cntw(c)27 v05 trust-wide implementation monitoring and …… · 1.3 nice guidance is published...

Document Title Trust-wide Implementation Monitoring and Coordination

of National Institute of Health and Clinical Excellence (NICE) Guidance

Reference Number CNTW (C)27

Lead Officer Medical Director

Author(s) (name and designation)

Simon Douglas Joint Director of Research and Development,

Innovation and Clinical Effectiveness

Dawn Oliver Clinical Effectiveness Manager

Ratified by Business Delivery Group

Date ratified May 2019

Implementation Date May 2019

Date of full implementation

May 2019

Review Date May 2022

Version number V05.1

Review and Amendment

Log

Version Type of change

Date Description of change

V05.1 Update Nov 19 Governance Changes

This policy supersedes the following which must not be destroyed:

Document Number Title

CNTW(C)27 – V05 Trust-wide Implementation Monitoring and Coordination of National Institute of Health and Clinical Excellence (NICE) Guidance

CNTW(C)27

Trust-wide Implementation Monitoring and Coordination of National Institute of Health

and Clinical Excellence (NICE) Guidance

Section Description Page No.

1 Introduction 1

2 Scope 1

3 Purpose 1

4 Roles and Responsibilities 2

5 Definitions 4

6 Trust Implementation of NICE Guidance 6

7 Systematic Approach to Implementing Guidance 6

8 Guideline Training 8

9 Implementation Process 8

10 Monitoring Guidance Implementation 8

11 Identification of Stakeholders 8

12 Equality and Diversity 9

13 Training 9

14 Policy Implementation 9

15 Fraud and Corruption 9

16 Fair Blame 10

17 Identification of Stakeholders 10

Standard Appendices – attached to policy

Appendix A Equality and Diversity impact Assessment Form 11

Appendix B Communication and Training Information 13

Appendix C Monitoring and Compliance Audit Tool 15

Appendix D Policy Notification Record Sheet - click here

Appendices listed separate to policy

Description

Appendix 1A Baseline Assessment Summary Form

Appendix 1B NICE Baseline Assessment Poster report Template

Appendix 1C NICE Baseline Assessment Presentation Template

Appendix 2 FLOWCHART – Implement TAGS

Appendix 3 FLOWCHART – Implementation NICE Guidance and Quality Standards

https://www.ntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

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Practice Guidance Notes- listed separate to Policy

PGN Number Description

NGP-PGN-01 Guidance for Clinicians leading the NICE baseline Assessment Process

NGP-PGN-02 Internal Dissemination of NICE Information

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Cumbria Northumberland, Tyne and Wear NHS Foundation Trust 1 CNTW(C)27 – Trust-wide Implementation Monitoring and Coordination of National Institute of Health and Clinical Excellence (NICE) Guidance – V05.1-Nov 19

1 Introduction 1.1 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust)

has an obligation to implement guidance issued by the National Institute for Clinical Excellence (NICE). National Institute for Health and Clinical excellence (NICE) recommendations are based on reviews of clinical and economic evidence carried out by independently constituted Guideline Development Groups.

1.2 The Role of NICE is to provide patients, health professionals and the public with

authoritative and reliable guidance in relation to:

The clinical management of specific conditions

The use of health technologies

The safety and efficacy of interventional procedures

The selection and evaluation of new or innovative procedures

The evaluation of innovation medical diagnostic technologies

Setting specific, concise statements and associated measures of achievable markers of high quality cost effective patient care through Quality Standards

1.3 NICE Guidance is published with the aim of ensuring that good health and

patient care in the NHS are in line with the best evidence of clinical and cost effectiveness. NICE Guidance provides patients, health professionals, managers and the public with authoritative, reliable and evidence-based guidance in relation to the use of health technologies, the clinical management of specific conditions and the safety and efficacy of interventional procedures.

2 Scope 2.1 The policy is intended for all Trust staff involved in the implementation of NICE

Guidance. It should be read in conjunction with the Trust’s CNTW(C)52 - Clinical Audit Policy.

2.2 The policy covers all aspects of NICE Technology Appraisals (TAs), Clinical

Guidelines (CGs), Interventional Procedures (IPGs), Public Health Programme Guidance (PHs), Public Health Interventional Guidance (PHIs), Quality Standards (QS) as well as recommending practices and procedures that health professionals should not do, ‘Do not Do’s’. The terms Guidance or NICE Guidance used in this document refer to all of these types of guidance.

3 Purpose 3.1 The Trust is committed to ensuring that there is a systematic, effective and

efficient process for implementing, monitoring and evaluating NICE Guidance.

