Patient Service Innovation in Healthcare

Introduction

The Patient Service Innovation (PSI) is referred to inclusion of improved or new health practices, policies, products, systems, technologies and service delivery methods that result to enhance healthcare of service users. This is essential as it creates improvement in patient satisfaction along with enhanced access to additional healthcare services that meet their additional needs and demands (Wass, Vimarlund and Ros, 2019). In the UK, the National Healthcare Services (NHS) is mainly responsible for managing healthcare services in the country. The NHS arranges and provides wide number of services in different healthcare domains to all individuals free of cost since its establishment from 1948 with exemption in few cases. In the current context, the NHS is seen to have taken various steps to raise awareness regarding diabetic foot ulcer among people. This is because diabetic foot ulcer has become an additional adverse health issue for individuals suffering from diabetes, experiencing leg amputation, suffering wounds and others in the UK (NHS, 2019). The current NHS services regarding diagnosis and treatment of diabetic foot ulcer (dfu) are not proactive and do not effectively predict the progress of the healing of the wounds or ulceration. This is evident as existing NHS guidance for management and treatment of dfu mentions that visually the foot ulcer wounds are to be assessed by the doctors to determine the progress of healing (NICE, 2019). In this context, often hindered accuracy of the health professionals are seen which leads them unable to adequately monitor and detect the progressing condition of the dfu, in turn, making patients suffer deteriorated condition (Randall et al. 2019). The NHS supports service improvement because they perceive that in this way innovation in care can be developed which is going to offer enhances service satisfaction to the people as well as reduce errors in care that may be raising the overall cost of certain care activities (NHS, 2020). In the current healthcare scenario for dfu management in the NHS, the health innovation to be made is inclusion of thermal imaging in detecting foot ulcer among diabetic patients. This means that through infrared thermography differences in temperature of the wound area, peri-wound area and reference area is to be detected for diagnosing and detecting healing progress of dfu in diabetic patients (Petrova et al. 2020). In the study by Adam et al. (2018), it is mentioned that manual detection of progress of healing of foot ulcer by viewing the area through the eye of clinician is unable to provide an accurate assessment of the wound. This is because of the inability of the naked eye of health professional to examine the internal healing progress of the tissue in the diabetic foot ulcer (dfu). In this dissertation, the theoretical context and background of the study topic are to be discussed. The aim and objectives along with rationale of the proposed innovation are to be explained. The change management strategy to be used for implementing the proposed innovation is to be discussed. Moreover, the way time management is to be made, leadership theory to be used along with evaluation of the innovation is to be presented. Further, the reflection on the nurse's role for service improvement is also to be discussed.

Theory

The National Health Service (NHS) was founded in the post-war era of 1948 and was first of its kind. The NHS was the first comprehensive health care system that offered free and universal health care at point of delivery (Gilbert, Clarke and Leaver, 2014). The intention behind the creation of the NHS was based on the idea that health care services should be accessible to everyone irrespective of financial status. Further, the essence of this is based on three fundamental principles, that is: it meets the needs of everyone, it is free at the point of delivery and should be based on the clinical needs of the person instead of their ability to pay for the services (Thomas and Rosser, 2018). The accessibility of these services in case of the suggested service improvement would help NHS to deliver use of thermal imaging in detecting progress of healing of diabetic foot ulcer (dfu) of diabetic patients for different social class irrespective of their economic condition to avail the services. This, in turn, would help NHS to create a better health management environment for dfu among all people in the UK. The NHS has taken steps in delivering care for dfu but challenges are being faced by them in accomplishing establishment of quality services regarding the condition. One of the challenges faced by NHS in managing dfu and other health conditions is delayed care to the patients suffering from diabetic foot ulcer out of lack of effective and timely diagnosis. This is evident from the study of Manu et al. (2018) where it is mentioned that diabetic patients across Europe such as the UK are found to be detected in hindered way by the physicians and the nurses. This has result individuals suffering from the disease unable to accessing early care for resolving diabetic foot ulcer (dfu) and led an enhanced life. As commented by Khalifa (2018), hindered detection of health condition is due to lack of following of effective values and principles of care. This is because without following the principles the healthcare professionals show inability to perform their duties of detecting and effectively treating deteriorated health condition. However, the NHS Constitution is being developed to cope with the challenge of not following principles and values in delivering care by the healthcare staffs in the NHS. In the NHS, the lack of presence of adequately trained staffs for managing and caring for wounds among the people has created challenge in delivering successful care to the service users (Buchan et al. 2019). This is because lack of experienced staffs is found to provide hindered wound care to the service users making them suffer deteriorated condition. As commented by Smith-Strøm et al. (2016), lack of wound management experience and education among nurses makes them unable to treat dfu. This is because the use of resources to be made along with the techniques to be used for dfu healing is not adequately received through the services of the inexperienced nurses. In order to resolve the issue, the Recruitment and Selection Policy is being developed by the NHS in which specific standards for selection and recruitment of each staff are mentioned (NHS, 2019). This was effective to cope with the challenge of recruitment of inexperienced staffs for wound care as the professionals understand the standards to be present in recruiting any staffs in the NHS for delivering effective care regarding the healthcare domain.

