The issue I intended to tackle can be defined as:
To develop a process, including the use of clinical audit methodologies and the use of technological innovations, to allow me to understand, implement and measure against the NICE Quality Standards as soon as possible following publication, so that I can provide the Trust Board and Commissioners with assurance that Mersey Care are delivering best practice.
This example was originally submitted to demonstrate implementation of QS1. This has now been updated and replaced by QS184. The updated quality standard should be referred to when replicating any aspect of this example.
- Dementia (QS184)
Aims and objectives
To develop a process, including the use of clinical audit methodologies and the use of technological innovations, to allow me to understand, implement and measure compliance against the NICE Quality Standards as soon as possible following publication, or at least by the year end, so that I can provide the Trust Board and Commissioners with assurance that Mersey Care are delivering best practice.
The 5 W's and H technique was used to generate discussion and assist define the issue to be addressed; i.e. the objectives:
-Who (Within Mersey Care: Governance Manager, Technology Information group, Auditor/support. Regionally: The North West Mental Health Clinical Audit Network, and the NICE North West Collaborative, two regional networks which I chair).
-What (The Quality Standards, what they're for, what to do with them and what my stakeholders expect).
-Where (Mersey Care NHS Trust and/or regionally)
-When (As soon as possible or by the end of each financial year)
-Why (Because the Trust Board and the Commissioners want assurance and because Mersey Care want to deliver best practice)
-How (Identify sample, develop audit tool, identify sources, identify auditor, data collection, data analysis/interpretation, report writing, further inquiry.
Reasons for implementing your project
As Mersey Care's Governance Manager, it is my responsibility to develop systems and processes for healthcare professionals to be aware of NICE recommendations (including Quality Standards), including the assessment of relevance of guidance, ensuring baseline assessments are completed and that action plans are developed and actioned to implement guidance.
The Trust links with more than one Commissioner and soon after the publication of the first Quality Standards, Commissioners were requesting evidence of compliance.
I invited a representative of the Commissioners along with a NICE representative to attend a regional meeting I Chair (the North West Mental Health Clinical Audit Network) and the group hosted a debate in an attempt to ascertain why and what the Commissioners requested from Trust's and how Trust's would be able to accommodate this in relation to the NICE Quality Standards and how and if NICE could help at all.
This issue along with the NICE Quality Standards in general, was discussed frequently across the Trust following their introduction; however no head way had been agreed to progress, leaving me with the following 'wants' to address:
-To use the quality standards
-To understand them
-To implement them
-To measure compliance with them
-To give commissioners what they want
-To give the Board what they want
Upon speaking to other local Trusts in the North West region regarding using the quality statements in NICE Quality Standards, I took the initiative to develop a systematic approach to using the quality statements as Sentinel markers, with an initial focus on the Dementia Quality Standard. My initial plans were discussed with NICE's North West Implementation Consultant, who was on hand to provide advice and support.
How did you implement the project
The six step model of change was used to plan the initiative which enabled me to describe the process to my stakeholders and monitor progress of the initiative (the green indicates steps completed and the amber indicates continued progress is being made).
Each stage was discussed within Mersey Care with the Trust's NICE Expert Group, a group I established as part of the re-development of a new NICE implementation process in Spring 2012, and which I was then nominated to Chair by the members. Members include a selection of medics and clinical professionals from the six clinical business units within the Trust.
I developed a data collection tool based on the quality statements, allowing the clinical audit team to study a small proportion of patients with a diagnosis of Dementia, conducting a baseline assessment of compliance against the statements and identifying each source of information.
Information was drawn from a range of sources:
-GP referral letter
-Acute care plan
-Statement of Care
-Patient notes/contact entry
The sources of information were discussed further with the Trust's Technology and Information Group (TIG) with the intention to develop a 'one-click' dashboard-style reporting system to retrieve live data from the Trust's clinical information system to ascertain the position of compliance with the quality statements at any time.
The benchmark results of compliance with the statements were discussed with clinicians and further investigation took place to gather more information in relation to some aspects.
Progress of the study was monitored against the six-step model to ensure specified timeframes were met.
Initial data was analysed against the criteria of the quality statements and the results were written using the 'nominator /denominator' terminology used within the quality standards. Where necessary, further investigation was undertaken; for example, comparisons to recent clinical audit results were made to confirm preliminary findings.
The final results of the study showed full compliance with seven of the requirements meeting criteria for reporting.
Two requirements focussed on people in the later stages of Dementia and none of the patients involved in the study met that criteria; therefore compliance against these were not monitored.
The results of the study identified an anomaly in relation to 'care coordinators' (quality statement four), which infers that all patients with Dementia should have a care coordinator and hence, following Care Programme Approach (CPA) terminology, is expected to be on CPA; which is not reflected in normal practice.
Following discussion at various forums, I received the support of the CPAA to submit a question to NICE at the 2012 conference, at the ICC, Birmingham. The NICE's North West Implementation Consultant took that question to discuss further in house to ensure I was provided with an adequate response. I have since been informed by the NICE's North West Implementation Consultant that this quality statement will be revised accordingly to reflect CPA terminology.
The study concludes with recommendations to open up discussion with health professionals caring for patients with dementia and to seek further advice and clarification from NICE regarding terminology relating to care coordinators.
The study also recommends that the sources of data required to inform this study are discussed with relevant parties; e.g. IT and the Performance Team, with the aim to develop a mechanism to extract the required data electronically.
Key learning points
Tackling this issue in this creative, innovative way allowed me to make use of techniques I have learned from recent study; being able to identify the relevant stakeholders and agree the role and powers of each individual stakeholder proved very valuable. Using a relevant model to plan and monitor progress maintained momentum of the project and assisted the project not to deviate off the agreed path. I advise any manager from any organisation to spend the time planning, involving discussion with stakeholders and probing into several scenarios prior to agreeing the best-fit solution for the organisation.
In the case of tackling using the Quality Standards efficiently and effectively, I advise other managers to investigate the current performance of their organisation and how that information is normally made available to the Board and Commissioners.
For me, my plans are to conduct a similar study for all relevant NICE Quality Standards. Local and regional bench marking is also being considered; and I am already planning the sixth study.