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Policy for the Implementation of NICE Guidance and NCEPOD

VIEWS: 19 PAGES: 19

									Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00




   Policy for the Implementation of NICE Guidance
           and NCEPOD Recommendations

 Version:                                   2

 Ratified by:                               Healthcare Governance Committee

 Date ratified:                             22 July 2010

 Name of originator/author/job title:       David Watson, Head of Clinical
                                            Effectiveness
                                            K Hingley, Interim Head of Clinical
                                            Governance

 Name of responsible                        Healthcare Governance Committee
 committee/individual:

 Date issued:                               July 2010

 Review date:                               July 2012

 Target audience:                           Trust Board
                                            Healthcare Governance Committee
                                            members
                                            Divisional Management Teams
                                            Director of Pharmacy




EQUALITY IMPACT
The Trust strives to ensure equality of opportunity for all both as a major employer and
as a provider of health care. This Policy Document has therefore been equality impact
assessed by the Healthcare Governance Committee to ensure fairness and
consistency for all those covered by it regardless of their individual differences, and
the results are shown in Appendix B.




                                           1
Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



        University Hospital of South Manchester NHS Foundation Trust




                           VERSION CONTROL SCHEDULE




 Version     Issue Date      Revisions from previous        Date of approval by
 number                               issue                     Committee

    1         December                                            17/12/07
                2007

    2        August 2010 Review – formerly known as               22/07/10
                         Handling of NICE & NSF
                         Guidelines




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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



Contents

Section                                                                      Page
1             Introduction                                                    4
2             Purpose                                                         4
3             Duties                                                          4
3.1           Duties within the Organisation                                  4
4.            Process                                                         6
4.1           Process for identifying relevant documents                      6
4.2           Process for disseminating relevant documents                    6
4.3           Process for conducting an organisational gap analysis           6
4.4           Gap Analysis and Action Plan                                    7
4.5           Escalation to NICE Non Compliance Panel                         8
4.6           Process for ensuring that recommendations are acted upon
                                                                              8
              throughout the organisation
4.7           Process for documenting any decision not to implement
                                                                              8
              NICE recommendations
5             Process for monitoring compliance with this the Policy for
              Implementation of NICE Guidance and NCEPOD                      8
              Recommendations
6             Standards/key performance indicators and process for
                                                                              9
              monitoring effectiveness
7             Dissemination,   Implementation    and   Access    to   this
                                                                              9
              Document
8             Review, Updating and Archiving of this Document                 10
9             References and Bibliography                                     10
10            Associated Documentation                                        10
11            Appendices                                                      10
              Appendix A - Plan for Dissemination                             11
              Appendix B - Equality Impact Assessment Tool                    12
              Appendix C - Definitions                                        13
              Appendix D - Flow Diagram                                       14
              Appendix E - NICE Baseline Assessment                           15
              Appendix F - NICE Guidance – Action Plan Template               17


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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



1.0       Introduction
1.1       The National Institute for Health and Clinical Excellence produces
          guidance covering a range of health care issues for primary, secondary
          and specialist care see appendix C for definitions. Guidance is issued in
          3 formats: -
          • Clinical Guidance (CGs)
          • Interventional Procedure Guidance (IPGs)
          • Technological Assessments (TAs)
          The National Confidential Enquiry into Patient Outcome and Death
          produces reports on a variety of themes, making broad recommendations
          to practice and the arrangements of care.
          The Trust will endeavour to comply with all relevant guidance and where
          this not possible escalate the reasons for this in line with Trust
          procedures outlined in this Policy. This policy also covers National
          Confidential Enquires/Inquires and also CISH and any reports relating to
          maternity services.
2.0       Purpose
2.1       The purpose of this policy is to provide a clear and effective system to
          support the receipt, dissemination, registration, reporting and monitoring
          of compliance with NICE guidance and NCEPOD report
          recommendations. The Policy will ensure that the Trust:
              • Provides a system for prompt and effective dissemination of all
                new guidance to relevant areas of the organisation
              • Maintains within Clinical Audit a register demonstrating current
                levels of compliance and progress against guidance
              • Has an audit trail in relation to the dissemination and
                implementation of guidance and reports on this to the appropriate
                Committees/groups
              • Complies with CQC requirements in relation to NICE/NCEPOD
              • Provides a system to monitor and report locally on non-compliance
                and for addressing areas of partial or non-compliance
3.0       Duties
3.1       Duties within the Organisation
3.1.1     The Chief Executive is the accountable officer with overall responsibility
          for patient safety and quality in the Trust. He /she shall ensure that
          reporting mechanisms clearly demonstrate that the Board is informed of
          all significant risk issues in relation to compliance with NICE guidance
          and NCEPOD reports in UHSM. The Chief Executive will ensure, via the
          Executive Medical Director that systems exist within the organisation for
          ensuring and compliance and monitoring of non-compliance.
3.1.2     The Executive Medical Director is the Board lead for patient safety and
          quality and is accountable to the Chief Executive for risks arising from
          partial or non-compliance. He/ she will ensure that safe systems and

