Setting the standards against
which clinical quality can be
measured
Dr Gillian Leng
Deputy Chief Executive, NICE
Areas to cover
• Confirming best practice –
developing Quality
Standards
• Developing and
implementing indicators
and metrics
• NHS Evidence – evidence
on best practice and NICE
pathways
Quality Standards
• A Quality Standard is a set of 10-15 specific, concise
statements that are markers of high-quality, clinical and
cost-effective patient care across a pathway or clinical
area
• Topics sequenced by National Quality Board (NQB)
• Aim: to offer clarity about what high quality care
looks like across the 3 dimensions of quality
ensuring:
– Patient care is effective
– Patient care considers patient experience
– Patient care is safe
• Over time a library of 150 topics is likely to be developed
Quality Standards – the evidence base
NICE Quality Standards
NICE
Quality
Standards
Based on evidence of best
practice and an
assessment of current care
Guidance
and related
products
Research and
audit evidence
Summarised evidencebased material: accredited
guidance
Primary research evidence is
synthesised into other
products – guidance, audit and
service models
Standards and high quality care
There is no statutory provision allowing
NICE Quality Standards to impact upon
registration requirements
Quality Standards are advice from NICE to
the NHS CB on high quality care.
Regulation
( Enforcement against Registration Requirements)
Development of commissioning guidance (NHS CB)
Commissioning Outcomes Framework
Provider Payment Mechanisms
Registration
requirements
Proportion of services
Standard of services Unsafe Substandard Adequate
NICE quality standards
Good
Excellent
Development of Quality Standards
Topic referral
from National
Quality Board /
Department of
Health
NICE sign off
process Cobadging
Topic Expert Group
Recruitment
Second TEG
Meeting:
Agreement of
final quality
standard
Topic Scoping
Review of Clinical
Guidelines and
development of
preliminary
prioritisation of
recommendations
with TEG Chair
Consultation of
draft quality
standard
First TEG
Meeting:
Wording of draft
statements and
measures agreed
Timing: 12 months following commencement, depending on
extent and nature of evidence sources and field
testing/consultation
Current Work Programme
2009-2010
2010-2011
Stroke
COPD
Dementia
CKD
VTE – Prevention
Diabetes
Specialist Neonatal Care
Depression
End of Life Care
Glaucoma
Chronic Heart Failure
Breast Cancer
Alcohol Dependence
Patient Experience
Topics in development
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Acute chest pain
Antenatal care
Asthma
Bipolar disorder in adults
Bipolar disorder in children and
adolescents
Colorectal cancer
Diabetes in children
Diagnosis and management of hepatitis B
Drug use disorders (over-16s)
Epilepsy in adults
Epilepsy in children
Falls in a care setting
Head injury
Hip fractures
Intrapartum care
Intravenous fluid therapy in hospitalised
adult patients
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Lung cancer
Management of myocardial
infarction
Management of ulcerative colitis
Meningitis in people under 16
Migraine/headache
Nutrition in hospital
Osteoarthritis
Ovarian cancer
Postnatal care
Pressure ulcers
Prostate cancer
Pulmonary embolism
Reflux disease (gastrooesophageal reflux disease)
Safe prescribing
Schizophrenia
Consultation shortly on the ‘Library’ of topics
Social Care Standards
Social care – formally added
to NICE’s remit in April 2012
Pilot of 2 social care topics for
standard development in 2011:
– Workshop with key group in July
2011 to inform the model
– Evidence base and
underpinning ‘guidance’ is
crucial
– Topics likely to bridge the health
and social care interface
Example - Stroke Quality Standard
www.nice.org.uk/aboutnice/qualitystandards/stroke
Stroke: quality statement 2
Patients with acute stroke
receive brain imaging within 1
hour of arrival at the hospital if
they meet any of the
indications for immediate
imaging.
Directly based on NICE clinical
guideline recommendation
Related stroke process measure
• Proportion of patients with
acute stroke who meet any of
the indications for immediate
imaging who have had brain
imaging within 1 hour of
arrival at the hospital.
[Numerator & Denominator
defined]
Process measures for each statement
Pros
Cons
A direct measure of the quality of
health care
Not all process measures directly linked
to health outcomes
- IF a link has been demonstrated
between a given process and
outcome
Can be a ‘tick box’ exercise
- Been done but …
- How well has something been done??
More sensitive than outcome measures Can be open to gaming
to differences in quality of care
-Mortality / morbidity
versus
-Use of therapeutic interventions
-Can therefore use at local level to
assess quality of care
Easy to interpret
Data available?
Relevant data sources highlighted
• Trusts can collect data via the Sentinel Stroke Audit,
Hospital Episode Statistics (HES) data and through
local data collection.
