POLICY ON THE IMPLEMENTATION OF NICE GUID ANCE

Size: px
Start display at page:

Download "POLICY ON THE IMPLEMENTATION OF NICE GUID ANCE"

Transcription

1 POLICY ON THE IMPLEMENTATION OF NICE GUID ANCE Document Type Corporate Policy Unique Identifier CO-019 Document Purpose To outline the process for the implementation and compliance with NICE guidance and to set out the responsibilities of staff involved in the implementation of NICE guidance within Worcestershire Health and Care NHS Trust Document Author Renata Bozikovova (Quality & Safety Coordinator) and Sam Whitby (Audit, Research and Clinical Manager) Target Audience All staff in Worcestershire Health and Care NHS Trust. Responsible Group Quality and Safety Committee Date Ratified March 2014 Expiry Date March 2017 This validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on or

2 Version History Version Circulation Date Job Title of Person/Name of Group circulated to 01 28/02/2014 Clinical Audit and Group Quality and Safety Committee Brief Summary of Change Accessibility Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number ( ). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting Instant telephone interpreting Document translation British Sign Language interpreting Training and Development Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development needs. 2

3 Contents 1. INTRODUCTION PURPOSE SCOPE DEFINITIONS DUTIES REPORTING IMPLEMENTATION MONITORING IMPLEMENTATION QUALITY INDICATOR EQUALITY IMPACT ASSESSMENT REFERENCES APPENDIX 1 RANKING TOOL TEMPLATE APPENDIX 2 RISK ASSESSMENT TEMPLATE APPENDIX 3 ACTION PLAN TEMPLATE APPENDIX 4 IMPLEMENTATION PROCESS FLOWCHART

4 1. Introduction This policy aims to outline the Worcestershire Health and Care NHS Trust s (WH&CT) processes for the implementation and compliance with National Institute for Health and Clinical Excellence NICE guidance, which should result in clear benefits for patients ensuring that the care provided is both clinically and cost effective. This policy also enables the Trust to comply with the standards set by the Care Quality Commission and NHS Litigation Authority. The process also supports the Trust s Quality framework and provides assurance to the Trust Board. The Trust is required to comply with all of its statutory obligations to meet the funding implications of the recommendations of all NICE Technology Appraisal Guidelines (TAG) within three months of the date of issue: unless where specifically exempted. Purpose The purpose of this policy is to ensure that the Trust has a robust mechanism in place for the dissemination, implementation, monitoring and audit of NICE guidance. This will ensure that: Patients are able to experience the most up-to-date clinically and cost effective care Patients are able to experience equity via the consistent application of the appropriate NICE guidance The trust complies with the requirements for its registration with the CQC. 2. Scope The policy outlines the process of implementation for all types of NICE guidance. Implementation of relevant guidance is to be supported by all healthcare professionals. 3. Definitions National Institute for Health and Clinical Excellence (NICE) NICE is an independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health Technology Appraisals Technology Appraisals are recommendations on the use of new and existing health technologies. The Secretary of State has directed that the NHS should normally provide funding and resources for medicines and treatments that have been recommended by NICE technology appraisals within 3 months of the date of publication. Clinical Guidelines Clinical guidelines provide guidance on the appropriate treatment and care of people with specific diseases and conditions. Interventional Procedures NICE Interventional Procedures guidance provides advice on the safety and the efficacy of new interventional procedures. These may be procedures approved for normal use, procedures which should not be used and those which may be used with certain safeguards. 4

5 Medical Technologies Guidance Medical technologies guidance is designed to help the NHS adopt efficient and cost effective medical devices and diagnostics more rapidly and consistently. The types of products which might be included are medical devices that deliver treatment such as those implanted during surgical procedures, technologies that give greater independence to patients, and diagnostic devices or tests used to detect or monitor medical conditions. Public Health Guidance Public Health guidance provides guidance on the promotion of good health and prevention of ill health. Diagnostic Technologies Guidance Diagnostic Technologies Guidance is designed to help the NHS adopt efficient and cost effective medical diagnostic technologies more rapidly and consistently. Patient Safety Guidance Patient Safety Guidance provides advice on patient safety solutions. Quality Standards NICE Quality Standards are markers of Quality Care for a variety of conditions. They demonstrate to the public and to patients, as well as health and social care professionals, commissioners and service providers the standards that should be met to assure satisfactory care. NICE Evidence Service NHS Evidence is a web-based search engine which allows NHS and public health sector staff to access clinical and non-clinical evidence which has been independently accredited. It encompasses national, international and local evidence sources and incorporates all National Library for Health sources it has four distinct categories: o o o o Clinical Knowledge Summaries Journals and Databases Evidence Search Evidence Uncertainties (UK DUETs) NHS Litigation Authority (NHSLA) Part of the NHS responsible for handling negligence claims made against NHS bodies in England The NHS Litigation Authority (NHSLA) requirements indicate that each trust must have an approved documented process for ensuring that agreed best practice as defined in NICE clinical guidelines, is taken into account in the context of the clinical services provided by the organisation, and that it is implemented and monitored. Care Quality Commission (CQC) The Care Quality Commission (CQC) is an independent regulator of health and social care in England CQC makes it clear that the primary responsibility for implementing NICE guidance lies with the local NHS. Outcome 4 states that: Healthcare organisations should reduce the risk of people receiving unsafe or inappropriate care, treatment and support by taking account of published research and guidance. 4. Duties 5.1 Senior Management Team (Directors) has responsibility for overseeing systems and processes for Clinical Quality. The Senior Management Team and Trust Board hold responsibility for the signing off the Trust s Quality Accounts, the annual declaration to the Care 5