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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



          procedures are in place and are being monitored. He/ she will notify the
          Chief Executive of any significant risks that may arise in relation to partial
          or non-compliance. He /she is responsible for the co-ordination and
          oversight of implementation of NICE guidance and will act as Chair of the
          Trust NICE Non-compliance Panel.
3.1.3     Head of Clinical Governance is responsible for ensuring that there are
          systems and processes for the management, dissemination and
          monitoring of NICE/NCEPOD guidance within the organisation. The Head
          of Clinical Governance is responsible for escalating and advising the
          Executive Medical Director of any issues in relation NICE/NCEPOD. The
          Head of Clinical Governance will be a member of the Trust NICE Non-
          compliance Panel.
3.1.4     Head of Clinical Effectiveness The Head of Clinical Effectiveness will
          monitor the systems and processes for the dissemination of NICE /
          NCEPOD guidance within the Clinical Audit Team and across the
          organisation. He/she will ensure that systems are regularly reviewed and
          audited and that each piece of guidance has a nominated clinical lead.
          He/she will also provide guidance and advice to the Deputy Clinical Audit
          Manager, Clinical Directors, Heads of Nursing, etc. in relation to NICE
          and NCEPOD, including support with gap analysis. He/she will be a
          member of the Trust NICE Non-compliance Panel.
3.1.5     Deputy Clinical Audit Manager is responsible for the management of the
          systems and processes for the dissemination and monitoring of
          NICE/NCEPOD within Clinical Audit and across the organisation. He/she
          will produce regular updates and reports for Healthcare Governance
          Committee including:
           • Receipt of new guidance
           • Progress in relation to compliance
           • Reasons for breaches of deadlines and actions taken to address this
          He/she will be a member of the Trust NICE Non-compliance Panel.
3.1.6     Clinical Directors are responsible for co-ordinating assessment of
          compliance with relevant colleagues, undertaking gap analysis (where
          appropriate) and implementation of guidance and report
          recommendations as necessary.
3.1.7     Consultants are responsible for assisting Clinical Directors in assessing
          compliance with guidance and supporting gap analysis (where
          appropriate) and implementing change in line with best practice.
3.1.8     Director of Pharmacy is responsible for reviewing, assessing and
          monitoring Guidance related to Medicines Management. Guidance
          related to Medicines will be reviewed and monitored by the Medicines
          Management Committee.




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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



3.1.9     Healthcare Governance Committee is responsible for monitoring the
          NICE and NCEPOD process and will receive regular reports in relation to
          activity including notification of new guidance, compliance, non-
          compliance and action being taken to address this. The Chair of HGC is
          the Executive Medical Director and he/she will escalate any issues
          relating to NICE / NCEPOD to the Board of Directors.
3.1.10    NICE Non-compliance Panel is responsible for the assessment and
          sanctioning of bids for pump priming monies in order to achieve full
          compliance for items of NICE guidance and NCEOD report
          recommendations.
4.0       Process
4.1       Process for identifying relevant documents
4.1.1     NICE Guidance – will be received via the NICE monthly e-bulletin by the
          Head of Clinical Effectiveness. Their receipt is registered in UHSM’s
          NICE guidance database.
4.1.2     NCEPOD Reports - Are received via NCEPOD distribution schedule to
          the Executive Medical Director and Head of Clinical Effectiveness. Their
          receipt is registered in UHSM’s report database.
4.1.3     Once these items are received, the Head of Clinical Effectiveness will
          review them to assess which Clinical Directorate they are relevant to.
          They will then be disseminated as appropriate.
4.2       Process for disseminating relevant documents
4.2.1     The Trust has a process for the dissemination and monitoring of NICE
          and NCEPOD reports within the organisation see appendix D. Following
          the approved process, these will be disseminated by the Deputy Clinical
          Audit Manager to relevant Clinical Directors for gap analysis and
          assessment. Dissemination takes the form of a letter to the relevant
          Clinical Director(s), with a copy of the guidance and documentation for
          them to undertake a gap analysis and detail the results of their
          assessment, see appendix E for relevant documents.
4.2.2     In the event of items of guidance or NCEPOD reports covering a range of
          clinical activity (e.g. CG 50 Acutely Ill Patients) then a task and finish
          group will be commissioned as appropriate by the Head of Clinical
          Governance or an existing group (e.g. Medicines Management
          Committee) will be tasked with assessment and implementation.
4.3       Process for conducting an organisational gap analysis
4.3.1     Assessment
4.3.1.1   The relevant Clinical Director and the relevant committee and/or Task
          and Finish Group are responsible for conducting a baseline assessment,
          in consultation with appropriate colleagues of the organisation’s current
          compliance with the guidance/ report recommendations. This baseline
          assessment will result in one of four possible conclusions: -