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3.2 The purpose of this policy is to ensure that all recommendations from NICE are considered by the appropriate areas within the Trust and that mandatory recommendations are implemented in a timely and effective manner. It sets out the processes to be followed, the roles and responsibilities involved and the escalation processes for areas of risk.

3.3 Implementing NICE Guidance supports the Trust to provide consistent improvements in peoples’ health and equal access to health care.

4 Roles and Responsibilities 4.1 The Chief Executive is responsible for implementation of NICE guidance who

maintains an overview of the implementation of NICE Guidance. This Trust-wide responsibility is delegated to the Director of Research, Innovation and Clinical Effectiveness (RICE).

4.2 The Director of Research, Innovation and Clinical Effectiveness has delegated

responsibility from the Chief Executive for the implementation process of NICE Guidance.

4.3 The Clinical Effectiveness Manager will be responsible for maintaining the record (NICE Guidance database) of existing guidance relevant to CNTW and updating as new guidance is published. They will coordinate the implementation of NICE Guidance by:

Disseminating guidance to key groups via the Clinical Effectiveness Committee

Reviewing and informing stakeholders of prospective guidance being issued from NICE

Ensuring effective processes for monitoring

Producing regular committee and group reports 4.4 The operational implementation responsibilities are delegated to other Directors

especially Group Directors who will ensure the guidance is implemented through a nominated Lead. Practical responsibility is delegated to the nominated Lead individuals (usually senior clinical practitioners) by Directors. Coordination of implementation of individual sets of guidance will be the responsibility of the Clinical Effectiveness Committee (CEC) which will review progress on a monthly basis based on the Trust NICE Guidance reporting systems.

4.5 Medication-related NICE Guidance (TAGS) is agreed at the North of Tyne Area

Prescribing Committee for inclusion in the North of Tyne formulary.

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4.6 The Clinical Effectiveness Committee is constituted to assure the Board that

evidence-based practice and in particular NICE Guidance is being implemented. This committee will identify guidance relevant to the work of the Trust. The Clinical Effectiveness Committee will recommend audits to be undertaken where appropriate following discussion with identified guidance implementation leads. The Clinical Effectiveness Committee will report directly to the Quality and Performance Committee and link to the Trust e-pathway group, the Medicines Management Committee and the Locality Business units and Clinical Networks

4.6.1 The Committee is responsible for the monitoring of Trust compliance with NICE Guidance and the escalation of any non-compliance to the Quality and Performance Committee, Business Delivery Group (BDG) and Corporate Decisions Team.

4.6.2 The Clinical Effectiveness Committee will:

Ensure compliance with the procedural framework for the implementation of NICE Guidance within CNTWFT

Undertake horizon scanning for emerging guidance

Establish clear planning and approval processes which consider relevant services provided and under the guidance from the relevant NICE lead, resources required to implement the guidance, costs of implementing the guidance, staff education and training and the changes in nature and provision of practice

Ensure that all relevant NICE leads are aware of NICE Guidance relevant to their service area and that this is supported by a robust implementation and review process

To identify and escalate areas of non-compliance

To ensure accurate records to relevant committees and Trust board as defined in the Trust reporting schedule.

4.6.3 The Clinical Effectiveness Committee is responsible for:

The dissemination, implementation and monitoring of NICE Guidance and reports to the senior Trust meetings

Reviewing this policy

Ensuring that the NICE lead undertakes an organisation gap analysis baseline assessment when NICE Guidance is issued that is relevant to the Trust and the gap analysis is reviewed by the Committee

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Where NICE Guidance is issued and is assessed by the NICE lead and identified that the Trust is non-compliant, these issues are logged and raised with the Business Delivery Group and the Trust Quality and Performance Committee as appropriate

4.7 The role of the nominated NICE lead clinicians is to liaise with relevant

stakeholders to assess current practice and implementation issues, assessing compliance against the relevant NICE Guidance and submitting the completed baseline assessment / gap analysis and actions plans to the Clinical Effectiveness Manager as appropriate.

4.7.1 The lead can, if required, attend the Clinical Effectiveness Committee to discuss the assessment and proposed action plan and agree any amendments. The lead will subsequently present the final assessment and action plan for approval at the Trust’s Business Delivery Group or Learning Improvement Groups (LIG) as determined by the CEC.

4.7.2 After approval of action plans and any other relevant decisions the lead is responsible for ensuring responsible officers are aware of their responsibility in line with the action plan and to ensure dissemination through the organisational structure.

