NICE Guidance and Quality Standard Assurance: A process change to improve effectiveness and efficiency

The aim was to develop a streamlined, robust and meaningful approach to our Trust NICE assurance process across our large clinical division. The Out of Hospitals Division is made up of over 30 different clinical services across acute and community settings covering the vast geographical area of East Sussex. The objective was to create a single, unified approach to the evaluation of NICE guidance and Quality Standards reaching across our uni- and multi-professional services caring for our adult population.

The clinical division was unable to be responsive to the compliance, evaluation and action requirements in relation to NICE guidance and Quality Standards. There was an extensive backlog, response timeframes where consistently breached and the quality of the assurance process was poor.

The challenges within the division were recognised as:

• Multiple professions, diverse range of services and large geographical areas
• Many NICE Guidelines have recommendations that span multiple services, professions and clinical settings that were challenging to achieve compliance evaluations and meaningful compliance assurance and cohesive action plans
• Lack of centralised oversight of compliance status and service/workforce development needs
• Unclear, fragmented and untimely communication processes
• Lack of awareness at a service and clinician level of the NICE assurance process that was required, negotiating the NICE website and the NICE resources and tools that were available to support evaluation
• The existing process was being undertaken by a single individual responsible for responding central to all guidance and quality standards for over 1000 staff, within 9 professional groups across more than 30 services
• No systematic process for the dissemination of guidance and standards across the division.
• No identified ‘NICE responders’
• No lines of accountability
• Reactive to breeching rather than proactively responding in a meaningful manner
• Inefficient and time consuming

It was essential to respond to these challenges and to develop a process that supported the quality assurance evaluation.  Improving compliance, awareness and engagement in the assurance process would lead to service improvements, produce cost benefits and support the Trust aim to be ‘Outstanding by 2020’.

A systematic process was developed and the steps required for successful implementation were identified and actioned, which included:

• A dedicated Governance Officer was appointed within the Division.
• Allocation of a dedicated Clinical Effectiveness Facilitator from within the Trust to the Division.
• Identification of a dedicated core multi-professional team with professional and service level expertise and oversight
• Establishment of a wider network of NICE responders across professions and services within the division
• Education of NICE responders on the NICE products and resources for evaluation and use of the NICE Tools for evaluation, responding and action plan development
• Development of a priority rating system to show levels of compliance and action plan implementation
• Fortnightly 1 hour conference calls with the core team were established to provide timely evaluations of NICE products, triage newly published guidance and quality standards and to follow-up outstanding action plans.

Brief NICE infograms are produced to ensure awareness of relevant recommendations and quality standards to relevant clinicians and service teams. NICE Matters are part of team meetings and governance agendas

When response evaluation is beyond the expertise of the core team, invitations are sent to relevant service or professional NICE responders to evaluate specific guidance. All contacts and responses are logged and followed up proactively, with action plan development supported and collaborative with service management.

The process re-design was continually evaluated to refine macro and micro elements to the process, combined with feedback and input from the wider responder group to develop the final process.

The NICE assurance system re-design has moved our Clinical Division from an extensive target breeches and poor levels of 65% compliance in responding to clinical guidance evaluations and 36% compliance in quality standard evaluations to consistently achieving 100 % of responses within the 3 month timeframe target. The re-design has supported the development and completion of more clinically and operationally meaningful and collaborative recommendation evaluations, action plans and service changes. At a central level, the Clinical Divisional has moved from a poor to outstanding clinical effectiveness position.

The implementation has had a direct impact on quality improvements across our many multiple services which now have the use of NICE resources and tools for supporting evaluation and impacts embedded in clinical and operational processes.

There was an accompanying 40% cost saving by utilising a clinical effectiveness facilitator rather than a senior clinician to co-ordinate our NICE assurance processes. 

Importantly, the Clinical Division has established much greater awareness, oversight, efficient processes and greater implementation of NICE guidance and use of quality standards to deliver its aim for high quality and cost-beneficial care. There is also more effective and robust processes of identifying areas for improvement and training. This significant improvement has been recognised at the Trust Awards for Quality Improvement. The changes have placed our Division’s services in a position to be proactive with cost-beneficial service developments and innovations compared to having poor oversight and benchmarking of the levels of evidence-based care and quality. 

Key learning

• Importance of education at all levels to support greater understanding of the value of NICE resources and the tools available to support better quality care and cost-effectiveness of services and future planning
• Embedding education and training on use of NICE resources and its website into Trust Induction
• Evaluation of current assurance systems and procedures along with determining local barriers and enablers to engagement with NICE resources
• Developing local NICE champions with services and professions has supported better processes and helped raise awareness
• Engagement and support at service manager and executive level to appreciate the value of investing in a robust process of assurance that requires dedicated time for evaluation and action plan achievement often required to be undertaken by clinicians under time pressures
• Establishing clear lines of accountability for seeking responses and achieving evaluations from services and professions within services
• Investing in support staff to undertake the administration requirements, data collation, reporting required

Next steps

• Where there is non-compliance with recommendations, establishing a dedicated forum within the Trust where clinicians at delivery level can influence service and financial forward planning and strategies for workforce development and input into resource allocation priorities.
• When aspects of NICE guidance were either not prioritised or beyond the scope of achievement for services, establishing a process of longer term follow-up for review evaluations.
• Identify more effective methodologies and methods to capturing impact data to demonstrate the quality and cost-effectiveness gains of local service improvements achieved through the development and achievement of action plans.