Shared learning database

University Hospitals Coventry & Warwickshire
Published date:
January 2014

We have developed, in-house, a bespoke Access database to enable monitoring and assurance of the Trust's status against NICE guidance. The database allows comprehensive and accurate reporting in numerous permutations at the touch of a button. The facilities for improved monitoring of progress and flagging when deadlines and next actions are due have enabled us to demonstrate an increase in compliance of more than 50% since the database was introduced in November 2011.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The overall aim of the project was to improve compliance with NICE guidance with the consequent associated benefits for patients and staff. We wanted clinicians to feel confidence in a systematic process to implementation of the best available evidence on which to base their practice. Additionally, it would help the organisation to meet standards set by the Care Quality Commission and (as was the case at the time the project was planned) the NHS Litigation Authority. The need for an accurate and reliable system for monitoring performance was identified in order to support this.
The objectives of the project were to:
- Provide a simple method of monitoring progress with implementation of each piece of NICE guidance published;
- Develop a robust system of assurance, for both internal and external reporting purposes, that NICE guidance is implemented as appropriate.

Reasons for implementing your project

University Hospitals Coventry and Warwickshire NHS Trust (UHCW) is one of the UK's largest teaching Trusts responsible for managing two major hospitals in Coventry and Warwickshire, which between them serve a population of over a million people. The majority of NICE guidance is applicable to the Trust.

When we took over responsibility for the implementation of NICE guidance in October 2011 there was already a bespoke Access database in use which had been developed in-house several years previously. My first task was to undertake a benchmark to determine compliance rate, whether there were associated UHCW clinical guidelines and whether clinical audits had been undertaken against compliance with the NICE guidance. I soon realised that this was not going to be feasible using the existing database so we trialled a proprietary version instead. This was cumbersome and was unable to generate the reports we needed. We made the decision to create a new database in-house that would meet our monitoring and reporting requirements.

We anticipated that an improved system that had the facility to monitor and report on progress with implementation would contribute towards improved compliance, an assumption which has in fact proved correct with an increase in compliance rate of more than 50%. Additionally we envisaged that a database which stored all the information for each piece of guidance in one place would enable us to work more efficiently and focus our efforts on the areas where additional support was required by the nominated guidance leads, thereby improving compliance yet further.

How did you implement the project

Initially I developed a project initiation document to define the project, to form a firm basis for management and the assessment of overall success and to communicate the proposed plan for approval.

In order to determine what should be recorded in the database, in the first instance we identified the information that would be required in order to monitor progress with implementation of guidance and to meet the assurance needs of the Trust. These have ranged from assurance reports to the Patient Safety Committee and NICE Implementation Group, reports identifying new guidance published by NICE for the month, Specialty-Group specific reports which are utilised for performance monitoring and various ad hoc reports. Considerable effort has been taken in the design of the database to ensure that it is easy to use and only includes information which is required for monitoring and assurance in order to avoid unnecessary data input and storage. Development has been an iterative process, with functions being added and amended as the need for them has become apparent. In fact, the database as it is now is almost unrecognisable from the original version.

We are currently in the process of revising the policy which supports NICE implementation and including within that the definitions of compliance for each type of guidance and an explanation of each of the classifications used on the database. This will help to ensure that clinicians derive maximum benefit from the Specialty Group-specific compliance reports which we provide on a monthly basis and are clear as to the requirements for implementation.

The only costs associated with the project related to the human resources required to define and develop the database. Since the use of the database improves efficiency these costs should be recouped in saved hours over time. Additionally there are of course the longer term savings associated with offering evidence-based and cost-effective practice to patients.

Key findings

The main result has been a significant improvement in compliance with NICE recommendations which has been achieved due to the ease with which we can now monitor progress and provide reports. The increase of more than 50% far exceeds our original expectations and it is anticipated that this will increase yet further as the database has been refined and an escalation policy introduced.

Functions which increase efficiency
- Hyperlinks to each piece of guidance on the NICE website and the completed baseline assessments to facilitate navigation to all the relevant detail;
- Summary of the guidance to avoid the potential for misinterpretation if the title of the guidance alone is recorded;
- TAs identified as recommended, not recommended or terminated to avoid confusion as to the requirements;
- The main specialty to which the guidance relates to enable specialty-specific reporting on compliance;
- A free-text log of progress with implementation to avoid the need to refer to individual emails to determine status;
- Cross-references to associated Trust guidelines and clinical audits to facilitate provision of evidence of compliance;
- The majority of the fields are completed via selection from a drop-down list;
- Cross-reference to guidance on classification of implementation status and the escalation policy to ensure accurate recording.

Functions which improve monitoring and reporting
- Ability to monitor IPGs which are not currently practiced but where there is the intention to do so in the future;
- Identification of Clinical Director and Guidance Lead to facilitate follow-up and escalation of non-compliance;
- Record of when 'next action due' to avoid non-compliant guidance being forgotten;
- Record of rationale for partial / non-compliance to ensure effective reporting;
- Calculates time from publication to implementation which enables reporting on compliance with Technology Appraisals within the requisite 90 days;
- Generates compliance monitoring reports to suit the requirements of the target audiences.

Key learning points

I realise now that the whole development process would have been more laborious if we had to rely on support from the Trust's IT team, although initially this seemed a disadvantage. Having a team member who is skilled in Access database development brought many benefits because it has meant that she has been able to make refinements as the need arises. Since clinical systems take priority over non-clinical database development work it would have been unlikely that the IT team would have been in a position to offer this level of support. It is only when working with the implementation of NICE guidance on a daily basis that one can appreciate the intricacies that are required from a monitoring and reporting system. These would have been difficult to relay to someone who is not au fait with the process and this possibly explains why the existing systems being marketed do not fulfil the necessary specification.

I would recommend that teams that don't have the luxury of a member who is conversant with complex database development might benefit from working with a rudimentary excel spreadsheet in the first instance (or whatever is the existing monitoring format). It would then be possible to log the requirements on an ongoing basis until such a time as you are in a position to feel confident that you have incorporated all the elements that you are going to want in a final version. If you are going to have to rely on development support but this can't be offered by your IT service, one option might be to approach a local university or college for assistance. IT students are often looking for projects as part of their course work and might be interested in undertaking the work for you, either for a nominal fee or at no cost. Alternatively, we might be able to help you. It might be prudent to get someone trained on the basics of Access (or whatever programme you choose.

Contact details

Joanne Kinborough Mata
Quality & Effectiveness Manager
University Hospitals Coventry & Warwickshire

Secondary care
Is the example industry-sponsored in any way?