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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



          - Not applicable to the organisation, response noted in the relevant
              database, no further action required
          - Fully compliant, response noted in relevant database, item is put
              forward for consideration for inclusion in Directorate programme of
              clinical audit
          - Partial compliance, response noted in relevant database, the process
              directs that the directorate management team undertake: gap analysis,
              risk assessments, cost assessments and develop action plans (see
              following section).
          - Non-compliant, response noted in relevant database, the process
              directs that the directorate management team undertake:
                  • gap analysis
                  • risk assessments and;
                  • Develop an action plan (see following section).
4.3.1.2    In rare cases, the Clinical Director may feel that they cannot fully support
           the guidance/ report recommendations. In this case, HGC will be advised
           of this and consider the implications of non-compliance and what further
           action is required. This will include formally advising the Board (see
           appendix 1.) and if necessary the Strategic Health Authority, the Care
           Quality Commission and NICE/NCEPOD. Minutes of the HGC meeting
           will fully document any decisions or reason for not implementing the
           guidance or report recommendations. The time scale for assessment will
           be four weeks from receipt of the guidance or report.
4.4       Gap Analysis and Action Plan
4.4.1.    In cases of partial or non-compliance, the Clinical Director and/or
          colleagues as appropriate will undertake an assessment registering this
          formally with the Deputy Clinical Audit Manager and if required on the
          Trust Risk Register. They will then undertake a detailed gap analysis with
          the support of the Head of Clinical Effectiveness and develop an action
          plan to support achievement of full compliance see appendix E.
4.4.2     If cost neutral, Clinical Directorates should then immediately develop and
          implement an action plan and review compliance status.
4.4.3     If not cost neutral, the Clinical Directorate management team should then
          consider potential design service and/or review commissioning
          arrangements to identify & release funding. If this is successful, Clinical
          Directorates should then immediately implement this and review
          compliance status.
4.4.4     If this is not possible, the Clinical Directorates will escalate to the NICE
          Non-compliance Panel.
4.4.5     The assessment and implementation timescale for TAs and IPGs is 3
          months from receipt. For CGs and NCEPOD reports, the timescale is 2
          years from receipt.




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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