6 Quality Commission (CQC), and the provision of information to Commissioners about the quality of care provided by the trust. The Chief Executive has overall responsibility for the quality of service delivery across the Trust. 5.2 Service Delivery Unit Leads and Clinical Directors (SDU) have overall responsibility for compliance with relevant NICE guidance within their own SDU, and should ensure that there are appropriate systems in place to cascade information pertaining to NICE within their SDU. 5.3 Deputy Medical Director chairs the Clinical Audit and Group and provides expert advice on the implementation of all NICE guidance across the organisation, and ensures that where areas of non-compliance are identified, these are then performance managed by the relevant SDUs and that these are reported to the Quality and Safety Committee via the Clinical Audit & Group s bi-annual report. 5.4 Clinical Audit and Group (CAEG) is a Trust-wide multi-disciplinary group (with representatives from all SDUs) which meets on a quarterly basis and reports to the Quality and Safety Committee. The group s remit is to ensure there are systems and processes in place to provide the Board with assurance around NICE guidance implementation within the Trust. The nominated members of the group will also provide a filtering and signposting of newly published guidance function, on a monthly cycle, via an group. 5.5 Quality/Governance Leads or equivalent individual(s) with responsibility for quality and safety governance review newly published guidance on a monthly basis. They then nominate a suitable clinical lead (referred to as the nominated Clinical Lead) for every piece of guidance applicable to their individual SDU. They work in collaboration with the nominated Clinical Lead, and provide input into the development of any action plan. They then monitor the implementation of the action plans and inform the Q&S Co-ordinator on progress, delays or any problems. 5.6 Nominated Clinical Leads** have responsibility for undertaking a NICE compliance assessment for each piece of NICE guidance that is relevant to their service/sdu, that they have been nominated to complete. The nominated Clinical Leads are also responsible for the formulation of robust action plans to address any areas of partial or non-compliance and for sharing these with their SDU Lead and all affected staff in that area. Where declarations of partial or non-compliance are made, the nominated Clinical Lead in conjunction with the Quality/Governance Lead will ensure a risk assessment is undertaken and escalated to the Clinical Director(s) and SDU Lead for their consideration of placement of relevant risks on the SDU s risk register. The nominated Clinical Lead will then report this back to the Q&S Coordinator for recording. **The nominated Clinical Lead will be the most suitably experienced professional e.g. doctor, nurse, OT, psychologist etc. 5.7 All staff involved in the assessment and care of patients are responsible for ensuring that they are cognisant with all of the latest published guidance and for ensuring that they take any recommendations contained in the guidance fully into account when deciding what services, treatments or advice to offer to patients. 5.8 Clinical Audit and Manager/ Quality and Safety Co-ordinator have responsibility for managing the processes for NICE guidance implementation. This includes the dissemination of new guidance within the Trust, circulating the NICE compliance assessments to the nominated Clinical Leads, monitoring the progress with completion of the assessments and action plans, providing advice with regard to ranking and risk assessing guidance and maintaining the Trust s compliance database, known as the NICE tracker. 6

7 6. Reporting 6.1 Clinical Audit and Group (CAEG) receives quarterly reports from the Quality and Safety Co-ordinator on: the progress made with regards to the implementation of relevant NICE guidance within each individual SDU the current levels of compliance and assurance across the trust any risks arising from non or only partial compliance with NICE guidance the monthly Quality Indicator figure 6.2 Quality and Safety Committee receives an overview reports containing the above from the Clinical Audit and Group on a bi-annual basis. 6.3 Finance and Performance Group receives a monthly summary report from the Quality and Safety Co-ordinator on: the progress made with regards to the implementation of relevant NICE guidance within each individual SDU the current levels of compliance and assurance across the trust any risks arising from non or only partial compliance with NICE guidance the monthly Quality Indicator figure 7. Implementation 7.1 Process for implementation of NICE guidance The Quality and Safety Co-ordinator sends out, in electronic format, all new NICE clinical guidelines (and other types of newly published guidance are also circulated for information) to the Deputy Medical Director and to the nominated representatives in each SDU (E.g. Quality or Governance Leads) to ascertain whether any of the clinical guidelines are of relevance to their services or not. The nominated representatives from each SDU then need to inform the Q&S Co-ordinator whether any of the clinical guidelines are relevant or not. If the guidance is relevant, the Q&S Co-ordinator then forwards the relevant guidance and the blank NICE compliance assessment to the nominated representative, so that they can co-ordinate the response. Within one month of receipt, the SDUs are required to rank all of the new relevant guidance for priority, using the ranking tool in the Table 1 below. It is recommended that the ranking process is undertaken by a minimum of three people to include the Quality Lead or their equivalent, clinical lead in the particular area of NICE guidance and the Q&S Co-ordinator. Table 1: Ranking tool Criteria High cost (treatment costs) High volume (amount of patients) High risk Evidence of a quality problem (incidents, complaints etc.) Not relevant (0) Limited relevance (1) Moderate relevance (2) Fully relevant (3) Score 7

8 Wide variation in practice Likely to improve healthcare outcomes as well as process improvements Likely to have economic and efficiency benefits Topic is a key professional or clinical interest Reliable sources of data readily available Potential for change Multidisciplinary project Interface project (Health Economy) Cost Improvement Programme Total score Table 2 lays out how scoring translates into relevance and priority for the service, and indicates the timeframe within which the base line compliance assessment should be completed, including action planning and audit. Table 2: Scoring key Score Relevance/priority Assessment timeframe 1-17 Limited relevance/ Low priority Consider not reviewing and place on Risk Register Moderate relevance/ Medium priority within 6 months Fully relevant/ High priority within 3 months Any guidance not ranked for prioritisation within 1 month of the SDU receiving the guidance is flagged red in the priority level column in Table 3 below, because it automatically becomes a high priority and therefore a high risk, if its importance to the service/trust is not known. It will therefore be reported with only level 1 assurance guidance circulated to Quality Leads. As mentioned above, every piece of ranked guidance needs to have a base line assessment completed in line with the timeframe associated with each priority level (see Table 2 above). For instance, a medium/moderate priority guideline would need to be assessed within 6 months and within 3 months if the guidance is rated a high priority for the service/trust. Therefore, if the guidance has been ranked as a high priority (see CGii in Table 4 below) but no baseline compliance assessment has been completed within the specified timeframe, then it will be reported with level 2 assurance only guidance has been ranked for priority, and it will be recorded as a high risk in the risk column. When there is a piece of guidance (example CGiii in Table 4 below) where the baseline compliance assessment has been completed and the level of compliance with that guidance has been established but no action plan has been agreed that would bring the service to compliance, then it will be reported with level 3 assurance compliance assessment 8

9 undertaken and level of compliance known. Again, Table 4 illustrates the different levels of risk associated with different priorities of guidance. As the level of scrutiny increases the level of risk reduces; the pyramid below is another way of showing this. Levels of scrutiny vs. levels of risk The gold standard to aim for is to be reporting level 5 assurance service is compliant with guidance as verified by clinical audit for all guidelines. Where guidance is ranked as a low priority for the service, it can be omitted from the baseline assessment. This is in response to the limited capacity within SDUs to review all NICE guidance. The non-assessed guidance would then be added to the relevant SDU Risk Register. This would then be monitored in light of any service changes which may result in the guidance becoming more relevant and hence a higher priority for the organisation. All low priority level guidance will be assessed by the Clinical Directors at regular intervals. Table 3: Levels of scrutiny Level of scrutiny Definition of level of scrutiny 1 Guidance circulated to Quality Leads 2 Guidance has been ranked for priority 3 Compliance assessment undertaken and level of compliance known 4 Action plan in place to deliver compliance 5 Service compliant with guidance as verified by clinical audit 9

