Shared learning database

Type and Title of Submission


'Quality Standards-the heart of effective pathways'


We are using NICE Quality Standards and localised Map of Medicine pathways in a novel approach to ensure that national and local guidelines are available to clinicians on demand, All relevant guidance is linked to one pathway, with information about local compliance and non-compliance. This will help to ensure that clinicians are always working in line with national and local best practice


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Does the submission relate to the implementation of a specific piece of NICE guidance?


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Description of submission


To improve patient safety and the effectiveness of care processes by providing better access to relevant local information on best practice guidance for clinicians on demand. To understand the organisations level of compliance with NICE Quality Standards for improvement opportunities and to mitigate the impact of commissioning changes. We needed something similar to the NICE Pathways, but with the ability to highlight local compliance or limitations.


To achieve these aims we set ourselves the following objectives: Provide a process to ensure that when a Quality Standard is published, all relevant NICE Guidance, local information such as policies, guidelines, and patient information is mapped to it and can be accessed with ease. To improve patient safety and clinical effectiveness. To measure organisational compliance with the NICE Quality Standard.


Local information, audit results and NICE Guidance were all being held in different systems, which were difficult to access The Trust needed a way to further integrate NICE Quality Standards into clinical practice and management. This approach will help demonstrate to all involved where we are compliant with Quality Standards and where we are not. The link between NICE guidance and the Map of Medicine project became apparent following the publication of the new NICE pathways, which are a useful tool but it was felt that local compliance with guidance needed to be taken into account and easily highlighted, to avoid any deviation from local arrangements.


The Map of Medicine Project Managers and National Guidance Implementation Co-ordinator will work closely with clinicians to develop locally defined pathways based on NICE Quality Standards. Following the publication of a new NICE Quality Standard, and the need for a pathway identified by the National Guidance Implementation Group, the Map of Medicine Project Managers will initiate a working group, including the National Guidance Implementation Co-ordinator and relevant clinicians. Every aspect of the patient journey is looked at in detail, and the information developed into a pathway. At each step of the pathway, the relevant NICE Guidance, Quality Standard and NICE Pathway will be highlighted and linked along with local guidelines, patient information and contact details. There are no additional costs in bringing these two existing work streams together.

Results and evaluation

The Stroke Quality Standard has been the first to be incorporated into a Map of Medicine and is due to be launched in January 2012. This project is in the very early stages so although it shows promise, there is not outcome data yet. However, data such as usage data, auditing number of appropriate referrals etc. will be available for evaluation purposes

Key learning points

Work in a small focussed group before circulating pathways to interested parties. Initially work with one or two clinicians to get the basis of the pathway started and then circulate to a wider audience for comment and discussion. Get the clinicians involved early. A top-down approach is also needed; therefore buy-in at management level is essential to support and enable the process.

View the supporting material

Contact Details

Name:Elaine Berisford
Job Title:National Guidance Implementation Co-ordinator
Organisation:Worcestershire Royal Hospital
Address:Charles Hastings Way
Postcode:WR5 1DD
Phone:01905 763333 x33095


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This page was last updated: 15 December 2011

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.