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					                                                                         CORP/COMM 10            v.1




    POLICY FOR THE RECEIPT, DISTRIBUTION AND REVIEW OF
             NATIONAL REPORTS AND GUIDANCE

        (incorporating NICE, NSF’s, National Confidential Enquiries and
                             High Level Enquiries)




 Name of author                              Mandy Dalton, Head of Risk & Legal
                                             Services
 Approved by (Committee/Group)               Clinical Review Group
 Date of approval                            7th December 2007
 Date issued                                 7th December 2007
 Review date                                 December 2009
 Target audience:                            Trust wide



WARNING: Always ensure that you are using the most up to date policy or procedure document. If you
are unsure, you can check that it is the most up to date version by looking on the Trust Website:
www.dbh.nhs.uk under the headings → ‘Freedom of Information’ → ‘Information Classes’ → ‘Policies and
Procedures’




                                             Page 1 of 12
                                                         CORP/COMM 10   v.1

        DONCASTER & BASSETLAW HOSPITALS
             NHS FOUNDATION TRUST


POLICY FOR THE RECEIPT, DISTRIBUTION AND REVIEW OF
         NATIONAL REPORTS AND GUIDANCE
   (incorporating NICE, NSFs, National Confidential Enquiries and
                       High Level Enquiries)




                         CONTENTS



   1.                    Introduction

   2.                    Policy Statement

   3.                    Scope

   4.                    Roles and Responsibilities

   5.                    Processes

   6.                    Organisational Learning

   7.                    References



                         Appendix 1 – Definitions

                         Appendix 2 – Gap Analysis

                         Appendix 3 – NICE Guidance pro-forma




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                                                                         CORP/COMM 10             v.1

                         DONCASTER & BASSETLAW HOSPITALS
                              NHS FOUNDATION TRUST


              POLICY FOR THE RECEIPT, DISTRIBUTION AND REVIEW OF
                       NATIONAL REPORTS AND GUIDANCE
                   (incorporating NICE, NSFs, National Confidential Enquiries and
                                       High Level Enquiries)


1.    INTRODUCTION

1.1   This policy has been developed to ensure that the Trust has in place a systematic approach for
      the receipt, distribution and review of the findings and recommendations from national reports
      and guidance.

1.2   Implementation of national guidance and advice is considered to be core to the objectives of the
      organisation and supports the core and developmental Standards for Better Health within the
      second domain – Clinical and Cost Effectiveness.

1.3   In addition, the NHSLA Risk Management Standards require that organisations ensure that
      agreed best practice as defined in the national service frameworks (NSFs), NICE clinical
      guidelines, national confidential enquiries (NCEs) and other nationally agreed guidance is taken
      into account.

2.    POLICY STATEMENT

2.1   The Trust is committed to ensuring that:
      • it complies with agreed best practice;
      • important lessons are learnt from events, which have occurred outside of the Trust,
      • patient safety and the quality of care maintained and where relevant, improved as a result.

2.2   To achieve this, the Trust will ensure that national guidance which impacts on local service
      provision is considered and, where relevant, acted upon. In each case a senior lead will be
      identified to oversee a process of review, evaluation and action planning.

2.3   Individual clinicians have responsibility for ensuring that their own practice complies with the
      requirements of guidance.

3.    SCOPE

      The policy sets out how the national reports and guidance are identified, disseminated, reviewed
      and, where appropriate, implementation is monitored and suitable records are maintained. The
      national reports and guidance include:

      • National Service Frameworks (NSFs)
      • National Confidential Enquiries (NCEs)
      • National Institute for Health and Clinical Effectiveness (NICE) Guidance
      • National Patient Safety Agency (NPSA) Alerts
      • Healthcare Commission Investigation Reports
      • Healthcare Commission Service Improvement Reviews and Audits
      • Safety Alert Broadcast System (SABS)
      • High Level Enquiries (HLEs)
      (Further details of each of these areas can be found in appendix 1)


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                                                                            CORP/COMM 10             v.1
4.      ROLES AND RESPONSIBILITIES

4.1     The process for managing the different types of reports and guidance, along with specific roles
        and responsibilities are detailed in the section 5 however the following general roles and
        responsibilities exist.

4.2     The overall responsibility for ensuring that the Trust takes account of national reports and
        guidance rests with the Board of Directors and for clinical issues, specifically with the Medical
        Director and the Director of Clinical Audit, Research & Effectiveness.

4.3     The Clinical Governance Sub Committee and Clinical Review Group take a lead in monitoring
        the implementation of action plans resulting from national reports and guidance.