The Clinical Governance is referred to shared responsibility of healthcare staffs for ensuring all the patients avail best care for coping with their health condition (Veenstra et al. 2017). The clinical governance ensures service improvement by indicating that staffs and management in healthcare are to be adequately educated and trained regarding innovative care process to be delivered to the patients (Specchia et al. 2016). The clinical governance ensures quality improvement by indicating organisation of clinical audits to determine the innovation to be made in the existing services for their high-quality impact on health outcomes of patients. The clinical governance ensures clinical excellence to be established by indicating risk assessment and patient improvement programs to be organised (Van Zwanenberg and Harrison, 2018). As mentioned by Askari et al. (2017), concerning clinical governance, the role of registered nurses is delivering innovative and enhanced care by identifying best practice and innovative interventions to be used in supporting patients. This is because registered nurses in advanced care are considered to be adequately experienced to determine best for the patients in managing their care. In the NHS, the challenge faced to make service improvement and innovation in services is lack of effective leadership and knowledge regarding the way to make changes in current services (NHS, 2020). In this respect, the NHS Leadership model is effective to support and resolve the challenge with creating service improvement and innovation in existing services. This is because the NHS Leadership Model mentions key principles to be followed to ensure effective leading of care practices in the healthcare field for improved health outcome of patients (Leigh et al. 2017). Thus, this model is to be used for establishing the chosen innovation as it would systematically direct the principles to the followed by the leader in the process for the success of the innovation. The NHS Long Term Plan 2019 focuses to assist aged people develop better well-being, improve community services and allow all individuals to have enhanced start for their life. The purpose is to be fulfilled by enhancing care services along with primary medical and community health support for the people (GOV, 2019). In the current service innovation, the NHS Long Term Plan 2019 can be of effective support as it is going to allow healthcare staffs involved with the innovation identify the factors to be considered in making the determined change and the strategies to be implemented for successful accomplishment of the change. In relation to the chosen intervention, the nurses in future require to know the way to use thermograph effectively to detect the progress of healing of diabetic foot ulcer (dfu). This is because differences in temperature achieved through thermograph are keys for diagnosing healing process of dfu by nurses (NHS Leadership, 2019). In future, the nurses to effectively implement chosen intervention have the ability to identify and use current evidence in making evidence-based practice that would offer enhanced quality support to the patients with dfu. Moreover, the nurses in future require effective leadership skills as it leads them work as a team in delivering enhanced care.

