Do Hospital Inspections Improve Quality of Care?

Nicky Broyd

April 12, 2019

A University of York study questions the effectiveness of Care Quality Commission (CQC) hospital inspections and calls for a rethink. 

Writing in the Journal of Health Services Research and Policy the researchers said that over 2 decades inspection regimes have become more complex and burdensome at a high cost to the NHS.

They argue inspections that take up fewer resources and focus on internal reviews towards improvements may be more effective.

However, the CQC disputed the findings and questioned the study methodology.

Better Performance Before Inspections

The team analysed data on adverse events routinely reported by all acute trusts in England from April 2012 to June 2016. Interruption points during the study period were CQC inspections. Five trusts were excluded due to missing data. The study period also included changes in inspection methods at 66 of the Trusts.

Key outcomes were falls causing harm and pressure ulcers used as proxies for the quality of nursing care.

Rates of pressure ulcers and falls with harm were found to be improving before CQC inspections.

In post inspection periods improvement trends in either measure were slower.

The authors write: "Our results suggest that the expectation of future inspection(s) may influence acute trust behaviour, but has not led to positive lasting change."

They conclude: "If increasing regulation has not delivered improvement, then it may be time to consider reducing the administrative burden of inspection and regulation and monitoring the costs and effects of doing so."

Staff Pressures

In a news release lead author Ana Cristina Castro, research fellow from the University of York's Department of Health Sciences, said: "Since 2013, CQC inspection teams regularly visit NHS Trusts over several days, with more than 150 inspection measures, and rate them against legally enforceable standards of care.

"This creates a significant pressure on staff before and during the inspection period, and also significant costs, not just of the CQC inspectors but also the NHS staff who are diverted from other activities.

"We calculated that one CQC inspection costs a hospital between £169,000 and £420,000 depending on its size and the preparatory activities performed.

"We suggest that a less resource-intensive approach should be considered so that all staff can focus appropriately on longer-term improvements."

Professor of Health Services Research and Policy at the university, Trevor Sheldon, and author of an accompanying editorial, added: "Research shows us that questionable effectiveness and high burden of health service inspection is not only true of the NHS, but also of health care systems internationally.

"The research shows that inspection regimes, like CQC, need to rethink their approach; health service and government leaders need to focus less on the methods of monitoring and more on promoting and supporting the many efforts that already exist nationally and within trusts to improve quality.

"The question that remains is, what is the right dose of oversight that will help improve quality of care, without adding to an already overburdened staff workload?"

'Crude Measure, Overly Simplistic View'

In an emailed statement a CQC spokesperson said: "To use rates of reported falls and pressure ulcers in isolation to determine CQC’s impact is a crude measure and presents an overly simplistic view that is not borne out in the quality and safety improvements we have seen through our hospital inspections. It also fails to recognise that increased reporting of such incidents may be a result of an improved risk management and a stronger learning culture.

"This research is based on [a] limited sample of inspections undertaken over 5 years ago at the start of our comprehensive inspection programme - which initially focused on high risk trusts such as those placed into special measures following a review by Sir Bruce Keogh.

"Since that time we have refined and strengthened our inspection methodology, moving towards a more intelligence driven approach. We continue to see the positive impact of regulation in driving improvements in care, with many hospitals able to improve their rating on re-inspection. As a result, patients across England are receiving better and safer care."

Responding to the CQC's statement via Medscape comments Ana Cristina Castro said: "The indicators that we chose, falls with harm and pressure ulcers, are of course partial, but they are important nursing-sensitive measures reflecting patient safety. These two indicators in isolation of course do not reflect the overall impact of CQC and its potential to influence culture – we analysed the effect solely of the inspections. Our research is consistent with international literature on inspection and accreditation, and with recent UK findings from other research groups in the UK (The King's Fund and University of Manchester).

"CQC argues that we looked at inspections at the beginning of their comprehensive inspection programme, when the focus was on hospitals at higher risk of failing. This is true, but hospitals with worse performance should perhaps be more likely to show an improvement after an inspection. We welcome the move towards a more intelligence-driven approach and look forward to further evaluations of the refined inspection regime in future years." 

Journal of Health Services Research & Policy (HSR). The effect of external inspections on safety in acute hospitals in the National Health Service in England: A controlled interrupted time-series analysis. Study paper.

Editor's Note: 15th April 2019 - This article was updated after publication to include further comment from the study's lead author.

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