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Policy for Processing NICE Guidance and Other National Best Practice Recommendations

Responsible Directorate:

Directorate of Patient Care and Professions

Responsible Director:

Sheila Dilks

Date Approved:

8 August 2008

Committee:

Governance Committee

Version Control Document Title Corporate Document number Author Contributors Version Date of Production Review date Post holder responsible for revision Distribution method Web address Restrictions

Procedure for Processing NICE Guidance and other National Best Practice Recommendations 1 Sam Royal, Catherine Smyth, Maria Freer 3 June 2008 August 2010 Clinical Effectiveness Lead Team Brief, NHS Kirklees Intranet alert, Forums, Weekly Bulletin None

Standard for Better Health Map Domain

Safety, Clinical and Cost Effectiveness, Governance

Core Standard Reference Performance Indicators

C2, C3, C5a, C5d, C7a, C7b 1. 100% of new guidelines are processed according to the PCT’s: Procedure for Processing NICE Guidance 2. The PCT’s Effectiveness database is up-to-date and displays the current implementation status of 100% of guidelines received by the PCT

NHSLA Risk Management Standards Map Standard 5 Learning from Experience Criteria 1.5.8, 1.5.9

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Contents Section

Page

1.

Introduction

3

2.

Associated Policies & Procedures

3

3.

Aims & Objectives

3

4.

Scope of the Procedure

3

5.

Accountabilities and Responsibilities

4

6.

Identification of Relevant Documents

5

7.

Procedure for Processing NICE guidance

5

8.

Procedure for Processing NSF’s

5

9.

Procedure for Processing NCE’s and HLE’s

5

10.

Definitions

5

11.

Risk Register

7

12.

Equality Impact Assessment

7

13.

Training Needs Analysis

7

14.

Sharing Lessons Learned

7

15.

Monitoring Compliance with this Procedure

7

16.

References

8

17.

Appendices

8

A

Procedure for Processing NICE Guidance - flowchart

9

B

8 Steps to Implementing NICE Guidance

10

C

NICE Guidance Proforma

14

D

Equality Impact Assessment Tool

15

E

Stakeholders Involved in the Development of this Policy

16

Appendices

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Policy Statement NHS Kirklees will have a systematic, robust and timely approach to the receipt, processing and implementation (where applicable) of NICE clinical guidelines, National Service Frameworks (NSF’s), National Confidential Enquiries (NCE) and other High Level Enquiries (HLE).

1.

Introduction

This document sets out how information about best practice is distributed to appropriate personnel to ensure the implementation of recommendations is monitored. It covers the process from initial identification, through to the dissemination, review and implementation of actions required to bring services in line with best practice recommendations.

It also supports the organisational compliance with Core Standards for Better Health, NHS Litigation Authority Risk Management Standard 5.1.8, 5.1.9, and any other such standard set out by regulatory bodies.

2.

Associated Policies and Procedures

This procedure should be read in accordance with the following Trust policies, procedures and guidance: • • • • 3.

Records Management Policy Incident Reporting Policy Clinical Audit Framework Whistleblowing Policy Aims and Objectives

The aim of these is to ensure a systematic, robust approach to processing all NICE guidance and other best practice recommendations being received by the Trust which will be achieved by meeting the following objectives: • • • • • 4.

To enable an up-to-date status of all NICE and other National guidance being processed To clarify roles and responsibilities within NICE and other National guidance implementation which takes account of the Commissioning and Provider relationship To enable a system whereby any barriers to implementation can be highlighted To provide an audit trail of implementation To consider any training needs required to ensure effective implementation

Scope of the Procedure

This procedure must be followed by all NHS Kirklees employees who are involved in the production/development/receipt and implementation of NICE guidance. It must be followed by all Page 3 of 19

staff who work for NHS Kirklees, including those on temporary or honorary contracts, bank staff and students.

Independent Contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. The Trust is happy to provide such advice and support as required. All Independent Contractors receive copies of NICE guidance and the Trust also provides copies of the NICE framework for their information.

5.

Accountabilities & Responsibilities

5.1

Lead Director

The Director for Patient Care and Professions - lead director at Board level responsible for Governance.

The Assistant Director for Quality and Clinical Governance - overall day to day responsibility for all aspects Governance.

