1. NCGC National Clinical Guideline Centre 16.02.11 Ian Bullock Jill Parnham Knowledge (evidence) translation and utilisation, leading to improved patient outcome ‘A whole healthcare systems approach’

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5. NCGC NCGC Commissioned by DH & NICE 20+ guidelines / QS in development Budget of £4.56 million (2,818,008 OMR) ~70 staff – specialist expertise EMB Inter related work with RCP Clinical Standards

6. NCGC UK STAKEHOLDERS context Patients Patients Professions NHS Industry NCGC

7. NCGC NCGC Vision that is: Focussed on quality (Quality Standards) Patient centred (High political priority) Clinically driven (Professionally important) Flexible (Diverse work programme) About valuing people (Always about people) Promoting continuous improvement (With growth inevitably comes increased responsibility)

8. NCGC The quality spiral Largest EB guideline centre in world Commissioned by DH / NICE 14 guidelines in development, rolling programme XXX scoping Full guideline takes XXX months

9. NCGC National Clinical Guideline Centre  Formed on April 1 st 2009  Merger of 4 National Collaborating Centres - Primary Care (RCGP) - Chronic Conditions (RCP) - Nursing and Supportive Care (RCN) - Acute Conditions (RCS)  Hosted by Royal College of Physicians

10. NCGC Guideline Development Multidisciplinary group Supported by technical team (researchers; health economists; information scientists and project managers) Technical team are members of the group with voting rights

11. NCGC Developing clinical guidelines 1. Scoping: Identify and refine the subject area 2. Convene multi disciplinary guideline development groups including patients/carers 3. Develop clinical questions: process started 4. Obtain and assess the evidence about the clinical questions 5. Analyse and present evidence to GDG 6. Translate the evidence into recommendations (clinical guideline) 7. Arrange external review of the guideline

12. NCGC Mark Twain ‘Synergy — the bonus that is achieved when things work together harmoniously.’

13. NCGC Answering the clinical questions Each recommendation needs to relate to a question Each question has to be addressed with a systematic review of the evidence Each systematic review requires –A question protocol listing inclusion/exclusion criteria –A comprehensive literature search –Each study reviewed to be quality assessed using NICE forms* –Each included study to have data extracted into an evidence table –Each outcome from each question to be synthesised into a meta- analysis (where possible)* –The collated estimate for each outcome to be assessed using GRADE* –Results written up in the guideline

14. NCGC Types of questions Aetiology/causation Diagnosis/screening Prognosis Effectiveness (therapy, clinician, organisation) Cost-effectiveness Harm Variation in practice Equity Experience and meaning

15. NCGC General structure of a clinical question The acknowledged structure is known as PICO –Population –Intervention (or exposure for prognosis) –Comparison (optional) –Outcome

16. NCGC PICO Structure – effectiveness example PICOAsk yourself Example Population (P) (patient/condition) How would I describe the group(s) of patients? People aged 12 or over who have...... Intervention (I) (drug, procedure, diagnostic test, exposure) Which main intervention, prognostic factor, exposure … xxxx or xxxx plus xxxxx Comparison (C) (optional) What is the main alternative to compare with the intervention? the same drug alone Outcome (O) What can I hope to accomplish, measure, improve or affect? Time to resolution of symptoms

17. NCGC NICE principles – include social value judgements Need evidence to recommend an intervention (can make ‘research only’ recommendations) Clinical and cost effectiveness Good use of resources Can make recommendation for a subgroup of population if clear evidence for effectiveness Involve and respond to stakeholders Equalities Transparency

18. NCGC How evidence presented to GDG 1.Details of study – where, population groups, interventions etc 2.Quality assessment – checklists/GRADE 3.Results – varies e.g. narrative, forest plots 4.Interventions – GRADE profiled 5.Meta-analysis where possible 6.Health economic modelling outcomes ‘evidence’

19. NCGC Why consider cost-effectiveness? The NHS does not have enough resources to do everything If it spends more on one thing, it has to do less of something else Could we do more good by spending money differently? Prioritise interventions with a high health gain per £ spent

20. NCGC Why are recommendations difficult in evidence based guidelines? No evidence Poor evidence Doesn’t answer the question Wrong patient group Wrong comparator Wrong outcome

21. NCGC Options when evidence poor/no evidence Extrapolate if possible (indirect evidence) Expert group discussion (informal consensus) Vote Formal consensus decision making Transparency and acknowledgement No recommendation

22. NCGC Guideline Development Timeline 20102011 2012 QuartersQuartersQuarters 123412341234 Scoping Development Consultation Validation Publication