10 Table 4: Reporting matrix Priority level Level of assurance Adjusted NICE Full Significant Moderate Limited No level of guidance (Level 5) (Level 4) (Level 3) (Level 2) (Level 1) risk CG i? High CG ii CG iii CG iv CG v Medium High High High Medium Medium High Medium Medium Low High Low Medium Low High Low When a newly published item of NICE guidance crosses several services and/or SDUs, it is strongly recommended that all interested parties form a small working group to address any issues arising from the NICE guidance recommendations, and to work jointly so that a unified Trust response can be given. All completed baseline compliance assessments should be reviewed and formally signed off by each SDU before they are submitted to the Q&S Co-ordinator. As best practice, it is suggested that a baseline audit of a small number of cases is undertaken to help inform the compliance assessment. Although, the individual SDU s are responsible for organising their own baseline audits, advice and support is available from the Quality and Safety Team. The Quality/Governance Lead ensures that any potential risks associated with the decision not to implement guidance have been considered and where applicable, added to the SDU risk register. The Quality Lead then notifies the Q&S Co-ordinator that this has been carried out, giving details of specific risks. The Quality/Governance Lead approves the action plans and monitors the implementation of the guidance and updates the Q&S Co-ordinator at regular intervals about the progress of implementation. The Quality/Governance Lead also informs the Q&S Co-ordinator if there are any delays or problems with the implementation of the guidance. All implementation timescales and progress are being recorded on the NICE tracker, which is managed by the Quality and Safety Team. All NICE guidance should be prioritised for clinical audit and placed on the three year rolling SDU clinical audit programme. Risk assessment framework A risk assessment template has been developed to record the risks associated with not implementing the relevant NICE recommendations. Any identified risk can then be described and a risk score attributed to it, and an agreed action added to show how that risk will be mitigated. 8. Monitoring the implementation of this policy The implementation of this policy will be monitored bi-annually through CAEG, which in return reports to QSC and the trust Board. The progress against the recommendations of all reports will be included in the Trust-wide Quality report. 10

11 The following matrix table illustrates how monitoring will be achieved: NHSLA Criteria Lead Monitoring Frequency Committee The sections below will contain all the requirements of the NHSLA risk management standards in relation to this policy. Who takes the lead responsibility How do we monitor that this is How often is this done? Which working groups etc. are involved The organisation has an approved, documented process for ensuring that agreed best practise as defined in NICE clinical guidelines and interventional procedures, is taken into account in the context of the clinical services provided by the organisation. As a minimum the document must include a description of the ; Trust Board Quality and Safety Committee reports Bi-annually Quality and Safety Committee Clinical Audit and Group a) Duties including leadership of the process at all stages of the process Chief Executive through the Executive Directors & Senior Managers Performance reviews Monthly Quality and Safety Committee b) Process for identifying relevant documents Audit, Research & Clinical Manager Horizon scans Quarterly Clinical Audit and Group c) Process for disseminating relevant documents Audit, Research & Clinical Manager Standing agenda item on SDUs Quality and Safety groups Monthly Clinical Audit and Group d) Process for conducting an organisational gap analysis Audit, Research & Clinical Manager & SDU Lead(s) Completed NICE Compliance Assessment For every piece of relevant guidance Clinical Audit and Group e) Process for ensuring that recommendations are acted upon throughout the organisation Clinical Audit and Group SDUs reports on progress made to Quality and Safety Committee Monthly Clinical Audit and Group d) Process for documenting any decision not to implement NICE recommendations Medical Director Decision recorded in the minutes of the Clinical Audit and For each piece of guidance NOT implemented Clinical Audit and Group Quality and 11

12 Group Safety Committee g) Process for monitoring compliance with all of the above Medical Director Report to Quality and Safety Committee and Trust Board Monthly and biannually Clinical Audit and Group Quality and Safety Committee 9. Quality Indicator for NICE guidance implementation Every piece of NICE guidance is scored using the ranking tool according to its level of scrutiny and assurance. The highest level of assurance Level 5 is achieved when the service is compliant with the relevant guidance as verified by clinical audit. The overall percentage will then be calculated and reported on, on a monthly basis. 10. Equality analysis This policy has undergone an equality analysis. 11. Reference National Prescribing Centre (2001). Implementing NICE Guidance: Radcliffe Medical Press NHS Litigation Authority Risk Management Standards for PCTs (May 2007) available at How to put NICE guidance into practice (2005) available at A guide to NICE (2005) available at The Audit Commission (2005) Managing financial implications of NICE guidance Appendix 1 Ranking tool template Prioritisation of guidance: ranking priority 12

13 Table 1 is a ranking tool to help rank each piece of guidance. Table 2 lays out how scoring translates into relevance and priority for the service, and indicates the timeframe within which the base line assessment should be completed, including action planning and audit. Table 1: Ranking tool Criteria High cost (treatment costs) High volume (amount of patients) High risk Evidence of a quality problem (incidents, complaints etc.) Wide variation in practice Likely to improve healthcare outcomes as well as process improvements Likely to have economic and efficiency benefits Topic is a key professional or clinical interest Reliable sources of data readily available Potential for change Not relevant (0) Limited relevance (1) Moderate relevance (2) Fully relevant (3) Score Multidisciplinary project Interface project (Health Economy) Cost Improvement Programme Total score Table 2: Scoring key Score Relevance/priority Assessment timeframe 1-17 Limited relevance/ Low priority Consider not reviewing and place on Risk Register Moderate relevance/ Medium priority within 6 months Fully relevant/ High priority within 3 months 13

14 Appendix 2 SDU: Title of the NICE guidance: NICE GUIDANCE RISK ASSESSMENT NICE Ref No. Risk Type Risk (description) Risk Score Risk Register Yes/No Planned Actions Current Status of actions (see key) Implement By Date Staff Member/Group/Team Responsible Responsible Manager Residual Risk Rating Current Status Key 1: Agreed but not yet actioned 2: Action in progress 3: Partial completion 4: Full completion 5: Action overdue 6: Not actioned (Please provide reason why) Risk Assessment Completed by: Job Title:... Date:.... Risk Assessment Completed by: Job Title:... Date:.... Risk Assessment Completed by: Job Title:... Date:.... Please send a completed copy to Renata Bozikovova, Quality and Safety Co-ordinator, Renata.bozikovova@hacw.nhs.uk

15 Rating the risk Risk scoring = consequence x likelihood (C x L) Likelihood Likelihood score Consequence score Rare Unlikely Possible Likely Almost certain 5 Catastrophic Major Moderate Minor Negligible For grading risk, the scores obtained from the risk matrix are assigned grades as follows: 1-3 Low risk 4-6 Moderate risk 8-12 High risk Extreme risk Instructions for use 1. Determine the consequence score (C) for the potential adverse outcome relevant to the risk being evaluated. 2. Determine the likelihood score (L) for the potential adverse outcome to the risk being evaluated. 3. Use table (above) to determine the likelihood score (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score. 4. Calculate the risk score the risk multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score) 5. Identify the level at which the risk will be managed in the organisation, assign priorities for remedial action, and determine whether risks are to be accepted on the basis of the colour bandings and risk ratings, and the organisation s risk management system. Include the risk in the organisation risk register at the appropriate level. 15

16 Appendix 3 Action Plan template Service: Title of the NICE guidance: Date completed: Action plan for the implementation of NICE guidance Intended outcome Action Name of person responsible To be completed by Please return the completed action plan to Renata Bozikovova, Quality and Safety Co-ordinator, Tel: , renata.bozikovova@hacw.nhs.uk 16