The Directors of Provider Services, Commissioning and Public Health - management responsibility for staff implementing and working towards these guidelines.

The Directors and Assistant Directors across the organisation - responsible for ensuring all staff are aware of and conform to these guidelines.

5.2

The Clinical Effectiveness Lead

Has the responsibility to support all aspects of the processing, implementation, monitoring and review of NICE and other best practice National guidance.

5.3

The Service Lead

Will be either from Public Health, Commissioning or Provider Services. They will be responsible for identifying the Implementation lead and for feeding back to the Clinical Effectiveness Lead via the Clinical Audit and Effectiveness Group on progress with implementation of the National guideline.

5.4

The Implementation lead

Will be responsible for pulling together the Implementation Group and developing and working thorough the action plan. Achievements to date and any barriers to implementation should be reported to the Clinical Audit and Effectiveness Group via the Clinical Governance Co-ordinator and copied to the Service Lead.

5.5

Committee Responsibility

The Clinical Audit and Effectiveness Group – This group is responsible for receiving NICE and other National guidance, assessing their relevance to the Trust and, if necessary, proposing an

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appropriate lead for implementation. This group is also responsible for monitoring and seeking assurance around implementation.

5.6

Clinical Governance Co-ordinator Responsibility

Will be responsible for ensuring all guidance is entered onto Effectiveness database, relevant information and proforma sent to identified implementation lead and action plan overviews monitored accordingly. They will ensure effectiveness database is up-to-date with current compliance status and that data for quarterly/6-monthly reports is made available.

6.

Identification of Relevant Documents

National reports and guidance are initially received into the Trust by the Chief Executive who will then cascade through the most appropriate Director(s).

7.

Procedure for Processing NICE Guidance

Refer to Appendix A 8.

Procedure for Processing National Service Frameworks (NSF’s)

The lead director will nominate a lead for each NSF. The nominated lead is responsible for identifying key stakeholders within provider organisations and co-ordinating a review of the NSF to identify current gaps and develop an action plan. Similarly to processing NICE guidelines it will be the responsibility of Service Leads (Public Health, Provider or Commissioning) to feed back to the Clinical Audit and Effectiveness Group on progress. This will include reporting on barriers to implementation and risks to the organisation.

9.

Procedure for Processing National Confidential Enquiries (NCE) and High Level Enquiries (HLE)

The Director of Corporate Services has overall responsibility for the implementation of recommendations from National Confidential Enquiries and High Level Enquiries. Compliance is monitored via the Governance Committee and the Board.

10.

Definitions NICE guidance NHS Kirklees has an obligation to implement guidance issued by the National Institute for Health and Clinical Excellence (NICE). The role of NICE is to provide patients, health professionals and the public with robust and reliable guidance on the current ‘Best Practice’.

NICE guidance covers: • •

Technology Appraisals – guidance on the use of new and existing health technologies (including drugs, medical devices and procedures) Clinical Guidelines – guidance on the appropriate treatment and care of patients with specific disease and conditions.

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• •

Interventional Procedures – guidance on the efficacy and safety of interventional procedures Public Health guidance – guidance that covers broad aspects of disease prevention or health promotion

Both the Healthcare Commission and NHS Litigation Authority standards relate to the implementation of NICE and best practice guidance and as a consequence, careful planning for effective implementation is now a crucial task for the Trust. NICE guidance has to be considered alongside other programmes such as the National Service Frameworks (NSFs), and other local and national guidelines. Planning for implementation of NICE guidance must therefore be incorporated into the commissioning and financial planning frameworks of the Trust.

National Service Frameworks National Service Frameworks (NSF) were introduced following the publication of The New NHS (DH 1997) and A First Class Service (DH 1998) and re-emphasised in the NHS Plan (DH 2000). They are long term strategies designed to improve the quality of specific areas of care and decrease variation across the country. They set standards of care, describe service models for the delivery of these standards with milestones and goals, and set out methods for monitoring progress with implementation.

