinical practice
benchmarking activity allows structured comparison of
these practices (see Figure 1). The, overall patient-
focused outcome for each considered area of practice
is agreed. Structures and processes are then identi®ed as
factors that would support the attainment of the
outcome. Through consideration of all available
evidence, the best possible practice within each factor
is then arrived at and accepted as the benchmark of best
practice. Unlike organizational benchmarks where best
practice refers to actual systems and processes (Codling
1992, Zairi & Leonard 1994), clinical practice bench-
marks include external consideration of what the stan-
dard of excellence consists of.
STANDARD OF EXCELLENCE/BENCHMARK
The Department of Health Document A First Class Service
refers to national standards of excellence (Department of
Health 19987 ), a term ascribed to clinical practice bench-
marks (Ellis & Morris 1997). It is, however, extremely
dif®cult to identify the level of performance required for a
standard of excellence (Attree 1993).
Excellence in a health service may be considered as
fully meeting the needs of patients. Indeed, patient-
focused outcomes are frequently referred to as the aim in
Department of Health documents in the UK, particularly
A First Class Service (Department of Health 19988 ).
However, if patient-focused care is accepted as the goal
of excellent health care, then each individual served may
arrive at their own de®nition of excellence, with value
judgements made (Attree 1993). This utopia is impracti-
cable for a national health service with limited resources,
and in the United Kingdom (UK) such a view of quality is
not strenuously pursued. For example, patient views
appear in the evaluative phase of clinical governance
(Department of Health 19989 ). It could be suggested that to
close the quality cycle such patient-led requirements,
which may be concerned with the process of health care,
should indeed inform the standards of excellence sought
and not just be part of the evaluation stage.
In clinical practice benchmarking, patients are not
directly involved in compilation meetings where bench-
marks for structures and processes are agreed but are
represented by appropriate consumer group members at
the overall outcome stage. Rather than personal views,
they can offer a wider patient perspective upon what
constitutes best practice, accepting the utilitarian view
that ®nite resources may have to be used in such a way as
to ensure the greatest good for the greatest number.
Aneuran Bevan at the inception of the NHS in the UK
recognized the rationalization required in a publicly
funded health service. He stated in 1948, referring to staff
and equipment availability, `¼ we shall never have all we
need. If we are short it is all the more reason why we
should intelligently use what we have got¼ ' (Cole 1998
p. 4). Intelligent use has recently been translated in the UK
into viewing quality as ensuring that whenever possible
practice is based upon available evidence of effectiveness
with `¼ clinical interventions¼ doing what they are
intended to do¼' (NHSE 1996 p. 45).
EVIDENCE-BASED PRACTICE
Where de®nitive evidence of the care required to achieve a
stated outcome exists, e.g. a particular pharmaceutical
intervention with measurable physiological effect, it can
be suggested that practice expected may be stated in an
uncompromising dictat. The outcome of action is so clear
that there is no room for discussion or compromise
Nursing and health care management issues Clinical practice benchmarking
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225 217
(Grimshaw & Russel 199310 ) or comparative benchmarking
activity. Professionals must comply. This is the basis for
the introduction of clinical governance in the UK (Depart-
ment of Health 199811 ). For example, National Service
Frameworks are being presented as offering `¼ clear
quality standards which all parts of the NHS will be
expected to meet¼' (Department of Health 199812 p. 14).
It would appear that in spite of professional bodies
releasing guidelines and locally adapted protocols to
assist practitioners in making clinical decisions (Long
1994), a professional peer review system is no longer
considered suf®cient to monitor and evaluate practice.
Even where care or a particular course of action's
effectiveness is dictated by high level evidence, national
guidelines are apparently seen by some professions, for
example medicine, as unacceptable restrictions upon
professional autonomous practice (Haines & Feder 199213 ,
Walby & Greenwell 1994). Mckenna (199514 ) suggests that
doctors take individual responsibility for their action.
They expect total freedom of clinical decision-making
which is potentially dangerous for both patients and
practitioners. Parkin (199515 ), however, states that nurses
act as an autonomous group accepting peer review of
professional standards.
