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Practical guidance on undertaking a service evaluation

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Practical guidance on undertaking a service evaluation

Practical guidance on undertaking
a service evaluation
Moule P et al (2016) Practical guidance on undertaking a service evaluation. Nursing Standard. 30, 45, 46-51.
Date of submission: 14 September 2015; date of acceptance: 17 December 2015. doi: 10.7748/ns.2016.e10277
Pam Moule
Professor of health
services research (service
evaluation), Faculty of Health
and Life Sciences, University
of West of England.
Julie Armoogum
Senior lecturer, Faculty
of Health and Life
Sciences, University of
West of England.
Emily Dodd
Clinical trials co-ordinator,
Faculty of Health and Life
Sciences, University of
West of England.
Anne-Laure Donskoy
Research partner and
survivor researcher,
Faculty of Health and Life
Sciences, University of
West of England.
Emma Douglass
Senior lecturer, Faculty of
Health and Life Sciences,
University of West of
England.
Julie Taylor
Senior lecturer, Faculty of
Health and Life Sciences,
University of West of
England.
Pat Turton
Senior lecturer, Faculty of
Health and Life Sciences,
University of West of
England
Abstract
This article describes the basic principles of evaluation, focusing on the evaluation of healthcare
services. It emphasises the importance of evaluation in the current healthcare environment and
the requirement for nurses to understand the essential principles of evaluation. Evaluation is
defined in contrast to audit and research, and the main theoretical approaches to evaluation
are outlined, providing insights into the different types of evaluation that may be undertaken.
The essential features of preparing for an evaluation are considered, and guidance provided
on working ethically in the NHS. It is important to involve patients and the public in evaluation
activity, offering essential guidance and principles of best practice. The authors discuss the main
challenges of undertaking evaluations and offer recommendations to address these, drawing on
their experience as evaluators.
Keywords
evaluation, evaluation methods, healthcare evaluation, service evaluation, patient
involvement, public involvement
EVALUATION seeks to answer questions
about how well an intervention, practice
or policy is working and is increasingly
undertaken in healthcare environments
(Clarke 2001). In nursing, evaluation often
focuses on care-delivery systems, where it
can determine the effectiveness of a service
(Moule and Goodman 2014). Nurses are
central to the healthcare workforce, and
may be the focus of an evaluation. They are
also increasingly undertaking evaluations
themselves, which requires them to develop
their understanding of the process. Several
undergraduate and postgraduate courses
include evaluation methods as part of
the curriculum, assessing the student’s
ability to plan and undertake small-scale
evaluations. However, these initiatives
reach a limited number of nurses. A wider
appreciation of the importance of
evaluation in practice is required.
This article outlines what is involved
in evaluation and discuss its relevance to
health care. It considers the importance of
preparation and how to involve patients
and members of the public in evaluation
activities. The authors explore the main
challenges in undertaking evaluations and
suggest ways to overcome these.
The importance of evaluation
Evaluation contributes significantly
to healthcare provision, reflecting the
increasing requirement to determine the
quality and effectiveness of public-funded
services, such as the NHS. The NHS
and third sector healthcare providers are
required to demonstrate that resources are
being used to deliver care and services in
the most effective and efficient way (Health
and Social Care Act 2012). There is
increasing demand for healthcare providers
to ensure they are continuously improving
the delivery of services for patients and
practising in accordance with the best
evidence available (Department of Health
(DH) 2010). This involves using research
and evaluation evidence and guidance from
organisations such as the National Institute
for Health and Care Excellence (NICE)).
nursingstandard.com volume 30 number 45 / 6 July 2016 / 47
The Five Year Forward View (NHS
England et al 2014) proposes that
new models of care delivery should be
developed, which will require evaluation.
It will be important to determine which of
these models are effective, and there should
be a commitment to real-time evaluation as
part of the implementation process (Ham
and Murray 2015).
With increasing pressure on resources
and the requirement to improve services,
there is a rising need to evaluate the
effectiveness and cost-effectiveness of
services (Health and Social Care Act 2012).
This is reflected in the revised approach to
commissioning health services.
The NHS Future Forum: Summary
Report on Proposed Changes to the NHS
(DH 2011) expressed an intention for the
Secretary of State to promote research
as an evidence base for commissioning
healthcare services. This involved creating
a new duty for clinical commissioning
groups (CCGs) to promote research and
a culture of innovation in the NHS.
