Best Practice: Consideration and implementation
of NICE Guidance
Policy: GV10
Policy Descriptor
This policy sets out the arrangements to ensure that Devon Partnership NHS
Trust takes NICE (National Institute for Health and Clinical Excellence)
guidance into account when providing clinical services. It sets out the
processes for the dissemination of such guidance, the responsibilities of
clinical leaders, managers and relevant groups and the reporting structures to
support the implementation. Finally it sets out the system in place to monitor
the above processes.
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GV10 Policy for the consideration and implementation of NICE
Guidance
v2.0
Previous policy dated July 2015
Shaun Alexander
Head of Experience, Safety and Risk
[email protected]
Sally Lloyd-Tomlins, Clinical Effectiveness Lead
[email protected]
Executive Director of Nursing and Practice Paul Keedwell,
Managing Partners, Heads of Profession, Clinical Directors
Local Delivery Unit managers and Clinical Team Leaders
2 March 2017
March 2017
March 2019
Contents
1.
Introduction ................................................................................................................. 3
2.
Purpose ....................................................................................................................... 3
3.
Definitions .................................................................................................................. 3
4.
Duties........................................................................................................................... 4
5.
Process for the Implementation of NICE Guidance ................................................. 5
6.
Action plan tracking process .................................................................................... 6
7.
Patient and Public Involvement ................................................................................ 6
8.
Monitoring ................................................................................................................... 6
9.
References .................................................................................................................. 6
Appendix 1 - Flow Diagram for the Implementation of NICE Guidance ........................ 7
Appendix 2 - Process Monitoring Tool ............................................................................ 8
These are the key points for action from this policy:

The NICE Implementation and Audit Group is responsible for overseeing and supporting
the process for the implementation of NICE guidance.

All agreed NICE implementation actions will be added to the Risk Management System
by the service / directorate that has identified the actions as part of their review. If the
actions have been identified by the NIAG or other corporate group it they will be added to
the RMS by the central clinical audit team

When implementing new national guidance, services are encouraged to consider their
client group and where possible involve individuals or groups at different stages of the
procedure, particularly where significant change is proposed.
2
1. Introduction
1.1.
The Devon Partnership NHS Trust is responsible for ensuring that agreed best practice as
defined in National Institute for Clinical Excellence (NICE) clinical guidelines and standards
is taken into account in the context of the clinical services provided by the organisation and
that where appropriate the guidelines are implemented and the whole monitored.
2. Purpose
2.1.
The purpose of this policy is to set out a coordinated process within the Trust for the
identification of relevant NICE guidance, its dissemination and implementation. In addition it
covers the undertaking of a self-assessed organisational gap analysis, action planning to
achieve compliance where appropriate and the highlighting of any risks that arise out of the
self-assessment. Finally it details the system in place to monitor the above processes.
3. Definitions
3.1.
Technology Appraisals (TAs) – These make recommendations on the use of new and
existing health technologies within the NHS. Each TA focuses on a particular technology,
which may be a drug, medical device, diagnostic technique, surgical procedure, or other
interventions. Approximately a third of TAs refer to technologies other than drugs.
3.2.
Clinical Guidelines (CGs) – These are concerned with the management of a particular
disease or condition, and may focus on any aspect (e.g. prevention and self-care,
management in primary and secondary care).
3.3.
NICE Implementation and Audit Group (NIAG) – a group of senior staff which meet to
ensure that the Trust is working to meet the requirements of the Best Practice:
Consideration and implementation of NICE Guidance Policy (GV10) and the NHS Audit
Committee Handbook. The group receives monthly reports from the Clinical Effectiveness
Lead to support the assurance reporting to the Quality and Safety Committee. A detailed
report is submitted to the Senior Management Board and Quality and Safety Committee
covering all NICE implementation activity and any identified areas of non-compliance with
the implementation process. The NIAG Clinical Group is a subgroup of the NIAG and is
responsible for the initial review and consideration of new guidance that has been published
and consideration of the most appropriate route for further dissemination and assessment.
3.4.
Interventional Procedure Guidance (IPGs) – NICE commenced the series of IPG
documents in July 2003 to assess whether or not interventional procedures are safe
enough and work well enough for routine use in the NHS. Guidance aims to protect the
safety of patients whilst supporting clinicians and healthcare organisations in the process of
introducing and auditing new procedures. The programme also scrutinises more
established procedures if there is uncertainty about safety or efficacy. IPGs are not relevant
to the work of the Trust as a Mental Health Trust it is not assessed on these.