The need for clinical governance powers was recog-
nized in the United States of America (USA) in 1992 when
the Joint Commission on Accreditation of Health Care
Organizations was established with powers to peer review
organizations, and the UK is following their lead. The
National Institute for Clinical Excellence and Commission
for Health Improvement (Department of Health 199816 ) are
being established with a remit to set and monitor stan-
dards.
In the complex world of health care, however, the
number of such stringent dictats is limited. Even if the
evidence base for practice appears undeniable, it must
always be remembered that the contexts of care vary, as do
the actual needs and desires of individual clients. In the
provision of a customer-led service, many variables are
beyond control. De®nitive outcomes cannot therefore be
categorically prescribed. It is in the process and where
indeterminate outcomes exist, e.g. patient satisfaction and
levels of partnership, that benchmarking activity may be
of particular value within practice development. It is also
in these areas that the availability of indisputable
evidence upon which to base a benchmark of best practice
remains problematic, particularly when it is the `softer'
elements of care (Wright 1994) that are under consider-
ation.
In clinical practice benchmarking it is accepted that the
identi®cation of benchmarks of best practice should
preferably be based upon, but not limited by, the avail-
ability of a scienti®c evidence base. Evidence is therefore
considered from any level of a hierarchy of evidence.
Figure 2 presents the classi®cation of evidence used by
the north-west paediatric benchmarking group. This is a
simpli®ed version of the NHS Centre for Research and
Dissemination's hierarchy (NHSCRD). This grades the
validity of available evidence to ensure that the value
attributed to the evidence and the conclusions drawn are
appropriate to the reliability of the results being used
(Oxman 1994).
The higher levels are reserved for reviews, for example
systematic reviews (Droogan & Song 1996) and meta-
analysis (Greener & Grimshaw 1996) like those presented
by the Cochrane Centre or NHSCRD. These higher level
reviews are, however, extremely limited in number and
take time to produce even when topics have been iden-
ti®ed. Meanwhile, patients are receiving care. In addition,
in some areas of practice the evidence considered is itself
poor. So, although reviewed, the ®nal report just further
highlights the weak evidence base available, with ®ndings
again classi®ed according to a hierarchy, rather than
giving de®nitive evidence around which benchmarks can
be built.
After reviews subsequent hierarchical levels continue to
concentrate upon quantitative methods of inquiry, e.g.
randomized controlled trials emphasizing the value of
quanti®able aspects of care (Oxman 1994). The kudos still
attributed to quantitative research methodologies (Bassett
1992) raises concerns that a dearth of such evidence could
prevent best practice being sought.
Using lower level evidence is only accepted in the
absence of more empirical, higher level evidence. If
viewed as a weighted hierarchy, qualitative studies and
indeed evidence that supports the provision of a human-
istic health service, are to be found at the bottom. The
lowest levels include the opinions and experience of
respected authorities based on clinical experience,
descriptive studies and reports and indeed the views of
Figure 2 Classi®cation of evidence.
J. Ellis
218 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225
those the health service actually serves, the patients
(Oxman 1994).
As previously stated, in the identi®cation of bench-
marks of best practice, all evidence is considered. The
benchmarking group have not used a hierarchy to categ-
orize evidence but have approached the classi®cation of
evidence without overt value judgements (see Figure 2),
still recognizing that empirical evidence should be
actively sought and used wherever available. This is
where clinical practice benchmarking differs from organ-
izational benchmarking where comparison is against
norms in practice (Codling 1992, Phillips 1995). The use
of all available evidence ensures that clinical practice
benchmarking allows comparison against best possible
practice with wide external focus, particularly for those
benchmarks based upon lower level evidence.
Using the classi®cation of evidence shown in Figure 2,
the evidence base that supports the benchmark statements
arrived at for 34 factors within ®ve areas of paediatric
practice is shown in Figure 3. This clearly demonstrates
that the identi®cation of an evidence base for best practice
for structures and processes involved in achieving patient-
focused outcomes, is most reliant upon opinions and
experiences of professionals or is identi®ed from national
reports or the published views of consumer groups.
