This is our journey to implement a governance process to implement and monitor NICE guidance. It began in 2011 when we became a community interest company with staff involvement at the heart of everything we do.
With reference to the NICE ‘Into Practice Guide’ (PMG30), our aim was to develop a robust policy and process which ensures that all published NICE guidance is assessed for its relevance to the services First Community provides and, where relevant, is compliant with the recommendations set out in the guidance. Whilst we recognise that top-level commitment to evidence-based practice and continuous quality improvement is essential to implementing NICE guidance and using NICE quality standards, we also ensure that the process is owned by the staff delivering clinical care, not just by senior managers.
Example
Aims and objectives
In 2011, following DH Policy Transforming Community Services ‘right to request’, First Community Health and Care CIC was launched. Becoming a social enterprise, community interest company (CIC) and separating from a large community provider (the second largest in England at that time) gave us the opportunity to review our governance and internal processes with regard to quality improvement, including the monitoring and implementation of NICE guidance, to help deliver our vision to ‘Rejuvenate the wellbeing of our community’, by providing first-rate care, through our first-rate people and offering first-rate value.
With reference to the NICE ‘Into Practice Guide’ (PMG30), our aim was to develop a robust policy and process to ensure all published NICE guidance is assessed for its relevance to the services First Community provides and we are compliant with the relevant recommendations set out in the guidance. Whilst we recognise that top-level commitment to evidence-based practice and continuous quality improvement is essential to implementing NICE guidance and using NICE quality standards, we also wanted to ensure that the process was owned by the staff delivering clinical care, not just by senior managers.
We know that putting NICE guidance into practice and using NICE quality standards to improve quality benefits everyone – people who use health and social care services and their carers, the public, NHS organisations, local authorities, health professionals, public health and social care professionals, and policy makers. By having a clear and comprehensive process to respond effectively to NICE guidance, patients can be assured that the care they receive from First Community is both clinically and cost effective.
The process also supports the Company’s governance framework, providing assurance to the Board, helping First Community to meet the standards set by the Care Quality Commission (CQC) and meeting some of the requirements set out in the NHS Constitution and the Health and Social Care Act 2012 (section 8).
Reasons for implementing your project
Since 2011, First Community has been providing services across the area of East Surrey and parts of West Sussex to a population of 178,000. Surrey is the fifth least deprived county in England with 61% of the population falling into the least deprived quintile. However, there are pockets of significant deprivation across the county.
First Community provides the following core services:
- Community Inpatients Services
- Community Services for Children and Young People
- Community Services for Adults (including end of life care) It is a staff owned social enterprise with an annual turnover of £21million with 450 employees.
The organisation re-invests any financial surplus from activities back into the business and local community. Pre-October 2011, our predecessor community provider organisation had a very high level NICE compliance reporting process, managed by senior managers with little or no feedback to front line staff delivering the services. The process did not allow for clinical services to respond directly to new and updated NICE guidance or contribute to compliance reviews; records of implementation were vague and any action plans to achieve compliance that might have existed were not being monitored. We therefore recognised the need to develop a new robust process for monitoring and implementation of NICE guidance which took account of a smaller organisation with fewer services and a flatter management structure whilst ensuring that all staff were engaged to ensure maximum impact on patient care.
As a new organisation we wanted to build a robust process for monitoring and implementing NICE guidance but recognised the need to triangulate NICE compliance with other quality improvement indicators including clinical audit, medicines management, learning and development, safeguarding, incidents and complaints.
The development of a Patient Safety and Quality Team which brought together the leads for all these areas has facilitated this triangulation. The role of our Clinical Quality and Effectiveness Group (CQ+E) in overseeing the Clinical Governance and CQC requirements of the Organisation and giving assurance to the Integrated Governance Committee and the Board was also key to the success of this venture.
How did you implement the project
Our biggest challenge was ensuring ownership by all our staff. It was important to consult with our staff at every stage to find out what would work best in First Community. We considered the following areas in consultation with our local NICE representative and with staff through the monthly CQ+E meetings:
Reporting framework: in 2013 we developed a NICE Implementation Policy which has subsequently been reviewed in 2015 and 2017. The policy reflects the ethos and culture of First Community, ensuring that all new NICE guidance is reviewed for relevance and compliance in a timely fashion and by the most appropriate person. Alongside the Policy we have developed compliance reporting templates which are regularly reviewed in partnership with staff. The creation of a central database records our compliance with NICE guidance.