It is expected that any new service or
intervention will be formally evaluated
to ensure it meets its intended aims and
outcomes and delivers the expected level
and standard of care. Therefore, it is
necessary to evaluate existing services
and current practice as well as new and
innovative approaches to care delivery.
Evaluation
The term ‘evaluation’ is regularly used in
nursing and healthcare. It is often used
interchangeably with the terms ‘research’
and ‘audit’, such that the distinctions
between them may be unclear. It is
important to ascertain what is meant by
evaluation and to understand the differences
between evaluation, research and audit
to avoid confusion. Evaluation, audit and
research all begin with a question, and
each aims to influence future practice. They
all use a systematic approach to collect,
analyse, and interpret data. However,
each approach has a different purpose
and context (Box 1) (Healthcare Quality
Improvement Partnership (HQIP) 2011).
Service evaluations seek to rigorously
review existing care provision, or an
aspect of an existing service, to appraise
how well it is meeting its aims and
objectives (HQIP 2011). They are
designed specifically for the service being
evaluated, so the data they produce
cannot be generalised to other contexts.
Service evaluations can be powerful tools
to determine which parts of a service
are effective and which parts require
improvement, providing an evidence base
for subsequent service improvement plans.
Service evaluations do not derive ‘new’
knowledge and therefore they do not
usually require full ethical approval.
Research studies aim to address a clearly
defined question to derive new knowledge,
which is transferable beyond the scope of
the study (Moule and Goodman 2014).
This is a significant difference between
research and a service evaluation.
While research seeks to extend or
generate new knowledge, audits and
service evaluations seek to answer
questions about how effective a service
is. Therefore, research studies require
full ethical approval, whereas this is
not usually required for audits and
service evaluations.
Audits measure an aspect of practice
against a recognised standard (HQIP
2011). They aim to ascertain if current
practice meets best practice standards,
so that actions can be taken to improve
practice. Audits are usually identified in an
organisation’s clinical audit plan as part of
clinical governance and quality monitoring
mechanisms. They require effective clinical
governance and should be a routine part
of a nurse’s clinical practice, but they do
not require full ethical approval.
Correspondence
pam.moule@uwe.ac.uk
Conflict of interest
None declared.
Review
All articles are subject to
external double-blind peer
review and checked for
plagiarism using automated
software.
Revalidation
Prepare for revalidation:
read this CPD article, answer
the questionnaire and write
a reflective account: rcni.
com/revalidation.
Online
For related articles visit the
archive and search using
the keywords.
To write a CPD article
please email gwen.clarke@
rcni.com. Guidelines on
writing for publication are
available at: journals.rcni.
com/r/author-guidelines
Box 1. Distinction between service evaluation,
research and audit
Service evaluation
» Measures an existing service without reference to a standard, and seeks to
assess how well a service is meeting its aims and objectives.
Research
» Aims to extend or generate new knowledge, which is transferable beyond
the scope of the study.
Audit
» Measures existing practice against a pre-determined standard.
(Healthcare Quality Improvement Partnership 2011)
48 / 6 July 2016 / volume 30 number 45 nursingstandard.com
evidence & practice / quality assurance
Service evaluation
Service evaluation is undertaken to benefit
service users, staff and the organisation
by systematically reviewing the existing
service. It involves assessing whether or
not a service delivers what is expected
and establishing the standard the service
achieves (Moule and Goodman 2014).
Theoretical approaches to service
evaluation
The three main theoretical approaches
to service evaluation are:
» Formative evaluation – this appraises
how a service or project can be improved
while it is still being implemented
(Bowling 2014).
» Process evaluation – this reviews the
implementation of a project, evaluating
how activities were accomplished and if
this was as intended in the project plan.
» Impact evaluation – this focuses on the
short-term and long-term outcomes of
a project or service, often in the context
of assessing whether a project or service
is meeting its aims and objectives
(Billings 2000). It is also known as
outcome evaluation.
Evaluation may be summative, occurring
at the end of a project or after a
new service has been designed and
implemented, or formative, occurring
at one or more stages during the
implementation of a project or new service.
The objective of formative evaluation is to
assess if a project is keeping to schedule,
and improving performance if it does not
meet expectations (Bowling 2014).
