A framework for using NICE Quality Standards to improve quality

To have a robust method of using NICE quality standards across the trust by; Ensuring staff are aware when a quality standard applies to their area of work so they can understand their performance in relation to it, share good practice and strive to improve if appropriate.
Collecting data routinely against each applicable quality standard, wherever possible embedding the measures into existing systems and so removing the burden on staff to audit where a measure specifies 'local data collection'

To date 39 of the 45 quality standards published are applicable to one or more of the services provided by Lancashire Care Foundation Trust (LCFT). The Trust wished to develop an internal systematic approach for considering and using quality standards (QS).
Until early 2013 the Trust had simply circulated QS to each clinical team for information, along with that months 'batch' of NICE guidelines; however it was becoming clearer that commissioners would want to know how teams performed against them. A considerable number of structure and process measures for the quality statements specify 'local data collection', and the quality team were concerned when the request for data was made that this would put considerable pressure on staff to provide data / audit 'at the drop of a hat'.
A framework for considering and using quality standards was developed internally by the NICE Lead in collaboration with key staff from the Quality Team. Clinical and Professional Leads were consulted on the final draft. The approach was 'tested' on QS24 Nutrition Support in Adults, and once the framework was found to work, approval was gained from the Governance Committee to adopt this approach with every NICE QS.
The framework contains the following key steps:
- Once published, quality standards are circulated to each team and service in the network (along with that months 'batch' of NICE guidelines). Teams are asked to identify whether they are applicable to their service
- An excel review sheet is developed by the NICE Lead; this breaks down every statement in the quality standard by structure, process and outcome measures. It makes it easier to identify which statements are applicable (as they may not all be), if the team believe them to be met and what evidence they have to support that belief.

A worked example: QS34 Self-Harm:
The NICE monthly monitoring process identified that the QS on self-harm was relevant to our specialist services network, which includes prison health, secure mental health and substance misuse services.
Once a guideline or QS is found to be applicable, the NICE Lead asks for an appropriate clinician or manager to be identified to work with her and complete a review of the quality statements in the standard. This is done by phone and the discussion typed up by the NICE Lead.
Due to previous work to implement the two NICE guidelines that underpins this QS (CG16 and CG133) the leads felt their services were meeting the majority of statements, and the 'mapping the metrics' exercise showed there was existing evidence for some of it via e.g. training records and environmental audits. The statements we could not provide evidence for were discussed with the audit team, and in agreement with the networks, included in the 2013/14 clinical audit programme. This information was made available on the TIB so the whole team could see the results of their work and understand areas where they need to make further improvements.
The audit department and networks have been fully engaged and supportive of the need to audit when a quality standard asks for 'local data collection'. However to avoid endless re-audits and duplication of effort, the NICE Lead is looking to integrate many of the quality statements into electronic care records, to affirm a clinical action has led to a statement being met (e.g. information discussed and given / assessment complete). This will involve joint work with the Information Technology department and the NICE Lead will present the case to the Executive Quality Committee seeking their support and commitment.
For details on a worked example of the QS2 on Stroke, please see the supporting material.

The NICE Lead piloted the framework on QS Nutrition in adults and identified that it was difficult to really understand performance unless each statement is broken down by the structure, process and outcome measures. This led to the development of an excel review sheet to use with each quality standard and has been the most single most significant enabler to using QS in the trust. Each review of QS takes an average of 20 minutes over the phone between the NICE Lead and the clinician. As the NICE Lead types up the review and does the metrics mapping, and liaison with the audit team if required, both staff and Managers have engaged and commented this framework is coordinated and 'painless' for them.
Because the QS are quite short in comparison to a guideline, the review is usually completed within six weeks of the quality standard being published. However it was a significant project to review the back catalogue of QS published before this framework was adopted - it took 7 months in total. When we initially audited against statements in QS34 on self-harm it was clear how the units had performed overall, but not clear how each team within that unit had done. For the results against quality standards to be meaningful they really need the data to be broken down to team level. This has resulted in a change to the way the audit team produce data in their audit reports - again teams have commented this is more useful to them.
The NICE Implementation Consultant refers staff in other Trusts to visit and hear about this work, so far we've had 5 visitors from neighbouring Trusts and many more emails. Everyone seems to have left with ideas and it's been helpful for us to get feedback and bounce ideas around. This valuable exchange of learning prompted us to write this up for the NICE shared learning database.

- Review your current NICE / audit / governance processes to see how work on QS standards can be embedded and useful without too much extra effort
- Develop an excel review sheet for each QS, this enables you to have a thorough way of reviewing the statements, it also makes them easier to report on
- Map each statement to existing metrics before asking for it to be included in the audit programme, it means you have to audit less
- Be cautious about assuming a QS will apply, many are specialist team focussed
- Be clear about whose responsibility each statement is in the care pathway. For example, a service user could potentially have their nutrition assessed by 3 different services in 24 hours all trying to evidence against QS on Nutrition support in adults.
- Where data does not exist, it's worth ensuring senior managers are supportive of the request to amend / change clinical systems. Make a presentation to your Executive team and get them on board.
- Many teams are moving towards electronic records, as with the worked stroke example above, this can be valuable opportunity to include ways of routine monitoring against a relevant quality standard.
- A key selling point for us is the phrase 'bringing clarity to quality', finally we have a definition of what a quality service looks like and when a team can demonstrate they are providing a quality service they should wear that badge with pride!