Reporting process: this allows for a Company-wide gap analysis and compliance review to be conducted that ensures recommendations are acted upon throughout the Company; a Process Flow Chart for Managing the Dissemination, Implementation and Monitoring of NICE Guidance is included in the Policy; all new and updated guidance is reviewed on a monthly basis through CQ+E where relevant guidance is allocated to a lead; we maintain an action register of outstanding compliance reports and action plans, reported through our monthly CQ+E.
Communication: new NICE guidance and monitoring of compliance reports and action plans through our NICE Action Register are a standing agenda items at the monthly CQ+E group; any relevant information and actions are cascaded via the clinical leads; new NICE guidance is included in the staff newsletter which is disseminated to all staff.
Training: in February 2013 we invited our NICE Implementation Consultant to co-deliver an introductory workshop about NICE to our senior team and clinical leads. In 2014, the Quality Improvement Facilitators developed bespoke Quality Improvement training for our staff which includes a section on NICE and the process for completing compliance reports; a brief introduction to NICE is included for all staff at induction.
Networking: we maintain close contact with our local NICE implementation lead and presented our journey at the South East Clinical Effectiveness Network in July 2016; our staff are encouraged to present examples of good practice at our annual quality improvement day. Being accessible: our Quality Improvement Facilitators, offer one-to-one support as required.
Key findings
First Community has been rated outstanding by CQC following an inspection of its services in March 2017 putting First Community in the top 2% of health organisations inspected by CQC in England. The report was published on 18 August 2017 and stated that: “First Community had an effective system for ensuring it followed up-to-date NICE guidelines. Every month, managers in the relevant area checked any updated NICE guidelines against existing protocols".
Managers subsequently produced an action plan and addressed any areas of non-compliance.” CQC also reported that First Community’s “organisational culture was open, trusting, caring of the employees and there was a tangible commitment to supporting staff to deliver high quality services.” This culture and the support of senior management including the Chief Executive, the Chief Operating Officer and the Chief Nurse and Director of Clinical Standards, enabled us to develop our policy and processes for NICE implementation with engagement across the organisation.
The NHS staff survey results for First Community in 2016 showed an engagement score of 4.04 compared to 3.79 for NHS Trusts nationally – putting First Community among the best in the UK for engagement. This is reflected in the positive shift we have seen in engagement with the NICE implementation process since 2013. We audited the process in 2013, 2015 and 2017 and found that the percentage of compliance templates returned within the timeframe given, or within one month after this date has steadily increased from 44% in 2013 to 63% in 2015 and 68% in 2017. This excludes TAs relevant to the services we provide, of which 100% are compliant within the statutory 90 day timeframe.
In the 2017 audit we also found that:
- All new NICE guidance was shared via Team Brief on a monthly basis following each CQ+E
- 98% of all published guidance was included in monthly lists for CQ+E and placed on the NICE tracking spread-sheet (we have since reviewed how we record this to ensure that guidance is not missed)
- 100% of relevant documents underwent a gap analysis
- 100% of action plans were implemented within the given timescales
Any recommendations not implemented had a robust rationale and was documented in Board agreement. First Community encourages its staff to celebrate and share good practice through external and internal networks.
Key learning points
We’re really proud of this piece of work because it is now well-embedded. The development of new frameworks and processes takes time and requires commitment at all levels – whilst strong leadership is key, co-design with all staff has been effective and we have consulted with stakeholders at all stages of the process.
Although, initially we were met by a lack of understanding and buy-in, a positive and open culture which facilitates staff engagement and innovation has ensured that we now have a robust process in place which is owned by all our staff.
We have found it helpful to reflect on the success of this project with reference to:
Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what will it take to accelerate progress. Milbank Q 1998;76(4):593–624’.
Direction and policy: Designed organisation and governance – policy (including reporting & action plan templates), monthly reporting at CQ+E.
Align individuals & teams: reporting process via service / clinical leads, standing agenda item at CQ+E and team meetings, included in annual clinical audit plans.
Structure and systems: Lead, communicate, engage – Board sponsor, CQ+E – identify lead for each piece of guidance and report, celebrate compliance with NICE guidance at annual QI Day.
Culture: Focussed on outcomes & benefits – for patients, staff & organisation; focus on the positives – what we are doing well but also identifying gaps and developing SMART action plans. Case for change – moving from a larger to a smaller organisation, new ethos - vision, mission and values.
Technical support: Developed capability and capacity – training (including ½day & 1-day workshops, induction).
Benefits: staff engaged at all levels, NICE guidance is meaningful and makes a difference to patient outcomes.