23. NCGC NICE (NCGC) and Quality Initiatives 2000 -2006 –Focus on guidance, not indicators or standards Clinical Guidelines; Public Health Guidance and Technology Appraisals –Developed audit tools directly based on NICE guidelines 2008 –Labour Government’s Next Stage Review –Expanded role for NICE in Quality Indicator Development NICE-managed QOF for general practice NICE to develop Quality Standards 2010 (July) –Coalition Government’s Health White Paper NHS Outcomes Framework NICE Quality Standards seen as central to delivering this

24. NCGC What are Quality Standards? Quality statements –Descriptive statements (5 to 10) of the critical infra-structural and clinical requirements for high quality care as well as the desirable/expected outcomes –Key points on care pathway Quality measures –Structure, process (and outcome) measures –“High Level” Quality Indicators Use at local level as audit criteria Inform subsequent national indicator development

25. NCGC What are Quality Standards? Audience descriptors –A description of what the quality standards mean for different audiences Service providers Health and Social Care Professionals Commissioners Patients

26. NCGC What is the purpose of Quality Standards ? To make it clear what high quality care is by providing definitions of clinical and cost-effective care To support benchmarking of performance To provide information to patients and the public about the quality of care they can expect

27. NCGC NICE Quality Standards programme Aims –To develop Quality Standards for topics selected by the National Quality Board (NQB)/ NHS Commissioning Board on an annual basis –To offer clarity about what high quality care looks like across 3 dimensions of quality ensuring: Patient care is effective Patient care considers patient experience Patient care is safe –To develop a comprehensive set 150 to be developed over 5 years

28. NCGC Current Work Programme 2009-2010 – Pilot Phase2010-2011 StrokeCOPD DementiaCKD VTE – Prevention Diabetes (Adults) Published May 2010Depression (Adults) Specialist Neonatal CareEnd of Life Care Published Autumn 2010Glaucoma Heart Failure Breast Cancer Alcohol Dependence Key: Patient Experience (x2) NCGC produced

29. NCGC Overview of Quality standards development Topic Evidence Source NICE or other NHS evidence accredited source Guidance RecommendationsQuality StatementsQuality Measures Requires Generates Distilled into Produce

30. NCGC Quality Standard Evidence Source 1)Policy Drivers 2)Audit evidence on current care NICE quality standard -Quality statements -Measures Clinical Guideline Recommendations -NHS Evidence Accredited Sources 1.Key Department of Health and other documents 2.National Clinical Audits - Current clinical practice (areas requiring improvement) NICE quality standards

31. NCGC NICE Stroke Quality Standard Scope of Quality Standard: –Care provided to adult stroke patients diagnosis and initial management, acute phase care, rehabilitation and long-term management Policy context: –Department of Health “National Stroke Strategy” (2007) –Department of Health “Reducing Brain Damage: faster access to better stroke care” (2005) Key development sources: Royal College of Physicians “National Clinical Guideline for Stroke” (2008) which incorporates NICE CG68 Diagnosis and initial management of acute stroke and transient ischaemic attack (2008) National Sentinel Audit for Stroke (2000 – ongoing)

32. NCGC Example quality statement for stroke In a high quality service for patients with stroke... Patients with acute stroke receive brain imaging within 1 hour of admission if they meet any of the indications for immediate imaging (QS2) Relevant CG recommendation –Brain imaging should be performed immediately (within 1 hour) for people with acute stroke if any of the following apply …

33. NCGC Example of quality measure for stroke Structure: Evidence of local arrangements to ensure 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. Process: 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]

34. NCGC What the quality statement means for each audience – stroke example Service providers ensure facilities and protocols are available for patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. Health care professionals ensure that patients under their care with acute stroke receive brain imaging within 1 hour of arrival at the hospital if the criteria for immediate imaging are met. Commissioners ensure that services they commission enable patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. Patients with acute stroke with any of the indications for immediate brain imaging can expect to receive this within 1 hour of arrival at the hospital.

35. NCGC Data Source Structure: Local data collection. Process: Trusts can collect data via the Sentinel Stroke Audit, Hospital Episode Statistics (HES) data and through local data collection.Sentinel Stroke AuditHospital Episode Statistics There exist existing quality assured indicators 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

36. NCGC How will quality standards be used? Used to drive up the quality of health care For use by: – patients, the public, health and social care professionals, commissioners and service providers Can be used in: – commissioning, payment mechanisms and incentives schemes such as CQUIN, Quality Accounts and Care Quality Commission special reviews

37. NCGC Measurement is crucial and can be linked to consultant appraisal

38. NCGC Stroke quality spiral Epidemiology Policy context Setting standards Measuring standards Improving quality of clinical care

39. NCGC UK stroke epidemiology

40. NCGC Stroke Stroke is one of the top three causes of death and the largest cause of adult disability in England, and costs the NHS over £3 billion (1,854,274,200 OMR) a year.