17 Appendix 4 Procedure flowchart for the Implementation of NICE guidance Start Clinical Directors and Quality and Safety Committee review score Set out date for re-audit Compliant and added to audit forward programme set out audit date Yes Yes Ulysses Alert with newly published guidance is distributed to Quality/Governa nce Leads/Clinical Directors in each SDU by the Q&S Coordinator Quality/Govern ance Leads/Clinical Directors action the alert on Ulysses indicating whether guidance is relevant or not Quality/Governa nce Leads/Clinical Directors notify Q&S Coordinator of all applicable guidance and the name of Clinical Lead(s) for each guidance Q&S Coordinator sends the Ranking tool and the baseline compliance assessment to the Nominated Clinical Lead (NCL) Nominated Clinical Lead (NCL) completes and returns the Ranking tool Is the guidance of Low priority? No Nominated Clinical Lead (NCL) completes and returns the NICE baseline compliance assessment to Q&S Coordinator and Quality/Govern ance Lead Completed NICE baseline assessment is reviewed by the SDU and sent to Q&S Coordinator and Quality/Gove rnance Lead Is the service compliant with guidance? Timescale: within 1 week of publicaton Within 1 month of receipt Within 1 month of receipt Within 1 month of receipt 3 or 6 months or N/A if low priority guidance Service is partially or non-compliant 17

18 Guidance is implemented when actions are completed. Added to the audit forward programme Quality/Gov ernancelea d monitors action plans and informs Q&S Coordinator of progress and any delays NCL and/or Quality/Govern ance Lead ensure development of a SMART action plan & returns it to Q&S Coordinator Yes Will the guideline be implemented? No Assessment is reviewed by the SDU consider placing on SDU risk register and inform Q&S Co-ordinator 18

Clinical Audit Strategy

Clinical Audit Strategy Clinical Audit Strategy Clinical Audit Strategy 2012/15 Document Type Strategy Unique Identifier CL-016 Document Purpose To map out the strategic direction of Clinical Audit within the Trust for the next

More information

Appendix 1. Policy on the Dissemination, Implementation and Monitoring of National Clinical Guidance

Appendix 1. Policy on the Dissemination, Implementation and Monitoring of National Clinical Guidance Appendix 1 Policy on the Dissemination, Implementation and Monitoring of National Clinical Guidance Policy Title: Executive Summary: Policy on the dissemination, implementation and monitoring of national

More information

Document Details Clinical Audit Policy

Document Details Clinical Audit Policy Title Document Details Clinical Audit Policy Trust Ref No 1538-31104 Main points this document covers This policy details the responsibilities and processes associated with the Clinical Audit process within

More information

Quality Impact Assessment Policy

Quality Impact Assessment Policy Quality Impact Assessment Policy Date: February 2016 Version: 2.1 Review Due: February 2018 Reader information Reference Directorate Document purpose Q005 Quality The purpose of this policy is to set out

More information

Central Alerting System (CAS) Policy

Central Alerting System (CAS) Policy Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Gary O Hare Executive Director of Nursing and Operations Tony Gray

More information

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Implementation Policy for NICE Guidelines

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Implementation Policy for NICE Guidelines The Newcastle upon Tyne Hospitals NHS Foundation Trust Implementation Policy for NICE Guidelines Version No.: 5.3 Effective From: 08 May 2017 Expiry Date: 02 March 2019 Date Ratified: 23 February 2017

More information

Date 4 th September 2015 Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate Director of Quality Laura Rowe, Compliance Manager

Date 4 th September 2015 Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate Director of Quality Laura Rowe, Compliance Manager TB 099/15 Meeting title Report title Trust Board Risk Management Strategy Date 4 th September 2015 Lead director Report author FOI status Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate

More information

Quality and Equality Integrated Impact Assessment Policy

Quality and Equality Integrated Impact Assessment Policy Subject: Quality and Equality Integrated Impact Assessment Policy Meeting: NHS MK CCG Shadow Board Date of Meeting: 2 October 2012 Report of: Alison Jamson, NHSMK&N Introduction NHS Milton Keynes Clinical

More information

QUALITY COMMITTEE. Terms of Reference

QUALITY COMMITTEE. Terms of Reference QUALITY COMMITTEE Terms of Reference CONSTITUTION 1. The Board of Directors approved the establishment of the Quality Committee (known as the Committee in these terms of reference) for the purpose of:

More information

VELINDRE NHS TRUST. Trust Procedure PROCEDURE FOR THE IMPLEMENTATION OF NATIONAL INSTITUTE OF HEALTH & CLINICAL EXCELLENCE (NICE) GUIDANCE

VELINDRE NHS TRUST. Trust Procedure PROCEDURE FOR THE IMPLEMENTATION OF NATIONAL INSTITUTE OF HEALTH & CLINICAL EXCELLENCE (NICE) GUIDANCE Clinical Excellence (NICE) Guidance VELINDRE NHS TRUST Trust Procedure Black 21 PROCEDURE FOR THE IMPLEMENTATION OF NATIONAL INSTITUTE OF HEALTH & CLINICAL EXCELLENCE (NICE) GUIDANCE Lead: Lisa Heydon-Mann

More information

CLINICAL GOVERNANCE AND QUALITY COMMITTEE Terms of Reference

CLINICAL GOVERNANCE AND QUALITY COMMITTEE Terms of Reference CLINICAL GOVERNANCE AND QUALITY COMMITTEE Terms of Reference CONSTITUTION 1. The Board of Directors approved the establishment of the Clinical Governance and Quality Committee (known as the Committee in

More information

POLICY FOR INCIDENT AND SERIOUS INCIDENT REPORTING

POLICY FOR INCIDENT AND SERIOUS INCIDENT REPORTING POLICY FOR INCIDENT AND SERIOUS INCIDENT REPORTING Policy Acceptance Applies to: All staff, patients, & carers Date Issued: 7 th March 2016 Status Ratified Version 4 Date for Review March 2018 Responsible

More information

Moderate injury requiring professional intervention. Requiring time off work for 4-14 days. Increase in length of hospital stay by 4-15 days

Moderate injury requiring professional intervention. Requiring time off work for 4-14 days. Increase in length of hospital stay by 4-15 days APPENDIX 1 SHCCG Risk Scoring Matrix Taken from NPSA Risk Matrix for Managers (January 2008) Table 1 Consequence scores Choose the most appropriate domain for the identified risk from the left hand side

More information

Prof. Paula Whitty Director of Research, Innovation and Clinical Effectiveness. Author(s) (name and designation) Date ratified January 2015

Prof. Paula Whitty Director of Research, Innovation and Clinical Effectiveness. Author(s) (name and designation) Date ratified January 2015 Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Clinical Audit Policy NTW(C)52 Medical Director Prof. Paula Whitty Director of Research, Innovation and Clinical

More information

CLINICAL GOVERNANCE STRATEGY. For West Sussex PCT

CLINICAL GOVERNANCE STRATEGY. For West Sussex PCT CLINICAL GOVERNANCE STRATEGY For West Sussex PCT 2006 2009 Agreed by the Clinical Governance Committee: 31/01/07 Effective from: 31/01/07 Review: 31/07/07 Page 1 of 8 Contents Page Introduction 3 Principles

More information

Governance and Quality Committee Review. Wendy Pugh Director of Operations and Nursing. Innovation Tom Jinks - Governance Manager.

