Master Class: ‘Putting evidence into practice’

25th November 2014

Emirates Stadium, Durham County Cricket Club

@AHSN_NENC

Wi Fi CodeNetwork: Durham GuestPassword: ‘greengrass’

Dr Jackie Gray

Project Director,

Collaborating for Better Care Partnership

Programme09.15 Welcome - Dr Jackie Gray, Project Director, Collaborating for Better Care Partnership

09.30 Knowing NICE guidance – Stephen Stericker, NICE Implementation Consultant

10.00 Implementing guidance: a Dementia case study – Dr Tolu Olusoga, Senior Clinical Director (MHSOP), Tees Esk & Wear Valleys NHS Foundation Trust

10.15 How to use NICE Quality Standards: advice for providers & commissioners of health & social care Stephen Stericker, NICE Implementation Consultant

10.45 Refreshment Break

11.00 Keynote speech – Val Moore, NICE Guidelines Implementation Programme Director

11.15 NICE workshops: practical support & implementation tools

(delegates to attend two out of three sessions)

11.15 Workshop session 1

11.45 Workshop session 2

Workshop options

Workshop 1: NICE Pathways and Evidence Services – Fran Wilkie

Workshop 2: NICE Commissioning resources – Christina McArthur

Workshop 3: NICE Fellows and Scholars – Jim Brown

12.20 NICE Into Practice: what does effective use of NICE guidance resources and tools look like? –Stephen Stericker, NICE Implementation Consultant

12.50 Summary and close – Dr Jackie Gray, Project Director, Collaborating for Better Care Partnership

13.00 Lunch and networking

www.ahsn-nenc.org.uk

Improve health & wealth

Partnership

• research

• practice

• industry

• Consistent evidence of failure to translate research findings into clinical practice – 30-40% patients do not get treatments of proven

effectiveness

– 20-25% patients get care that is not needed or potentially harmful

• Schuster, McGlynn, Brook (1998) Millbank Memorial Quarterly Grol R (2001). Med Care

• Wide discrepancies primary care vs FTs

• FT difficulties with tools relying on electronic extraction

• Impact on patient processes and outcomes is not routine practice

• Numerous factors affect progress - 3 key areas: – a) the nature of the guidance

– b) the intra-organisational context

– c) the external organisational context

• Support for a Regional Collaborative – Complex guidelines affecting major pathways

– Regional benchmarking, audit, and sharing good practice

– Cross boundary working

– Clinical engagement to develop clinical champions and leaders

– Support for commissioners in terms of prioritisingguidance

• Implementation expertise and resources

• Leadership

• Metrics

• Frail elderly – End of life care – COPD

( Diabetes, Dementia )

Using NICE guidance and quality standards to improve practice April 2013

What your organisation needs to have in place

– A multi-disciplinary forum

What your organisation needs to do

– Raise local awareness

– Plan ahead – guidance in development

NICE PG1

• Improved awareness of NICE implementation resources

• Consider relevant local challenges

• Clinical engagement & clinical leadership

Dr Stephen Stericker

NICE Implementation Consultant

Putting Evidence into practice

Dr Stephen Stericker, Implementation Consultant (North)

Knowing NICE guidance

Dr Stephen Stericker

NICE Implementation Consultant (North)

http://www.ted.com/talks/ben_goldacre_battling_bad_science.

html

The role of NICE

• To identify good practice using the best available evidence

• To help resolve uncertainty for the public, patients and professionals

• To reduce variation in the availability and quality of practice and care

April 2013 – social care guidance and standards

Table top exercise

• Work in two’s

• Review the information in the different coloured boxes.

• Match up the guidance type (yellow), with the description (green) and the example (pink) .

• Decide which guidance is mandatory.

