2 Using NICE guidance and related quality standards in provider organisations

2.1 Assess services against NICE guidance or quality standards

NICE guidance

NICE guidance could be defined as a set of systematically developed recommendations, based on the best available evidence, to guide decisions for a particular area of care or health issue. When guidance is published, you might not know if you provide services in the way that NICE recommends and the extent to which you might need to change what you do. The person named as the lead for implementing the piece of guidance should work with colleagues to compare current practice with the recommendations. NICE produces baseline assessment tools to help organisations evaluate whether their local practice is generally in line with NICE guidance recommendations and any actions that are needed to implement them more fully.

NICE quality standards

A NICE quality standard is a concise set of statements designed to drive and measure priority quality improvements. Each NICE quality standard is informed by accredited evidence-based guidance. The Health and Social Care Act (2012) declares that the Secretary of State, in discharging their duty to improve the quality of services, 'must have regard to the quality standards prepared by NICE'. The care system should also have regard to them in planning and delivering services, as part of a general duty to secure continuous improvement in quality.

NICE quality standards can highlight key areas for improvement. An initial assessment should consider for each statement in the quality standard:

  • whether the statement is relevant to the organisation

  • how the current service compares with the statement

  • the source of the evidence to support this

  • what actions or resources would be needed in order to improve the service so that it meets the statement

  • an initial high-level assessment of risk associated with not making these improvements.

Sources of information to support the initial assessment could include:

  • a completed baseline assessment and/or action plan for related guidance

  • new or existing service user feedback

  • complaints or serious untoward incidents (SUIs)

  • audit information (including national audit data)

  • prescribing or activity data

  • views of the service or team

  • process maps and service user experience interviews.

For both guidance and quality standards, there should be local agreement about timelines for completion of initial assessments, but providers should note that their commissioners will also require an indication of any need for improvement in the services they commission.

Tips and resources

The national clinical audits and registries collect data on evidence-based standards and provide NHS trusts with benchmarked reports on performance.

Process mapping is a technique used to identify all the interconnected pathway steps and decisions in a process. Process maps can cover a short and simple sequence of actions by 1 person (such as point-of-care testing) or a complex set of activities involving many different people over time (such as the end-of-life care pathway).

The benefits of mapping the process include:

  • an overview of the complete process from beginning to end, helping staff to understand how complicated the system can be for users

  • enabling staff to see the process from the user's perspective

  • a starting point for the improvement project

  • highlighted opportunities for cost savings and adopting more efficient processes.

You may find this NICE Health Technologies Adoption Programme guide to mapping care pathways helpful, if you would like more information.

This NHS Improvement resource may be helpful if you would like an overview of quality improvement methodology including advice on process mapping and other measurement techniques.

See shared learning examples of:

2.2 Locally prioritised quality improvement

The initial assessment of how a service compares with a quality standard can be helpful to an organisation in a number of ways:

  • An assessment showing that the service provided is in line with (or 'meets') the quality standard, informed by readily available evidence, can provide assurance to the provider organisation's board and commissioners of the service.

  • This kind of positive assessment can also be included in a trust's quality account or an organisation's quality profile.

  • An assessment indicating areas needing quality improvement can help inform local quality improvement programme planning, and can support discussions with commissioners about local quality improvement incentive schemes (including the local commissioning for quality and innovation [CQUIN] scheme in the NHS).

  • The findings can inform the organisation's annual audit programme (by identifying priority areas for audit) and business planning (by informing discussions with commissioners for the next planning round).

  • The assessment can help inform local risk management. This should be in collaboration with the service's commissioners.

The assessment might highlight areas where only small changes are needed to achieve the quality standard. In this case, local quality improvement work could start straightaway. Those involved in the quality improvement project can be confident that their efforts to improve the service so that it meets the quality standard will have a positive impact on the outcomes of people using their services.

There may be local agreement to focus on some of the statements within the quality standard rather than the whole quality standard. If the organisation's board in conjunction with the commissioners decide not to prioritise a topic for improvement at the current time, this should be recorded and a date for review of this decision agreed and noted. Any significant risks associated with the decision should also be recorded on the organisation's risk register.

2.3 Supporting changes in services not currently in line with NICE guidance or quality standards

Convene a project team

If your organisation is not providing services currently in line with NICE guidance and/or there is local agreement that quality improvement work should take place for a service to meet a NICE quality standard, a project team will be needed to take the work forward. This project team might be an existing group already working on quality improvement relating to a service or identified need (for example, a project team leading on work to address a need identified by the local joint strategic needs assessment or, in a small provider organisation, the senior management team). Sometimes it will be necessary to convene a new project team. The team should have clear objectives and agree the project timescales at the start of the project.

Tips and resources

NHS Improving Quality (NHS IQ) gives the following advice on convening a project team:

'Having the right people involved from the beginning with the right expertise will give your project the best chance of sustainable success. If the right people are not involved from the start, it will be much harder to engage and involve these people at a later date.