Current NSFs are: • • • • • • • • • •

Mental Health (1999) Paediatric intensive Care (1999) Coronary Heart Disease (2000) Cancer (2000) Older People (2001) Diabetes (2001 & 2003) Renal Services (2004) Children and Maternity Services (2004) Long Term Conditions (2005) Chronic Obstructive Pulmonary Disease (COPD) (due in 2008)

National Confidential Enquiries and High Level Enquiries National Confidential Enquiries (NCE) are nationally defined audit programmes that ensure learning from serious incidents.

NICE received responsibility for the four Confidential Enquiries from the Department of Health in 1999: • Confidential Enquiry into Maternal Deaths (CEMD), • Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI), • National Confidential Enquiry into Perioperative Deaths (NCEPOD) • Confidential Enquiry into Suicide and Homicide by People with Mental Illness (CISH)

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The Enquiries aim to improve clinical practice through the investigation of deaths in specific circumstances.

High level enquiries (HLE) address similar issues regarding serious incidents that cannot and should not be dealt with through the usual local procedures. Examples include the Climbie Inquiry (2003) and Shipman Inquiry (2004).

11.

Risk Register NICE/Best Practice guidance that can not be implemented for any reason may be put onto the corporate and local risk register in consultation with the Risk Management Team.

Concerns raised by staff regarding implementation and compliance may also be raised through the Whistleblowing Policy.

12.

Equality Impact Assessment

All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.”

This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.

In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices.

This Policy guidance was found to be compliant with this philosophy after applying the Equality Impact Assessment Tool (see Appendix D).

13.

Training Needs Analysis

No specific training is required before these guidelines can be implemented. Further information on NICE guidelines and processes can be found at www.nice.org.uk 14.

Sharing Lessons Learned

All lessons learned from NICE and other National best practice guidelines will be reported into the Clinical Audit and Effectiveness Group via the relevant service lead. Any recommendations will be cascaded into clinical teams through operational managers.

15.

Monitoring Compliance with this Procedure

An audit of the compliance to this procedure will be included in the Trust’s annual audit programme, this will include measurement against the following standards: 1. 100% of new guidelines are processed according to the PCT’s: Procedure for Processing NICE Guidance.

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2. The Trust’s Effectiveness database is up-to-date and displays the current implementation status of 100% of guidelines received by the Trust.

The Clinical Effectiveness Lead will be responsible for carrying out this audit on an annual basis.

The Audit Report will be presented to the Clinical Audit and Effectiveness Group with a summary report to the PEC and Trust Board.

16.

References

NHS National Institute for Health and Clinical Excellence www.nice.org.uk 17.

Appendices

Appendix A: Appendix B: Appendix C: Appendix D: Appendix E:

Procedure for processing NICE Guidance – Flowchart Guide for Implementing NICE Guidance – 8 steps to implementing NICE guidance NICE Guidance Proforma Equality Impact Assessment Tool Key Stakeholders consulted / involved in the development of the document

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Appendix A NICE guideline to Clinical Effectiveness Lead

Guideline entered onto Effectiveness Database by Clinical Governance Co-ordinator (Public Health guidance entered by Project Officer, Public Health)

Guideline presented to Clinical Audit & Effectiveness Forum to see if relevant to the Trust

YES

NO

8 week turnaround

Clinical Audit & Effectiveness Forum sends to relevant service lead for confirmation of implementation lead – 2 week deadline given

Effectiveness Database updated to record ‘not relevant to the Trust’

Implementation lead sent relevant information & requested to complete NICE guidance proforma within 8 weeks of receipt

Implemenation lead to involve relevant stakeholders in completion of proforma, including time scaled action plan. Completed proforma returned to Clinical Governance Co-ordinator (Public Health guidance proforma returned to Project Officer, Public Health)

Clinical Governance Co-ordinator & Clinical Effectiveness lead to ensure completed proforma is presented to Clinical Audit & Effectiveness Forum & actions/implementation status logged onto Effectiveness database

Clinical Audit & Effectiveness Forum, via the Clinical Effectiveness lead, to monitor all action plans, producing quarterly reports showing status of completion and risks to implementation and subsequent impact on the organisation (e.g. resources)

Any guidance unable to be fully implemented to be formally discussed at Governance Committee

On completion of all actions, guidance can be considered “fully implemented”. Clinical Effectiveness lead to inform Clinical Audit lead to ensure inclusion in audit programme

Clinical Audit & Effectiveness Forum will produce 6-monthly progress report for Governance Committee, with summary report to Professional Executive Committee & Trust Board, highlighting achievements, barriers & risks to organisation. Impact on training & medication also highlighted Page 9 of 19

Appendix B

Eight Steps to Implementing NICE Guidance The Trust has established a systematic approach to implementing NICE guidance, outlined in the following 8-step process.