Dr Tolu Olusoga

Senior Clinical Director (MHSOP),

Tees, Esk & Wear Valleys NHS Foundation Trust

Implementing guidance- a Dementia Case

study : Tees, Esk and Wear Valleys NHS

Foundation Trust

Dr Tolu Olusoga

Consultant Psychiatrist

Senior Clinical Director

Mental Health Services for Older People

Introduction

Overview of Tees, Esk and Wear Valleys NHS Foundation

Trust (TEWV) and Mental Health Services for Older People

NICE Guidance and the Dementia Care Pathway

Roll out of the Dementia Care Pathway in TEWV

Metrics

Audit

Key Challenges

Lessons learned

Overview of TEWV

We provide a range of mental health, learning disability

and substance misuse services for the 1.6 million

people living in County Durham, the Tees Valley,

Scarborough, Whitby, Ryedale, Harrogate, Hambleton

and Richmondshire.

We deliver our services by working in partnership with

seven local authorities and Clinical Commissioning

Groups, a wide range of voluntary organisations, as

well as service users, their carers and the public.

Overview of TEWV

Our Mission : To improve peoples lives by minimising

the impact of mental ill health or a learning disability

Strategic Goals:

1 To promote excellent services, working with the

individual users or our services and their carers to

promote recovery and well being.

2 To continuously improve the quality and value of our

work

Overview of TEWV

3 Localities: Durham and Darlington; Tees wide; North

Yorkshire

Up to 80% of our work is with people with dementia

and their families

We also work with people with Young Onset Dementia

and their families

18 teams (CMHTs and Memory Services) and 9

wards trust wide required to deliver the Dementia Care

Pathway

Mental Health Services for Older People

NICE Guidance

The Dementia Care Pathway in TEWV incorporates:

CG42: Dementia: supporting people with dementia and

their carers in health and social care ( 2006)

TA 217: Donepezil, galantamine, rivastigmine and

memantine for the treatment of Alzheimer’s disease

( 2011)

Dementia Care Pathway

– Main Need/ Diagnostic

Falls

Associated

Clinical Link

Pathways Behaviours

that Challenge

Layout of Pathway standards

Non Pharmacological interventions –

Intervention toolkit

Cognitive Coping Strategies

Cognitive rehabilitation

CST Group

Environmental Considerations

End of Life Care

Meaningful Activities

Physical Health & wellbeing

Psycho Education

Psychological therapies

Rollout of the Dementia Care pathway

in TEWV

RPDW event (most recent is June 2014)

Identification of Lead practitioners in each locality

Appointment of Dementia Care Pathway Facilitator to

work alongside the Service Development Manager.

Roll out plans developed, tailored to local needs

Ongoing support to localities provided by Dementia

Care Pathway Facilitator.

Metrics

Audit (April 2014)Areas of Good Practice:

Comprehensive assessment

FACE

Clustering Tool

neuroradiology request (according to Newcastle Guidance)

In the Pharmacological stage recent medical history, list of current

medication, review of mental health and any risk, prescription issued with

appropriate medication information leaflet, and assessment for side

effects of medication were done well.

Areas for improvement:

Documented evidence of steps in the Assessment, Non-pharmacological

and Pharmacological stages needs to be improved.

Key Challenges

Electronic Record (Paris)

Wide spread geography

Variations in teams and resources

Readiness to deliver the pathway

Lessons Learned

Pathway needs to be as Lean as possible

Pathways need local ownership to be successful

Facilitator role is crucial for leading the pathway

Local team training works better than large locality

events

Continuous improvements in pathways is a must

Metrics and audit are vital

Thank You!

Any Questions?

Stephen Stericker

NICE Implementation Consultant

1. Health technologies– technology appraisals

– interventional procedures

– Medical technologies

2. Clinical practice guidelines

3. Public health guidelines

4. Social care guidelines

5. Safe staffing guidelines

We produce guidelines in the following areas

What are NICE quality standards?

Evidence Guidance Quality

Standards

A NICE quality standard is a

concise set of statements

designed to drive and

measure priority quality

improvements.

