Deborah O’Callaghan (left) and Jane Moore show how putting NICE guidance into practice and using NICE quality standards to improve quality benefits everyone
- Healthcare and social care providers need to demonstrate that their services are effective and safe, and that they offer quality and value for money
- NICE Into practice guide1 provides:
- practical, in-depth support for providers and commissioners
- comprehensive advice about improving quality using NICE quality standards
- tips, links to resources, and case studies showing how other people are improving care using NICE guidance
- advice on convening a project team and tips on stakeholder engagement.
- A NICE quality standard is a concise sets of statements designed to drive and measure priority quality improvements. It can:
- demonstrate evidence of quality care
- provide assurance that a service ‘meets’ the quality standard
- highlight key areas for improvement
- promote and inform health equality and wellbeing locally
- support discussions with commissioners
- inform service reviews.
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In an increasingly diversified and competitive environment, healthcare and social care providers need to be able quickly and easily to show how their organisation is performing and demonstrate their focus on improving quality. They also need to be able to evidence value for money to commissioners and be open and transparent about how safe and effective their services are. One way of doing this is to use relevant NICE guidance and quality standards to show where high-quality care is being provided, and highlight areas for improvement.
People working with local communities have a crucial role in tackling health inequalities and promoting people’s health and wellbeing. NICE guidance and related quality standards provide evidence-based advice and information to feed into local planning cycles and take forward priorities identified in joint health and wellbeing strategies. NICE guidance and related standards can also inform service reviews and help shape the work of local scrutiny committees.
The potential for NICE guidance and quality standards is considerable. Health professionals generally know about NICE guidance and how it can support the planning and delivery of safe, effective care. Increasingly, NICE is establishing itself as a reliable source of guidance for social care colleagues as our library of resources grows. However, we know that changing practice and service models in line with the latest guidance often presents challenges. Complex relationships between a wide range of organisations can mean that change takes a long time, but we know that certain factors may help to foster an environment that supports change.
The NICE field team works with NHS, local authority, and other organisations to help put NICE guidance into practice, ensuring regular interaction with those striving to improve healthcare and social care services. The field team comprises eight implementation consultants who cover England and Northern Ireland.
NICE quality standards and the Into practical guide
Although awareness of the purpose and potential for NICE guidance remains high, the field team is frequently asked for advice on how NICE quality standards can be used locally to achieve high-quality care. It became apparent that people in both provider and commissioning organisations would appreciate some practical but in-depth advice to support their work. In 2013, NICE published the Into practice guide (see www.nice.org.uk/intopracticeguide)1 to help people to implement its guidance. This online resource has now been updated to include more comprehensive advice on how to use NICE quality standards to improve quality. The advice is presented in distinct sections for healthcare and social care providers, and for commissioners.
The content of the guide is based on our work with NHS organisations and local authorities across the country, and the published literature. The guide is made up of helpful tips, links to resources, and examples of how other people have used NICE guidance and related quality standards to improve the quality of healthcare and social care.
There is no single model for effective implementation; different organisations will implement NICE guidance in different ways. However, the guide is based on some common principles from the published literature about the factors that may help to foster an environment that is conducive to change.
Implementing guidance locally
Every organisation or team will have its preferred approach to service improvement and our suggestions for implementing NICE guidance are designed to be flexible and to fit into local improvement models and structures. The guide has been formatted to enable easy access to advice and resources on specific aspects of guideline implementation and quality improvement. Or it can be used as a way to benchmark the effectiveness of local processes.
Structure of the guide
The first section of the Into practice guide provides information about the potential benefits of implementing NICE guidance and quality standards and highlights links to regulatory and outcomes frameworks. It then goes on to describe a systematic approach to receiving, disseminating, and considering newly published NICE guidance and standards. Key features of effective processes for implementing NICE guidance include:
- high-level support and clear leadership
- a nominated lead for the organisation
- a multidisciplinary forum
- a local policy
- good local awareness
- a named lead for each relevant guideline and/or quality standard.
A section on using NICE guidance and related quality standards in provider organisations then follows.
The final section of the guide is on using NICE quality standards to commission quality services. The practical steps described in these two sections are reciprocal, describing a collaborative approach to implementation and quality improvement between provider and commissioner. Such an approach should avoid unnecessary duplication of effort and reduce the need for unplanned data collection and reporting.
Using NICE guidance and related quality standards
Once it has been agreed that guidance and/or a related quality standard is potentially relevant to the organisation’s service offer or commissioning portfolio, the first step is to assess services against recommendations or quality standard statements.
NICE guidance is a set of systematically developed recommendations, based on the best available evidence. Its key purpose is to guide decisions for a particular area of care or health issue. When guidance is published, a named lead should work with colleagues to compare current practice with the recommendations. NICE produces baseline assessment tools to help with this.
A NICE quality standard is a concise set of statements designed to drive and measure priority quality improvements. Each NICE quality standard is informed by accredited evidence-based guidance and can be used to highlight key areas for improvement. An initial assessment should consider for each statement in the quality standard:
- whether the statement is relevant to the organisation/commissioning portfolio
- how the current service compares with the statement
- the source of the evidence to support this
- what actions or resources would be required in order to improve the service so that it meets the statement
- an initial high-level assessment of risk associated with not making these improvements.