41. NCGC Stroke In 2008-09, the direct care cost of stroke was at least £3 billion annually, within a wider economic cost of about £8 billion (4,945,200,233 OMR). Without preventative action, there is likely to be an increase in strokes as the population ages.

42. NCGC Stroke One in four people who have a stroke die of it. There are approximately 110,000 strokes and 20,000 TIAs per year in England. 300,000 people are living with moderate to severe disabilities as a result of stroke.

43. NCGC National stroke picture

44. NCGC NICE Acute Stroke Guideline Took 24 months to develop 18 experts plus technical team Rigorous and systematic methodology Published 2008 Looked at thousands published papers Based recommendations upon 200 key papers Made 62 EB recommendations

45. NCGC Stroke care pathway

46. NCGC ‘Time lost is brain lost’ Pathway derived from the evidence based NICE guideline

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50. NCGC Guidelines The NICE guideline (July 2008) covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered.

51. NCGC Guidelines The RCP Intercollegiate Stroke Working Party (ICSWP) National Clinical Guidelines for Stroke (published July 2008) includes all of the recommendations from this NICE guideline.

52. NCGC National stroke guidelines Nested within Setting the standard

53. NCGC Guidelines and audit National guidelines provide clinicians, managers and service users with summaries of evidence and recommendations for clinical practice. Implementation of guidelines in practice, supported by regular audit, improves the processes of care and clinical outcome.

54. NCGC National stroke audit In the UK, the National Sentinel Stroke Audits have documented changes in secondary care provision over the last 10 years, with increasing numbers of patients being treated in stroke units, more evidence-based practice, and reductions in mortality and length of hospital stay.

55. NCGC DoH National Stroke Strategy This strategy sets out what should be done to achieve the necessary revolution in stroke care. It set an ambitious agenda to deliver world-class stroke services, from prevention right through to life-long support.

56. NCGC The Strategy is intended to provide …. a quality framework against which local services can secure improvements to stroke services advice for commissioners in the planning, development and monitoring of services; does not act as a clinical guideline – the NICE & RCP guidelines fulfil these roles.

57. NCGC Strategy example…..the link between policy and audit Stroke unit quality: stroke unit care is the single biggest factor that can improve a person’s outcomes following a stroke. Successful stroke units are built around a stroke-skilled multidisciplinary team that is able to meet the needs of the individuals. How does your local unit rate on the Royal College of Physicians’ National Sentinel Stroke Audit?

58. NCGC RCP national stroke audit Acknowledgement to Alex Hoffman Voluntary participation Snapshot every 2 yrs Organisational & clinical audit High quality data submitted on a web based tool Over 70 data items Audit annual budget £240k (148,321.40 OMR)

59. NCGC Stroke audit 100% UK hospital participation rate 159 trusts (201 sites covering 249 hospitals) N=11,353 pts

60. NCGC Stroke audit Run by clinicians Individual hospital reports with results benchmarked against national averages Reports to Department of Health and Parliament Extensive media coverage

61. NCGC Organisational audit criteria Presence of a stroke unit Quality of stroke unit All patients admitted to a stroke unit Staffing ratios on a stroke unit Multidisciplinary team work Patient involvement TIA services Thrombolysis service and coverage

62. NCGC Clinical audit criteria Delay to scanning Prompt assessments Therapy dose Antithrombotics Communication with agencies and patients

63. NCGC What audit does well National audit with 100% participation compares structure and process against evidence based standards for the UK and provides: –a snapshot of care and organisation or services –a national benchmark –hospitals and patients and managers comparable information –a starting point for improving care –an indication of the rate of change across the country and between regions and hospitals since 2001

64. NCGC Evolution of evidence 2004 - 08 2008 NICE and RCP guidelines “All patients with suspected stroke should be admitted directly to an acute stroke unit” Admitted to a stroke unit: 2004 = 46% 2008 = 74% 2010 = 88%

65. NCGC Stroke unit service An acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patients. Regular multidisciplinary team meetings occur for goal setting.

