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Improving quality of care by co-design of regulatory inspection methods

Healthcare and inspectorate organisations working together to co-design better inspection methods to improve healthcare quality and facilitate a culture of improvement

Read comments 10
  • Idea
  • 2018

Meet the team: InspectionCo-designTeam


  • Olive MacLeod, Chief Executive, Regulation and Quality Improvement Authority (RQIA), Northern Ireland
  • Professor Michael Donnelly, Health Services Research Group Lead, Centre of Excellence for Public Health NI, Queen's University Belfast
  • Dr Charlene Treanor, Research Fellow, Centre of Excellence for Public Health NI, Queen's University Belfast
  • Dr Martin Dempster, Health Psychologist and Statistician, School of Psychology, Queen's University Belfast
  • Connie Mitchell, Home Manager, MD Healthcare
  • Ann Keppler, Collegeland Nursing Home Registered Manager

Inspection systems are used to promote healthcare quality improvement and are based on the assumption that externally promoted adherence to evidence-based standards (through inspection or assessment) result in higher quality healthcare. The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland, and encouraging improvements in the quality of those services.

In 2017 RQIA initiated a project to consider the introduction of a new inspection assessment framework. The project team recognised from the outset that the inspection framework should be informed by best available evidence and stakeholder consultation, be feasible, and should facilitate a culture of improvement across inspection areas. Since then our team of inspectorate personnel from RQIA and academics from Queen’s University Belfast has been working together to identify and synthesise all available evidence to inform the design of a new inspection framework.

First we identified the range of components included in inspection systems for health and social care internationally and organised these components under the three categories proposed in Boyne’s (2002) framework, namely:

a)    Director – the standards, targets or goals to which the inspected organisation is expected to adhere

b)    Detector  – the methods by which an organisation is assessed with respect to the Director elements

c)    Effector – the ways by which an inspected organisation might be influenced to initiate improvements within their organisation.

These categories are similar to those proposed by the Health Foundation in their 2006 review of international evidence around regulation and quality improvement in healthcare.

We then conducted a systematic review of evidence for effectiveness of specific components of inspection systems. Consistent with the findings reported in the Health Foundation’s review, we found little rigorous investigation of the impact of external inspection methods on care quality outcomes. However we did find some evidence that specific ‘effector’ components, such as forms of action planning, performance feedback and benchmarking, and report cards might be effective in improving care outcomes in the context of regulatory inspection.

We now want to use this evidence to improve inspection ‘effector’ (e.g. feedback) methods. We will do this by co-designing a new feedback strategy which can be used by inspectorate personnel and care organisations to improve quality of care.

We will use a modified Delphi methodology to involve key stakeholders from UK inspection authorities, healthcare managers and staff, and quality improvement personnel in the co-design of an acceptable, valued, feasible and evidence based model for improvement of care quality through inspection feedback. Delphi panels will be presented with the evidence from our previous review, including examples of strategies such as goal-setting, implementation intention-based action-plans, collaborative improvement plans, academic detailing, and various forms of benchmarking. Panels will discuss and rate the various strategies, including assessments of appropriateness, feasibility and necessity. The panels’ deliberations and decisions will be used to produce at least one inspection feedback strategy, and a logic model to explain how the strategy is expected to result in healthcare quality improvement.  Members of our team have previously used this methodology successfully for the development of healthcare quality indicators.

We believe that by working with service providers and inspectorates in equal partnership, and by sharing ways of working between organisations we can use best available evidence alongside stakeholder experience and expertise to design a feedback strategy which supports quality improvement, is sensitive to contextual barriers and facilitators, and is both acceptable and feasible within the care environment.

