Clinical audit for improvement 2013

NICE

Val Moore

Implementation Programme Director, NICE

February 2013

To cover

• An update from NICE• NICE Quality Standards, feedback from the field and

support for service improvement and measurement• The role of clinical audit in monitoring adherence to

standards?

The beginning

• NICE was launched in 1999 as the National Institute for Clinical Excellence to drive the uptake of new technologies across the NHS and standardise care.

• Initial work programme was the development of recommendations on new technologies, based on an assessment of clinical and cost effectiveness.

Followed by…. significant growth

More guidance for the NHS: clinical guidelines, interventional procedures, medical technologies

Public health guidance

Implementation programme

NHS Evidence and the National Electronic Library for Medicines – and accreditation

The British National Formulary transfer

National Prescribing Centre

Quality standards

Current NICE functions

The future – what’s on the horizon• Social care:

– Guidance – Quality standards– Support for uptake

• Health– Standards & indicators

• Technology assessment– Value-based pricing– Highly specialised technologies (HST)

• Adoption of new technologies– Transfer of the NHS Technology Adoption Centre– Innovation Health and Wealth

• New relationships – and a new status

Guidance and quality standards

‘Sentinel markers’A prioritised set of concise, measureable statements designed to drive quality improvements across a pathway of care.

A comprehensive set of recommendations for a particular condition or service area

Annual NICE field team visits to over 500 top teams or key opinion formers

and 100 meetings and events

And exceeds 80% coverage of NHS organisations

And 80% of upper tier local authorities

Provider perspectives

“I wasn’t aware of quality standards until you explained what they are. I can see how they can help drive improvements in patient outcomes. They are obviously very significant and we should be using them....but how?”

Mental Health Medical Director

Provider perspectives....positives

• Extremely useful tool to improve quality and challenge assumptions that good quality care is already delivered

• Supportive of the aims of quality standards• Easy to read and practical• We are using them!

Provider perspectives....positives

• Extremely useful tool to improve quality and challenge assumptions that good quality care is already delivered

• Supportive of the aims of quality standards• Easy to read and practical• Examples:• Stroke QS helped Camden Provider Services improve access to

physiotherapy - now offered to 90% of appropriate patients• Taunton & Somerset NHS FT used specialist neonatal care QS as

a quality improvement lever - parents involvement within 24 hrs of admission

Provider perspectives......negatives• Unaware, or aware of QS but not sure how to use

them/significance• Think commissioners will use them to withhold payment• Difficult to measure as they cut across organisational

boundaries - worry over the potential number of measurable indicators

• Not mandatory therefore not a priority• Perceived to be overly complex• The suggested measures and definitions do not

always read across to measures routinely collected as part of national data sets or national audits

Commissioner perspectives....positives

• ‘QS are excellent’ - mainly positive feedback about their potential value for commissioners and service providers

• Aware of QS and beginning to incorporate them into contracts and service specifications

• A “springboard” for service redesign and quality improvement (example Oxfordshire/ Bucks CCG)

• Can be used to commission evidenced-based best practice services

• Can drive improvements in quality through links to reimbursements

• Used by Trusts for contracting/procurement

Commissioner perspectives....negatives

• Growing awareness but not complete• Not sure how to use them• Not effective to use quality standards as a CQUIN• Comments on alignment to the provisional CCG

Commissioning Indicators set• The volume of quality standards may overwhelm the

capacity of the health and social care system to respond

• Perceived “burden” of data collection especially for providers

• Need to know that a dialogue is in place with CQC, OFSTED and NHSLA

Quality measures and indicators for NICE quality standards

Quality Measures

• Broad definitions• Additional definitions may

be needed and can be adapted for local use

• Not formally tested• Use- Provide a focus for

quality improvement activity

Formal Indicators

• Highly defined and reproducible

• Cannot be adapted and definitions should be followed

• Tested as part of development process

• Use- Provide a focus for quality improvement activity

• Provide a mechanism for comparison

Measurement support products at launch of the quality standard

• Commissioning and benchmarking ( and budgeting) tools

• Action planning • Data collection tools

• The H&SC Information Centre continues to produce quality assured indicators derived from quality standards - approved by independent committee for the menu on the NICE website

Support for commissioners using the quality standard

Support to consider the cost of implementing the changes required to achieve the quality standard at a local level

Identifies potential savings

Highlights areas of care with potential implications for commissioners

Signposts commissioners and service providers to a package of support tools to assist implementation of NICE guidance and service redesign

Action planning tool for use by commissioners or providers

Data collection tool

Data collection tool for all suitable process measures involving patient/ service user records

Back to the future of NICE…social care pilots

• Combined dementia (interventions and care) quality standard to be published in April

• Care audit pilot on dementia care in residential homes planned for 2014 – HQIP and SCIE leading this

• Care of looked after children quality standard to be published in April

• National Collaborating Centre appointed to develop guidance from April 2103 (SCIE and partners)

Referred social care topics and timelines

Topic Guidance Quality Standard

Mental wellbeing in older people

Already available Late 2013

Autism in adults and children Already available Late 2013

Medicines management in care homes

2014 2015

Transition between health and social care

2015 2016

Older people with multiple co-morbidities

2015 2016

Domiciliary care 2015 2016

Child maltreatment 2015 2016

Transition between child adult services

2015 2016

Highly specialised technology assessment (HST)

• Ministerial request to assess very high cost, low volume drugs (and potentially other technologies) for people with rare or very rare conditions from April 2013.

• A role currently provided by Advisory Group for National Specialised Services - AGNSS

• Interim process likely to include:– Current NICE appraisal topic selection process– Company submission plus academic review– New Advisory Committee for HST– Adaptation of AGNSS decision making framework– Public consultation and appeal– Formal link to nationally commissioned specialised services– Guidance to the NHS and funding direction

Value-based pricing – how it might work

• Only new medicines launched after January 2014• Higher price thresholds for medicines that:

– Tackle disease of high unmet need or severity– Demonstrate greater therapeutic improvements and

innovation– Demonstrate wider societal benefits

• Categories and weights determined by the Secretary of State for Health:– On the basis of empirical research– Within a framework determined in advance

NHS Technology Adoption Centre

• NTAC established at the end of 2007 to provide a more systematic approach to adoption of new technologies.

• Aims to enable organisations to better understand and overcome their adoption barriers.

Their mission is: “To work directly with industry and the NHS at a clinical, managerial and procurement level to identify and overcome the hurdles to adoption for innovative technologies which have already demonstrated clear benefits to patients and will improve system efficiency.”

Transfer of NTAC to NICE

• The proposal in the Sunset Review is to transfer NTAC to NICE

• Alongside other NICE implementation functions, this provides a focus on supporting uptake of new technologies

• It will add capacity to work with the Innovation Health and Wealth agenda.

Innovation health and wealth

Key areas relevant to NICE:– A NICE Implementation

Collaborative to support the implementation of NICE guidance

– A ‘NICE compliance regimen’ for the funding direction attached to NICE TAs, to ensure rapid and consistent implementation – innovation scorecard and work on local formularies

– Working with Academic Health Science Networks

Climate conducive to promoting uptake

Future NICE functions