Background

As the prevalence of diabetes increase globally so does the complications associated with the disease. These complications include diabetic foot ulcer which results from macrovascular disease, neuropathy and peripheral arterial disease which places the diabetic at much greater risk with their life expectancy being reduced by up 15 years. The implications from diabetic foot disease-causing ulcer and amputations have detrimental effects on human life as well as financial straining on the health service. Data suggest that the NHS allocates more funds towards diabetic food disease than breast, prostate and lung cancer combined. Clinical evidence suggests there is need better patient outcome concerning quality of care. Nonetheless, this doesn't translate into any public, clinical or political consideration (Kerr, 2019). Similarly, evidence suggests that survival after undergoing amputation as result of diabetic foot ulcer (dfu) is only two years for 50% of patients. Additionally, 60% survival rate in 5 years for those who reported ulceration is found. The reports suggest 7000 of the diabetic population undergoes lower limb amputation annually, and are 23 times more likely to have amputations compared to the non-diabetic population. Likewise, in comparison to individuals with other chronic illnesses such chronic obstructive pulmonary disease or those on haemodialysis with renal impairment those with active ulcer and those who have undergone lower limb amputation have a declined quality of life. A diabetic foot ulcer is common and ongoing issue for the diabetic population, further studies indicate that within 3months a quarter of those develop new ulcers after having had one healed. In the period 2014-15, the NHS spent £972m on diabetic foot ulcers and lower limb amputations and two-thirds of the expenditure have been reported to be in primary care, outpatient setting and community. Nonetheless, there is need for improvement in diabetic foot care and data suggests that improvement strategies are required. Furthermore, the National diabetes foot care audit concluded that often patients experience long waits for specialist foot care. The number of people who access these services without referral account for one third, with two-fifths of the rest not being able to access services for two weeks after initial referral. This doesn't align with NICE guidelines in which it is recommended that those with an active foot ulcer in the diabetic population should be referred to the foot care service or foot protection service within 24hours post initial foot examination (Kerr, 2017). Chammas, Hill and M.E (2016) study stipulate a significant discrepancy in the mortality rate in DFU patients compared to non-diabetic patients. The retro prospective study conducted from 1989 to 2000 found 243 DFU patient deaths who attended a diabetic foot clinic in King's college hospital. Of those subjects who attended during that period, there is 121 death in postpartum examination shows the confirmed deaths had ulceration. They concluded that neuropathic diabetic foot ulcer increases the mortality rate and considerable risk of premature death.

Equally the diabetic patient occupies 20% of hospital beds in the UK, of those further one third develop ulcers while in hospital. Which is why putting in place preventive measures have been on the forefront, as delays of in diagnosis and management of diabetic foot ulcer (DFU) have shown to increase mortality and morbidity as well as high incidences of amputations rates (Goulding and Bale, 2019). the International Working Group on the Diabetic Foot (IWGDF) guidelines on the prevention and management of diabetic foot disease (2019) include prevention as one of its core guidelines. Utilising evidence-based strategies to implement to reduce the incidence of dfu and thereby reducing costs, mortality, morbidity and overall quality of life (Van Nettan et al. 2020). Likewise, the prevalence of diabetes is estimated to rise to 50million by 2025 so will the complications. 75% of deaths were attributed to macrovascular complications in the diabetic population. Decisions are clinical practice is informed by utilising the best evidence-based practice available and as such international and national guidelines mostly focus on management and treatment. However, recently the prevention aspect has been put on the forefront such as the IWGDF) highlighted five key elements of prevention strategies. These include ('Identifying of at risk-foot', 'regular inspection and examination of at risk-foot', 'Education Patient, family, and health care provider', 'routine wear of appropriate footwear', and 'treatment of pre-ulcerative signs'. Although the classification of at risk has been identified in the literature, which includes those with diabetes without an active foot ulcer but shows signs of peripheral neuropathy, 'with or without foot deformity' as well as peripheral artery disease or those who have undergone amputations and those with history of foot ulcer. The guideline, therefore, recommends that all diabetic patients should have annual feet checks, and for those at increased risk on more regular basis, nonetheless, there is inadequate robust data concerning screen in terms of the how, when and who (Chapman, 2017)