5.      PROCESSES

5.1     National Service Frameworks

5.1.1   National service frameworks (NSFs) are long term strategies for improving specific areas of
        care. They set measurable goals within set time frames. NSFs:
        • Set national standards and identify key interventions for a defined service or care group
        • Put in place strategies to support implementation
        • Establish ways to ensure progress within an agreed time scale
        • Form one of a range of measures to raise quality and decrease variations in service.

5.1.2   The publication of new national service frameworks will be identified by the Clinical Audit
        Manager via the weekly Department of Health Chief Executives bulletin.

5.1.3   Due to the size and scope of the NSF’s it is recognised that different processes are required for
        each framework however the following principles will apply:
           A lead will be identified for each NSF who will be responsible for reviewing the NSF and co-
           ordinating the required action. Where NSF’s contain a wider spread of issues leads may be
           identified for different sections.
           As a minimum twice-yearly updates will be presented to the Clinical Governance Sub
           Committee detailing progress made and outstanding issues, in particular highlighting where
           a national milestone has not, or will not, be met. At this point, a decision by the Board of
           Directors will be made with regard to entry onto the Corporate Risk Register.

5.2     National Confidential Enquiries

5.2.1   National Confidential Enquiries are nationally co-ordinated studies in which clinicians
        confidentially review practice on a given topic. The results of these reviews are then brought
        together to provide a national picture and develop recommendations. These confidential
        enquiries come within the umbrella of the National Institute for Clinical Excellence (NICE) and,
        as such, Trusts are required to respond to recommendations contained within their reports in the
        same way as NICE guidance. (For further details see appendix 1 – Definitions)

5.2.2   The Trust’s local National Confidential Enquiry Reporter (NCER) will take a lead in ensuring that
        the recommendations arising from National Confidential Enquiries are considered by the Trust
        and will specifically:
        • Check all relevant websites on a monthly basis to identify any new reports.
        • Maintain a database of all published and expected reports.
        • Inform the Clinical Governance Sub Committee when a new report has been published.

5.2.3   Whenever a new Confidential Enquiry report is published, the NCER will review the report,
        decide which Directorate(s) the report applies to and develop a ‘gap analysis’ detailing each of
        the recommendations (see appendix 2 for the gap analysis template).


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                                                                             CORP/COMM 10              v.1
5.2.4   The gap analysis aims to identify for each recommendation:
        • Whether the Trust is fully compliant, partially compliant or non-compliant.
        • For those recommendations where we are fully compliant, what evidence we have to
           support this view.
        • For those recommendations where we are partially or non-compliant what action is required,
           the timescale for implementation and responsibility.

5.2.5   Copies of the report and gap analysis will be forwarded to the appropriate Clinical Director who
        will be asked to nominate an appropriate individual(s) to complete the gap analysis. This
        request will be copied to the Directorate Clinical Governance Lead and shared with the
        Directorate Clinical Governance Group for information.

5.2.6   Responses are collated centrally and any conflicts in response will, in the first instance, be
        referred back to the relevant Clinical Directors for further discussion. If agreement still cannot
        be reached, the issue will be referred to the Medical Director to facilitate discussion and reach a
        consensus.

5.2.7   Following completion of the gap analysis, an action plan will be developed to address any areas
        of partial or non-compliance. Each action will include details of the responsible officer(s) and
        timescale.

5.2.8   In the rare cases where a decision is taken not to comply with the recommendation the
        directorate response should include justification for this decision.

5.2.9   All new action plans will be added to the Trustwide plan held by the Clinical Audit, Research and
        Effectiveness department.

5.2.10 A Confidential Enquiry progress report will be presented annually, to the Clinical Governance
       Sub-Committee. This report will contain:
       • Progress against existing action plans
       • Details of the Trust compliance against newly-published confidential enquiries and new
          action plans
       • Details of the reasons for any departures from recommended practice.

5.2.11 Following presentation at the Clinical Governance Sub Committee, a copy of the progress report
       will be sent to Directorate Clinical Governance Leads for presentation at Directorate Clinical
       Governance Meetings.

5.3     NICE Guidance

5.3.1   NICE is an independent organisation responsible for providing national guidance on promoting
        good health and preventing and treating ill health. NICE issues various different types of
        guidance – for further details see appendix 1 – Definitions.

5.3.2   The Clinical Audit Manager will centrally co-ordinate the distribution of guidance, and will
        maintain a central database and library of guidance.

5.3.3   All guidance is issued via the National Institute for Health and Clinical Excellence web site on
        the 25th of each month. In addition, paper copies of Interventional Procedure guidance and
        summary Technology Appraisal and Clinical Guidelines documents are received by the Trust.

