Clinical NICE Implementation Policy Document Control Summary Status: Replacement. Replaces: NICE Implementation Policy C/YEL/gen/09. Version: v1.0 Date: November 2015 Author/Title: Owner/Title: Steven Hazeldine- Clinical Audit Team Leader Liz Lockett - Associate Director of Quality & Risk Approved by: Policy and Procedures Committee Date: 17/12/2015 Ratified: Trust Board Date: 28/01/2016 Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Provide high quality recovery focused services January 2016 January 2019 NICE. Guidelines. Guidelines. Effective. Standards. Best practice. Associated Policy or Standard Operating Procedures NICE Implementation Standard Operating Procedure Contents 1. Introduction... 2 2. Definitions... 2 3. Purpose... 3 4. Responsibilities... 3 5. Monitoring Compliance... 5 Change Control Amendment History Version Dates Amendments
1. Introduction Good clinical guidance, successfully implemented, can improve the healthcare of the whole population. Successful implementation depends on the effectiveness of the implementation process and its acceptance by all healthcare professionals, service users and carers. The National Institute for Clinical Excellence (NICE) was set up in April 1999 its role is to provide patients, healthcare professionals, and the public with authoritative, robust, reliable guidance on best practice. NICE provides several types of guidance: 2. Definitions i. Clinical guidelines guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales. ii. Public health guidelines - guidance making recommendations for populations and individuals on activities, policies and strategies that can help prevent disease or improve health. The guidance may focus on a particular topic (such as smoking), a particular population (such as schoolchildren) or a particular setting (such as the workplace). iii. Social Care guidelines - guidelines aiming to improve outcomes for people who use social care support by ensuring that social care services and interventions are effective and cost-efficient. iv. NICE guidelines From January 2015 all guidance previously released under the headings of Clinical guidelines (CG), Public health guidance (PH) and Social Care guidelines (SC) are being classified as NICE guidelines (NG) v. Technology appraisals guidance on the use of new and existing medicines and treatments within the NHS in England and Wales vi. Interventional procedures - procedures used for diagnosis or for treatment that involves making a cut or a hole to gain access to the inside of a patient's body, gaining access to a body cavity, using electromagnetic radiation. vii. Medical technologies guidance - focuses specifically on the evaluation of innovative medical technologies (including devices and diagnostics). viii. Diagnostic technologies guidance - focuses on the evaluation of innovative medical diagnostic technologies in order to ensure that the NHS is able to adopt clinically and cost effective technologies more rapidly and consistently. ix. Cancer service guidance - The focus of the cancer service guidance is to guide the commissioning of services and is therefore different from clinical practice guidelines. It is based upon the implementation of the NHS Cancer Plan Page 2 of 5
It is the first 6 sets of guidelines which relate to services provided by South Staffordshire and Shropshire NHS Foundation Trust. 3. Purpose This policy aims to describe the Trust s process of responding effectively to NICE guidance, which should result in benefits to patients, ensuring that the care provided is both clinically and cost effective. The process supports the Trust s Quality Framework and provides assurance to the board. The purpose is to ensure that NICE guidance is distributed to all appropriate personnel, that implementation is monitored when required and that suitable records are maintained, as directed by the Clinical Audit Project Group. 4. Responsibilities Trust Board is responsible for: Setting policy for the organisation through powers delegated to relevant committees; Ensuring policy is implemented through agreed management arrangements; Ensuring they are alerted to relevant issues arising that may affect policy; Recognising the importance of a system being in place to ensure the dissemination, implementation and monitoring of NICE guidance. Quality Governance Committee reports to the Board will provide assurance that the Board members are kept informed and that the system is working effectively. Associate Director of Quality and Risk The Director of Quality and Clinical Performance has overall delegated responsibility for the implementation of NICE guidance within the Trust. The Associate Director of Quality and Clinical Performance is ultimately accountable for the process of dissemination, implementing and monitoring of NICE guidance effectively and efficiently, and has determined that this responsibility is delegated to the directors(s) with lead responsibilities for clinical quality and the Clinical Audit Team. Responsibilities also include: Supported by the Clinical Audit Project Group (CAPG) and Clinical Audit Team, initial assessment of relevance to the trust, of newly published NICE guidance and subsequent allocation clinical directors to identify or confirm nominated lead for the production of a position statement and implementation. Supported by the Clinical Audit project Group, review completed position statements and recommendations/implementation plans. Production of regular reports to commissioners detailing progress against NICE guidance implementation. Horizon scanning and forward planning in relation to NICE guidance; Page 3 of 5
Clinical Directors are responsible for: Identifying a lead from their directorate for each appropriate NICE Guideline to lead on the development of a position statement and implementation. Ensuring NICE guidance is disseminated and implemented in line with relevant pathways. Relevant clinical audit activity is undertaken to support assurances around the implementation of NICE recommendations. Clinical Audit Team The Clinical Audit Team shall have responsibility for the distribution and monitoring of NICE guidance, within the Trust. Duties include a responsibility to: Disseminate newly published guidance to the Associate Director of Quality and Risk and CAPG to assess relevance to the Trust and identify appropriate clinical director(s) and or implementation leads; Coordinate completion of position statements within a timely manner, using the agreed Trust template; Maintain a database of Trust responses to NICE guidance; Develop a programme of systematic NICE Guidance audits within the Clinical Audit Forward Programme, based upon Trust priorities and supported by recommendations within completed position statements; Produce quarterly progress reports for the Quality Governance Committee; Disseminate and raise awareness of newly published relevant NICE guidance to staff within the trust in conjunction with Trust library services; Where the decision has been made to not implement a piece of NICE guidance, this shall be recorded in the minutes of the Clinical Audit Project Group, recorded on the NICE database and shared within the report to the Quality Governance Committee. Medicines Optimisation Committee Judge relevance of NICE Technology Appraisals to the organisation. Appoint an appropriate individual to develop a position statement for each relevant Technology Appraisal. Agree and monitor NICE audit activity. Identify and agree a time period for delivery of audit report action plans. Ensure re-audit criteria and timeframe are included in the Clinical Audit Forward Plan. Chief Pharmacist The Chief Pharmacist will ensure Technology Appraisals are reviewed by Medicines Optimisation Committee and assess the current status of any prescribing issues within the Trust. Page 4 of 5
Directorate Governance Groups are responsible for: Supporting the production of NICE position statements from a nominated clinical lead; Providing opportunities for sharing and discussing the implementation of newly published NICE guidance; Agreeing a programme of clinical audit activity that encompasses all relevant NICE guidance, as well as approving subsequent audit recommendations and monitoring their implementation. Identified Leads are responsible for: Ensuring that an initial position statement/gap analysis review is undertaken for any NICE guidance/quality Standard for which they have been identified as the lead. Formulating a robust action plan to address any areas of partial or non-compliance and sharing these with directorate governance groups the Clinical Audit Project Group. Make recommendations in the position statement action plan as to the frequency of related clinical audit to be included in the Trusts rolling annual audit programme. Monitoring the implementation of position statement recommendations and supporting subsequent clinical audit activity. 5. Monitoring Compliance The Clinical Audit Project Group shall provide a summary report to the Quality Governance Committee on a quarterly basis, showing progress against the implementation and monitoring of relevant NICE guidance. The Clinical Audit Project Group will monitor the content of clinical audit forward programme to ensure all relevant NICE guidance is subject to structured assessment of compliance. Page 5 of 5