On study by Mcdonald et al (2017) found that the use of thermal camera could potentially be used in identifying hot regions in diabetic patients with neuropathy that had healthy feet. They hypothesised that diabetic patients with neuropathy and healthy feet without pre-ulcerative region should have thermally symmetric regions on both feet. 32% showed areas of hotspots in the basal region of the foot, and those with thermally symmetric feet accounted for 68% out of 103 participants recruited. Nonetheless, the study didn't include a control group however this indicates such tool could make it possible to be utilized in the assessment of thermal emissivity of the feet. The study also had a cut-off point at 2.2oC in comparison of the two feet in the thermal state. In a pilot study, conducted by Aliahmad and colleagues it is found that they examined the incorporation of thermal imaging as a predictor tool in the healing condition of the diabetic foot ulcer. They established that isothermal maps of thermal images most likely could predict at week four the healing direction of the ulcers (Aliahmad et al., 2019). Similarly, one other study concluded that there is a substantial reduction in at-home infrared foot temperature monitoring when compared to standard care (Lavery et al., 2004). Nonetheless, the use of such non-invasive tools isn’t generally incorporated in clinical practice.

Rationale

What is your chosen innovation?

The use of thermal imaging to diagnose or detect areas of ulceration on the feet of the diabetic patient is the chosen innovation. In the outpatient clinical setting, patient education of daily feet checks is to be done. Initially, all those in this group would learn how to carry out on daily feet checks and this technology is for those of the at-risk of ulceration, history of ulceration or have had a recent amputation.

How will this field-specific innovation address the area of concern (clinical gap) outlined in the Background section?

Currently, most resources and efforts are directed at managing active ulcer. This method is not widely explored in the clinical setting although a large number of diabetic patients have persistent dfu and amputations resulting from related complications. Thermography has the ability to detect temperature changes in the affected area, thus predicting the development of This would bridge the gap of clinical gap in terms of management by incorporating prevention before the ulcer occurs. This would see reduction in the incidence of recurrence of dfu as well as predicting the development of dfu. Furthermore, this innovation has the potential to reduce hospital admission directly linked to diabetic foot disease as well as saving money for the health service. Clinicals can based on evidence make decisions if patients present risk of developing dfu and such employ early screening and thereby avoid further complications and reduce the incidences of those ulcers.

How might patients benefit from this innovation?

The NHS outcomes framework domain 2 in which it concerns with enhancing quality of life for those with long term condition aligns with the innovation, in which patients have possibility to get early screening and detect the development the dfu or recurrence of dfu. Furthermore, it would improve quality of life and health outcomes for the diabetic population. Background studies indicate that if integrated into practice this could potentially have the means to reduce mortality, morbidly and amputation rates. The success of such strategy depends on patients getting education of feet checks and as such carrying out as recommended by the health professional. This depends on their level of risk. Nonetheless, this innovation is targeted at the most at-risk patients and therefore they would have to carry out daily feet. Equally, this requires the engagement of the health service in the outpatient setting to carry out early screening. The success of the innovation can be measured by observing the number of patients who develop ulcers in the hospital if there is reduction. Secondly, measuring how many of those who have healed redevelop a new ulcer? Lastly, the number of amputations long term would also decline. The first trial would run for six months and have the possibility to run over a year.

Barnes (2004) argues that change management theories consist of extensive contradictory and confusing approaches. Kurt Lewin's planned change model is predicated on the assumption that to facilitate change within an organization firstly, the organization needs to create an environment for change in which they unfreeze current state to a neutral state. This allows for process of unlearning of past practice behaviour and the introduction of new behaviour to occur(Wojciechowski et al. 2016). Thus, at this stage nurses are to be made to realise that the current technique for diagnosis and management of diabetic foot ulcer (dfu) is not effective as they do not allow adequate monitoring or enhanced health of patients. The second assumption of this model is that after the original status of work is unfrozen, then the way change is to be implemented is to be determined (Ellis and Abbott, 2018). In the PSI, at this stage, leaders responsible to improve are to mention that way thermography can be included for assessment and diagnosis of dfu for effective care delivery. In this stage, change is to be implemented for project which is to be done with the involvement of the multi-disciplinary team in terms of leadership theory what will be the role of different members of the MDT?. The last stage of Lewin’s model informs that organization is to refreeze the implemented change (Lv and Zhang, 2017). Thus, in the current project, leaders to refreeze the implemented change are to ensure through effective monitoring that health professionals regularly use thermography for diagnosis of diabetic foot ulcer (dfu). The advantage of using Lewin's Change Model is that it includes simple and easier steps to be followed that can be understood and efficiently implemented in creating change within organisation (Al-Shammari and Al-Harbi, 2018). Thus, using the model in this PSI would allow the people responsible for making the change to experience ease in implementing the improvement at work. This is because no complex steps are present to confuse the implication of the change making the leaders ensure effective continuity of the services regarding dfu. However, the limitation of Lewin's change model is that it creates insecurity among the employees to be able to make a new change (Basu, 2017). Thus, using the model in improving services for dfu would create insecurity among the healthcare staffs to ensure whether or not they can effectively abide and successfully implement the change with their skills. As criticised by White (2019), confusion and insecurity among healthcare staffs to make a change lead to create error in services. This is because hindered confidence leads the healthcare staffs unable to use their skills and doubtfully provide care to patients which are not adequate to the quality standards. Thus, the model is not to be used for making the change.

