No abstract

Objective-To explore and describe the implementation of the Royal College of Nursing's approach to audit-the dynamic standard setting system-within the current context of health care, in particular to focus on how the system has developed since its inception in the 1980s as a method for uniprofessional and multiprofessional audit.Design-Qualitative design with semistructured interviews and field visits. Setting-28 sites throughout the United Kingdom that use the dynamic standard setting system. Subjects-Quality and audit coordinators with a responsibility for implementing the system; clinical staff who practice the system.Main measures-Experiences of the dynamic standard setting system, including reasons for selection, methods of implementation, and observed outcomes. Results-Issues relating to four themes emerged from the data: practical experiences of the system as a method for improving patient care; issues of facilitation and training; strategic issues of implementation; and the use of the system as a method for multiprofessional audit. The development of clinical practice was described as a major benefit of the system and evidence ofimproved patient care was apparent. However, difficulties were experienced in motivating staff and finding time for audit, which in part related to the current format of the system and the level of training and support available for clinical staff. Diverse experiences were reported in the extent to which the system had been integrated at a strategic level of quality improvement and its successful application to multiprofessional clinical audit.Conclusions-The Royal College of Nursing's dynamic standard setting system can successfully be used as a method for clinical audit at both a uniprofessional and multiprofessional level. However, to capitalise on the strengths of the system, several issues need to be considered further. These include modifications to the system itself, as well as a more strategic focus on resources and support for audit, better integration of quality initiatives in health care, and a continuing focus on ways to achieve true multiprofessional collaboration and involvement of patients in clinical audit.

Protocols provide great potential to deliver best practice. However, questions remain about the benefits of protocol-based care.

The paper describes a multiproject practice development programme undertaken over a period of 1 year. The background and development of the programme are outlined, whilst attention is paid to the innovatory nature of the work, particularly the use of inductive, deductive and integrated approaches to both change implementation and project supervision. The programme was monitored throughout using different data sources and the paper uses evaluative material retrospectively to provide answers to organizational and professional difficulties which arose during the course of the programme. The authors conclude that the use of combinations of different models for practice development has potential, but requires careful supervision. They also recommend that those involved in practice development are made fully aware of its local or micropolitics, and develop strategies to deal with change before it occurs, not after it has taken place.

Protocols provide great potential to deliver best practice. However, questions remain about the benefits of protocol-based care.