4.5       Escalation to NICE Non-compliance Panel
4.5.1     This panel is chaired by the Executive Medical Director and membership
          will consist of the Head of Clinical Governance, the Business Planning
          Manager, Head of Clinical Effectiveness, Deputy Clinical Audit Manager
          and with representation from the Clinical Directorate as appropriate.
4.5.2     Where a Directorate has been unable to resolve a partially or non-
          compliant item of guidance/ report recommendations via the process
          described in section 4 they will be invited to come to the panel with the
          gap analysis, action plan and a costed business case
4.5.3     The Panel will review and assess the business case and advise on
          amendments if required. The Panel is able to allocate 12 months ‘pump-
          priming’ monies to support the business case. The Clinical Directorate will
          be expected to address funding once this initial funding ends.
4.5.4     If the panel is unable to offer funding and the Clinical Directorate is
          unable to achieve full compliance, the Executive Medical Director will
          then advise Trust Board and SHA. The Chief Executive will then inform
          NICE/NCEPOD and the Care Quality Commission.
4.6       Process for ensuring that recommendations are acted upon
          throughout the organisation
4.6.1     The process for ensuring that recommendations are acted upon
          throughout USHM is through reporting to the Healthcare Governance
          Committee, see section 5.
4.6.2     Progress reports relating to NICE/NCEPOD guidance will be provided by
          the Deputy Clinical Audit Manager for the Clinical Directorate Governance
          meetings 4 times a year and will detail items of none or partial
          compliance for review and action.
4.7       Process for documenting any decision not to implement NICE
          recommendations
4.7.1     The process for documenting any decisions not to implement NICE
          recommendations is that the relevant Clinical Director will write to the
          Executive Medical Director, outlining the reason for not implementing the
          guidance/report recommendation, they will also indicate what risk
          assessment has demonstrated, including what mitigation and
          monitoring/audit arrangements are in place
4.7.2     The Executive Medical Director will communicate this to the Trust Board
          and request Chief Executive to advise relevant commissioners and
          NICE/NCEPOD.
5.0       Process for monitoring compliance with this the Policy for
          Implementation of NICE Guidance and NCEPOD
          Recommendations
5.1       Minimum requirements to be monitored will be as follows:
          a) duties including leadership for all stages of the process
          b) process for identifying relevant documents

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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



          c) process for disseminating relevant documents
          d) process for conducting an organisational gap analysis
          e) process for ensuring that recommendations are acted upon
              throughout the organisation
          f) process for documenting any decision not to implement NICE
              recommendations
5.1.1      Process for monitoring e.g. audit
          A report and action plan detailing the elements described under the
          minimum requirements.
5.1.2     Responsible individual/ group/ committee
          The Head of Clinical Effectiveness.
5.1.3     Frequency of monitoring
          Twice a year. However, exceptions will also be escalated to HGC if
          required.
5.1.4     Responsible individual/ group/ committee for review of results
          Healthcare Governance Committee.
5.1.5     Responsible individual/ group/ committee for development of the
          action plan
          Head of Clinical Effectiveness and the Deputy Clinical Audit Manager
5.1.6     Responsible individual/ group/ committee for monitoring of the
          action plan
          Head of Clinical Governance and Healthcare Governance Committee.
6.0       Standards/key performance indicators and process for
          monitoring effectiveness
6.1       Standards for performance is 100% of relevant items of guidance/ report
          recommendation will be assessed against compliance and implemented
          within stated times scale (3 months TAs & IPGs and 2 years CGs and
          report recommendation), with the exception of those items where the
          Trust is professionally unable to support.
6.2       Performance indicators will be: -
          - Number of relevant TAs declared compliant/ number of relevant TAs
             published
          - Number of relevant IPGs declared compliant/ number of relevant IPGs
             published
          - Number of relevant CGs declared compliant/ number of relevant CGs
             published
          - Number of relevant NCEPOD reports declared compliant/ number of
             relevant NCEPOD reports published
7.0       Dissemination, Implementation and Access to this
          Document
          This policy is to be circulated to members of the Healthcare Governance
          Committee, Clinical Directors, and their management teams. The policy
          will be available to staff via the Trust Policy intranet site.


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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



8.0       Review, Updating and Archiving of this Document
          This policy will be reviewed every two years or more frequently if there is
          a change for e.g. to national guidance. Any previous versions will be
          archived according to the process described in the Policy ‘Arrangements
          for the Development and Approval of Foundation Trust-wide Policies or
          procedural documents’.
          http://uhsm-
          intranet/policies/Trustwide%20policies%20operational%20policies%20and%20guidel/Arrangements%2
          0for%20the%20Development%20and%20Approval%20of%20Foundation%20Trustwide%20Policies%20
          or%20procedural%20documents%20V2.00.pdf

9.0       References and Bibliography
          Nil
10.0      Associated Documentation
          Nil
11.0      Appendices
          Appendix A - Plan for Dissemination
          Appendix B - Equality Impact Assessment Tool
          Appendix C – Definitions
          Appendix D – Flow Diagram
          Appendix E – NICE Baseline Assessment
          Appendix F – NICE Guidance – Action Plan Template




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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



Appendix A - Plan for Dissemination of Policy or procedural documents

To be completed and attached to any document which guides practice when submitted to the
appropriate committee for consideration and approval.

 Title of document:        Implementation of NICE Guidance and NCEPOD
                           Recommendations V2.00
 Date finalised:           July 2010               Dissemination lead:            D Watson
                                                   Print name and contact         Head of Clinical
 Previous document                  No             details
 already being used?                                                              Effectiveness

 If yes, in what format    NA
 and where?