5.3.4   As soon as practicable after the date of publication, newly issued guidance will be accessed
        centrally from the NICE website, and a decision made as to the appropriate directorate(s) to
        review and implement the guidance www.nice.org.uk.




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                                                                             CORP/COMM 10             v.1
5.3.5   The guidance will be forwarded in electronic format, to the Clinical Director for the relevant
        directorate(s), copied to the Directorate Clinical Governance Lead and shared with the
        Directorate Clinical Governance Group(s), and to the Drugs & Therapeutics Committee if
        appropriate. In addition, each month, a list of all guidance issued, and its distribution, will be
        forwarded to all Clinical Directors, Clinical Governance and Clinical Audit Leads for information.

5.3.6   The Clinical Director will be asked to nominate an individual to review the guidance and respond
        on behalf of the directorate. The review of the guidance should identify:
        • The Trust’s current position in relation to the guidance
        • Any implications for clinical practice
        • Any financial consequences of implementing guidance
        • Any other implications for the Trust
        • Any plans for local audit

5.3.7   Following this review, the relevant directorate(s) will complete the review proforma (see
        appendix 3), which will be signed-off by the Clinical Director and then forwarded to the Clinical
        Audit Manager.

5.3.8   Where directorates do not meet the requirements of NICE guidance, and are for any reason
        unable to comply, or feel that the guidance is inappropriate to the local circumstances, this will
        be reported by the Directorate Clinical Governance Lead to the Trust Clinical Governance Sub
        Committee.

5.3.9   Directorates will agree any changes in local practice which are required in order to comply with
        NICE guidance. Where guidance has an impact on more than one directorate, Clinical Directors
        or their nominated deputy will liaise regarding implementation of the guidance.

5.3.10 All NICE Guidance is considered by the PCT Clinical Effectiveness Unit which is required to
       take note of any potential financial implications of the Guidance and that these are duly noted
       and acted upon when commissioning services from the Trust.

5.3.11 Responses received will be incorporated into a report, to be received by Clinical Governance
       Sub-Committee annually. Any actions will be monitored by the Clinical Governance Sub
       Committee.

5.3.12 A database of the Trust’s position in relation to each piece of guidance and issues raised during
       review, and library of all issued guidance, will be maintained centrally.

5.4     National Patient Safety Agency (NPSA) Alerts

5.4.1   The NPSA is a special health authority created to co-ordinate learning from patient safety
        incidents occurring in the NHS; which includes the monitoring, analysis and development of
        patient safety solutions for issues identified through the National Reporting and Learning
        System. Advice and recommendations for action are distributed to trusts using the Safety Alert
        Broadcast System (SABS) in the following formats:
        • Safer Practice Notice (SPN)
        • Patient Safety Alert (PSA).

5.4.2   These alerts are received via the Safety Alert Broadcast System (SABS) process. Please refer
        to Policy and Procedures relating to the reporting of adverse incidents involving medical devices
        and dissemination of safety alert broadcasts CORP/RISK 6 for further information.

5.4.3   The Medical Technical Services Manager receives all SABS and will send the SPN/PSA to the
        nominated lead. The nominated lead will ensure a review is undertaken of the SPN/PSA with
        relevant specialties to identify action required and timescales for completion.



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                                                                           CORP/COMM 10             v.1
5.4.4   The SPN/PSA and completed gap analysis will be presented to the Clinical Governance Sub-
        Committee, Clinical Review Group, Directorate Clinical Governance Groups and other groups
        as appropriate to agree action required by the Trust and any resource implications.

5.4.5   Progress with the action taken will be monitored via the Medical Technical Services Manager
        and reported to the Clinical Review Group. Once actions are complete a programme of review
        and audit will be agreed.

5.5     Healthcare Commission Investigation Reports

5.5.1   The Healthcare Commission investigates serious service failures in the NHS, where the
        situation meets the necessary criteria or when instructed to do so by the Secretary of State for
        Health. Following each investigation the Healthcare Commission publishes a report of it’s
        findings including recommendations for the organisation under investigation.

5.5.2   The Chief Executive will take active steps to ensure that the recommendations arising from
        Healthcare Commission investigation reports are considered by the Trust and will specifically:
        • Check the Healthcare Commission website on a monthly basis to identify any new reports.
        • Maintain a database of all published and expected reports.

5.5.3   Whenever a new report is published, the Chief Executive will review the report and identify an
        Executive Lead and appropriate Operational Lead. The Operational Lead will develop a ‘gap
        analysis’ detailing each of the recommendations (see appendix 2 for the gap analysis template).