RESPECTED AUTHORITIES/EXPERTS
If the evidence base available represents the views of
respected authorities, for the compilation of each bench-
mark the membership of the meeting has to vary, to ensure
involvement of experts in the particular ®eld. In addition,
written support and evidence is sought from key stake-
holders. The national picture is ascertained for the north-
west group through literature reviews undertaken by
representatives from six universities and through an
external review panel of national paediatric experts. The
external focus is as wide as possible to ensure that best
practice is identi®ed.
It is important to involve all leading experts in the ®eld,
taking into account geographical strengths and limita-
tions. For example the north-west paediatric bench-
marking group membership includes three paediatric
lead hospitals, specialist centres and many district general
hospital units. All trusts are invited to send a represen-
tative to these meetings. Where possible this will be the
acknowledged expert practitioners who possess a special-
ized body of knowledge and have extensive expertise in
the area of practice under consideration, a de®nition of
experts that is supported by English (1993) and Eraut
(198517 ).
The involvement of experts is important for two
reasons. First it ensures that consideration of how to
develop quality health care services is not limited or
delayed by the lack of research ®ndings. Expert consensus
from across 27 Trusts is accepted in the identi®cation of
factors and in arriving at benchmarks of best practice. In
addition, involving experts allows the `¼untapped
resource¼' (Meerabeau 1992 p. 108) of experts' tacit
knowledge to be extracted so that best practice bench-
marks bene®t from experts' holistic views and artistry and
do not merely become a tick list of skills.
Experts not only attend compilation meetings but also
are encouraged to publicly verbalize and share the nature
of expert practice. This assists practitioners in compiling
action plans that will enable them to develop holistic best
practice. Experts involved in identifying benchmarks and
assisting with action planning can come from many
disciplines, depending upon the area under consider-
ation.
NURSING-LED INTERDISCIPLINARYWORKING?
The health care team includes members from many
different professional groups. Unless all are uni®ed in
seeking to achieve a mutual cause in achieving patient-
focused outcomes, interactions will be protective of
professional self-interest and communication poor (Covey
198918 ). All will approach effective delivery of quality care
from a different professional perspective (Walby & Green-
well 1994). Initiatives such as clinical practice bench-
marking require an agreed vision that reminds all that the
central tenet of health care services is to provide high
quality care to patients. If such a vision is shared it should
prevent divisive fragmentation of health care services and
repetition of effort caused by power games and profes-
sional protectionism (Poulton & West 1993, Walby &
Figure 3 Evidence bases for factor benchmark statements
(according to classi®cation in Figure 2). Total number of factors
considered � 34.
Nursing and health care management issues Clinical practice benchmarking
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225 219
Greenwell 1994), and thus help to promote multidisci-
plinary collaboration.
Benchmarking in the north-west of England is a
nursing-led initiative. Although members of the multidis-
ciplinary team are invited to meetings the attendance and
input remains inconsistent, with greater enthusiasm from
the professions allied to medicine and support services
than the medical profession. The compilation of patient-
focused benchmarks may therefore, according to attend-
ance, require members to problem-solve beyond the
con®nes of their particular knowledge base (Diller 1990).
Multidisciplinary effort may have to occur outside the
formal benchmarking working groups. It could be
surmized that the playing of the doctor±nurse game (Stein
et al. 1990, Sweet & Norman 1995) continues in imple-
menting changes and completing the quality improvement
benchmarking cycle (see Figure 1).
If effective channels of communication did not exist
previously, they have to be established under the guise of
practice development. The resultant improved relation-
ships, shared knowledge and expertise appear to lead to
mutual recognition of merit. It is, however, interesting to
note that the experience of the north-west group is, in
areas where improvement in practice is reliant upon
collaborative action with medical colleagues, that bench-
marking scores appear to suggest that practice has
worsened. For example, when the organization of dedi-
cated paediatric theatre lists was identi®ed as best prac-
tice within the paediatric elective surgery benchmark, the
pre-benchmarking activity score was better than the score
attained after 12 months of benchmarking activity. This is
the only factor where practice did not develop in the area
of elective surgery and was also the only factor where
development was dependent upon collaborative multidis-
ciplinary working.