A project sponsor and involvement from the top of your organisation (member of the executive team or the portfolio holder for the service) is necessary to champion your project and provide strategic direction to the project. This type of involvement also provides support to discuss issues, celebrate achievement and provide access to human resources, finance, analysts, communications, estates and IT teams when required.'

Early questions that the local project team may wish to consider are:

  • Which approach/intervention/technology will be selected and why? (Consider evidence of effectiveness in the local setting, cost effectiveness or cost comparison to alternative options, acceptability to user, patient, clinician or organisation)

  • How will the project be funded?

  • How will the effectiveness of the project be best measured (for example financial impact and effect on clinical, health or wellbeing outcomes)?

  • How will local metrics be identified and measured?

  • Who will be responsible for collecting data?

  • How will any necessary training and education be provided?

  • Are there any obvious challenges and how could these be met?

For larger projects, it may be advisable to have both a core team involved in the day-to-day work of the project and a wider 'stakeholder group' of people whom you can co-opt into the project as appropriate and who need to be kept informed. People in different roles will bring a range of experience, skills and ideas to the team. However, it is essential to involve people who will use the service because they will bring a vital perspective to the project and will often have the best ideas for quality improvement.

If it is likely that major changes will be made to the service that could affect referral pathways, user access or other services external to the organisation, it is important to agree with the service's commissioners how they and partner organisations should be involved.

Tips and resources

Developing an effective communication plan

Experiences that NHS organisations have shared with the NICE Health Technologies Adoption Programme indicate that good communication between all stakeholders is important when implementing a significant change. This includes all those who will be affected by the planned changes. The communication plan should include:

  • how stakeholders will be updated on progress and how frequently this will occur

  • barriers to change and proposed solutions

  • how feedback from stakeholders will be received and answered

  • how successes or useful experiences from the project will be shared.

Identify barriers to change

Changing established behaviour of any kind is difficult. It is particularly challenging in health and social care because of the complex relationships between a wide range of organisations, professionals, services users and carers.

Certain factors may help to foster an environment that is conducive to change. An organisation where there is strong leadership and everyone is focused on improving care and outcomes is likely to develop motivated staff with a desire for continuous improvement. However, barriers to changing established practice may prevent or impede progress in all organisations, whatever the culture. To understand more about barriers to change and how to identify and overcome them, see the NICE guide on how to change practice: understand, identify and overcome barriers to change.

Tips and resources

The NICE guide how to change practice: understand, identify and overcome barriers to change provides practical suggestions based on evidence and experience to help people implement NICE guidance.

The guide is split into 3 parts:

  • Part 1 discusses the types of barrier to change encountered in healthcare.

  • Part 2 offers practical suggestions for how to identify the barriers to change in your organisation.

  • Part 3 shows how to overcome these barriers, and highlights potential levers to help people do this. Real-life examples are provided to illustrate how the methods described have brought about positive changes in a range of situations.

When implementing a change in a care setting, teams may find hurdles during the implementation process. These may relate to individual organisations or particular technologies, or be generally applicable. As the project develops it is important for the project team to highlight issues that arise and to discuss appropriate solutions. Some common problems and suggested solutions are shown in the table below.

Implementation barrier

Solution

Capital costs

Preparing a business case

Choosing appropriate metrics to show cost benefit

Investigating alternative purchase options

Educational needs of staff

Ensure that all staff are available for training sessions

Ensure that staff competency is assessed and maintained

Ensure that training is documented and maintained

Governance and quality assurance

Ensure that internal quality control systems and external quality control assessments are followed

Ensure that appropriate audit arrangements are in place

Ensure that local governance policies have been followed and appropriate personnel involved

Develop and update policies and standard operating procedures

Develop an action plan

Working with the project team, develop an action plan that details the steps needed to put the guidance into practice or improve services so that they meet the quality standard.

When implementing NICE guidance, look at the recommendations that the baseline assessment identified as not currently being carried out, and assign actions to each one.

If you are focusing on a NICE quality standard, you may already have some ideas for change that were recorded when you undertook your initial assessment of how the service compared with the quality statements. Some of these could be turned into actions. Other key sources of ideas for change include:

  • The NICE guidelines on which the quality standard was based.

  • NICE Evidence Search (provides free open access to a unique index of selected and authoritative health and social care evidence-based information).

  • NICE local practice collection has case studies giving practical tips and detailing lessons from implementing NICE guidance and using NICE quality standards to improve services.

  • C4EO works with local areas and services (across the public, private, voluntary and community sectors) to gather examples of excellent local practice which have led to significantly improved outcomes for children, young people and their families.

  • NICE savings and productivity collection gives evidence to support quality and productivity at a local level. The savings and productivity collection does not constitute NICE guidance; however, many examples are supported by NICE guidance and therefore represent practical examples of using guidance.