A database has been designed to track the implementation of NICE guidance through each step of this process.

Step 1 – Identifying the Implementation Link(s) NICE guidance is produced on a regular basis and circulated to PCTs. Health professionals, as with all evidence-based information, have a professional obligation to apply this to their every day practice.

PCTs have a responsibility for ensuring the guidance is implemented within their organisation: •

NICE guidance arrives in the Trust and is received by the Clinical Effectiveness Lead

•

The Clinical Effectiveness Lead will ensure that it is logged onto the PCT Effectiveness database

•

The Clinical Effectiveness Lead will present the NICE guidance to the Clinical Audit and Effectiveness Forum

•

The Clinical Audit and Effectiveness Forum will undertake an initial assessment of the guidance to establish if it is relevant to the Trust. If it is not relevant, rationale to support the decision must be provided and minuted. If it is relevant, guidance will be forwarded to a designated lead within appropriate service, e.g. commissioning, provider, public health, asking for a 2 week deadline to confirm implementation lead.

•

The Clinical Effectiveness Lead will link with the identified implementation lead and report back on progress to the Clinical Audit and Effectiveness Forum. Information must be submitted 8 weeks from issue.

•

The Trust’s Effectiveness Database will track the guidance through the various states of implementation and will be kept up to date by the Clinical Governance Co-ordinator.

Step 2 – Dissemination within the PCT The Clinical Effectiveness Lead for the Trust will liaise with the identified implementation lead as follows: The identified NICE implementation lead receives: • • • • •

Covering letter explaining the process with timescales etc NICE guidance proforma (see Appendix C) Copy of the NICE guidance Copy of this support material Offer of support from the Clinical Governance Team Page 10 of 19

Step 3 – Establish who needs to be involved Any systematic approach to changing professional practice should include plans to monitor, evaluate, maintain, review and reinforce any changes made. To ensure this happens, it is important that all the relevant people are involved and that someone takes a lead role in overseeing and co-ordinating this process.

The implementation lead(s) will: •

Liaise with relevant groups/individuals regarding the guidance. Wherever possible an existing group/network should be used. New groups or structures should not be set up when existing ones could fulfil this requirement.

•

Where NICE guidance has implications for prescribing the implementation lead should liaise with the Medicines Management Team who can offer further support and guidance.

Step 4 – Assess the current status In order to know what needs to be done, an initial assessment of the current status is required.

The following may help with this thought process: • • • • • •

Has the guidance been implemented already? Is this the case across the whole of the patch?

Is there a need to review current policies, procedures and protocols?

Can this be graded as fully or partially implemented, or not known?

Is there any data available that indicates or proves that the guidance is being followed?

Would this be captured through other sources?

What are the opinions of the ‘local experts’ – can we evidence this?

Is there a need to run a very small survey to obtain a simple “snapshot” of current practice?

This assessment should be recorded on the NICE guidance proforma.

Step 5 – Assess the implications of implementation As with any change in practice, there are likely to be a number of implications. Consider the following: • • • • • • •

Will there be major changes in practice required?

Will there be capacity or resource issues associated with the changes required?

Will we need to update protocols?

Will there be any training needs for staff?

Will people be receptive to change?

Will there be any additional costs, both in terms of implementation and into the future when following the guidance?

What might some of the barriers be to implementation?

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• • • •

Are there any potential risks to implementing this guidance? Do these identified risks need to be entered onto the PCT Risk Register?

What will the impact on prescribing be – will it go up or down?

Should there be any information made available to the public?

What might the impact be on commissioning?

This assessment should be recorded on the NICE Guidance Proforma (see appendix C).

Step 6 – Develop and agree an action plan The action plan must feel achievable and relate directly to the implementation of the guidance.

Any major resource implications should be built into the Trust’s business planning arrangements through the normal channels. Support is available from appropriate members of the Trust, e.g.