In 1996, Kotter build his change model upon Lewin's model; however, the Kotter model consists of eight steps. Similarly, to Lewin, the first stage is concerned with creating sense of urgency, forming a powerful guiding coalition, create vision, communicate the vision, empower others to act upon the vision, plan and create short-term wins, consolidate improvements and produce still more change and lastly institutionalize new approaches. In the first stage similar to Lewin establishing sense of urgency and articulating rationale for creating change. Inherent in this stage is the element of addressing and identifying potential barriers or crisis. It's important at this stage to provide evidence from external sources to validate the credibility of the change targets. Likewise, change agents should also aim to reduce complacency in that they provide powerful, vivid rationale for change. The second stage involves assembling and backing of important stakeholders and influential organizational leaders. They would be able to inspire, motivate and persuade the support of others to successfully implement change (Calegari, Sibley and Turner, 2015). Critics of this model argue that Kotter based model on personal and research experience as such didn't include any external references. Nonetheless, there is empirical evidence for the applicability of the model in that it's dynamic and is a great starting point with the 8 stages for leaders to follow. Implementation of this model has been found to most likely improve the chance of success. However, the critics also argue that the implementation phase doesn't provide enough explicit direction on the process of implementation (Wenthworth, Behson and Kelley, 2020). Adkar model of change is comprised of 5 stages (Awareness, Desire, Knowledge and Ability). The chosen change model for this PSI is the ADKAR model and it indicates that initially, awareness of the change is to be built (Glegg, Ryce and Brownlee, 2019). In this respect, at first, the nurses and health professionals are to be informed about the hindrance of using visual and touch assessment in diagnosis and early detection of diabetic foot ulcer (dfu) along with monitoring of its healing process. This is because without awareness of the risks or hindrances of present care process the health professionals cannot understand the reason behind the change to be made (Lawrence and Frater, 2017). In the second stage, that is desire it is mentioned that employees are to show positive attitude towards participating and supporting the change (Austin, Chreim and Grudniewicz, 2020). As mentioned by Gonzalez et al. (2017), support towards using specific care is achieved with effective presentation of evidence regarding its positive impact on patients. It indicates that to make healthcare staffs desire of creating the change of introducing thermograph for diabetic foot ulcer (dfu) assessment effective evidential support for its positive action on patient health management is to be informed. This is because it would make healthcare staff understand the essentiality of introducing the change in turn showing desire and support for the PSI. The ADKAR model allows measuring the progress of the change at individual level (Wong et al. 2019). Thus, the model is to be used as it allows the leaders for change to understand extent of achievement and what further is to be done towards creating successful change.