A set of systematically developed

recommendations to guide decisions for

a particular area of care or health issue

Research studies - experimental

and observational, quantitative

and qualitative, process

evaluations, descriptions of

experience, case studies

Source guidance• Prevention and control of healthcare-associated infections. NICE

public health guidance 36 (2011)

• Surgical site infection. NICE clinical guideline 74 (2008)

• Inadvertent perioperative hypothermia. NICE CG65 (2008)

• Department of Health (2013) UK five year antimicrobial resistance strategy 2013 to 2018

• Public Health England (2013) Protocol for the surveillance of surgical site infection: surgical site infection surveillance service

• Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) (2011) Antimicrobial stewardship 'Start smart – then focus'.: guidance for antimicrobial stewardship in hospitals (England)

Source guidance (cont)• Department of Health (2010) The Health and Social Care Act 2008:

code of practice on the prevention and control of infections and related guidance

• Department of Health (2010) Uniforms and workwear: guidance on uniform and workwear policies for NHS employers

• Department of Health (2010) MRSA screening – operational guidance 3

• Department of Health (2009) National Decontamination Programme: theatre support pack

• Department of Health (2008) MRSA screening – operational guidance 2

Source guidance• Social Care Institute for Excellence (2011) IMCA and paid relevant

person's representative roles in the Mental Capacity Act Deprivation of Liberty Safeguards. SCIE guide 41.

• Social Care Institute for Excellence (2010) Personalisation: a rough guide. SCIE guide 47.

• Social Care Institute for Excellence (2010) Independent mental capacity advocate involvement in accommodation decisions and care reviews. SCIE guide 39.

• Social Care Institute for Excellence (2010) Dignity in care. SCIE guide 15.

• Social Care Institute for Excellence (2009) Practice guidance on the involvement of Independent Mental Capacity Advocates (IMCAs) in safeguarding adults. SCIE guide 32.

Source guidance

• Social Care Institute for Excellence (2009) Commissioning and monitoring of Independent Mental Capacity Advocate (IMCA) services. SCIE guide 31.

• Social Care Institute for Excellence (2007) Implementing the Carers (Equal Opportunities) Act 2004. SCIE guide 9.

• NICE (2006) Dementia. NICE clinical guideline 42.

Table top exercise:Each table is allocated a ‘setting’,

Discuss 3 ways that Quality Standards can be used in the setting .

• Health provider (primary care, secondary care, pharmacy)

• Commissioner (CCG, NHS England Area Team, Local authority, Commissioning support units)

• Public Health team in Local Authority,

• Local authority Social Care provider (including voluntary and independent sector)

10 mins

Using NICE Quality Standards

NICE quality standards can highlight key areas for improvement. An initial assessment should consider for each statement within the quality standard:

• whether the statement is relevant to the organisation

• how the current service compares to the statement

• source of information to evidence this

• what actions/resources would be required in order to improve the service so that it meets the quality standard statement

• an initial assessment of risk associated with not making these improvements

Sources of information to support this initial assessment could include:

• baseline assessments/actions plans for NICE clinical guidelines

• performance / activity data

• new or existing patient/service user feedback

• complaints or Serious Untoward Incidents (SUIs)

• audit information (including national audit data)

• prescribing data

• views of the service/team

• process maps

• service user experience interviews or focus groups

• Assessments by regulators such as OfSTED or CQC

Locally prioritised quality improvement

The initial assessment can:

• provide assurance

• inform a trust’s quality account, a local authority’s local account or a quality profile

• indicate areas requiring quality improvement:– inform local quality improvement work/programme planning

– support discussions with commissioners

• Inform the organisation’s annual audit programme (by identifying priority areas for audit) and business planning

• Inform local risk management, in collaboration with the service’s commissioners

Quality Standards support for commissioning

• Highlights the key actions that commissioners should take

• Identifies opportunities for collaboration and integrationat a local and regional level

• Identifies the benefits and potential costs and/ or savingsfrom implementing the changes needed to achieve quality improvement

• Directs commissioners and service providers to resourcesthat can help them implement NICE and NICE-accredited guidance

Support for commissioning – Heart Failure Services

• Context and epidemiology (prevalence, emergency admission and readmission rates, case for improvement)

• Resource implications (for each stage of the pathway)

• Cost impact (e.g. echo waiting list)

• Link to commissioning and benchmarking tool to assess the level of service needed locally and the associated costs and savings

• Definitions and links to source guidance (e.g. multidisciplinary team structure)

• Links to national drivers and other useful resources including patient information leaflets, exemplar CQUIN goals and ‘Es of self management’

Case study - NHS Stockport CCG & Stockport Metropolitan Borough Council

• Wanted to integrate quality agendas, with a systematic & evidence based approach to quality

• Designed a process & set up small steering group to evaluate all QS (tested it with QS1& 30 on dementia)

• Where indicated by initial assessment, set up small topic specific task & finish groups, which identified actions required to improve, and act upon them.