PRACTITIONER INVOLVEMENT
Clinical practice benchmarking focuses upon practice and
therefore must involve practitioners at the patient inter-
face at all stages of the cycle (see Figure 1). Practitioners
should identify the structures and processes that underpin
good practice, score and comment upon actual practice,
and then use the comparative scores to share develop-
ments and innovations. Practitioners provide and receive
practical support, preventing unnecessary repetition of
effort (Ellis 1995, Ellis & Morris 1997). This is a notable
difference from organizational and clinical benchmarks,
where managers and external experts (Phillips 1995)
arrive at the benchmarks.
In patient-focused practice benchmarking, managers
formally commit themselves to providing practical
support for practitioners and assist in the identi®cation
of areas for consideration. The practitioners, however,
actually agree and score the benchmarks (Ellis 1995, Ellis
& Morris 1997). Their involvement heightens their moti-
vation to achieve (Mears 1995) and this is supported by
ensuring that the scoring is not unnecessarily complex or
time consuming (Locke 1968). The benchmarks are seen as
realistic goals of achievable best practice which will,
according to Locke's (1968) motivational change theory,
promote change.
SCORING
Clinical practice benchmarking continuum statements for
scoring are made as objective as possible to ensure
reliability and validity of scoring. They are also reviewed
by the external review panel. However, due to the nature
of the outcomes, and the evidence upon which they are
based, it is accepted that there is an element of subjectivity
in benchmark scoring.
Benchmarking continuums cannot be considered
continuous variables. Comments made to explain the
scores awarded are therefore probably of more value than
the actual numeric scores. The comments are used to
consider parity of scoring and objectivity of benchmarking
continuum statements, but most importantly, they support
the actual sharing and compilation of action plans.
It could be suggested that for some practitioners consis-
tently low scoring might de-motivate or create an
unhealthy competitive spirit. However, as Codling (1992
p. 19) states, dissatisfaction may be useful as it stimulates
a desire for change. In addition, it is important to
acknowledge the effect of health professionals' commit-
ment to patients. Deming, an international ®gure in
quality improvement, stated when he was asked to look
at quality improvement in health care that those entering
health care professions are eager to perform well (Deming
1982). Indeed being able to identify how current practice
compares with others appears to be a motivator for
developments. The professionalism of practitioners is
supported by the apparent honesty of scores that practi-
tioners award practice. Scores obtained are randomly
validated through cross-scoring with nursing students
who are on clinical placements and quali®ed nursing
colleagues from the same practice area.
Practitioners appear to accept the need to score honestly
so that they can use the comparison results directly to
develop practice and to improve quality through moti-
vating and in¯uencing others.
SHARING AND NETWORKING
Sharing and networking can occur through the circulation
of comparative data to all member units or at speci®c topic
meetings. Practitioners and experts from all member units
attend these meetings and top scorers are asked to share
directly their good practice. Unlike organizational bench-
marking, in clinical practice benchmarking scores are not
J. Ellis
220 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225
anonymized, which facilitates openness and sharing. It is
this sharing and networking that differentiates clinical
practice benchmarking from other quality improvement
initiatives. Without it clinical practice benchmarking may
be considered a quality assessment or audit activity,
showing that a unit is `¼doing right things right¼' (NHSE
1998 p. 3) but not providing realistic and practical support
in the development of best practice.
Practitioners can demonstrate their acceptance of their
professional duty to ensure that through all possible
avenues of action their patients receive the best possible
care (UKCC 199219 ). Indeed clinical practice benchmarking
provides a quality improvement approach that realisti-
cally meets the aims stated in the UK's A First Class
Service document which demands that `¼evidence based
practice is supported and applied routinely in everyday
practice¼' (Department of Health 199820 p. 36).
INCONSISTENCIES IN SERVICE
If this aim is fully achieved it could be argued that there
should be no inconsistencies or geographical variance in
the standard of care. As Frank Dobson (former UK Secre-
tary of State for Health) stated, the delivery of high quality
care `¼should not depend upon the geographical accident
of where¼' patients `¼happen to live' (Department of
Health 199821 p. 2).