5.5.4   The gap analysis aims to identify for each recommendation:
        • Whether the recommendation is applicable to the Trust
        • For those recommendations which are applicable whether the Trust is fully compliant,
           partially compliant or non-compliant.
        • For those recommendations where we are fully compliant, what evidence we have to
           support this view.
        • For those recommendations where we are partially or non-compliant what action is required,
           the timescale for implementation and responsibility.

5.5.5   All action plans will be added to the Trustwide plan held by the Clinical Audit, Research &
        Effectiveness department.

5.5.6   On completion of the review a report and action plan will be presented to Clinical Governance
        Sub-Committee. Ongoing monitoring of the action plan will be undertaken on a six-monthly
        basis.

5.6     Healthcare Commission Improvement Reviews

5.6.1   An improvement review is a review of a particular aspect of healthcare that is applied in every
        relevant organisation. Its aim is to encourage each organisation taking part to improve the
        quality of healthcare it provides to patients and the public.

5.6.2   When an improvement review is initiated the Chief Executive will identify an appropriate
        individual to lead the data collection on behalf of the Trust. This individual will:
        • Ensure that accurate data is submitted within the deadlines set.
        • Be responsible for ratifying the provisional data
        • Reviewing the trust’s results and co-ordinating an action plan to address areas of concern.

5.6.3   On completion of the review a report and action plan will be presented to the Clinical
        Governance Sub Committee. Ongoing monitoring of the action plan will be undertaken on a six-
        monthly basis.



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                                                                              CORP/COMM 10             v.1
5.7      Safety Alert Broadcast System (SABS)

         Please refer to Policy and Procedures relating to the reporting of adverse incidents involving
         medical devices and dissemination of safety alert broadcasts CORP/RISK 6.

5.8      High Level Enquiries

5.8.1    In addition to the reports detailed above a wide range of other ad-hoc national reports are
         published which may be relevant to the Trust. Identification of these reports will be by the Chief
         Executive via the weekly Department of Health Chief Executives bulletin.

5.8.2    These reports will be considered by the Medical Director and Director of Nursing who will decide
         on appropriate action, for example full review of recommendation, presentation to appropriate
         meetings, etc.

5.8.3    If a full review of recommendations is required the process for Healthcare Commission
         Investigation Reports will be followed.

5.8.4    The Clinical Audit, Research and Effectiveness department will maintain a database of these
         reports including details of action identified.


6.       ORGANISATIONAL LEARNING

6.6.1.   The Clinical Governance Sub-Committee will be accountable for ensuring completion of actions
         plans, in full, and will be provided with evidence of lessons learned

6.6.2.   It is essential that staff receive information and feedback on all national reports and guidance.
         This will be provided locally via Directorate Clinical Governance Groups and on an annual basis
         within the Director of Clinical Audit, Research and Effectiveness Annual Report.

7.       REFERENCES

            Standards for Better Health, Department of Health, July 2004
            NHSLA Risk Management Standards for Acute Trusts (2007)
            Guidelines for reviewing the participation in the National Confidential Enquiry into Patient
            Outcome and Death and implementing NCEPOD Guidance.
            Policy and Procedures relating to the reporting of adverse incidents involving medical
            devices and dissemination of safety alert broadcasts CORP/RISK 6.




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                                                                         CORP/COMM 10             v.1
                                                                                        APPENDIX 1
DEFINITIONS

1.    National Confidential Enquiries

1.1   There are currently three National Confidential Enquiries/Inquiries:
      • The National Confidential Enquiry into Patient Outcome & Death (NCEPOD)
      • The Confidential Enquiry into Maternal and Child Health (CEMACH)
      • The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

1.2   The National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
      reviews medical clinical practice and makes recommendations to improve the quality of the
      delivery of care. This is done by undertaking confidential surveys covering many different
      aspects of medical care and making recommendations for clinicians and management to
      implement.