 Proposed action to        NA
 retrieve out-of-date
 copies of the
 document:

 To be disseminated        How will it be                   Paper        Comments
 to:                       disseminated, who will             or
                           do it and when?                Electronic

 Clinical Directors        Trust global email and         Electronic
 and their teams           to all Clinical Directors.
                           The Head of CE will
                           action this.




             Dissemination Record - to be used once document is approved.

 Date put on register /                                 Date due to be reviewed
 library of policy or
 procedural documents


   Disseminated to:         Format (i.e.          Date                 No. of     Contact Details /
 (either directly or via     paper or         Disseminated             Copies       Comments
     meetings, etc)         electronic)                                 Sent




                                                   11
Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



Appendix B - Equality Impact Assessment Tool

To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval.

                                                       Yes/No            Comments

 1.   Does the policy/guidance affect one group
      less or more favourably than another on the
      basis of:

         •    Race                                      No

         •    Ethnic origins (including gypsies and     No
         travellers)

         •    Nationality                               No

         •    Gender                                    No

         •    Culture                                   No

         •    Religion or belief                        No

         •    Sexual orientation including lesbian,     No
         gay and bisexual people

         •    Age                                       No
 2.   Is there any evidence that some groups are        No
      affected differently?
 3.   If you have identified potential                  No
      discrimination, are any exceptions valid,
      legal and/or justifiable?
 4.   Is the impact of the policy/guidance likely to    No
      be negative?
 5.   If so can the impact be avoided?                  NA
 6.   What alternatives are there to achieving the      NA
      policy/guidance without the impact?
 7.   Can we reduce the impact by taking                NA
      different action?

If you have identified a potential discriminatory impact of this procedural document, please
refer it to [insert name of appropriate person], together with any suggestions as to the action
required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact [insert name of
appropriate person and contact details].




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Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



Appendix C Definitions


IMPLEMENTATION - A specified set of activities designed to put NICE guidance
into practice. (How to put NICE guidance into practice)

TYPES OF NICE GUIDANCE:
Technology appraisals are recommendations on the use of new and existing health
technologies. The Secretary of State has directed that the NHS provides funding and
resources for medicines and treatments that have been recommended by NICE
technology appraisals normally within 3 months from the date that NICE publishes the
guidance. Core standard C5 states that healthcare organisations should ensure they
conform to NICE technology appraisals.
Clinical guidelines provide guidance on the appropriate treatment and care of people
with specific diseases and conditions. Implementation of clinical guidelines forms part
of developmental standard D2 which states that patients should receive effective
treatment and care that conforms to nationally agreed best practice, particularly as
defined in NICE guidance.

Guidance on interventional procedures covers the safety and efficacy of surgical
procedures. Core standard C3 states that healthcare organisations should protect
patients by following NICE interventional procedures guidance.


Public health guidance provides guidance on the promotion of good health and the
prevention of ill health. The implementation of NICE public health guidance will help
you meet the standards in the seventh domain such as the core standards C22 and
C23 and developmental standard D13




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          Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00



          Appendix D                                            Process for Implementing NICE Guidance & NCEPOD
                                                                                 Recommendations

                                                                                                                                                  8 Weeks

                                               3 Months (TAs & IPGs) – 2 Years (other items)
START




                Clinical Director or
Head of        Relevant committee/               Fully                Audit programme
  CE                 T&FG for                  compliant               2 year review
                   assessment


                                               Guidance                    Undertake:              Outcome =
                                              accepted but                Gap analysis            cost neutral
                                                partially               risk assessment                 Or
                                               compliant               cost assessment         funding identified &   Implement action plan
                    Applicable                                                and                   available
                                                                       develop action
                                               Guidance                       plan
                                             accepted but
                                             not compliant

                                                                                                Redesign service
                                                                         Outcome =                    and/or
                                                                         No funding                                       Funding                   Resolution
                                             Guidance not                                             review
                                                                          available              commissioning         identified and           Funding available via
                  Not applicable              accepted                       or                  arrangements to         available                 other means
                                                                           service              identify & release
                                                                          redesign                   funding
                                                                          required


                Log on database                                                                Residual funding gap        Escalate
                                       Notify HGC & PCT                                          despite efficiency   NICE Non-compliance
                                                                                               savings and redesign      Funding Panel