3.5.
Public Health Programme Guidance – Public health programme guidance deals with
broader action for the promotion of good health and the prevention of ill-health. This
guidance may focus on a topic, such as smoking, or on a particular population, such as
young people, or on a particular setting, for example, the workplace.
3.6.
NICE Quality Standards – NICE quality standards are a set of specific, concise
statements that act as markers of high-quality, cost-effective patient care, covering the
treatment and prevention of different diseases and conditions. Derived from the best
available evidence such as NICE guidance and other evidence sources accredited by NHS
Evidence, they are developed independently by NICE, in collaboration with the NHS and
social care professionals, their partners and service users, and address three dimensions
of quality - clinical effectiveness, patient safety and patient experience.
3
3.7.
Quality and Safety Committee – a group of senior staff and executive managers who
examine the Trust’s systems and processes in respect of reporting quality and clinical
safety which will include a monthly review of the Trust’s Corporate Risk Register, incidents,
inquiries, learning from experience and clinical governance scorecard. They will receive
reports from other committees and make recommendations providing assurance to the
board and ensuring learning and feedback is embedded across the Trust.
4. Duties
4.1.
The Clinical Effectiveness Lead (CEL)
4.1.1. Maintains a database of all published NICE guidance.
4.1.2. Horizon scans for new NICE guidance and collates a monthly list of all guidance
published and in development by the National Institute for Health and Clinical
Excellence for consideration by the NICE Implementation and Audit Group with
regard to relevance to the Trust.
4.1.3. Registers all guidance on the database under appropriate priorities.
4.1.4. Presents agreed relevant guidance to identified Integrated Care Pathway (ICP)
Groups or Leads for consideration, review and completing of a compliance
assessment. Where there is no ICP this will be undertaken by the identified service
or clinical lead.
4.1.5. Receives completed reviews and compliance assessments back from the ICP
groups/leads or service / clinical leads and presents to the NICE Implementation
and Audit Group at its next meeting.
4.1.6. Registers the full process and final action plan in the relevant folder for the particular
piece of guidance on the Clinical Audit shared drive.
4.1.7. Provides a monthly report to NICE Implementation and Audit Group identifying any
areas of risk or issues.
4.2.
NICE Implementation and Audit Group
4.2.1. Receives details of all new NICE guidance for review and determination of their
relevance to the trust. This responsibility is delegated to the NIAG Clinical Group
which is a subgroup of the NIAG and is responsible for the initial review and
consideration of new guidance that has been published and consideration of the
most appropriate route for further dissemination and assessment.
4.2.2. Where confirmed as relevant the identification of either the appropriate integrated
care pathway (ICP) for detailed review and confirmation of compliance. Where not
related to an existing ICP the identification of the appropriate service / clinical lead
for further review and confirmation of compliance.
4.2.3. Receives all completed reviews and compliance statements and agrees these prior
to further action or implementation.
4.2.4. Receives all completed audits of compliance with ICPs / NICE guidance at the
agreed timescales and agrees related action plans.
4.2.5. Provides an agreed position statement to the Quality and Safety Committee which
describes the level of compliance with all guidance determined as relevant, risks
4
identified in relation to overall compliance and recommendations for further action
required.
4.3.
ICP Group / Lead or Service / Clinical Lead
4.3.1. Receive and action requests made by the NICE Implementation and Audit Group to
complete reviews and compliance statements.
4.3.2. Submit completed reviews and compliance statements. Attend and present (as
agreed) to the NICE Implementation and Audit Group.
4.3.3. Provide updates of progress and actions at agreed timescales to the NICE
Implementation and Audit Group.
4.3.4. Provide a point of contact and lead for any agreed clinical audit against the ICP /
NICE guidance.
5. Process for the Implementation of NICE Guidance
5.1.
The NICE Implementation and Audit Group is responsible for overseeing and supporting
the process for the implementation of NICE guidance. The process is described in the
flowchart in Appendix 1.
5.2.
The Clinical Effectiveness Lead (CEL) carries out a monthly horizon scan of all new NICE
guidance and submits this to the NICE Implementation and Audit Group.