Governance and Quality Committee Review. Wendy Pugh Director of Operations and Nursing. Innovation Tom Jinks - Governance Manager. Board meeting date: 29 th May 2013 Agenda Item number:10.1 Enclosure:5 Title and Quality Committee Review Accountable Director: Author (name & title): Wendy Pugh Director of Operations and Nursing Rosie

More information

CLINICAL GOVERNANCE AND QUALITY COMMITTEE. Final - Terms of Reference - Final

CLINICAL GOVERNANCE AND QUALITY COMMITTEE. Final - Terms of Reference - Final CLINICAL GOVERNANCE AND QUALITY COMMITTEE Final - Terms of Reference - Final CONSTITUTION 1. The Board of Directors approved the establishment of the Clinical Governance and Quality Committee (known as

More information

Quality Governance (Audit, Compliance and CQC) Manager

Quality Governance (Audit, Compliance and CQC) Manager Quality Governance (Audit, Compliance and CQC) Manager Service Location Central Office Worcester Cranstoun is a charity empowering people to live healthy, safe and happy lives. Our skilled and compassionate

More information

The Mid Yorkshire Hospitals NHS Trust. Risk Management Strategy

The Mid Yorkshire Hospitals NHS Trust. Risk Management Strategy The Mid Yorkshire Hospitals NHS Trust Risk Management Strategy Document control Author Assistant director governance and patient safety Director sponsor Medical Director Date August 2011 Version 6 Draft

More information

RESPONSE TO RECOMMENDATIONS FROM THE HEALTH & SOCIAL CARE COMMITTEE: INQUIRY INTO ACCESS TO MEDICAL TECHNOLOGIES IN WALES

RESPONSE TO RECOMMENDATIONS FROM THE HEALTH & SOCIAL CARE COMMITTEE: INQUIRY INTO ACCESS TO MEDICAL TECHNOLOGIES IN WALES Recommendations 1, 2, 3 1. That the Minister for Health and Social Services should, as a matter of priority, identify means by which a more strategic, coordinated and streamlined approach to medical technology

More information

QUALITY COMMITTEE. Terms of Reference

QUALITY COMMITTEE. Terms of Reference QUALITY COMMITTEE Terms of Reference This Committee will report to NHS Halton CCG Governing Body on the development, improvement and monitoring of all areas of quality. This will include clinical effectiveness,

More information

The safety of every patient we care for is our number one priority

The safety of every patient we care for is our number one priority HUMBER NHS FOUNDATION TRUST INFECTION PREVENTION AND CONTROL STRATEGY 2015-2017 1. Introduction Healthcare associated infections (HCAI) continue to be a major cause of patient harm and although nationally

More information

Clinical Audit Policy

Clinical Audit Policy Clinical Audit Policy DOCUMENT CONTROL Version: 5 Ratified by: Quality Assurance Group Date ratified: 3 July 2017 Name of originator/author: Clinical Quality Lead Senior Clinical Audit Facilitator Name

More information

Process and methods Published: 23 January 2017 nice.org.uk/process/pmg31

Process and methods Published: 23 January 2017 nice.org.uk/process/pmg31 Evidence summaries: process guide Process and methods Published: 23 January 2017 nice.org.uk/process/pmg31 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).

More information

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care.

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Associated Policies Being Open and Duty of Candour policy CG10 Clinical incident / near-miss

More information

Clinical Audit Strategy 2015/ /18

Clinical Audit Strategy 2015/ /18 Audit Strategy 2015/16 2017/18 Audit Strategy v8 Head of Integrated Governance Oct 2014 1 CLINICAL AUDIT STRATEGY, 2015/16 to 2017/18 Executive East Cheshire NHS Trust sees clinical audit as a cornerstone

More information

EAST & NORTH HERTS, HERTS VALLEYS CCGS SAFEGUARDING CHILDREN & LOOKED AFTER CHILDREN TRAINING STRATEGY

EAST & NORTH HERTS, HERTS VALLEYS CCGS SAFEGUARDING CHILDREN & LOOKED AFTER CHILDREN TRAINING STRATEGY EAST & NORTH HERTS, HERTS VALLEYS CCGS Page 1 of 16 DOCUMENT CONTROL SHEET Document Owner: Directors of Nursing and Quality Document Author(s): Beverly Mukandi - Deputy Designated Nurse Safeguarding Children,

More information

Primary Care Quality Assurance Framework (Medical Services)

Primary Care Quality Assurance Framework (Medical Services) PCC/15/021 Primary Care Quality Assurance Framework (Medical Services) 1.0 Introduction: From the 1 April 2015 the responsibility for monitoring quality and responding to concerns arising from General

More information

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. Health and Social Care Directorate Quality standards Process guide

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. Health and Social Care Directorate Quality standards Process guide NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Health and Social Care Directorate Quality standards Process guide December 2014 Quality standards process guide Page 1 of 44 About this guide This guide

More information

The following tables define the impact and likelihood scoring options and the resulting score: - Risk score. Category

The following tables define the impact and likelihood scoring options and the resulting score: - Risk score. Category LIKELIHO OD NHS Eastern Cheshire Clinical Commissioning Group: Quality Impact Assessment Tool v1 Overview This tool involves an initial assessment (stage 1) to quantify potential impacts (positive or negative)

More information

Equality and Diversity

Equality and Diversity Equality and Diversity Vision Statement Yasmin Mahmood Senior Associate Equality and Diversity May 2016 page 1/9 Introduction NHS Merton CCG is committed to ensuring equality, diversity and inclusion are

More information

Sample CHO Primary Care Division Quality and Safety Committee. Terms of Reference

Sample CHO Primary Care Division Quality and Safety Committee. Terms of Reference DRAFT TITLE: Sample CHO Primary Care Division Quality and Safety Committee Terms of Reference AUTHOR: [insert details] APPROVED BY: [insert details] REFERENCE NO: [insert details] REVISION NO: [insert

More information

Audit Report. ITC First Aid

Audit Report. ITC First Aid Audit Report ITC First Aid 23 October 2013 Note Restricted or commercially sensitive information gathered during SQA Accreditation s quality assurance activities is treated in the strictest confidence.