1.3   The Confidential Enquiry into Maternal and Child Health (CEMACH) aims to improve the
      health of mothers, babies and children by carrying out confidential enquiries on a nationwide
      basis. CEMACH is a self governing body managed by its own board with members nominated
      by eight Royal Colleges including:-
      • Royal College of Obstetricians & Gynaecologists (RCOG)
      • Faculty of Public Health (FPH)
      • Royal College of Anaesthetists (RCA)
      • Royal College of General Practitioners (RCGP)
      • Royal College of Midwives (RCM)
      • Royal College of Paediatrics & Child Health (RCPCH)
      • Royal College of Pathologists (RCPath)
      • Royal College of Psychiatrists (RCPsych)

1.4   The Confidential Enquiry into Suicide and Homicide by People with Mental illness (CISH)
      considers all incidences of suicide and homicide that occur within mental health services in the
      UK. Although the focus of the recommendations from this enquiry is on mental health services
      the Trust considers the impact of the recommendations for our services

2.    NICE Guidance

2.1   The National Institute for Health and Clinical Excellence (NICE) is an independent organisation
      responsible for providing national guidance on the promotion of good health and the prevention
      and treatment of ill health. NICE currently published 3 types of guidance:
      • Technology Appraisals
      • Clinical Guidelines
      • Interventional Procedures

2.2   Technology Appraisals are recommendations on the use of new and existing medicines and
      treatments within the NHS in England and Wales, such as:
      • medicines
      • medical devices (for example, hearing aids or inhalers)
      • diagnostic techniques (tests used to identify diseases)
      • surgical procedures (for example, repairing hernias)
      • health promotion activities (for example, ways of helping people with diabetes manage heir
          condition).

      Since January 2002, the NHS has been legally obliged to provide funding and resources in
      England and Wales for medicines and treatments recommended by NICE’s technology
      appraisal guidance. This means that when NICE recommends a technology, the NHS must
      ensure it is available to those people it could help, normally within 3 months of the guidance
      being issued.
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                                                                          CORP/COMM 10            v.1

2.3   Clinical Guidelines are recommendations on the appropriate treatment and care of people
      with specific diseases and conditions within the NHS in England and Wales. Clinical guidelines
      are based on the best available evidence.

      In general, doctors, nurses and other healthcare professionals in the NHS are expected to
      follow NICE’s clinical guidelines. But there will be times when the recommendations will not be
      suitable for someone because of his or her specific medical condition, general health, wishes or
      a combination of these.

2.4   Interventional Procedures are used for diagnosis or treatment that involves one of the
      following:
      • Making a cut or a hole to gain access to the inside of a patient's body - for example, when
           carrying out an operation or inserting a tube into a blood vessel.
      • Gaining access to a body cavity (such as the digestive system, lungs, womb or bladder)
           without cutting into the body - for example, examining or carrying out treatment on the
               inside of the stomach using an instrument inserted via the mouth.
      • Using electromagnetic radiation (which includes X-rays, lasers, gamma-rays and ultraviolet
           light) - for example, using a laser to treat eye problems.

      NICE interventional procedure guidance looks at one or more procedures for a particular
      condition. However, these may not be the only procedures or treatments available for that
      condition and therefore the clinical healthcare team can consider what other options are
      available.




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                                                                                                                                      CORP/COMM 10           v.1
                                                                                                                                                   APPENDIX 2
                                              DONCASTER & BASSETLAW HOSPITALS NHS FOUNDATION TRUST

TITLE

                                                     Gap Analysis – DATE
______________________________________________________________________________________________________________________

Introduction

Background to the Study/Report

Gap Analysis

No.        Recommendation                       Compliance1         Comments                   Action required (if non or partial   Timescale   Responsibility
                                                                                               compliance)




1
    Compliance should be rated as full, partial or non-compliance
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                                                                                                                         CORP/COMM 10                           v.1
                                                                                                                                                 APPENDIX 3
                        DONCASTER & BASSETLAW HOSPITALS NHS FOUNDATION TRUST
                                   NICE Guidance
______________________________________________________________________________

Title:................................................................................................................................................

Ref: .........................................................           Month of Publication: ............................................

Response from: ................................................................................................................ .............

on behalf of ....................................................................................................................................
______________________________________________________________________________

1. Are procedures/drugs covered by this guidance used at DBHFT?
                              Yes              Please go to question 2
                              No               Please return form

2. Is the Trust fully compliant with this guidance?
                                   Yes
                                   No               Please go to question 3

If yes, please give evidence e.g. policy, audit results etc ....................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

3. Please detail areas of non-compliance..........................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

4. Please detail action required to achieve compliance e.g. change in practice, training, equipment,
   audit, PCT funding etc.

Action Required                                                            Responsibility                        Timescale                    Cost2?




______________________________________________________________________________

Clinical Director Authorisation – For directorate responses the Clinical Director must agree the above
assessment.

Name: .....................................................              Signature:...................................................................
______________________________________________________________________________
                                                      Please return your complete form to
                                                     Shaun Young, Clinical Audit Manager
2
    Please indicate if there will be any cost associated with this action and give an approximate cost if possible.
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