The knowledge stage mentions that gathering information by the staffs to understand the ultimate goal of the change is to be supported so that they have clear concept of the aspects to be achieved through the change (Gordon and Pollack, 2018). In this respect, the leaders making the change are to communicate effective knowledge about the care goals for dfu intended to be achieved and the way they can be accomplished by the staffs so that healthcare professionals and nurses have detailed knowledge of activities to be executed in making the change. The fourth stage is ability which indicates that learning of new skills is to be supported for the employees in making any change (ChePa, Jasin and Bakar, 2018). Thus, training and education for healthcare staffs in using thermography to diagnose dfu is to be provided to make them efficient and able to participate in the change. The reinforcement stage indicates that after making the change is to be made clear to staffs that no turning back to previous activities are allowed (Rajiah and Bhargava, 2017). This is to be ensured through effective monitoring of work activities of healthcare staffs responsible in making the change to ensure they go on implementing the altered services in continuous manner for support health of diabetic patients with dfu. The ADKAR model is focussed on mentioning needs that are to be done for achieving successful outcome of the change which are not mentioned in Kotter's or Lewin's change model (Ileri and Arik, 2018). Thus, this model is to be used as it allows clear understanding of rules to be followed for achieving outcome of the change. The change would take place in the outpatient diabetic foot clinic and change agents include the multidisciplinary diabetic foot team, podiatry, and foot screening team. Together they would select individuals at risk for a trial period to come to the clinic to firstly be screened and then provided with education on how to carry out daily feet check. Based on the screening using thermography can a course of treatment to prevent the ulcer from developing or recurring put in place. At the stage of implementation for reinforcement, external and internal factors would be considered such as resistance and that can be dealt with by including all members in the change steps. Equally, preserving a good relationship between leaders and the employees allows for a sense of security and creates stability (Kachian, Elyasi and Haghani, 2018).The limitation to be faced in executing the change is lack of regular feet checking of the vulnerable patients as they may consider the procedure to be monotonous and inappropriately related to ensure them enhanced health. However, through use of evidence and effective health education, the vulnerable individuals are to realise the importance of the regular checking of their feet and the risk to be faced for their health for avoiding following the procedure.

Leadership theory re: successfully implementing a change

In making the change, transformational leadership is to be used in the project. As mentioned by Choi et al. (2016), transformation leaders collaboratively work with the subordinates and staffs to identify need of the change, developvision for change and execute the change. This leads to create a common cause among the staffs to be considered to make change. The transformation leaders include their subordinates in each step of the change and influence them to share ideas as well as participate in making the change. It leads to make the staffs feel valued which in turn influence them to show enhanced support in accomplishing the change (Olvera et al. 2017). In the PSI, by following transformation leadership, the style of leadership would be inclusion of healthcare staffs from the beginning of the change to determine need of introduction of thermograph for le ulcer diagnosis and share ideas to be used in making the change. In transformation leadership, leaders provide motivation and stimulations to the staffs to inspire their vision and enhance their creativity in accomplishing activity (Fischer, 2016). This is to be accomplished in the current improvement by allowing healthcare staffs to brainstorm ideas and vision to be followed in making the change of using thermograph to be successful for long-term. The success of the change also is predicated on the leader’s own attitudes towards the change. This essential as their attitude influence the employees' attitude towards change. According to the social constructive view is that the employees based on the interactions with others such as the leaders specifically as they are prominent figures in that regard, and therefore base their understanding upon that. Following that premise, this indicates that team leaders are crucial figures in guiding the implementation of the innovation. As such the employees will look at their proximal leader for guidance in the process of own understanding of implementing the change (Farahnak, Ehrhart, Torres and Aarons, 2020). Establishing trust between the employees and the leader affects the willingness of the team members performance and overall commitment to the change. Therefore, gaining the trust of the employees is essential as that when the change brought and only when the employees trust the leadership, they follow them. This, in turn, paves the way for culture that can foster the adaption of change in the organization. A positive culture creates and influences the attitudes and behaviour of the team members, and thereby improves performance. Additionally, this will also motivate employees and creates a sense of belonging for them in the organization (Jun Hao and Yazdanifard, 2015).For this project this would mean they employees must understand why this is necessary and how they are part of improving the quality of life for the service users, whiles reducing morbidity and mortality. The theory of motivating change is predicated on the premise that the organization shapes the right psychological-structural means for the success of large-scale sustained change. This indicates that there must be a personal motivation for action, collective support and frameworks that enable the capacity, capability and opportunity for the action to be implemented. Rather than focusing on once particular change- it focuses on generating long-term cultural improvement in which staff members positive attitudes are sustained. Lastly, when staff see evidence of success, they are more likely to seek further opportunity in the future and aids in the sustainability of the change (Breckenridge et al. 2019).