More information

MATERNITY SERVICES RISK MANAGEMENT STRATEGY

MATERNITY SERVICES RISK MANAGEMENT STRATEGY Trust Board Agenda Item 8.3 Enc 10 Appendix 1 January 2012 MATERNITY SERVICES NORTH CUMBRIA MATERNITY SERVICES RISK MANAGEMENT STRATEGY 2011-13 DOCUMENT CONTROL Author/Contact Head Of Midwifery / Clinical

More information

Awarding body monitoring report for: Association of British Dispensing Opticians (ABDO)

Awarding body monitoring report for: Association of British Dispensing Opticians (ABDO) Awarding body monitoring report for: Association of British Dispensing Opticians (ABDO) February 2008 Contents Introduction... 4 Regulating external qualifications... 4 About this report... 5 About the

More information

HOME TREATMENT SERVICE OPERATIONAL PROTOCOL

HOME TREATMENT SERVICE OPERATIONAL PROTOCOL HOME TREATMENT SERVICE OPERATIONAL PROTOCOL Document Type Unique Identifier To be set by Web and Systems Development Team Document Purpose This protocol sets out how Home Treatment is provided by Worcestershire

More information

NHS continuing health care joint dispute resolution procedure

NHS continuing health care joint dispute resolution procedure Title: Developed by: Document type: Policy library: Sub Section: Document status: Date of ratification: Ratified By: Date to be reviewed: Version NHS continuing health care joint dispute resolution procedure

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Spire Wellesley Hospital Eastern Avenue, Southend-on-Sea, SS2

More information

Patient Safety, Quality & Risk Committee Terms of Reference

Patient Safety, Quality & Risk Committee Terms of Reference Patient Safety, Quality & Risk Committee Terms of Reference Status: Chair: Clerk: Frequency of meetings: Quorum: Sub Committee of the Trust Board Non Executive director Associate Director of Governance

More information

Medicines Governance Service to Care Homes (Care Home Service)

Medicines Governance Service to Care Homes (Care Home Service) Medicines Governance Service to Care Homes (Care Home Service) Locally Enhanced Service Authors: Ruth Buchan, Senior Pharmacist Medicines Management 4th Floor F Mill Dean Clough Halifax HX3 5AX Tel-01422

More information

Appendix 1 MORTALITY GOVERNANCE POLICY

Appendix 1 MORTALITY GOVERNANCE POLICY Appendix 1 MORTALITY GOVERNANCE POLICY 1 Policy Title: Executive Summary: Mortality Governance Policy For many people death under the care of the NHS is an inevitable outcome and they experience excellent

More information

JOB DESCRIPTION DIRECTOR OF SCREENING. Author: Dr Quentin Sandifer, Executive Director of Public Health Services and Medical Director

JOB DESCRIPTION DIRECTOR OF SCREENING. Author: Dr Quentin Sandifer, Executive Director of Public Health Services and Medical Director JOB DESCRIPTION DIRECTOR OF SCREENING Author: Dr Quentin Sandifer, Executive Director of Public Health Services and Medical Director Date: 1 November 2017 Version: 0d Purpose and Summary of Document: This

More information

Quality and Safety Committee Terms of Reference

Quality and Safety Committee Terms of Reference Approved May 2016 Quality and Safety Committee Terms of Reference 1. Constitution The Quality and Safety Committee is established as a sub-committee of The Hillingdon Hospitals NHS Foundation Trust (THH)

More information

The use of lay visitors in the approval and monitoring of education and training programmes

The use of lay visitors in the approval and monitoring of education and training programmes Education and Training Committee, 12 September 2013 The use of lay visitors in the approval and monitoring of education and training programmes Executive summary and recommendations Introduction This paper

More information

DR KUMAR CQC INSPECTION ACTION PLAN

DR KUMAR CQC INSPECTION ACTION PLAN DR KUMAR CQC INSPECTION ACTION PLAN REVIEWED: 28 TH DECEMBER 2015 RED NOT COMPLETED AMBER STARTED TO COMPLETE or SUPPORT AGREED WITH OTHER PARTNERS/ AGENCIES GREEEN COMPLETED GENERAL CQC CONCERNS ASSURANCE

More information

NICE Charter Who we are and what we do

NICE Charter Who we are and what we do NICE Charter 2017 Who we are and what we do 1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing evidence-based guidance on health and

More information

Health Visitor and School Nurse Preceptorship Guidance. Version No 2

Health Visitor and School Nurse Preceptorship Guidance. Version No 2 Livewell Southwest Health Visitor and School Nurse Preceptorship Guidance Version No 2 Notice to staff using a paper copy of this guidance The policies and procedures page of LSW intranet holds the most

More information

NHS. The guideline development process: an overview for stakeholders, the public and the NHS. National Institute for Health and Clinical Excellence

NHS. The guideline development process: an overview for stakeholders, the public and the NHS. National Institute for Health and Clinical Excellence NHS National Institute for Health and Clinical Excellence Issue date: April 2007 The guideline development process: an overview for stakeholders, the public and the NHS Third edition The guideline development

More information

Internal Audit. Health and Safety Governance. November Report Assessment

Internal Audit. Health and Safety Governance. November Report Assessment November 2015 Report Assessment G G G A G This report has been prepared solely for internal use as part of NHS Lothian s internal audit service. No part of this report should be made available, quoted

More information

CLINICAL AND CARE GOVERNANCE STRATEGY

CLINICAL AND CARE GOVERNANCE STRATEGY CLINICAL AND CARE GOVERNANCE STRATEGY Clinical and Care Governance is the corporate responsibility for the quality of care Date: April 2016 2020 Next Formal Review: April 2020 Draft version: April 2016

More information

Hospital Discharge and Transfer Guidance. Choice, Responsiveness, Integration & Shared Care

Hospital Discharge and Transfer Guidance. Choice, Responsiveness, Integration & Shared Care Hospital Discharge and Transfer Guidance Choice, Responsiveness, Integration & Shared Care Worcestershire Mental Health Partnership NHS Trust Information Reader Box Document Type: Document Purpose: Unique

More information

Methods: Commissioning through Evaluation

Methods: Commissioning through Evaluation Methods: Commissioning through Evaluation NHS England INFORMATION READER BOX Directorate Medical Operations and Information Specialised Commissioning Nursing Trans. & Corp. Ops. Commissioning Strategy

More information

Removal of Annual Declaration and new Triennial Review Form. Originated / Modified By: Professional Development and Education Team

Removal of Annual Declaration and new Triennial Review Form. Originated / Modified By: Professional Development and Education Team Review Circulation Application Ratificatio n Author Minor Amendment Supersedes Title DOCUMENT CONTROL PAGE Title: Mentorship in Nursing and Midwifery Policy Version: 14.1 Reference Number: Supersedes:.14.0

More information

Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy

Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy SUPERVISED COMMUNITY TREATMENT AND COMMUNITY TREATMENT ORDERS (S17(A)) POLICY Document Type Policy Unique Identifier CL-010

More information

Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience Craig Newby Patient Safety Officer

Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience Craig Newby Patient Safety Officer Document Title Reference Number Security Management Policy NTW(O)21 Lead Officer Author(s) (name and designation) Executive Director of Nursing and Operations Tony Gray Head of Safety and Patient Experience

More information

Document Details Title

Document Details Title Document Details Title Quality and Equalities Impact Assessment (QEIA) Process Guidance Trust Ref No 2046-45852 Local Ref (optional) Main points the document This document explains the process for QEIA,