For both guidance and quality standards, there should be local agreement about timelines for completion of initial assessments, but providers should note that their commissioners will also require an indication of any need for improvement in the services they commission.
Locally prioritised quality improvement
The initial assessment of how a service compares with a quality standard can be helpful to an organisation in a number of ways:
- an assessment showing that the service ‘meets’ the quality standard, informed by readily available evidence, can provide assurance to the organisation’s board and commissioners
- this kind of positive assessment can also be included in a trust’s quality account or an organisation’s quality profile
- an assessment indicating areas needing quality improvement can help inform local quality improvement programme planning and can support discussions with commissioners.
The assessment might highlight areas where only small changes are needed to achieve the quality standard. In this case, local quality improvement work could start straightaway.
There may be local agreement to focus on some of the statements within the quality standard rather than the whole quality standard. If the organisation’s board, in conjunction with the commissioner(s), decide not to prioritise a topic for improvement at the current time, this should be recorded and a date for review of this decision agreed and noted.
Supporting changes in services not currently in line with NICE guidance or quality standards
If services are not in line with NICE guidance and there is local agreement that quality improvement work should take place, a project team will be required to take the work forward. This project team might be an existing group (e.g. a project team leading on work to address a need identified by the local joint strategic needs assessment or, in a small provider organisation, the senior management team). Sometimes it will be necessary to convene a new project team. The guide provides detailed advice on convening a project team and tips on stakeholder engagement.
Identify barriers to change
Certain factors may help to foster an environment that is conducive to change. An organisation where there is strong leadership and where everyone is focused on improving care and outcomes is likely to develop motivated staff with a desire for continuous improvement. However, barriers to changing established practice may prevent or impede progress. The Into practice guide contains links to resources to help you to understand more about barriers to change and how to identify and overcome them.
Develop and deliver the action plan
An action plan should be agreed by the project team, detailing the steps needed to put the guidance into practice or to improve services so that they meet the quality standard. When implementing NICE guidance, actions should be assigned to each recommendation that the baseline assessment identified as not currently being carried out.
If the focus is a NICE quality standard, some change ideas may have been recorded during the initial assessment that could be turned into actions. Other suggestions, including the source guidance, NICE evidence search (www.evidence.nhs.uk), and the shared learning database, are detailed within the guide.
Organisations will then need to assess how much it will cost (or save) to implement an action plan. It might be possible to make some changes using existing resources, or to make savings, or to free up capacity for other activities. NICE costing and commissioning tools can help estimate the resource impact and potential savings based on the local population.
Measure quality improvement
Measurement is essential if we are to show that a change has resulted in an improvement. If a measurement reveals there has been no improvement as a result of the change, we know that we need to adapt the change or try something different.
When implementing a NICE guideline, an organisation may choose to conduct an audit of current practice against the recommendations. Re-audit should form part of the audit cycle. NICE has developed audit tools to make the process of auditing practice easier.
When using a NICE quality standard to inform quality improvement work, the quality measures associated with each statement will help assess the impact of the project. The quality standards also indicate when national quality assured indicators currently exist and can be used to assess the service against the quality statement.
As changes are implemented according to the action plan, measures should be repeated to evaluate how effective the changes have been. By managing the implementation of change (for example, by piloting each change for an agreed period of time) and monitoring the effects (by repeating the measure), you can respond appropriately to any unforeseen consequences as a result of the change or slightly adjust the change so as to achieve a better result.
It is also recommended to repeat the measure periodically once the standard has been reached so that organisations can be confident that the improvements are being sustained.
Worked examples are contained within the Into practice guide, along with case studies detailing how organisations are using NICE quality standards locally. There is also practical advice on how to identify local sources of data where required.
Provide high-level assurance
It is advisable for the organisation’s NICE lead to produce an annual report for assurance at the highest level of the organisation, detailing how effective the organisation has been at implementing NICE guidance. The report could also include an indication of position against the NICE quality standards and progress with any quality improvement projects. Commissioners will also require assurance about the extent to which your services are in line with NICE guidance and showing continuous quality improvement. Establishing an assurance process that meets the needs of the board and commissioners can save a lot of duplicated effort and avoid ad hoc requests for data.
Share your success
Implementation of NICE guidance and the use of quality standards should also be included in annual quality accounts, or the organisation’s quality profile, to provide assurance that statements of high-quality care are being used to measure the organisation’s services and make improvements.
As more local authorities and social care organisations start to use NICE guidance and related quality standards, we will gather more case studies and examples relevant to that sector, and update the Into practice guide to reflect and share their experiences. If you have a local process that you would be happy to share, perhaps you could consider submitting it by using our online form www.nice.org.uk/sharedlearning as a NICE shared learning example?
- NICE. Into practice guide. NICE: April 2013, updated May 2014. Available at: www.nice.org.uk/intopracticeguide (accessed 4 July 2014)G