                                              Formally liaise                                                                                 Executive Medical
                                                with NICE/                                                                                    Director to inform
                                                                                                                      No funds available      Trust Board & PCT
                                                NCEPOD

                                                                                                                      Chief Executive to
                                                                                          14                                inform             No Resolution
                                                                                                                       NICE/NDEPOD
Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00


Appendix E – NICE Baseline Assessment

Please consider how the recommendations will have an impact on patient numbers, staffing, equipment & training, budgets, service provision:

Clinical Guideline                       Date of Publication                   Lead:                       Guidance

Introduction

Relevant to primary care: Yes/No
If yes, please identify the manner in which this impacts on primary care:

Relevant to Secondary care: Yes/No
If yes, please identify the manner in which this impacts on Tertiary care:

Social Services: Yes/No
If yes, please identify the manner in which this impacts on Social Services

NICE Audit Criteria Developed: Yes

NICE Implementation Guidance Developed: Yes

NICE Costing Criteria: No

                                                                  Current Position

       Recommendations                             Status                          Evidence         Identified Gaps in service provision or
                                         1 = Not applicable
                                                                                                      evidence required to demonstrate
                                         2 = Fully Compliant                                                     compliance
                                         3 = Partial Compliance
                                         4 = Non-compliant




                                                                              15
Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00


                                                               Current Position

       Recommendations                         Status                            Evidence              Identified Gaps in service provision or
                                     1 = Not applicable
                                                                                                         evidence required to demonstrate
                                     2 = Fully Compliant                                                            compliance
                                     3 = Partial Compliance
                                     4 = Non-compliant




Does the implementation of the guidance have any organisational or financial implications for the delivery or commissioning of services?
Yes/No
Estimate of financial resource implications if known:
Cost saving Yes/No             Cost Neutral Yes/No            Requires funding Yes/No       If yes, estimate of amounts required
Are they any changes required in the way that services are delivered to patients in order to implement the guidance? Yes/No

Minimal                    Moderate                           Significant
Where possible please quantify changes required:
Any additional comments



To be completed by the Clinical Governance team

Date sent out:                       Date returned:                                                    Further action required:




                                                                            16
Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00

Appendix F – NICE Guidance – Action Plan Template

The baseline assessment will have identified which recommendations are not currently being carried out. Insert these into the table and assign
actions to each one.

   Recommendation               Action needed to           Resource needed to            Who is responsible               Target date
                                     comply                     comply




                                                                      17
Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00




                                                             nd
Department of Clinical Audit                                2 Floor
                                                            F Block
Tel:   0161-291-5828                                        Wythenshawe Hospital
Fax:   0161-291 5821                                        Southmoor Rd
                                                            Wythenshawe
                                                            M23 9LT




Date



Dear Colleague

Re: NICE Guidance [name of guidance]

The above NICE Guidance has recently been published and is available via the NICE
website or the Clinical Audit Department.

As part of the guidance implementation process it is the role of the Healthcare Governance
Committee to measure staff awareness of this guidance on behalf of the Trust.

I would therefore be grateful if you could complete the attached questionnaire and return it to
me at the above address.

Please contact me if you require any further information.

Yours faithfully




Jonathan Swift
Deputy Clinical Audit Manager




                                              18
Policy for the Implementation of NICE Guidance and NCEPOD Recommendations V2.00




1.   Are you aware of the above NICE Guidance?                        Yes           No

2.   Is your clinical practice consistent with the guidance?          Yes           No

3    If No, please describe in what way(s) your practice is at variance with the guidance

     .....................................................................
     .....................................................................
     .....................................................................

4.   If your practice currently varies from NICE guidance, are you likely to change your
     practice in order to comply with the guidance in the future?
                                                                      Yes          No

     If No are you following other guidelines?                        Yes           No

     If you are following other guidelines please state which?

     .....................................................................

     If you are not following other guidelines, why do you not intend to follow the NICE
     guidance?

     .....................................................................
     .....................................................................
     .....................................................................

5.   Does implementation of the guidance have any organisational or financial implications
     for your practice?
                                                                 Yes            No

     If yes, please identify the number of patients likely to receive this treatment within your
     practice and if possible, the estimated costs

     .....................................................................
     .....................................................................
     .....................................................................

6.   Are there any changes required in the way that service is delivered to patients in order
     to implement the guidance?

     .....................................................................




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