More information

Moving and Handling Policy

Moving and Handling Policy Moving and Handling Policy Ratified Quality, Patient Safety and Risk / 16/04/2014 / 2014-40 Status Ratified Issued April 2014 Approved By Quality, Patient Safety and Risk Committee Consultation Quality,

More information

AGENDA ITEM NO: 046/17

AGENDA ITEM NO: 046/17 AGENDA ITEM NO: 046/17 GOVERNING BODY MEETING: Governing Body Meeting DATE OF MEETING: 13 th September 2017 REPORT AUTHOR AND JOB TITLE: Rebecca Knight Head of Assurance & Risk REPORT TITLE: STRATEGIC

More information

Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement

Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement Job Description Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement Grade 8b Tenure: Permanent Location of Post:

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Liverpool Heart & Chest Hospital NHS Foundation Trust Thomas

More information

Framework for managing performer concerns NHS (Performers Lists) (England) Regulations 2013

Framework for managing performer concerns NHS (Performers Lists) (England) Regulations 2013 Framework for managing performer concerns NHS (Performers Lists) (England) Regulations 2013 Information reader box NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information

More information

Specialised Commissioning Oversight Group. Terms of Reference

Specialised Commissioning Oversight Group. Terms of Reference Specialised Commissioning Oversight Group Terms of Reference Specialised commissioning oversight group terms of reference 1 1.1 Purpose NHS England is responsible for commissioning specialised services

More information

How to use NICE guidance to commission high-quality services

How to use NICE guidance to commission high-quality services How to use NICE guidance to commission high-quality services Acknowledgement We are grateful to the many organisations and individuals who have contributed to the development of this guide. A list of these

More information

Non Medical Prescribing Policy

Non Medical Prescribing Policy Non Medical Prescribing Policy Author: Sponsor/Executive: Responsible committee: Ratified by: Consultation & Approval: (Committee/Groups which signed off the policy, including date) This document replaces:

More information

Lone worker policy. Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead

Lone worker policy. Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead Document level: Trustwide (TW) Code: GR33 Issue number: 3 Lone worker policy Lead executive Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead 01244 397618

More information

PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE

PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE Page 1 DOCUMENT CONTROL SHEET Name of Document: Patient Safety and Quality Committee Terms of Reference Version: 5 File Location / Document Name:

More information

Prevention and control of healthcare-associated infections

Prevention and control of healthcare-associated infections Prevention and control of healthcare-associated infections Quality improvement guide Issued: November 2011 NICE public health guidance 36 guidance.nice.org.uk/ph36 NHS Evidence has accredited the process

More information

SAFEGUARDING CHILDREN POLICY

SAFEGUARDING CHILDREN POLICY SAFEGUARDING CHILDREN POLICY The child s needs are paramount, and the needs and wishes of each child, be they a baby or infant, or an older child, should be put first Working Together 2015 p 8 Keeping

More information

abcdefghijklmnopqrstu

abcdefghijklmnopqrstu Healthcare Policy and Strategy Directorate Quality Division Dear Colleague INTRODUCTION AND AVAILABILITY OF NEWLY LICENSED MEDICINES IN THE NHS IN SCOTLAND Dear Colleague This guidance sets out the policy

More information

NHSLA Risk Management Standards

NHSLA Risk Management Standards NHSLA Risk Management Standards 2012-13 for NHS Trusts providing Acute Services Brighton and Sussex University Hospitals NHS Trust Level 1 October 2012 Contents Executive Summary... 3 Assessment Outcome...

More information

Document Title Investigating Deaths (Mortality Review) Policy

Document Title Investigating Deaths (Mortality Review) Policy Document Title Investigating Deaths (Mortality Review) Policy Document Description Document Type Policy Service Application DWMH Trust wide Version 1.0 Policy Reference no. POL 351 Lead Author(s) Name

More information

November NHS Rushcliffe CCG Assurance Framework

November NHS Rushcliffe CCG Assurance Framework November 2015 NHS Rushcliffe CCG Assurance Framework ASSURANCE FRAMEWORK SUMMARY No. Lead & Sub Committee Date placed on Assurance Framework narrative Residual rating score L I rating in 19 March 2015

More information

Warrington CCG Operational Safeguarding Children Health Forum. Terms of Reference

Warrington CCG Operational Safeguarding Children Health Forum. Terms of Reference Warrington CCG Operational Safeguarding Children Health Forum 1 Introduction Terms of Reference 1.1 The Operational Safeguarding Children Health Forum (the Health Forum) is established within the Safety

More information

Food Hygiene Rating Scheme A Report for the National Assembly of Wales

Food Hygiene Rating Scheme A Report for the National Assembly of Wales Food Hygiene Rating Scheme A Report for the National Assembly of Wales Review of the Implementation and Operation of the Statutory Food Hygiene Rating Scheme and the Operation of the Appeals System in

More information

Mortality Policy. Learning from Deaths

Mortality Policy. Learning from Deaths Mortality Policy Learning from Deaths Name of Author and Job Title: Frank Jacobs, Datix project manager Ian Brandon, Head of governance and risk Name of Review/ Development Body: Ratification Body: Mortality

More information

Northumbria Healthcare NHS Foundation Trust. Charitable Funds. Staff Lottery Scheme Procedure

Northumbria Healthcare NHS Foundation Trust. Charitable Funds. Staff Lottery Scheme Procedure Northumbria Healthcare NHS Foundation Trust Charitable Funds Staff Lottery Scheme Procedure Version 1 Name of Policy Author Alison Nell Date Issued 1 st March 2017 Review Date 1 st March 2018 Target Audience

More information

British Association of Dermatologists

British Association of Dermatologists Guidance producer: British Association of Dermatologists Guidance product: Service Guidance and Standards Date: 13 March 2017 Version: 1.2 Final Accreditation Report Page 1 of 26 Contents Introduction...

More information

NHS East and North Hertfordshire Clinical Commissioning Group. Quality Committee. Terms of Reference Version 4.0

NHS East and North Hertfordshire Clinical Commissioning Group. Quality Committee. Terms of Reference Version 4.0 NHS East and North Hertfordshire Clinical Commissioning Group Quality Committee Terms of Reference Version 4.0 1. Introduction 1.1 The Quality Committee (the committee) is established in accordance with

More information

UKMi and Medicines Optimisation in England A Consultation

UKMi and Medicines Optimisation in England A Consultation UKMi and Medicines Optimisation in England A Consultation Executive Summary Medicines optimisation is an approach that seeks to maximise the beneficial clinical outcomes for patients from medicines with

More information

RISK MANAGEMENT STRATEGY

RISK MANAGEMENT STRATEGY RISK MANAGEMENT STRATEGY Version Number 6.1 Version Date February 2018 Policy Owner Chief Executive Author Trust Risk and Patient Safety Manager First approval or date last reviewed The Risk Management

More information

Solent. NHS Trust. Patient Experience Strategy Ensuring patients are at the forefront of all we do