Prior to benchmarking activity in the north-west, prac-
titioners were, as Lipsky (199222 ) suggests, apparently
ignorant of developments outside their own area of
practice or sphere of in¯uence. This had led to unneces-
sary repetition of dissemination effort and wasteful dupli-
cation of actual research activity. For example, at the ®rst
north-west meeting, practitioners from paediatric units
across 27 NHS Trusts identi®ed that current isolated
development efforts in each trust were concentrated
around the same six areas of practice. Indeed researchers
appeared to be failing to accept their responsibilities in
ensuring dissemination of research ®ndings (Luker &
Kenrick 1995). This was true even where an evidence
base for practice was identi®able and effectiveness of
practice application had been clearly demonstrated. There
was no consistency in the evidence base in use or the
quality of health care.
Figure 4 shows practice-benchmarking scores obtained
from NHS paediatric units around the north-west of the
Figure 4 Range of scores
awarded by practitioners: pre-
benchmarking activity
(10 � best practice).
Nursing and health care management issues Clinical practice benchmarking
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225 221
UK, before quality improvement benchmarking activity.
Each chart relates to a particular area of practice, e.g.
adolescent care. Along the x axes are the different struc-
tures and processes that professional consensus identi®ed
as essential for the attainment of patient-focused outcomes
in that area of practice. They appear as Factor 1 (F1),
Factor 2 (F2), etc. The y axes relate to the scores awarded
for that factor. Practitioners were asked for each factor to
compare their actual practice against a continuum of
practice descriptors with a 10 score signifying attainment
of the benchmark of best practice. Scores for the number of
Trusts stated have been collated, to show for each factor
the range of scores, self-awarded by practitioners across
the north-west.
The graphs (Figure 4) highlight the inequalities in
practice at the commencement of clinical practice bench-
marking and do not promote con®dence in the equality of
National Health Service provision in the UK. Figure 5
compares these initial scores with scores awarded after
approximately 24 months of benchmarking quality
improvement activity.
The y axes again show the scores awarded and the x
axes relate to the structures and processes, the factors.
This time, however, the `pre' column relates to scores
prior to any actual quality improvement activity, and the
`post' column, relates to scores after 24 months of quality
improvement activity. The cycle in Figure 1 has been
completed and the inner update circle commenced with
benchmarks re-scored. The dotted line divides the
different factors.
Figure 5 shows that in most factors the range is closing.
This indicates that after 24 months of clinical practice
benchmarking activity, there is apparently less variance in
the benchmarking scores awarded by practitioners, which
may suggest greater consistency in practice in the partic-
ular areas considered. In addition, for some factors, the
median scores are also improving which suggests that the
quality of care may also be improving. However, the same
hospitals were included in the sample for both `pre' and
`post' results and due to non-receipt of some scores,
comparable sample numbers are small. Therefore, results
have to be approached with some scepticism. In addition,
there is dif®culty in ascertaining whether these improve-
ments can be directly attributed to benchmarking and
further evaluation is required.
Comparison of re-score results is, however, only one
measure of the effects of clinical practice benchmarking
activity. It is important also to acknowledge that the
bringing together of practitioners has a far wider impact
upon practice. Networking promotes general exchange of
Figure 5 Benchmark scores
comparing pre- and post-
benchmarking activity in a
speci®ed area of practice:
showing the range of scores
and the median scores for
each factor. j � range of
scores; --- � division between
different factors; j � pre-
benchmarking activity
median score; r � post-
benchmarking activity
median score.
J. Ellis
222 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225
information and also creates a wider supportive culture,
especially important in areas of specialist practice where
practitioners can feel isolated and ill-informed.
NATION-WIDE DISSEMINATION
Having identi®ed benchmarks of best practice these could,
as suggested earlier, provide invaluable standards of
excellence to be achieved nation-wide (Department of
Health 199823 ). However, if practice benchmarks are based
on lower level evidence (Oxman 1994) they may re¯ect
only local needs and provision. The greater the specialist
knowledge and the higher the level of evidence upon
which a benchmark is based, the wider the applicability of
a clinical practice benchmark will be.