Data Quality/Information Team, Medicines Management Team, Clinical Governance Team.

It maybe beneficial to consider existing mechanisms in relation to: • • • •

Existing educational training programmes Local champion or a specialist lead Various different approaches being more effective than one single approach Newsletter/information exchanges

Ensure this is agreed with the individuals identified and the ‘lead group’.

This action plan overview and identified audit tool should be recorded on the NICE Guidance Proforma.

Step 7 – Monitoring Process It is important that progress against the action plan is monitored. The service lead will be required to inform the Clinical Audit and Effectiveness Forum of progress, including achievements to date and barriers and risks to implementation. The lead would also need to capture any modifications in respect of the guideline and subsequent actions, including rationale for this approach and evidence of any additional risk or benefit.

Identified audits will need to be included within the Trust’s Annual Audit Programme.

Step 8 – Progress and Assurance The Clinical Audit and Effectiveness Forum will produce a 6 monthly progress report for the Governance Committee, with a summary report to the Professional Executive Committee and Trust Board, each report highlighting achievements, barriers and risks to the organisation. Impact on training and medication will also be highlighted.

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Contacts available for support Victor Thompson, Clinical Governance Team Manager victor.thompson@kirkleespct.nhs.uk – tel: 01924 351531

Maria Freer, Clinical Effectiveness Lead maria.freer@kirkleespct.nhs.uk – tel: 07903 755644 or 01924 351646

Sam Royal, Clinical Governance Co-ordinator sam.royal@kirkleespct.nhs.uk – tel: 01924 351403

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Appendix C

NICE GUIDANCE PROFORMA Title and number of guidance Date guideline published Service Lead Clinical Lead Current Status of Compliance with recommendations (please highlight in bold) Non Compliant Partially Compliant

Fully Compliant

In what aspects are we compliant? Please attach evidence to support this (include – financial implications, equipment & training implications)

In what aspects are we non compliant? (include – financial implications, equipment & training implications)

Have links been made with Medicines Management Team?

Yes/No (please highlight)

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Action Plan Overview Action (link to relevant recommendations)

Lead

Timescale

Evidence of activity to date Barriers/Risks (please attach evidence as required)

Links to other groups/orgs

Anticipated timescale for full compliance: Identify mechanisms of audit (consider cross-referencing to other activity that would provide evidence of implementation)

Has any formal audit of compliance with the guidance been undertaken? Yes/No (please highlight) If yes, please attached a copy of audit/copy of your report

Proforma completed by:

Date:

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Appendix D Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Insert Name of Policy / Procedure Yes/No 1.

Comments

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

No

• Ethnic origins (including gypsies and travellers)

No

• Nationality

No

• Gender

No

• Culture

No

• Religion or belief

No

• Sexual orientation including lesbian, gay and

No

bisexual people • Age

No

• Disability - learning disabilities, physical disability,

No

sensory impairment and mental health problems 2.

Is there any evidence that some groups are affected differently?

No

3.

If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4.

Is the impact of the policy/guidance likely to be negative?

No

5.

If so can the impact be avoided?

N/A

6.

What alternatives are there to achieving the policy/guidance without the impact?

N/A

7.

Can we reduce the impact by taking different N/A 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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Stakeholder Consultation

Appendix E

Involvement and participation of others in the process of developing these guidelines as shown below:

Stakeholders name and designation

Key participant

Feedback requested

Feedback accepted

NHS Kirklees Clinical Chair: Sue Smith Audit and Effectiveness Group

Yes

Yes

Pam Lumb

Yes

Yes

Tina Quinn

Yes

Yes

Judith Hooper

Yes

Yes

David Wood

Yes

Wider discussion required re: dental practices not being computerised.

Director of Patient Care & Professions to discuss.

Practice Nurse

Yes

Wider discussion required regarding practice procedures.

Whistleblowing policy & text added to policy.

Policy Group

Yes

Development

Yes

Yes

Carol McKenna

Yes

No

Jan Giles

Yes

No

Lynne Hall Bentley

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Jim Barwick

Yes

No

Rachel Carter

Yes

No

Tony Cooke

Yes

No

Vicky Dutchburn

Yes

No

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