NICE Quality Standards: The Most Misused Audit Tool in the NHS

The Fundamental Purpose of NICE Quality Standards

NICE Quality Standards (QS) are concise, evidence-based statements designed to drive measurable quality improvements within specific areas of care. They are not clinical guidelines. Understanding this distinction is critical to their correct application.

What Quality Standards Are Designed For

• Setting Benchmarks: QS define the priority areas for quality improvement in a specific topic, describing what high-quality care looks like.
• Supporting Commissioning: They help commissioners plan and purchase services that meet defined quality criteria.
• Enabling Measurement: QS provide a framework for assessing performance against national priorities.
• Informing Service Design: They support the development of care pathways and service specifications.

Quality Standards are derived from the most important recommendations within a corresponding NICE Guideline (NG). They are intentionally selective, focusing on areas with the most significant potential for improving patient outcomes, reducing inequality, or delivering efficiency.

When Not to Use a Quality Standard for Audit

Misapplication of QS is the most common reason for audit proposal rejection at governance approval stages. Recognising these scenarios will prevent wasted effort.

Common Misuse Scenarios

• As a Primary Diagnostic or Treatment Guideline: QS do not provide the comprehensive clinical detail found in NICE Guidelines (NG). Auditing a specific drug dosage or a complex diagnostic pathway requires the full NG, not the high-level QS.
• For "Tick-Box" Compliance Checks: Using a QS to simply check if a policy exists (e.g., "Does the trust have a policy for X?") is a low-value audit. QS are about measuring the impact and delivery of care, not just the existence of documentation.
• When the Population is Too Narrow: A QS covers a broad patient group. Auditing against a QS statement with a very small, highly specific cohort (e.g., auditing QS 201 for COPD in a specialist cystic fibrosis clinic) is often inappropriate.
• As a Substitute for a Local Needs Assessment: Do not default to a QS simply because it exists. The best audits address identified local clinical risks, incidents, or variations in care, which may not align perfectly with a national QS priority.

Correct Audit Phrasing Using Quality Standards

The language used in an audit proposal and its measurement plan is crucial. Vague aims lead to uninterpretable results.

Structuring the Audit Aim

A well-structured aim explicitly links the local improvement goal with the specific, measurable element of the Quality Standard.

Defining Measurable Criteria

Each Quality Standard statement is supported by "Quality Measures." These are structured as:

• Structure Measures: Evidence that systems, facilities, and resources are in place (e.g., "Proportion of patients offered a follow-up within 7 days").
• Process Measures: Evidence that care is delivered according to the standard (e.g., "Proportion of patients who received a specified intervention").
• Outcome Measures: Evidence that the care achieves the intended results (e.g., "Rate of hospital readmission within 30 days").

Your audit criteria must be directly mapped to these measure types.

Example for Foundation Trainees: Diabetes Foot Care

QS Statement (from QS 19): "People with diabetes and a foot ulcer are referred immediately to a multidisciplinary foot care service."

Poorly Defined Criterion: "To see if referrals are done." (Vague, unmeasurable).

Well-Defined Criterion: "The proportion of patients presenting to the Emergency Department or Acute Medical Unit with a new diabetic foot ulcer who have a documented referral to the multidisciplinary foot care service made on the same day of presentation."

Examples of Rejected vs Accepted Audits

Contrasting these examples clarifies the distinction between misapplication and correct use for different training levels.

Example 1: Atrial Fibrillation (QS 93)

Example 2: Sepsis (QS 161)

Actionable Guidance for Governance Teams and Audit Leads

Governance teams play a vital role in guiding clinicians towards high-quality, meaningful audit projects.

Checklist for Approving QS-Based Audits

• Specificity: Does the audit aim reference a specific QS statement by number and exact wording?
• Measurability: Are the audit criteria directly translatable into a quantifiable measure (a percentage, a time, a rate)?
• Local Relevance: Does the project address a known local gap, risk, or variation in care?
• Appropriate Scope: Is the patient population and time frame feasible for a complete audit cycle?
• Improvement Focus: Is the intent to drive change, or is it merely a data collection exercise? The proposal should outline plans for implementing changes based on findings.

Supporting Trainees

For Foundation Year and Core Trainees, the focus should be on learning the audit cycle methodology. Recommend they:

• Choose a single, straightforward QS statement.
• Select a clearly defined patient group (e.g., "patients admitted with a primary diagnosis of COPD").
• Extract one or two key process measures to audit.
• Ensure the project can be completed within their rotation.

For Registrars and SAS Doctors, encourage more complex projects that may involve re-audit, multi-departmental pathways, or the analysis of outcome measures linked to process changes.

By applying this structured approach, NHS clinicians and governance teams can ensure that NICE Quality Standards are used as the powerful quality improvement tools they were designed to be, moving beyond tick-box exercises to deliver meaningful, measurable enhancements to patient care.