  • Service user surveys or interviews.

  • Focus groups.

Finally, remember to nominate leads for each action and agree timelines for their completion.

Tips and resources

Spread the responsibility among interested parties to help share the workload.

Give realistic deadlines to motivate people to complete the actions agreed.

Keep a risk register to help manage risks associated with the project. An issues log will help capture what has been learnt from the project and may help with future improvement work.

Develop a culture of evidence-based practice throughout the organisation by publicising resources to support this at every opportunity. Using a range of methods can be effective (for example, a presentation at staff inductions or educational events, newsletter articles, links from your intranet learning pages to NICE's online learning resources, and working with your communications team to develop good news stories).

NICE podcasts can help to increase awareness and knowledge. Opinion leaders (such as those speaking in NICE podcasts) can successfully promote evidence-based practice. They can motivate and inspire health and social care professionals to achieve the best possible care.

Effective patient and service user involvement is a fundamental part of good practice in quality improvement, and can help to ensure that services are planned and delivered with a focus on the interests of patients, service users and carers.

See shared learning examples of:

Assess cost and service impact, and develop a business case

Organisations should assess how much it will cost (or save) to implement an action plan. It might be possible to make some changes using existing resources or to make savings, or free up capacity for other activities.

Your organisation might need to consider capital needs (such as equipment), staffing and training needs, and capacity issues. These will need to be addressed by local delivery and planning processes. You should also consider whether any longer-term savings can be made as a result of early actions to promote health and wellbeing. It is important that organisations have a process for working together with local partners to implement NICE guidance because it can help to even out the costs and savings.

You could use the NICE costing tools to develop a business case. These tools can help you estimate the cost impact of implementing NICE guidance based on your local population.

When appropriate, a resource called 'Support for commissioning' is provided with each NICE quality standard to help you review the potential cost impact and implications.

Tips and resources

When a NICE technology appraisal recommends the use of a drug, treatment or other technology, the NHS must usually provide funding and resources for it within 3 months of the guidance being published. If the Department of Health issues a variation to the 3-month funding direction, details will be available on the NICE website. If there is no NICE technology appraisal guidance on a drug, treatment or other technology, decisions on funding should be made by the commissioner.

A business case is a structured document that presents information and evidence to help decision-making when starting a project. It contains the facts needed to secure support (not always financial) and resources from senior management and commissioners. To find out more about how to build a business case, see the NICE Health Technologies Adoption Programme resource on building a business case.

2.4 Measuring quality improvement

Measurement is essential if we are to show that a change has resulted in an improvement. If a measurement shows that there has been no improvement as a result of the change, we know that we need to adapt the change or try something different.

NICE guidance

Your organisation may choose to conduct an audit of current practice against NICE guidance to measure and, if needed, improve the quality of care you are providing. Re-audit should form part of the audit cycle. NICE has developed audit tools to make the process of auditing practice easier.

Tips and resources

The Healthcare Quality Improvement Partnership (HQIP) provides resources to support local audit for quality improvement, including applying audit methods to social care.

See shared learning examples of:

Quality standards

Each NICE quality standard contains a concise set of quality statements (usually 6–8 statements, up to a maximum of 15 in exceptional circumstances) and associated measures.

The quality statements describe high-priority areas for quality improvement. These statements may address prevention, as well as elements of health and social care, and promote an integrated approach to improving quality.

Quality measures accompany each quality statement and aim to improve the structure, process and outcomes of health and social care. Quality measures are generally specified in the form of a numerator and a denominator that define a proportion (numerator/denominator).

Using NICE quality standard 48 for depression in children and young people as an example, the process measure is:

  • Numerator – the number of people in the denominator who have their health outcomes recorded at the beginning and end of each step in treatment.

  • Denominator – the number of children and young people receiving treatment for depression.

The proportion is the number of children and young people receiving treatment for depression who have their health outcomes recorded at the beginning and end of each step in treatment. The aim of quality improvement work in this area is to increase the proportion. By monitoring the proportion, you can measure the impact of improvement work and ensure that changes are resulting in improvements to care.

At present there are limited health and social care outcome measures that can be used as quality measures. Therefore, the focus of the quality measures is on improving the processes of care that are considered to be linked to health outcomes.

The quality standards also indicate when national quality assured indicators currently exist and measure the quality statement. See also information about the National Library of Assured Indicators developed by the Health and Social Care Information Centre.

Identifying local sources of data

When national data do not exist, you will need to identify local sources of data to enable you to measure the impact of any changes that you make. The measures you use and the methods for collecting the data need to be clear, concise and detailed so that exactly the same information can be collected before and after each change.