Solent. NHS Trust. Patient Experience Strategy Ensuring patients are at the forefront of all we do Solent NHS Trust Patient Experience Strategy 2015-2018 Ensuring patients are at the forefront of all we do Executive Summary Your experience of our services matters to us. This strategy provides national

More information

Quality Assurance Framework

Quality Assurance Framework Quality Assurance Framework NHS Bromley Clinical Commissioning Group Quality Assurance Framework was developed to support the commissioning, contract monitoring and procurement processes. NAME OF ORGANISATION/SERVICE

More information

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Central Alert System (CAS) Policy and Procedure

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Central Alert System (CAS) Policy and Procedure The Newcastle upon Tyne Hospitals NHS Foundation Trust Central Alert System (CAS) Policy and Procedure Version No.: 4.1 Effective From: 6 August 2013 Expiry Date: 6 August 2016 Date Ratified: 2 August

More information

ASBESTOS MANAGEMENT POLICY

ASBESTOS MANAGEMENT POLICY ASBESTOS MANAGEMENT POLICY Version 5.0 File ref ASBESTOS MANAGEMENT POLICY Date approved June 2016 Date to be reviewed June 2019 To by reviewed by ASBESTOS STEERING GROUP Asbestos Management Policy June

More information

Moving and Handling Policy

Moving and Handling Policy Moving and Handling Policy Ratified Status Approved Final Issued 28 April 2016 Approved By Quality, Patient Safety and Risk Committee Consultation Executive Committee Equality Impact Assessment Embedded

More information

Quality and Governance Committee. Terms of Reference

Quality and Governance Committee. Terms of Reference Quality and Governance Committee Terms of Reference 1. Constitution 1.1 The Clinical Commissioning Group s Governing Body hereby resolves to establish a Committee of the Governing Body known as the Quality

More information

COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR:

COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: MINDING THE GAP COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: GOVERNANCE ASSURANCE AND PERFORMANCE. 1. INTRODUCTION AND CONTEXT Providing, delivering and developing the highest standards

More information

h. HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST LEARNING FROM DEATHS POLICY. Broad Recommendations / Summary

h. HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST LEARNING FROM DEATHS POLICY. Broad Recommendations / Summary 201 2017.473h. HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST LEARNING FROM DEATHS POLICY Broad Recommendations / Summary In-hospital death occurs. Patient 18 years of age or above. Yes Child Death Review

More information

Annual Complaints Report 2014/15

Annual Complaints Report 2014/15 Annual Complaints Report 2014/15 1.0 Introduction This report provides information in regard to complaints and concerns received by The Rotherham NHS Foundation Trust between 01/04/2014 and 31/03/2015.

More information

INTRODUCTION TO THE UK PUBLIC HEALTH REGISTER ROUTE TO REGISTRATION FOR PUBLIC HEALTH PRACTITIONERS

INTRODUCTION TO THE UK PUBLIC HEALTH REGISTER ROUTE TO REGISTRATION FOR PUBLIC HEALTH PRACTITIONERS INTRODUCTION TO THE UK PUBLIC HEALTH REGISTER ROUTE TO REGISTRATION FOR PUBLIC HEALTH PRACTITIONERS This introduction consists of: 1. Introduction to the UK Public Health Register 2. Process and Structures

More information

CONTINUING HEALTHCARE POLICY

CONTINUING HEALTHCARE POLICY BEFORE USING THIS POLICY ALWAYS ENSURE YOU ARE USING THE MOST UP TO DATE VERSION CONTINUING HEALTHCARE POLICY 1 SUMMARY This policy describes the way in which the five Primary Care Trusts in NHS North

More information

CARERS POLICY. All Associate Director of Patient Experience. Patient & Carers Experience Committee & Trust Management Committee

CARERS POLICY. All Associate Director of Patient Experience. Patient & Carers Experience Committee & Trust Management Committee CARERS POLICY Department / Service: Originator: All Associate Director of Patient Experience Accountable Director: Chief Nursing Officer Approved by: Patient & Carers Experience Committee & Trust Management

More information

NON-MEDICAL PRESCRIBING POLICY

NON-MEDICAL PRESCRIBING POLICY NON-MEDICAL PRESCRIBING POLICY To be read in conjunction with the Medicines Policy, Controlled Drug Policy and the FP10 Prescribing Forms Policy Version: 5 Date of issue: August 2017 Review date: August

More information

How NICE clinical guidelines are developed

How NICE clinical guidelines are developed Issue date: January 2009 How NICE clinical guidelines are developed: an overview for stakeholders, the public and the NHS Fourth edition : an overview for stakeholders, the public and the NHS Fourth edition

More information

Learning from Deaths Framework Policy

Learning from Deaths Framework Policy Learning from Deaths Framework Policy Profile Version: 1.0 Author: Dr Nigel Kennea, Associate Medical Director (Mortality) Executive/Divisional sponsor: Medical Director Applies to: All staff Date issued:

More information

SERVICE SPECIFICATION FOR THE PROVISION OF LONG-ACTING REVERSIBLE CONTRACEPTION SUB-DERMAL CONTRACEPTIVE IMPLANTS IN BOURNEMOUTH, DORSET AND POOLE

SERVICE SPECIFICATION FOR THE PROVISION OF LONG-ACTING REVERSIBLE CONTRACEPTION SUB-DERMAL CONTRACEPTIVE IMPLANTS IN BOURNEMOUTH, DORSET AND POOLE Revised for: 1 April 2015 Updated: 16 April 2015 Appendix 2.2 SERVICE SPECIFICATION FOR THE PROVISION OF LONG-ACTING REVERSIBLE CONTRACEPTION SUB-DERMAL CONTRACEPTIVE IMPLANTS IN BOURNEMOUTH, DORSET AND

More information

Informing Patients of their Rights under Section 132

Informing Patients of their Rights under Section 132 Policy: I9 Informing Patients of their Rights under Section 132 Version: I9/05 Ratified by: Trust Management Team Date ratified: 12 June 2013 Title of Author: MHA Office / Health Records Manager Title

More information

Positive and Safe Management of Post incident Support and Debrief. Ron Weddle Deputy Director, Positive and Safe Care

Positive and Safe Management of Post incident Support and Debrief. Ron Weddle Deputy Director, Positive and Safe Care Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Positive and Safe Management of Post incident Support and Debrief NTW(C)13 Ron Weddle Deputy Director, Positive

More information

HERTFORDSHIRE COMMUNITY HEALTH SERVICES

HERTFORDSHIRE COMMUNITY HEALTH SERVICES HERTFORDSHIRE COMMUNITY HEALTH SERVICES Minutes of the Hertfordshire Community Health Services Board Meeting Held on Thursday 22 nd July 2010 in the Boardroom, Howard Court Welwyn Garden City. Key Points

More information

HEALTH AND SAFETY POLICY

HEALTH AND SAFETY POLICY HEALTH AND SAFETY POLICY Version: 4 Ratified by: Trust Board (Required) Date ratified: January 2016 Title of originator/author: Title of responsible committee/group: Head of Corporate Business Date issued:

More information