Willett Jo, Barclay Michelle, Mukoro Felix, Sweeney Grace
Improvement Science and Capability Building, NHS England and NHS Improvement, Cheylesmore House, Quinton Road, Coventry CV1 2WT, UK.
Int J Qual Health Care. 2021 Jul 3;33(3). doi: 10.1093/intqhc/mzab090.
In the National Health Service (NHS) in England, traditional approaches to evidencing impact and value have an important role to play but are unlikely to demonstrate the full value of national quality improvement programmes and large-scale change initiatives in health and care. This type of work almost always takes place in complex and complicated settings, in that it involves multiple players, numerous interventions and a host of other confounding factors. Improvement work is usually emergent, with cause and effect only understood in hindsight; challenges around contribution and attribution can lead the key players to question how they can be certain that the described or observed changes are due to their intervention and would not have happened without them. In this complex environment, there is a risk of oversimplifying the observed impact and focusing instead on those things that are easier to measure, missing that which is important but more difficult to evidence.
Between 2016 and 2019, an action-orientated approach, drawing on realist and development evaluation approaches, was taken to designing and testing the Impact Framework. First, we undertook a pragmatic review of tools and approaches used by others to capture and demonstrate their impact both within and outside the health and care environment. Following the identification and review of these tools and approaches, and in consultation with national improvement teams in England about their evaluation challenges and aspirations, we developed a set of underpinning principles to inform the design and build of the framework. The principles were informed and finessed following conversations with improvement teams and programme leads in NHS England with respect to the challenges that they were facing and their aspirations in terms of demonstrating their impact and learning as they worked.
The 'Impact Framework' described in this article offers a practical approach to capturing the impact of improvement work at any scale, taking account of unintended outcomes, considering attribution and contribution, and using a narrative approach to uncover the difference made by improvement initiatives in rich detail. In this article, we describe how the Impact Framework has been used with one of NHS England's national programmes, Time for Care, which was delivered between 2016 and 2020.
The Impact Framework continues to be used, developed and further tested by national improvement programmes being delivered by NHS England and NHS Improvement and is updated regularly. The framework has been developed to be accessible to frontline teams and is supported by a set of resources to help improvement teams and individuals to use by themselves (https://www.england.nhs.uk/sustainableimprovement/impact-framework/).
在英格兰国民医疗服务体系（NHS）中，传统的证明影响和价值的方法发挥着重要作用，但不太可能充分展现国家质量改进计划以及卫生与护理领域大规模变革举措的全部价值。这类工作几乎总是在复杂的环境中开展，因为它涉及多个参与者、众多干预措施以及一系列其他混杂因素。改进工作通常是渐进式的，因果关系往往只能事后理解；围绕贡献和归因的挑战可能导致关键参与者质疑他们如何能够确定所描述或观察到的变化是由于他们的干预，并且没有这些干预就不会发生。在这种复杂的环境中，存在将观察到的影响过度简化的风险，转而关注那些更易于衡量的方面，从而忽略了重要但更难证明的方面。
2016年至2019年间，采用了一种以行动为导向的方法，借鉴现实主义和发展评估方法，来设计和测试影响框架。首先，我们对其他人在卫生与护理环境内外用于捕捉和展示其影响的工具和方法进行了务实的审查。在识别和审查这些工具和方法之后，并与英格兰的国家改进团队就其评估挑战和期望进行协商，我们制定了一套指导框架设计和构建的基本原则。在与NHS英格兰地区的改进团队和项目负责人就他们所面临的挑战以及他们在工作中展示其影响和学习的期望进行交谈之后，这些原则得到了完善。
本文所述的“影响框架”提供了一种实用方法，可用于捕捉任何规模改进工作的影响，考虑意外结果，考量归因和贡献，并采用叙述方法详细揭示改进举措所带来的差异。在本文中，我们描述了影响框架如何与NHS英格兰地区的一个国家计划“关爱时刻”（2016年至2020年实施）一起使用。
影响框架继续被NHS英格兰地区和NHS改进部门实施的国家改进计划所使用、开发和进一步测试，并定期更新。该框架的设计便于一线团队使用，并得到了一系列资源的支持，以帮助改进团队和个人自行使用（https://www.england.nhs.uk/sustainableimprovement/impact-framework/）。