Another concern with widening the use of set bench-
marks is that if practitioners' ownership is lost, the
motivation effect upon the practitioners may be reduced
(Mears 1995). One possible solution could be to use
national benchmarks for scoring but to ensure then that
benchmarking activity is undertaken locally with local
networks for comparison of scores and the sharing and
supporting of developments in practice. With this
scenario, practitioners may accept national benchmarks
as helping them to identify areas for practice development
effort, with high scoring colleagues locally providing
practical guidance for the development of best practice.
The national quest to meet the identi®ed benchmarks
would help to ensure support from managers and
employers.
IMPACT OF BENCHMARKING
Benchmarking provides all those involved with a `¼real-
istic achievable picture of the desired future¼' (Codling
1992 p. 19). Clinical practice benchmarking has a greater
impact as it not only promotes the copying of examples of
best practice, but through the use of all available evidence
advances the continuous quest for best possible practice.
The requirement to attain set outcomes may for many
practitioners be considered beyond their sphere of in¯u-
ence and expertise. Through benchmarking activity prac-
titioners can themselves identify the structures and
processes that will support them in attaining required
outcomes and may indeed enable them to surpass expec-
tations.
The perceived impact of benchmarking over other
quality initiatives is summarized in Table 1.
Practitioners are in control. They not only participate in
identifying the goals to be attained but are mutually
supportive in achieving developments in practice that
have a positive effect upon patient care. Benchmarking
activity is not only about auditing practice to ensure
practice is achieving required measurable outcomes
(Gillies 1996, NHSE 1998) but supports open comparison
and sharing to allow continuous improvement and devel-
opment. Benchmarking pushes the boundaries of best
practice ever onwards. Practitioners, aware of develop-
ments elsewhere, can develop practice with minimal
effort, concentrating resources on new areas for practice
development.
CONCLUSION
The central tenets of a clinical practice benchmarking
group are that:
· The focus is the provision of best possible care for a
patient.
· Benchmarks are not dependent upon the existence of
high level research but utilize all available evidence.
· Factors considered include not only desired outcomes
but also the structures and processes that support the
attainment of patient-focused outcomes.
· Practitioners lead the benchmarking activity.
· Managers support practitioners' efforts.
· Honesty, openness and willingness to share is essen-
tial.
Table 1 Perceived impact of
benchmarking over other
quality initiatives
Quality initiatives Benchmarking
Fit for purpose ® Best possible practice
Traditional practice ® Evidence-based practice
Internal focus ® External focus
Professional fragmentation of care ® Patient-focused care
Internal ef®ciency ® Recognized excellence
Management-led ® Practitioner-led with management support
Pockets of good practice ® Dissemination of good practice
Outcome measurement ® Process improvement to outcome improvement
What is done ® How it is done
Achieving agreed standards ® Continuous improvement
Repetition of effort ® Sharing
Competitive protectionism ® Open comparison and sharing
Nursing and health care management issues Clinical practice benchmarking
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 215±225 223
Clinical practice benchmarking activity is increasingly
being recognized as a valuable practice development and
quality improvement initiative with groups appearing in
many specialities throughout the United Kingdom. The
paediatric-benchmarking group in the north-west was
established 5 years ago with support from the chief
nurses' of®ce and the Department of Health. Initial
scores demonstrated the wide variety in the quality of
care children and families could have expected to
receive in the north-west. Benchmarks are re-scored
every year and initial evaluation of the north-west
project suggests not only that practice is developing,
but also that by working together, sharing developments
and innovations, practitioners are helping to ensure that
wherever they are cared for, patients can expect a
similar high standard of care.
Clinical practice benchmarks may be considered to be
an aspiration for gold standards for practice, formalizing
the utilization of all levels of available evidence. However,
developments in practice are reliant upon how the
benchmarks and the comparative data obtained are
utilized. It is suggested that the effectiveness of bench-
marking activity is reliant upon practitioner commitment
and openness.
Professionals employed in caring professions should
not approach developments in patient-focused best prac-
tice as competitive. All professionals involved in health
care are under a duty of care, which involves ensuring the
uniform provision of a high quality health service. Clinical
practice benchmarking is one continuous quality improve-
ment initiative that professionals may wish to consider to
support the sharing of evidence-based practice.
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