Time Management

The Time Management is referred to the ability to plan effective use of time so that productivity at work can be established (Holmqvistet al. 2018). The time management helps to set effective deadlines that when appropriately abided by leads the professionals to show efficiency and productivity at work (Parajuli and Doneys, 2017). Thus, the time management in the current project for service improvement is required so that effective professionalism and productivity at work can be ensured to accomplish the change within deadline. The time management leads to avoid unwanted stress by leading individuals to understand how much work is left and the way it can be set according to deadline to accomplish it on time (Forsyth, 2016). Thus, time management in the current PSI is required to reduce unwanted stress to be created among the healthcare staff due to confusion about the way work is to be managed in accomplishing the change. The time management in this project is also required to avoid the inefficient flow of work and lack of focus along with effective procrastination of way to accomplish the change. The PSI for implementing thermography use in diagnosis of diabetic foot ulcer (dfu) in diabetic patients is to be performed within 12 months. A detailed execution of the plan along with deadline is mentioned in the Gantt chart presented in the Appendix. (Refer to Appendix 1)

Evaluation

The evaluation is referred to objective and systematic examination of ongoing activities in a project to determine its relevance, effectiveness, efficiency, sustainability and impact on current and future conditions (Samset and Christensen, 2017). As commented by Nivet al. (2017), quality assurance is management of desired level of quality in a product or service. This is to ensure it meets the needs and demands of the people to ensure their satisfaction. The evaluation in quality assurance is important as it allows assessing and comparing the quality standards of developed services or products with the determined standards (Panneerselvam, 2017). In this PSI, the quality assurance of the changed healthcare services is to be evaluated to determine the extent to which they can meet the predetermined healthcare standards for dfu. The clinical excellence is referred to improvement of effective professional and humanism skills, enhancement of interpersonal skills, developing updated knowledge for delivering the clinical intervention and others (Coppersmith, Sarkar and Chen, 2019). The evaluation of clinical excellence is required to determine the progress of clinical excellence along with innovation and new skills and expertise needed to be included for the health professionals to deliver unhindered and high-quality care to people (Hussain, Ariyachandra and Frolick, 2017). In this PSI, evaluation of clinical excellence is required to determine the additional skills and expertise to be needed by the professionals to successfully accomplish the change. The evaluation of the patient service innovation (PSI) is to be made by using pre and post clinical audits, Likert scale measurement of knowledge, patient's satisfaction survey and staff feedback assessment. The clinical audit is referred to the process of executing systematic review of care based on implemented change and explicit criteria of services (Sivertsen, Graverholt and Espehaug, 2017). The pre and post clinical audit in the mentioned PSI is to be performed by examining the efficiency of provided care for diabetic patients with diabetic foot ulcer (dfu) before and after introduction of thermography in enhancing their health and well-being. The result of post clinical audit after change if indicates higher efficiency of care that ensures enhanced well-being of diabetic patients with dfu in comparison to pre-clinical audit would indicate that the change was successful. This is because it would indicate people are receiving better care after the impaction of the change regarding their dfu. (Refer to Appendix 2)

The Likert scale allows individuals to express regarding the extent of their agreement and disagreement for a particular statement (Linnemannet al. 2016). The Likert scale measurement of knowledge for healthcare staffs is to be performed for evaluating the success of the change after its implementation by assessing their extent of agreement towards the new services. The survey and feedback from the patients regarding their service satisfaction are to be used for evaluating the PSI. This is because positive change creates improved satisfaction of services among patients and shows greater response towards availing it (Brown et al. 2018). Thus, improved feedback and more support of the change from the patients would indicate its success. The positive outcome of the change can be sustained through effective screening and monitoring of working of healthcare staffs and nurses. This is because screening and monitoring would indicate to the extent the change is being followed and assistance in aspects within services required by healthcare staffs to resolve any raised gap to implement the outcome of the change. (Refer to Appendix 3)