• Working together led to consistent approach, combined knowledge, avoided duplication, more powerful approach to change, feeds into formal structures.

Case study – Greater Manchester Sector Led Improvement

• NICE guidance & quality standards are pivotal to Greater Manchester's sector-led improvement approach to driving improvements in public health

• Process of self-assessment and peer review• Local action plans are developed and reviewed

regularly by LA peers to ensure that NICE guidance & quality standards are being implemented and that performance against PHOF (Public Health Outcomes Framework) measures improves in the long-term

Case study - Lancashire Care Foundation Trust

• Aimed to develop a robust method of using NICE quality

standards across the trust

• Ensuring staff are aware when a quality standard applies

to their area of work so they can understand their

performance in relation to it, share good practice and

strive to improve if appropriate

• Clinical lead completes a review of the statements

• Using existing evidence where available eg. training

records and environmental audits

Case Study – Cumbria Adult Social Care

“Cumbria Adult Social Care is committed to adopting

National Institute for Health and Care Excellence (NICE)

guidelines and quality standards throughout their

contracted social care services”.

Val Moore

NICE

Guidelines Implementation Programme Director

What guides the implementation strategy for NICE?

AHSN North East and North Cumbria

26 November 2014

What guides the implementation strategy for NICE?

• Feedback

• Theory and evidence

• Our position in the health and social care system (levers, alignment and avoiding duplication)

• Being able to listen to, encourage, use and support local agents of change

Implementation – why it is important to

NICE

• Guidance alone doesn’t improve healthcare

• The way guidance is developed and presented

makes a difference to how it is received and

used

• Facilitators and barriers exist at the system,

organisation, peer group and individual levels

• Interventions such as audit, visits, education

can improve adoption

Feedback• Challenges of implementing NICE guidance

Results from a survey of 683 clinicians and managers in 2011

Main barriers to implementation

• Lack of trust in guidance

• Lack of organisational

support - structures and

processes

• Resources (or lack of

them)

• Poor knowledge of

support from NICE

It’s worth it!

• Compelling evidence that it’s possible to change professional behaviour to improve quality of care

• No Magic Bullet – most interventions effective under some circumstances, none effective in all

• Evidence suggests need for tailoring of interventions based on:

– formal barrier assessment

– explicit intervention design• We encourage this through our fellows & scholars schemes,

Shared learning local practice examples, and in the choice of tools NICE produces

Strategic alliances in the health and

social care system• Chair, Chief Executive and SMT activities e.g. Royal

Colleges, Clinical Commissioning Assembly, ADASS

• Partnership Agreements e.g., NHS England, Care

Quality Commission, HEE, Ofsted, Monitor, the NIC,

and AHSNs

• Aligned strategic aims:

– system levers for implementation & improvement

– little point in producing what no-one wants/needs,

and avoiding duplication

• Independence of NICE

Local engagement

• 8 strong field team, plus medicine associates, plus NICE fellows and scholars

• Success criteria over 3 years for engagement with CCGs, Area Teams, Local Authorities, provider trusts, networks, PHE units, social care commissioners etc.

