This document summarizes a master class on implementing evidence into practice using NICE guidance and quality standards. The event included presentations on NICE guidance and quality standards, a case study on implementing dementia guidance, and workshops on NICE pathways and resources. The goal was to improve awareness of NICE implementation support and consider challenges to applying evidence locally.

1. Master Class: ‘Putting evidence into practice’
25th November 2014
Emirates Stadium, Durham County Cricket Club
@AHSN_NENC
Wi Fi Code
Network: Durham Guest
Password: ‘greengrass’

2. Dr Jackie Gray
Project Director,
Collaborating for Better Care Partnership

3. Programme
09.15 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

5. www.ahsn-nenc.org.uk
Improve health & wealth
Partnership
• research
• practice
• industry

6. • 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

8. • 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

9. • 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 prioritising
guidance

11. • Implementation expertise and resources
• Leadership
• Metrics
• Frail elderly – End of life care – COPD
( Diabetes, Dementia )

13. 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

14. • Improved awareness of NICE
implementation resources
• Consider relevant local challenges
• Clinical engagement & clinical leadership

15. Dr Stephen Stericker
NICE Implementation Consultant

16. Putting Evidence into practice
Dr Stephen Stericker, Implementation Consultant (North)

17. Knowing NICE guidance
Dr Stephen Stericker
NICE Implementation Consultant (North)
http://www.ted.com/talks/ben_goldacre_battling_bad_science.
html

18. 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

19. 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.

20. Dr Tolu Olusoga
Senior Clinical Director (MHSOP),
Tees, Esk & Wear Valleys NHS Foundation Trust

21. 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

22. 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

23. Overview of TEWV

24. 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

25. 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

26. 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

27. 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, rivastigmineand memantinefor the treatment of Alzheimer’s disease
( 2011)

28. Dementia Care Pathway
–Main Need/ Diagnostic
Falls
Associated
Clinical Link Pathways
Behaviours
that Challenge

30. Layout of Pathway standards

31. 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

34. 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.

35. Metrics

36. 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.

37. Key Challenges
Electronic Record (Paris)
Wide spread geography
Variations in teams and resources
Readiness to deliver the pathway

38. 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

39. Thank You!
Any Questions?

40. Stephen Stericker
NICE Implementation Consultant

41. 1.Health technologies
–technology appraisals
–interventional procedures
–Medical technologies
2. Clinical practice guidelines
3. Public health guidelines
4.Social careguidelines
5.Safe staffing guidelines
We produce guidelines in the following areas

42. 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

45. 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 strategy2013 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)

46. 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

48. 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.

49. 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.

50. 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

51. 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

52. 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

53. Locally prioritised quality improvement
The initial assessment can:
•provide assurance
•inform atrust’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

54. Quality Standards support for commissioning
•Highlights the key actionsthat commissioners should take
•Identifies opportunities for collaboration and integrationat a local and regional level
•Identifies the benefitsand 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

56. 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’

61. 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.

62. 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

63. 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

64. 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”.

65. Val Moore
NICE
Guidelines Implementation Programme Director

66. What guides the implementation strategy for NICE?
AHSN North East and North Cumbria
26 November 2014

67. 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

68. 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

69. Feedback
•Challenges of implementing NICE guidance Results from a survey of 683 clinicians and managers in 2011

70. 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

71. It’s worth it!
•Compelling evidence that it’s possible to change professional behaviourto 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

72. 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

73. 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

74. 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

75. 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)

76. 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

77. Theory and experience tells us these characteristics are vital to success
•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

78. 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

80. 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%)

81. Uptake data example

82. 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

83. Contact me
val.moore@nice.org.uk
twitter@nicecomms
twitter@valmooreatpb

84. Stephen Stericker
NICE Implementation Consultant

85. .
• 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

86. 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

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

88. Dr Jackie Gray
Project Director,
Collaborating for Better Care Partnership

89. • 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

90. Lunch and Networking

91. Thank you