5.3.
The NICE Implementation and Audit Group reviews all the guidance and determines
whether it is relevant to the trust.
5.4.
The NICE Implementation and Audit Group identifies whether the guidance is relevant to
an existing or proposed Integrated Care Pathway (ICP).
5.5.
If it is relevant to and ICP, the ICP group or lead is asked to complete a detailed review of
the guidance and provide a compliance statement to include an exception statement
where elements of the guidance will not be implemented.
5.6.
Where no ICP exists or is under development, the NICE Implementation and Audit Group
identifies an appropriate service or clinical lead to complete a detailed review of the
guidance and provide a compliance statement.
5.7.
The ICP Group(s) or identified service/clinical lead complete a detailed review of the
guidance and provides a compliance statement, this should include actions required to
achieve full compliance and agreed timescale for audit. These are submitted to the NICE
Implementation and Audit Group for review and approval.
5.8.
The NICE Implementation and Audit Group receives all completed reviews, compliance
statements and associated action plans for review and approval.
5.9.
The agreed review and compliance statement is recorded in the relevant folder for the
particular piece of guidance and on the Trust NICE guidance database on the Clinical
Audit shared drive.
5.10.
The NICE Implementation and Audit Group will consider any identified current service
developments or new services and the possible implication of previously published
guidance, particularly where these were deemed as not relevant at the time.
5
5.11.
The NICE Implementation and Audit Group provides an agreed position statement to the
Quality and Safety Committee which describes the level of compliance with all guidance
determined as relevant, risks identified in relation to overall compliance and
recommendations for further action required.
6. Action plan tracking process
6.1.
All agreed NICE implementation actions will be added to the Risk Management System by
the service / directorate that has identified the actions as part of their review. If the actions
have been identified by the NIAG or other corporate group it they will be added to the RMS
by the central clinical audit team.
6.2.
The NICE Implementation and Audit Group are informed of any concerns via a monthly
report and will determine the required action and/or escalation.
6.3.
A flow diagram of the implementation process is at Appendix 1
7. Patient and Public Involvement
7.1.
When implementing new national guidance, services are encouraged to consider their
client group and where possible involve individuals or groups at different stages of the
procedure, particularly where significant change is proposed.
8. Monitoring
8.1.
Responsibility – the process of monitoring compliance with this policy will be the
responsibility of the Clinical Effectiveness Lead who will report to the NICE Implementation
and Audit Group.
8.2.
Method – compliance with the policy and related process will be reported by exception
monthly to the NICE Implementation and Audit Group.
8.3.
The CEL will be responsible for collecting evidence for compliance with the standards, as
detailed in Appendix 2, on a rolling basis, and will collate it and present the results in the
form of a report which will be presented to the NICE Implementation and Audit Group.
8.4.
The report will highlight any gaps in the documentation and any areas where performance
against the standards is giving cause for concern, and will assess performance against any
previous action plans which had been put in place.
8.5.
Results and action planning – The NICE Implementation and Audit Group will make
recommendations based on the report and take immediate remedial action where
necessary. The performance against the action plan will form part of the regular six-monthly
monitoring.
8.6.
The Quality and Safety Committee is informed of any concerns via a bi-monthly report.
9. References
National Institute for Health and Clinical Excellence (NICE) www.nice.org.uk
6
Appendix 1
7
Appendix 2 - Process Monitoring Tool
Standards
NICE guidance
Evidence
A database of all published NICE guidance will be kept
Database
A monthly list of guidance will be drawn up and presented to the NICE Implementation
and Audit Group for consideration of relevance
Minutes of meeting
Relevance of guidance is indicated on the Trust Database
Database
Relevant guidance is considered by ICP or Service / Directorate Leads and review /
compliance statements
Completed reviews / compliance statements
and minutes of meeting
Action plans are added to the Risk Management System (RMS)
The RMS
The Trust will not be implementing the guidance
Completed reviews / compliance statements
and minutes of meeting
The Quality and Safety Committee will be informed of any issues by submission of the bimonthly NIAG report
Reports and minutes of meeting
Areas of risk reported will be reported to the NICE Implementation and Audit Group and
Q&S Committee and added to the risk register if appropriate
Reports and minutes of meeting
Risk register
8