Initially we intend to design this new inspection strategy for use within the independent nursing home sector in Northern Ireland. In 2011, the Northern Ireland HSC Safety Forum identified nursing homes as a priority for improvement work, and a multi-agency (IHI modelled) collaborative was established to support quality improvement in the independent nursing home sector, including representation from Public Health Agency, Health & Social Care Board, RQIA, general practitioners, Carers NI, AGENI, Independent Care Homes and HSC Trusts.  Hence there is already an urgency to promote quality improvement in the nursing home sector in Northern Ireland, and a model for agencies to work together towards these aims. We have now expanded our team to include colleagues working in the independent nursing home sector in Northern Ireland, and involved previously in QI collaboratives. Northern Ireland is also embarking on a regional quality improvement drive, including training of healthcare staff in quality improvement tools and techniques, and the formation of several Communities of Practice in key areas. These initiatives reflect the enthusiasm and appetite for quality improvement across the health and social care system in Northern Ireland.

Whilst our feedback strategies will be designed specifically for use within the independent nursing home sector in Northern Ireland, we will be able to use our logic model to help us to adapt the methods for use in other healthcare sectors and locations.

Recent feedback from the Q community and other contacts indicates a need for a broader consensus based agenda for quality improvement work in the context of inspection methods. Hence we will also ask our panel members to produce an agenda for future work in the field.

How you can contribute

  • We would like to hear from colleagues who have experience of feedback methods in all areas of healthcare and across the UK
  • Please contact us if you are interested in joining one of our Delphi panels to co-design a new inspection feedback strategy for nursing homes.
  • We are particularly interested in feedback from key stakeholders, i.e. inspectorate and nursing home personnel. Let us know what you think about the value of this idea. What barriers and facilitators do you foresee?


  1. At the recent IHI/BMJ Quality Forum there was a session exploring the role of inspection 'What has inspection ever done for improvement.' There are some interesting comments on the session's twitter feed -qfb3.

  2. Hi Joy. Thanks for supporting us. I've just come across the title of your PhD 'Regulation for Improvement'. We would love to connect with you about this. I will get in touch.

  3. Guest

    Linda Graham 4 years, 2 months ago

    I would be interested in this project.

    1. Thanks for your interest Linda. Google tells me you work in the care home sector in NI. That's great - thanks for getting in touch. I'm speaking about our project at the next meeting of the Independent Sector Nurse Managers meeting at RCN head office next week. Maybe I'll meet you there, and if not, I'll get in touch afterwards.

  4. I love this idea - moving towards a regulatory approach informed by evidence, drawing on behavioural science and especially feedback to influence how organisations and individuals behave. Great to see a focus on care homes - where good quality care could improve quality of life and prevent so many problems an an important scale (falls, infections, unnecessary medication...). This got me thinking - What is the purpose of regulation and inspection? To influence the quality of care generally or to highlight the cases where quality is below an acceptable threshold? Can regulators promote good care as well as highlight poor care?

    1. Thanks Declan. Interestingly, our systematic review identified some inspection initiatives in the US that have used a kind of academic detailing, where 'good practice' representatives have provided supervision to other inspectees who need to improve in specific care areas. Also, the guide produced by Iriss/Care Inspectorate in Scotland have recommended an approach where inspectors identify 2-3 members of staff with great practice who can then mentor other staff. If funded we plan to present these sorts of ideas to stakeholder panels (along with a summary of their supporting evidence) - who will then use this evidence, combined with expertise to develop at least one improvement strategy to be used in the context of inspection.

  5. Guest

    Ethna McFerran 4 years, 2 months ago

    Perhaps the RCN NIRAQ group I’m involved with may be able to help in some way - happy to connect the dots!

    1. Yes - that would be fantastic. The RCN would be a key stakeholder in this project, but I wasn't aware of the RCN NI Research and Quality Group. Many thanks Ethna. I will be in touch soon!

  6. Guest

    Gerry McKenna 4 years, 2 months ago

    This sounds like a very innovative project with potential for real improvement in patient care.  I am very supportive and would be very interested in contributing to the project if possible.

    1. Hi Gerry

      Thanks for your support. Yes - the project is innovative. There has been some related work by other teams, such as the Iriss and Care Inspectorate in Scotland:

      but this will be the first intiative to produce a feedback ('effector') approach which blends best available published evidence and multiple stakeholder expert opinion.

      Let's get in touch off-line to discuss collaboration opportunities.

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