Mersey Care NHS Trust focused on the use of NICE quality standards in its Strategic Framework, objectives and SMART targets during 2013/14; this includes conducting an initial gap analysis followed by a move towards full compliance against the standards. The language used surrounding the work initially included "implementation" and "compliance", It became clear that NICE would intend quality standards to be "aspirational" and to drive "quality improvement" and this led to the initial aims and objectives to be modified.
The trust reviewed all current NICE quality standards between April and June 2013 in order to identify gaps and areas for future development; as well as designing a trust specific approach to describe the required metrics for quality and effective mental health service provision, with a particular focus on physical health care.
Aims and objectives
The objectives of the project were:
1. To complete by June 2013 a comprehensive gap analysis in respect of published NICE quality standards
a. Identify quality standards that are directly relevant to trust core business, partially relevant and/or completely not relevant
b. Identify the quality statements within each standard that are directly relevant to trust core business, partially relevant and/or completely not relevant
c. Develop a work plan and schedule for the required gap analyses
2. To produce a standardised trust template for use during gap analysis
a. Enable a consistent approach to undertake analyses
b. Enable a consistent approach to recognise metrics
c. Maintain a systematic approach when considering all newly published quality standards
3. To report to senior management any identified gaps
a. Agree a reporting framework
b. Agree frequency of reporting
c. Agree appropriate forum and format of reporting
4. To inform senior management of any organisational requirements to reduce identified gaps
a. Identify appropriate and responsible senior managers
b. Identify any subject experts
c. Agree their roles and responsibilities to take forward recommendations
5. To monitor progress made toward reducing any identified gaps
a. Agree all relevant metrics
b. Agree frequency and format of reporting
c. Periodic evaluation of progress made
Reasons for implementing your project
As of 2013 the trust's strategic framework highlighted the need to focus on all quality standards with the view that there should be parity between mental health and physical health provision. The trust developed SMART objectives to ensure that all Quality Standards were utilised. From the outset the trust wanted to gain assurance that it was demonstrating full implementation in relation to all quality standards. However some work was required before this assurance could be sought, that is, a gap analysis of what information was available that the trust could use to understand its position, and what actions might be needed to address any gaps in information.
It was anticipated that the gap analysis would lead to the development of a report and action plans so that there would be full use of quality standards by March 2014.
There are a number of services that the trust provides where service users are cared for over a long period of time, it is essential that effective physical healthcare is accessible. Therefore these service users require access to primary care as well as the care provided by the expert mental health care teams.
The language used surrounding the work initially included "implementation" and "compliance". During that time it became clearer that quality standards were to be "aspirational" and would drive "quality improvement" and this led to the initial aims and objectives to be modified.
How did you implement the project
- Establishment of a project group with appropriate capabilities, knowledge of the trust and NICE expertise.
- Use of a GANT chart to ensure effective project management ¡V this included a clear schedule of events and tasks.
- Development of a standard template document for assessing each quality standard and the associated statements and measures - a key tool to achieve delivery of this work.
- Agreed and actioned a reporting framework.
A number of challenges were identified in performing the gap analyses, these included:
- A differing approach to measurements and outcomes between quality standards as the work programme of NICE evolved.
- The apparent change of perspective NICE took during development of the quality standards; specifically from QS10 onwards.
- Different definition of young people within different quality standards; range from 16 to 19th birthday and dependent on definition used in the clinical guideline that underpinned the quality standard.
- Ability to identify relevant services within the organisation that individual quality standards apply to.
- Competing priorities in the trust and limited resources created pressure to deliver on the original tasks identified in the GANT.
- The need to adapt the original SMART target to reflect NICE¡¦s evolving approach to the development of quality standards.
To tackle the challenges, a number of actions were taken:
- Review of the template document post QS10 to adapt to the change in perspective.
- Maintaining a settled and consistent project group to mitigate against any inconsistencies that may occur.
- Regular contact with NICE to seek points of clarity and to feedback on perceived barriers and obstacles to the project work, including reporting to NICE on the difficulties in identifying the audience and understanding that the variation in service design means that there will always be a number of discrepancies.
- Setting aside time to manage the work, working with staff internally as well as commissioners to understand priorities and select the areas to target.
- Having an open discussion that described the quality standards as being aspirational and to drive quality improvement within the trust to address the original SMART targets and help to engender a collaborative approach across the organisation as well as with commissioners.
The key results included:
- Several quality standards initially considered not to be relevant to the trust were now deemed relevant, although only certain statements were applicable.
- Many of these 'newly' deemed relevant statements could be aligned to trust policy, for example, physical health care.
- Some individual statements were considered too broad for practical application rather than mental health service specific.
- Some measures clearly applied to the whole healthcare system rather than individual organisations; therefore, in order to assess our own progress we were required to look for metrics that were more mental health care specific.
The completed gap analyses were evaluated, summarised and reported through presentation to the trust's Clinical Senate on schedule. A visual aid was developed to illustrate the flow of quality standards along the patient's care pathway to assist reporting. Current developments include:
- An interactive tool that will enable all staff to deliver consistent quality care across the whole organisation.
- A portfolio of Mersey Care Quality Standards (MCQS) which align to the equivalent NICE quality standards.
- Agreed time scales for the development of MCQS and a reporting schedule to Clinical Senate.
- Engagement with subject experts within the trust during Phase Two (set of gap analyses of quality standards published 1 April to 30 September 2013.
- To refocus the work plan of the NICE Expert group to prioritise the trust?s approach to use the NICE quality standards.
Key learning points
- Agreeing suitable resources. Although the project was completed on schedule this was at the risk of other responsibilities being side-lined in order to prioritise this work. There is also a need to engage subject experts at the earliest opportunity as their input is vital to successful outcomes.
- Developing a consistent approach. The template document developed for the project was vital in assisting reliable analyses. The effectiveness of the template needs to be evaluated at regular intervals to encompass the changing stylistic approaches of the NICE quality standards and the need for an organisational systematic approach.
- Reading the fine details. The trust initially dismissed some quality standards as being not applicable to the care delivered; however analyses highlighted that some quality standards contain good practice points, for example, access to appropriate information on physical health care problems, that will enable the trust to drive forward quality care provision not only for the delivery of its core services but also to support services accessed within the wider health economy.
- Engaging in goal setting. This project was led by the trust's strategic framework developed outside of the project group. It became evident early in the project that some of the initial objectives needed revising to ensure successful use of NICE quality standards could be made.
The overall learning point gleaned by the project group is taking the time to analyse the context of each quality standards within your own organisation undoubtedly adds essential value to driving quality of care forward, especially within approaches that look at the robust delivery of care pathways.