NHS Improving Quality advises that improvement projects benefit from current, real-time data to provide a clear understanding of a service and the impact of any small-scale changes. To get this information, you may need to explore the information available from local databases or consider collecting the information manually. The following is an example of a data collection plan, although you could incorporate these actions into your overall project action plan.

Data collection plan

Team:

Completed by:

Date:

Specific question

What data do you require?

What source will be used to get the required information?

Who will collect the data?

How often will the data be collected?

Do you foresee any potential problems?

What is your analysis plan?

Lead

Due date

Source: First steps towards quality improvement: a simple guide to improving services. NHS Improvement, 2011.

Once you have agreed which measures you will use and where your data will come from, you will need to decide how to present the data so that you can see if there have been improvements as a result of the change you have made. Run charts are particularly useful for this because they provide a way of tracking the impact of a change over a period of time, and this helps to maintain the motivation of the improvement project team (the Institute for Healthcare Improvement has a tool you can download). You will also need to establish who else will want to see the data and how often. You might find that your organisation's board and your service commissioners will require periodic updates.

Establishing your baseline

With agreed measures and data sources in place, you can now establish your baseline. Depending on the availability of data to support your initial assessment, this may be the first measure of the current situation – that is, before any quality improvement changes have taken place. This is your starting point.

Tips and resources

NHS Improving Quality gives the following advice:

'Ask yourself what are you trying to achieve? What would tell you that you had achieved it? What would you need to have in place to know you were making progress towards that aim? These questions should help you identify what you need to measure and therefore what data you will need.'

2.5 Deliver the action plan

To enable effective implementation, all partner organisations should sign up to the action plan. The NICE guide on how to change practice: understand, identify and overcome barriers to change can help you.

It is important to consider ways of coordinating work across the health and social care community. Collaboration reduces duplication of effort and ensures a coordinated, standardised response to each piece of guidance locally. If the project crosses numerous organisational boundaries, it is a good idea to identify a lead commissioner for the project because commissioners will have good oversight of the whole care pathway and can take a coordinating role.

Tips and resources

See shared learning examples of:

If you are a doctor, leading an improvement project focused on meeting a NICE quality standard for a service can be an excellent way of showing your engagement in quality improvement activity as part of the revalidation process.

2.6 Evaluate your actions, provide high-level assurance and share your success

Evaluate your actions

As you implement changes according to your action plan, you will need to evaluate how effective they have been. The relevant NICE audit tools can help you review the impact of implementing the guideline and highlight any adjustments needed to ensure sustained improvement.

If you are engaged in a quality improvement project with the aim of achieving the NICE quality standard for a service, it is likely that you will be implementing a series of changes and monitoring them closely for impact. By managing the implementation of change (for example, piloting each change for an agreed period of time) and monitoring the effects (by repeating the measure), you can respond appropriately to any unforeseen consequences as a result of the change or slightly adjust the change so as to achieve a better result. You will also find it is often easier to gain people's cooperation with a 'pilot' because they can be assured that a subsequent permanent change will be positive.

You will need to repeat the associated measure after each change so that you can see whether or not the change has had a positive impact on quality (that is, it has developed the service towards achieving the quality standard). It is also recommended to repeat the measure periodically (perhaps 6-monthly at first and then annually) once the standard has been reached so that you can be confident that the improvements are being sustained.

The change process described is called a PDSA (Plan Do Study Act) cycle. To find out more about this method, see First steps towards quality improvement: a simple guide to improving services (NHS Improvement). If you would like to read about other change models and frameworks, the C4EO change models resource may be of interest.

Provide high-level assurance

It is advisable for the organisation's NICE lead to produce an annual report for assurance at the highest level of the organisation, detailing the use of evidence-based guidance, such as NICE guidance, and how effective the organisation has been at putting it into practice. The report could also include an indication of your position against the NICE quality standards and progress with any quality improvement projects aligned to the quality standards. Your commissioners will also require assurance about the extent to which your services are in line with NICE guidance and showing continuous quality improvement. Establishing an assurance process that meets the needs of your board and your commissioners can save a lot of duplicated effort and avoid ad hoc requests for data.

Share your success

Implementation of NICE guidance and the use of quality standards should also be included in annual quality accounts, or your organisation's quality profile, to assure the organisation and the public that statements of high-quality care are being used to measure the organisation's services and make improvements.

When the process works well, it is important to publicise it. Sharing success and failure helps everyone. Consider a submission to the NICE local practice collection, share your tips with other organisations or contact your local communications team to discuss ways of sharing your success locally through organisations' news bulletins, development days and even the local press.

Tips and resources

See shared learning examples:

Periodically review services already in line with NICE guidance or quality standards

Review services periodically to ensure good practice is maintained. You could prioritise what you review based on local priorities and information from other sources (such as national audits).

You may also want to ensure that good practice is maintained by building it into local policies and guidelines, appraisals and organisation induction plans. It could also be added to business development templates to ensure that guidance is considered when services change.