66. NCGC Hyper acute service Specialist hyper-acute stroke units bring experts and equipment under one roof to provide: rapid assessment – a patient must arrive in a specialist stroke ward, no more than two hours after having a stroke, and be assessed by a specialist; access to a CT scan within 30 minutes of arrival; early thrombolysis, if the scan shows they are needed, within three hours of having a stroke (and 30 minutes of arrival); 24/7 monitoring in a high dependency bed; and a multi-disciplinary specialist team on call 24/7; including consultants, specialist nurses and therapists.

67. NCGC Audit – stroke unit The proportion of stroke patients who spend more than 90 per cent of their hospital stay on a stroke unit has increased from 51% in 2006 to 58% in 2008 and reached 70% 2010.

68. NCGC Audit – time to stroke unit In 2008, only 17% of stroke patients reached the stroke unit within 4hrs of their arrival at hospital. By 2010 this has more than doubled to 38% but there is massive room for improvement.

69. NCGC Thrombolysis rate 1.8% in 2008 5% in 2010 This should increase further as more areas of the country start providing 24 hour a day seven day a week hyper acute stroke services.

70. NCGC Alteplase Treatment must be started within 3 hours of onset of the stroke symptoms and after prior exclusion of intracranial haemorrhage by means of appropriate imaging techniques.

71. NCGC NICE recommendations Alteplase is recommended for the treatment of acute ischaemic stroke when used by physicians trained and experienced in the management of acute stroke. It should only be administered in centres with facilities that enable it to be used in full accordance with its marketing authorisation.

72. NCGC Alteplase Alteplase should only be administered within a well organised stroke service with: staff trained in delivering thrombolysis and in monitoring for any associated complications immediate access to imaging and re- imaging, and staff appropriately trained to interpret the images.

73. NCGC Audit – AF and stroke ~12,500 strokes a year directly attributable to AF. NICE guideline recommends that the most effective treatment, for patients with AF post-stroke, is with warfarin. However………

74. NCGC 2011 pre publication findings People admitted with stroke: Only 27% who were recorded as having AF before their stroke were taking warfarin Failure to anticoagulate large numbers of people at risk of stroke due to AF

75. NCGC Audit 26 standards used to calculate score IMPORTANTLY over the 10 years of audit we have been able to identify 9 key indicators, a minimum dataset Known as a ‘bundle of stroke care’

76. NCGC Minimum dataset Following the third round of audit in 2002 a minimum dataset was selected to best represent the total clinical process for each hospital. Between 2006 and 2008 this was reduced to 9 key indicators in consultation with the Department of Health and the Healthcare Commission.

77. NCGC 9 key audit indicators 1Patients treated for 90% of stay in a Stroke Unit 2Screened for swallowing disorders within first 24 hours of admission 3Brain scan within 24 hours of stroke 4Commenced aspirin by 48 hours after stroke 5Physiotherapy assessment within first 72 hours of admission 6 Assessment by an Occupational Therapist within 4 working days of admission 7Weighed at least once during admission 8Mood assessed by discharge 9Rehabilitation goals agreed by the multi-disciplinary team

78. NCGC Audit changes over time NoQuality indicator % compliance2004200620082010 1Pts treated for 90% stay in stroke unit-515870 2Swallowing scrned 24hrs admission63667283 3Brain scan 24hrs of stroke59425970 4Commenced aspirin 48 hrs of stroke68718593 5Physio assess within 72hrs admission63718491 6OT assess within 4 WDs admission-496683 7Weighed during admission52577283 8Mood assess by discharge47556580 9MTD rehab goals agreed68768694 Average for 9 indicators-607283

79. NCGC % pts with all 9 indicators This “bundle” of indicators describes the percentage of patients receiving all 9 key standards nationally and within each hospital trust Individual hospital results provided National data publically available

80. NCGC NCGC work leading to Oman Quality Improvement Funded, published and acclaimed work informing health care decisions in another health care context is possible:

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82. NCGC PARIHS: The theoretical frameworkSTROKE Oman policy and professionals NCGC

83. NCGC Information and knowledge upon which decisions about care are based: 1. Research 2. Clinical Experience 3. Patient Experience 4. Local Information/Data The Nature of Evidence http://www.parihs.org/pages/core_parihs_papers.html

84. NCGC The process is about: 1. Evidence 2. Context 3. Culture Evidence translation leading to utilisation

85. NCGC The quality spiral Largest EB guideline centre in world Commissioned by DH / NICE 14 guidelines in development, rolling programme XXX scoping Full guideline takes XXX months Omani ‘evidence translation and utilisation’ Omani national audit providing ‘benchmarking for quality’ Omani ‘healthcare system change leading to sustainable improvements’

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87. NCGC Henry Ford Coming together is a beginning Keeping together is progress Working together is success