Role of nurses in service improvement and innovation

The accomplishment of the PSI lead to learn that in future to challenge any innovation within healthcare service effective evidence through research is to be gathered and presented. This is because evidence of information act as proof to challenge whether or not the innovation is going to earn fruitful results for the patients as well as service providers (Portney, 2020). In order to lead innovation in healthcare, collaborative participation of all healthcare staffs from different level of the organisation is required in future. This is because it would help to implement the innovation at each level ensuring holistic improvement in delivery of care services that provided high-quality service satisfaction to patients (Karam et al. 2018). In order to act as a registered nurse in future, executing the PSI lead to learn that implementing innovation in healthcare requires adequate planning along with time management to ensure it is accomplished within a mentioned time to deliver enhanced care to patients at the earliest. The PSI led to the learning that in future to act as a registered nurse to create innovation selection of well-direct leadership style in relation to the change is essential. This is because effective leadership style helps the leaders to understand the way they are to act in supporting and directing their subordinates to make the change. The PSI led to learn that in future to make innovation as a registered nurse use of multi-disciplinary team is to be made. This is because multi-disciplinary team provides wide number of ideas to be followed from different field of expertise to ensure the determined change is implicated in holistic manner. The PSI has helped for the future registered nurse to understand ways of evaluating innovation to determine its extent of success after implication. The PSI has created enhanced ability to implement innovation in future as registered nurse as it has mentioned the flow of work to be considered in achieving the change. The innovation in healthcare is required to be supported by the nurses for excellent care delivery to patients because it allows taking a systematic approach to optimise safety, transparency and quality of services (Marques-Quinteiroet al. 2019). As mentioned by Patterson and Zibarras (2017), innovation in healthcare helps to resolve gaps in care services as well as replace hindered care service activities. This is because innovation leads health professionals and staffs to implement new skills and techniques in delivering existing care services that have enhanced impact on the health of the patients. Thus, it lead to the learning as future registered nurse that innovation in healthcare is to be established so that effective quality care with less error in services can be provided. This is essential as it would reduce relapse rate of diseases and chances of rehospitalisation for patients proving enhanced care by nurses (Kelly and Young, 2017). The PSI led to the learning that in future while acting as registered nurse to implement innovative care an effective change management model is to be followed. This is because the model with provide structured support and direction of planning the innovation to ensure its success.

Conclusion

The patient service improvement (PSI) proposal is developed to implement thermoregulation services for detecting diabetic foot ulcer (dfu) among diabetic patients. This is because existing visual assessment to determine healing progress and diagnosis of dfu for diabetic patients is seen to create error and wrong result of diagnosis for many individuals. Further, the existing dfu diagnosis way is unable to allow diabetic people develop self-efficacy to determine and screen the progress of their dfu in everyday manner. The challenges faced by NHS to manage diabetic foot ulcer in current scenario is lack of abiding by the core values and principles by the healthcare staffs, hindered commitment of care and others. These are effective tried to be controlled through the NHS Constitution, NHS Five Year Forward Plan and others. In the period 2014-15, the NHS spent £972m on diabetic foot ulcers and lower limb amputations and two-thirds of the expenditure have been reported to be in primary care, outpatient setting and community. Thus, to reduce the cost and ensure better care for diabetic patients with diabetic foot ulcer this PSI is being developed. The ADKAR Change Management model is being followed to implement the PSI as it will help to systematically understand the extent of achievement from the change. The change is going to take place in outpatient diabetic foot ulcer clinics and transformation leadership style is to be used for directing the change. The evaluation of the PSI’s success is to be determined by Likert scale measurement, receiving feedback from patients and healthcare staffs and executing clinical audits. The innovation in healthcare is to be supported by the registered nurses as it allows lowering cost of care, enhance service quality, lower error in care and others. The time management for the PSI is required to be made so that the project is accomplished with 12 months as determined by the leader.

reference

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