A thematic review of the guidelines relevant to mental health services identified some common themes running through each guideline. Organisational barriers were preventing some of these recommendations from being implemented. Targeted work has been undertaken to remove or reduce these barriers, resulting in increased level of implementation across all guidelines.
Lancashirecare NHS Trust
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?
To remove or reduce barriers to guideline implementation. To undertake a thematic review of common themes in NICE guidelines for mental health services. To identify organisational barriers that were preventing recommendations in guidelines.
My post was established and funded for 12 months to manage the implementation of NICE guidelines relevant for a mental health trust. In practice this meant firstly identifying which guidelines were relevant, then what our current level of implementation was (undertaking a baseline assessment against each). The baseline assessment was undertaken by a working group of clinicians who had a particular interest in the topic i.e. bipolar, self harm. As I facilitated each of these groups I found there were common barriers to implementation, usually as a result of an organisational barrier i.e. no policy, no written information etc.
We identified 5 key barriers; 1) a lack of written information for each disorder 2) no process or policy for advance statements 3) a lack of access to psychological therapies 4) weak systems (e.g. IT) for monitoring physical health 5) no up to date information about self help or voluntary agencies. I worked with each corporate department to overcome organisational barriers, i.e. with the communications department to develop leaflets, and with the library to have easily accessible information about self help. One of the biggest changes was the work undertaken with the IT department to amend our electronic systems (patient record) to enable recording of physical health monitoring (e.g. bipolar and schizophrenia guidelines), advance statements (most MH guidelines), carers assessments (dementia guideline) etc. This was timely as the IT department were consulting with staff to change the system anyway, to make it fit for purpose. I made sure NICE guidelines were one of the key inputs into that work. Apart from the cost of my post (band 7, 35k per annum), the other costs were minor and managed out of existing budgets. One of the key methods for identifying the barriers is the use of the gap analysis (aka baseline assessment). This is used to identify areas of non compliance, and by completing them across each piece of guidance will lead to common themes being identified. The template for this is appended, and other Trusts are welcome to adopt / amend as they see fit.
Some projects are ongoing, however all of the strands of implementation have enabled staff on the ground to implement the recommendations. We know the recommendations are based in evidence. For example, the Trust policy on advance statements has a template appended which has been included on the electronic recording system. This and staff training on the policy has resulted in staff being able to discuss advance statements with our service users, whereas they didn't feel able to before. At baseline, we identified there was only one formal advance statement in use across the Trust. We will relook at this after the policy has had time to be embedded (agreed for July 11). It is acknowledged this project, whilst meeting its aims and objectives has few visible outcomes currently. The organisational barriers have been reduced, and we have baseline information about current practices; but outcomes and benefits will only become apparent in the next 6-12 months.
1. Know your barriers. If a recommendation / guideline is not being implemented, use root cause analysis (RCA) techniques to work out why. The aim of this is to look beyond surface reasons for something not being implemented, to wider system / process issues. For example, satisfaction surveys identified that patients were not receiving written information. It might be easy then to 'blame' Clinicians for this, but looking more deeply, the Trust did not have a suite of leaflets, readily accessible to give to patients. 2. Accept embedding guidelines into practice may require a culture change, and be prepared to do groundwork so people 'trust' the guidelines 3. Engage staff on the ground to tell you what the barriers are, and work with Senior managers and Execs to help you fix them. 4. Set clear outcomes, and when you become weary of the project, or a bit lost, revisit them and put yourself back on track.
NICE Implementation Lead
Lancashirecare NHS Trust
Is the example industry-sponsored in any way?