• MOUs with most AHSN’s, coordinated by Sally Chisholm, Programme Director for Health Technologies Adoption, and supported by the Field team

• Education plan to influence and support education providers

Implementation programme strategy

and support

• Working with & through

others

• Needs assessment

based

• Raise awareness

• Motivating for change

• Practical support

• Evaluation uptake

Support for education and learning

Support for service improvement and audit

Support for commissioning

Practical support

• Routine guidance support tools: baseline assessment, costing and resource impact tools, audit criteria

• Other discretionary guidance support tools: Support for commissioning using the quality standard, online learning modules 4x per year

• Endorsement programme: statement from NICE in the guidance support tool about its alignment to the relevant guidance or quality standard(s)

Example:-CG174 IV fluid therapy in adults

Resources to support implementation

• Intravenous fluid therapy in adults in

hospital: algorithm poster set

• Intravenous fluid therapy in adults in

hospital: diagram of ongoing losses

• Intravenous fluid therapy in adults in

hospital: composition of commonly used

crystalloids table

• Clinical audit tool

• Baseline assessment tool

• Clinical audit tool

• “Do not do” recommendations

www.nice.org.uk/guidance/cg174/resources

Theory and experience tells us these characteristics are vital to success

• Ensure organisational structures and processes are in place

Board level leadershipDay-to-day operational lead for quality appointedMulti-disciplinary forum for strategic decisionsNominated lead for each new development System in place for ongoing monitoring and reporting to

the board

A systematic approach

• Ensure organisational structures and processes are in

place

Board level leadership Day-to-day operational lead for

quality appointed Multi-disciplinary forum for

strategic decisions Nominated lead for each new

development System in place for ongoing

monitoring and reporting to the board

Are you aiming to improve the quality of healthcare?

Identify the best available evidence-based guidance

Check whether services are currently in line with best practice

Develop an initial plan to overcome any barriers to change

Check if the plan can be delivered within existing resources

Finalise the action plan and implement

Evaluate ongoing success through systematic measurement

Evaluating uptake

Number of ‘active’ products with uptake data (published before March 2014)

• Technology Appraisals 231 163 (70.5%)

• Clinical Guidelines 140 74 (53%)

• Quality Standards 57 28 (49.1%)

• Public Health Guidelines 51 5 (9.8%)

Uptake data example

NICE Fellows and Scholars programme

Jaqueline Fletcher, Senior Professional Tutor Department of Dermatology and Wound Healing, Cardiff University

Andrew Hartland, Bariatric Physician and lead for Obesity services, Walsall Hospitals Trust

Andy Tilsden, Director Skills for Care

Jenny Gordon, Programme Manager for Evidence into practiceRoyal College of Nursing

Contact me

val.moore@nice.org.uk

twitter@nicecomms

twitter@valmooreatpb

Stephen Stericker

NICE Implementation Consultant

.

• Web based guide to help health & social care organisations use NICE

guidance & quality standards to achieve high quality care in local settings

• Suggests what an organisation can put in place, & what staff can do to

use NICE guidance & quality standards to improve outcomes & get the

best value for money

• Includes helpful tips, links to other resources and shared learning

examples of ways other people have used NICE guidance & standards

• For commissioners, providers, quality improvement specialists, clinical

governance or NICE leads, anyone implementing one specific piece of

guidance, anyone planning or scrutinising care services.

• Guide isn’t intended to be prescriptive or place limitations on what you

might choose to do – it’s a good starting point!

Into Practice Guide

Taking today’s insights forward into your

organisation: when, where, how and what

Step 1: Choose a priority area for implementing NICE guidelines

or using quality standards and write an action that you want to take

in your organisation.

Step 2: Write:

When you will do it (be specific)

Where you will do it (be specific)

How you will do it (be specific)

What help or support might you require from

• The organisation

• The AHSN

• NICE

• Others eg training and development, strategic clinical networks

etc 10 mins

The best laid plans…Now, imagine yourself enacting that when, when and how

plan.

Can you envisage anything preventing you from doing it?

How would you feasibly address that barrier?

Write:

IF barrier __________________________ occurs

THEN I WILL ________________________ to ensure

I can enact my plan10 mins

Then spend 10 mins discussing with the person next to you.

Dr Jackie Gray

Project Director,

Collaborating for Better Care Partnership

• Sign up for the e- bulletin at the registration desk (if you haven’t already)

Resources will be available on:

Slide Share - slide deck will be uploaded (link included in next e-bulletin)

AHSN web site www.ahsn-nenc.org.uk

NEQOS web site www.neqos.nhs.uk/

Twitter - @AHSN_NENC

Lunch and Networking

Thank you