Reading the big picture

In my previous post I discussed the importance of being able to gather enough information (evidence) about a service in order to be able to construct the ‘big picture’ or overview of how it is operating. The term ‘evidence’, of course, relates to the idea that the CQC’s key lines of enquiry (KLOEs) provide a useful framework for gathering such information. CQC inspections, broadly speaking, work by the inspection team gathering as much evidence as possible regarding the quality of the service and then summarising their findings in their reports. My suggestion to providers and managers has always been that there is nothing to stop them doing something similar.

However, as with most things in life, it isn’t quite that simple. Firstly, managers need to have systems and processes that allow them to gather such evidence in the first place. And secondly, they then need to know how to ‘read’ or make sense of that information. As I pointed out in the previous post, information itself is not much good unless it can be ‘translated’ into meaningful knowledge.

In terms of how you gather such KLOE evidence in the first place, there are a number of different ‘tools’ and other systems on the market. My own company, Therapeia, provides one such tool, which is based on the familiar spreadsheet design, but there are other approaches as well. The key consideration here is whether such a tool or system can handle large amounts of information, whether this information is actually relevant, and whether the information can be easily ‘manipulated’ in order to rearrange various parts of the data into different groupings so as to facilitate analysis. It is also helpful if such data can be easily shared both within the service and with other agencies, including the CQC itself. Taking all these considerations together means that paper-based systems are really a non-starter.

I mentioned the point about large amounts of information because although there are ‘only’ twenty four main KLOEs (the so-called ‘sub-KLOEs’ are simply additional prompts to help with the main ones), in order to gather enough meaningful evidence it is important to gather at least three pieces of evidence for each KLOE, preferably from different sources. This is in order to corroborate the evidence and give it more weight. So you are already looking at at least seventy two pieces of information, and it wouldn’t hurt to have even more. The other point, though, is that such an evidence gathering process needs to be ‘dynamic’, and as I mentioned in my previous post, all this means is that the auditing process is continuous. In other words, it is not enough simply to conduct one ‘cycle’ of evidence gathering and then to sit back until the CQC arrives, or to wait another year before starting on the next cycle. Things change quickly in any service so it is essential to keep the evidence up to date.

Although this may all sound rather onerous, it’s really a matter of getting into the habit of regularly collecting evidence for each KLOE. I would recommend, if possible, spending about 30 minutes a day on this, and focusing on one particular KLOE. This means that in principle, and assuming a five day week, a complete cycle of auditing could be completed within five weeks before starting the process over again, although in subsequent cycles things should be easier because only some of the evidence will need to be updated.

But in many ways that was the easy bit! Yes, there is also the question of what kind of evidence to collect, but the CQC does provide some useful and detailed guidance on this which I have reproduced here. However, even supposing you are able to gather all the evidence and it at least appears to have some relevance to the KLOEs, how do you actually make sense of it. In other words, what does it actually tell you about your service. Or, to put it another way, what kind of (big) ‘picture’ does it present to you regarding your service?

At this point I want to address what appears to be quite a common misunderstanding regarding the KLOEs and the idea of a ‘KLOE audit’. A number of mangers and providers have used the word ‘compliance’ when talking to me about KLOEs, and seem to think that a KLOE audit is simply a way of ensuring that their service is ‘compliant’. This is a misnomer; the KLOEs do not ‘measure’ how ‘compliant’ a service is, although they can certainly help detect when a service is in breach of particular statutory regulations. To put it another way, a service could comply with all the necessary regulations but still be rated ‘requires improvement’. So clearly, ‘compliance’ is not enough.

The reason I mentioned this is that it would not really be helpful simply to ‘read’ the evidence in order to look for ‘compliance’. And, in fact, the only way you could do this would be to look for what’s missing. In other words, it’s usually the lack of something that points towards non-compliance with the regulations, not the presence of it. For example, gaps in care plans or medication records would point towards a possible compliance issue, as would the absence of proper quality assurance systems.

So how do you ‘read’ the evidence in order to get a sense of the ‘big picture’? One option, of course, is to engage a third party to do it for you, e.g. an external consultant with knowledge in this field. Another is to bring in someone from your quality assurance team, if you are lucky enough to have one, and let them look at the evidence. The third option, assuming you have the time and inclination to do so, is to spend time working through the evidence yourself.

If you do opt for the third option, then one way to approach it is to think about how the CQC inspection team would go about it. In fact, you could aim to produce your own version of a CQC report, broken down into the five domains (Safe, Effective, Caring, Responsive and Well-led). As you will (hopefully) have already collected all the evidence under these headings, i.e. using the KLOEs, then this should be a fairly straightforward exercise. And this is why I suggested earlier that any audit system you use should be capable to rearranging the data in various ways in order to facilitate analysis. The first thing you want to do is to sort the evidence by domain and KLOE. If you are using a half-decent audit system then this will allow you to filter on a particular domain or individual KLOE, so you are not distracted by all the other evidence.

So, for example, you could select all the ‘Safe’ pieces of evidence, and start with them. And as I mentioned earlier, one thing you can look out for is what’s missing; where are the gaps in the evidence for each of the ‘Safe’ KLOEs? Would it be wise to gather some more evidence for a particular KLOE? And looking at the evidence you actually have, what does this tell you about how safe (in this example) the service is? There is no ‘right’ or ‘wrong’ answer to this question, but if you compare what evidence you actually have with the CQC KLOE guidance you will be able to make a reasonable judgement regarding the quality of the evidence.