• Sentinel Stroke Audit CV02
– Proportion of stroke patients given a brain scan
within 24 hours of stroke
• DH WCC Assurance Framework Acute 36
– Percentage of stroke admissions given a brain scan
within 24 hours
Outcomes Framework and Standards
Duty of quality
7
NHS OUTCOMES FRAMEWORK
Domain 1
Domain 2
Domain 3
Domain 4
Domain 5
Preventing
people from
dying
prematurely
Enhancing
the quality
of life for
people with
LTCs
Recovery
from
episodes of
ill health /
injury
Ensuring a
positive
patient
experience
Safe
environment
free from
avoidable
harm
2
Duty of quality
Duty of quality
1
NICE Quality Standards
(Building a library of approx 150 over 5 years)
3
Commissioning
Outcomes
Framework
6
4
Commissioning
Guidance
5
Provider payment mechanisms
tariff
standard
contract
CQUIN
Commissioning / Contracting
NHS Commissioning Board - Specialist services and primary care
GP Consortia – all other services
Duty of quality
QOF
Stroke and the Outcomes Framework
DOMAIN 1
Preventing
people dying
prematurely
DOMAIN 2
Enhancing quality of
life for people with
long-term conditions
DOMAIN 3
Helping people
recover from ill
health
Overarching
indicators
Mortality from
causes amenable
to healthcare
Health-related quality of
life
Emergency
readmissions within
28 days
Improvement
areas
Under 75
mortality rate
from
cardiovascular
disease
•Proportion of people
feeling supported to
manage their condition
•Employment of people
with long-term conditions
•Unplanned hospitalisation
for chronic ambulatory
care sensitive conditions
•Heath-related quality of
life for carers
•Improving
recovery from
stroke
•Proportion of older
people still at home
91 days after
discharge into
rehab services
Encouraging use of standards
National Outcomes
Framework
• Triggering a review of local performance
against relevant national outcome indicators
Local provider
payment
mechanisms
• Best practice tariff
• Commissioning for Quality Improvement
Initiatives (CQUIN)
• Quality Outcomes Framework (QOF)
Local
commissioning
mechanisms
• Commissioning Outcomes Framework (COF)
• Indicators for local use
Commissioning Outcomes
Framework
The Commissioning Outcome
Framework will be a set of
indicators designed to reflect
good commissioning.
Indicators will be used to:
• allow the NHS Commissioning Board to
identify the contribution of consortia to
achieving priorities for health
improvement
• enable consortia to benchmark their
performance and identify priorities
• provide the potential for some indicators
to be linked to quality premium payments
Summary of key NICE elements
NICE clinical guidelines, public health guidance, technology
appraisal guidance and NHS Evidence accredited sources
NICE quality standards – quality statements
Quality measures – QOF indicators and COF indicators
NICE Commissioning guidance
NICE Pathways
We’ve published a lot of guidance!
Products
Numbers
Cancer service guidance
10
Clinical guidelines
122
Interventional procedures
341
Technology appraisals
222
Medical technologies
Public health
Safety solutions
Total
Excludes superseded guidance
3
34
2
734
And so…. NICE pathways
1. To bring together related
guidance, between and within
topics
2. To link other products – Quality
Standards, audit tools etc
3. To provide a useful format for
commissioners
4. To improve digital formatting for
easier access
Easier, quicker access to the
evidence
How the Pathways work
Information nodes
Detailed advice appears on the right
Links to other information
• Easy access to other supportive information from the
toolbar at the top of the screen – including
implementation support and commissioning advice
• Links to quality standards and statements where these
exist
• Future developments will facilitate access to indicators
and data collection systems
Access via the NICE website
…and NHS Evidence
Rolling out Pathways
• 18 topics now launched,
based on Quality
Standard areas,
including:
• VTE prevention
• Dementia
• Stroke
• Depression
• Exercise
• Alcohol
• Smoking
•
Target for 2011/12 is to
produce 60 new NICE
Pathways
• Topics will be prioritised
based on:
– publication of Standards
– new/updated guidance
– those cross referenced
the most, such as
maternity
Key messages
• Quality Standards represent key elements
of best practice to drive up quality
• Meeting Quality Standards will help
improve national outcomes and inform
local practice and data collection
• NICE pathways facilitate access to
standards and underpinning guidance
• NHS Evidence provides access to
guidance, Standards, support tools and a
range of other evidence-based information
to inform local decision-making
What does this mean for NHS Evidence?
NHS Evidence is a health and
social care information service
providing access to evidence-based
information to deliver high quality
care.
It aims to:
- provide BREADTH of information to all
users of NHS Evidence
- provide easy OPEN ACCESS to
information
- maintain the QUALITY of information
available to users
Feedback
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Over half a million unique
visitors to NHS Evidence each
month
1.2 million searches performed
each month
More than 90% of users believe
the information they access
through NHS Evidence is robust
Search results plus information panels