Shared learning database

Type and Title of Submission


Using the Quality Standard for specialist neonatal care to inform local quality improvement work in an acute trust.


How this trust is using a NICE Quality Standard to improve the quality of specialist neonatal care. Emphasis is on promoting an ethos of continuing improvement rather than introducing an additional compliance exercise. This has been achieved by aligning with existing quality improvement projects.

Does the submission relate to the general implementation of all NICE guidance?


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


Full title of NICE guidance:

QS4 - Specialist Neonatal Care

Is the submission industry-sponsored in any way?


Description of submission

Aims and objectives

The Trust aimed to establish and test a standardised review process for identifying the existing programmes of work that aligned with the statements within Quality Standards. The exercise aimed to establish whether the statements were covered by existing measurement arrangements and whether service development actions would be required in order to meet the standard described by the statements. The Specialist Neonatal Care Quality Standard was included within the set forming a pilot of the review process and of the templates designed to facilitate and record the review.


The Neonatal Care service was already involved in a Commissioner-led assessment programme considered relevant to the QS Statements.

The trust's approach to Quality Standards was discussed at our MEAG (Measurement, Effectiveness and Audit Group) which identified and agreed the clinical lead for the work to:

'Review all NICE Quality Standards to identify the alignment with existing guidance implementation and clinical indicator measurement activity and agree who in the Trust should be assigned as lead in taking account of the standard?'


The relevant statements within the Quality Standard were identified for action (Statement 4 of the Neonatal QS was not considered to be within the Unit's direct influence). Reporting timescales from the nominated project lead were set as: 3 months for the initial progress briefing report, 6 months for an interim report detailing measurement and service development needs per statement and 12 months for a full assurance report including summary performance against the measures identified. For the initial briefing, 4 key questions were asked of the QS:
1) Which statements are relevant for our acute service (and which are for others)? 2) Can the statements be adopted as drivers for existing quality improvement programmes/aligned with other accreditation/measurement activity?
3) For which statements is measurement possible/desirable/already happening/required? (and how will data collection and measurement be performed?)
4) By what method will the position against the statements be reviewed and shortcomings identified/resolved?
Preparation of the initial briefing report enabled the capture of key information through discussion with the Clinical Director. This established that the Neonatal Network held considerable influence, and that, with the shift to Specialist Commissioning underway, there was an opportunity to align with a current Unit designation process against criteria drawn from the DH Neonatal toolkit. Further review of each statement with the Clinical Outcomes Lead for SNICU established that benchmarked performance review via the Network Badger dataset could also be used. The development of a local clinical quality dashboard could also be harnessed for monitoring QS performance alongside the existing Network measurement requirements. For this QS, the review identified no specific cost implication as the clinical quality dashboard project was already established and resource for this accounted for within the Governance Support Unit team.

Results and evaluation

Initial briefing identified several opportunities for aligning current improvement work to achieve the quality standard, for example:
- Evidence of nursing competencies, but not all medical competencies, are readily available, so this will be an area for action to improve.
- A new dashboard measure will be created to monitor performance for a senior staff member seeing parents within 24 hrs of admission-also a Badger dataset measure.

We agreed to include new measures on our clinical dashboard (rate of review at age 2 for babies admitted)-identified need for some manual entry.

The outputs of the review were received at the Measurement, Effectiveness and Audit Group for both appraisal of the content and evaluation of the templates. The process successfully enabled the QS to be integrated as a driver for improvement whilst providing assurance of the statements being taken into account in a systematic way by the organisation.

Key learning points

In our experience, the key determinant of success is effective clinical input. In this case the main contact was engaged both with the Network and the clinical effectiveness, audit & measurement agenda.

The central group (MEAG) had a clear role to play in bringing focus to this, and other, quality standards. This helped to make the Quality Standard part of mainstream quality improvement and assurance processes.

Find a governance/measurement-minded lead. Ours was very enthusiastic about the whole concept of clinical outcomes measurement.

Don't turn a Quality Standard into a formal assessment/compliance process-use it as a vehicle to drive and support continuous quality improvement.

Provide short, timely briefing reports. Our Governance Support Unit took on this role and distributed the updates as appropriate.

Contact Details

Name:Lincoln Andrews
Job Title:Compliance Manager
Organisation:Taunton and Somerset NHS Foundation Trust
Address:Musgrove Park Hospital
Postcode:TA1 5DA


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This page was last updated: 31 January 2012

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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.