Many evaluations use a mixed-methods
approach, involving both quantitative and
qualitative data (Moule and Goodman
2014). The precise methodology used
depends on the aims of the service
evaluation and what it is intended to
measure. The evaluator’s role is to combine
multiple strands of evidence to develop a
judgement on the value of the service or
intervention in question.
Preparing for an evaluation
It is important to clarify the aims and
objectives of the assessment before
planning an evaluation (Parry et al 2013).
What do the funders of a service want
the evaluation to tell them? This should
be established by reviewing written
documentation, such as a project proposal
or evaluation proposal, and may be
clarified through conversations with the
main partners involved, for example
funders of the service, service providers and
service users.
An effective understanding of the aims,
objectives and main partners in the project
should inform decisions about what the
evaluation should measure or review,
who should be involved in the evaluation
and what methods and methodologies
should be used.
Service funders and principal partners
may have been involved in developing
guidelines regarding what they would like
the evaluation to ascertain. They may also
suggest who else should be involved in
the evaluation and the methods that could
be used. Partners who have been engaged
in developing a plan for the evaluation
are more likely to be supportive of the
evaluation team, for example helping
with access to sites and recruitment of
participants. The evaluation team may
suggest subtle changes to a proposed
evaluation plan, which should be discussed
and explained at an early stage of the
process. Some useful questions to consider
when preparing to undertake an evaluation
are provided in Box 2.
NHS Research and Development
Forum (2006) guidance can help to
determine the nature of a proposed
Box 2. Useful questions for undertaking an evaluation
» Is everyone clear about the aims and objectives of the evaluation?
» Who are the main partners and has the team made contact with them?
» What is the role of patients and the public?
» What are the best methods to collect the data required to answer the
questions?
» Is the proposal achievable in the timescale available?
» Is the proposal achievable in the budget available?
» Are necessary approvals in place before starting this evaluation?
» Is it clear how to access the information or data required?
» Are the gatekeepers (staff who will facilitate access to an evaluation site
or data) known? Are they able to recruit participants or promote the
evaluation?
» What contingencies are in place if things do not go according to plan?
» What outputs are expected from the evaluation?
nursingstandard.com
For related CPD articles visit
evidenceandpractice.nursingstandard.com
volume 30 number 45 / 6 July 2016 / 49
study and whether it constitutes clinical
audit, research or service evaluation.
NHS ethical approval processes are not
usually required for service evaluations.
However, it is important to inform the
research and development office at any
NHS organisation taking part in a service
evaluation, especially if participants
will be recruited from there. These
participants may be service users, carers or
staff members.
The research and development office
may require the evaluation to be registered.
If so, this should be started as early as
possible so as not to delay the evaluation
process. The research and development
office is also a useful resource for advice
and support and can offer guidance in
various governance areas, for example
maintaining project records.
The time it takes to complete a service
evaluation ranges from a few months to
2 years. Planning and time management
is essential, especially in shorter projects,
where the ability to ‘hit the ground
running’ is particularly important.
A clear schedule or project plan should
delegate tasks to members of the team
and set deadlines for their completion.
Regular review of the schedule should
ensure the project is running on time
and within budget. A risk register can be
used alongside the project plan, which
includes the risks or barriers to meeting
the aims and objectives. It also includes the
contingency plans that can be put in place
to minimise these risks and barriers. The
project team can try to establish solutions
as early as possible to avoid delays and
overcome potential issues. These plans
can be discussed with the project funders
if issues arise.
The evaluation team should identify the
main individuals who can provide access
to potential data or participants early in
the project and establish relationships
with them. A personal approach is often
effective, for example members of the
evaluation team may consider attending
team meetings or service user meetings to
promote the project. Providing a ‘face’ for
the project team can improve participant
recruitment and gain local support.
Involving members of the public
The involvement of patients and members
of the public in health and social care
research is a healthcare policy requirement
(Health Research Authority 2013, National
Institute for Health Research 2014).
Patient and public involvement is context
specific, so their activities may vary from
project to project. This may be influenced
by financial considerations such as ‘is
there a patient and public involvement
budget?’ Other considerations include
‘what do you want to involve patients
and members of the public for?’ and ‘are
you looking to involve them at all stages
of the project, from deciding the research
question through to the dissemination of
the findings, or are you looking to involve
people in an advisory capacity?’ Providing
clear information about the purpose of
their involvement will help to clearly define
the practicalities of their inclusion.
The same core principles that apply
to patient and public involvement in
research also apply to evaluation activities.
Guidelines and supporting documentation
for this are widely available (INVOLVE
2009). Patient and public involvement
members should be approached as early
as possible in the project to enable them
to work as part of the evaluation team.
They may be involved in reflecting on their
personal experiences of the service under
evaluation. Service users may be involved
at different stages of the process. They
often advise on the evaluation design,
recruitment and data collection. Some
participants may be keen to be involved
in all aspects of the study, including
assistance with data collection and
analysis, writing reports, and dissemination
activities, such as presenting the findings
and co-authoring articles.
It is good practice to include at least two
patient and public involvement members
from the beginning of the project, or as
early as possible (Pollard et al 2015). This
provides an opportunity for support and
shared working between patient and public
involvement members. It is recommended
that there is a named person in the
evaluation team who is responsible for
overseeing all aspects of patient and public
FURTHER RESOURCES
The INVOLVE website
can be accessed at
www.invo.org.uk
The National Institute
for Health and Care
Excellence website
can be accessed at
www.nice.org.uk
50 / 6 July 2016 / volume 30 number 45 nursingstandard.com
evidence & practice / quality assurance
involvement, to improve this aspect of an
evaluation (INVOLVE 2009). The role of
this person may range from acting as a
link between the project and patient and
public involvement members to managing
the practicalities of their involvement, for
example, payments to patient and public
involvement members and Disclosure and
Barring Service (DBS) checks.
The University of the West of England,
Bristol developed Public Involvement
in Research: Guidelines for Good
Practice (University of the West of
England 2011), which have since been
evaluated (Pollard et al 2015). These
guidelines emphasise the challenges of
achieving patient and public involvement
in research and evaluation and offer
practical solutions. Involving patients
and members of the public in evaluations
requires care, time, clarity of purpose and
flexibility; it also requires effective logistics,
communication skills and planning. For
example, there is the challenge of logistical
realities when involving members of the
public who have specific involvement needs
because of impairments or disabilities.
Challenges in evaluation
Unrealistic expectations
Funders and organisations commissioning
an evaluation may sometimes expect more
than can be delivered. Evaluators should
be clear about the aims and objectives of
the evaluation and what can and cannot
be achieved (Parry et al 2013). The project
aims and objectives should be referred
to regularly as it develops, to ensure the
evaluation is continuing to deliver what
was intended.
Staff and members of the public involved
in evaluations may also have expectations,
either as participants or members of the
evaluation team. The evaluation team
should make clear to participants what
they are committing to and what will
be expected of them. There may also be
tensions between practice requirements
and time for the evaluation, particularly
when clinical staff are involved. It is
important that managers understand the
time commitments involved and have
agreed to support staff release and staff
contributions to the evaluation. This
requires negotiation and agreement of
resources early in the evaluation, and
may include a budget commitment in the
evaluation project to fund additional staff
time.
Relationships
There can be challenges in identifying
and recruiting the essential partners for
an evaluation. Failing to identify all
partners may lead to some people being
excluded. This may affect the evaluation
and hinder the evaluation process, so
that there may be reduced commitment
to recruitment and data collection. If the
evaluation is undertaken from a distance,
it can be difficult to determine the local
sensitivities, expectations or experiences
of the partners involved or to assess their
support for the evaluation.
It is important to employ strategies to
engage partners and participants. This can
be done by identifying local advocates who
can promote the project, by using methods
to support recruitment such as posters or
media advertising, or ensuring the project
funders are able to help with recruitment.
Evaluations are often long-term
projects and there may be changes in the
organisation or staff involved during the
evaluation. A change in personnel may
result in essential contacts being replaced
by others. New staff may have different
working styles, less engagement with the
evaluation or different expectations and
interpretations of what the evaluation is
seeking to achieve. This can be particularly
challenging if written communication does
not reflect what has been verbally agreed.
Thus, it is important that the evaluation
team acknowledge and respond to any
changes to the project aims and objectives.
This may include informing new staff
of the project. Alternatively, this may
require alterations to the project aims or
proposed plan, if the project funders or
commissioners of the evaluation change.
Cultural environment
By definition, evaluation takes place when
a change in practice has been made or
suggested (Pollard et al 2015). Staff may

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