5 Definitions 5.1 NICE Recommendations - 5.1.1 These are based on a review of clinical and economic evidence. Clinical

evidence measures how well the medicine or treatment works whilst economic evidence measures how well the medicine or treatment works in relation to costs. NICE are clear that something can be both expensive and good value.

5.2 Technology Appraisals (TAGs) - 5.2.1 TAGs are recommendations on the use of new and existing health technologies

within NHS England and Wales. This will include:

Medicines (e.g. Drugs)

Medical Devices (e.g. Hearing Aids)

Diagnostic Techniques (e.g. tests to identify diseases)

Surgical Procedures (e.g. Hernia repair)

Health Promotion Activities (e.g. patient education)

5.2.2 As stated in the NICE publication ‘How to put NICE Guidance into practice – a

guide to implementation for organisations’ (NICE, 2005) the Secretary of State has directed that the NHS provides funding and resources for medicines and treatment that have been recommended by TAGs.

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5.2.3 There is an expectation that NICE Technology Appraisals will be implemented within three months of publication. The timescale for implementation of other NICE Guidance is more flexible. Planning for implementation must be incorporated into the commissioning and financial planning frameworks of the Trust.

5.3 Clinical Guidelines (NICE Guidelines NG) 5.3.1 These are recommendations on the appropriate treatment and care of patients

with specific diseases and conditions within the NHS in England and Wales. They are there to support the knowledge and skills of experienced healthcare professionals. NICE recognises that full implementation of some guidelines may take place over several years and cross over different healthcare sectors.

5.4 Interventional Procedures 5.4.1 Interventional procedures are used for treatment or diagnosis that involves one

of the following:

Making an incision to gain access to the inside of the human body (e.g. carrying out an operation or inserting a tube into a blood vessel)

Gaining access to a part of the body (e.g. digestive system, lungs, womb, bladder) without making an incision (e.g. access to the stomach gained by inserting instruments via the mouth)

Using electromagnetic energy (x-rays, lasers, gamma rays and UV light) or ultrasound (e.g. Laser eye treatment)

Interventional procedures are not usually relevant to Mental Health and Learning Disability Trusts.

5.5 Public Health Guidance 5.5.1 Public Health Guidance provides information on the promotion of good health

and the prevention of ill health. This includes employers and professionals in organisations who have a direct or indirect role in improving health in the workplace (e.g. Human Resources, Occupational Health). It includes information for patients around healthy lifestyle including education, services and information.

5.6 Quality Standards 5.6.1 Quality Standards are a set of specific, concise statements and associated

measures. They set out aspirational, but achievable markers of high quality, cost effective patient care, covering the treatment and prevention of different diseases and conditions.

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6 Trust Implementation of NICE Guidance 6.1 The Trusts approach follows the principles set out in the NICE publication ‘How

to put NICE Guidance into practice – a guide to implementation for organisations (NICE, 2005):

Board support and clear leadership

Support from Clinical Effectiveness to coordinate the process

Multidisciplinary committee to consider new guidance and consider recommendations

Systematic approach to financial planning and implementation of guidance

Evaluation and audit 6.2 The Clinical Effectiveness Manager, will inform the Business Delivery Group

(BDG) of any newly published guidance relevant to the Trust. The Trusts Quality and Performance Committee will also be informed in their scheduled report.

6.3 The report to BDG will be an initial alert together with an indication of further

action where required. Leads will be identified by BDG to initiate baseline assessment and draft action plans with the support of the Clinical Effectiveness Manager.

6.4 Relevant guidance will be added to the agenda of the next available Clinical Effectiveness Committee for any discussion. Guidance where it is initially unclear of relevance will be highlighted for discussion to assess and any decision not to implement will be recorded in the minutes and updated in the Trust NICE Guidance registers.

7 Systematic Approach to Implementing Guidance 7.1 The prioritising and planning for implementing newly published NICE Guidance

is the responsibility of the Business Delivery Group in conjunction with the relevant locality committees. For each set of guidance a local position will be established. This local position is informed by the baseline template that NICE publishes with each new set of guidance which provides a ready-made standard to audit current practice against, bespoke audits and/or the collective views and evidence provided by a purpose agreed focus group.

TAGs – The process that recommendations are acted upon throughout the Trust are set out in Appendix 2

CGs/NGs – The implementation process for Clinical Guidelines are identified in Appendix 3

QS & PH – The implementation process of Quality Standards and Public Health Guidance is identified in Appendix 3

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7.2 Assessing Resource Implications

7.2.1 Implementation of NICE Guidance may have some financial, service and/or workforce implications. Funding implications will be identified as early as possible by the designated Lead conducting the baseline assessment, with the support of the Finance Directorate, and in collaboration with commissioners and appropriate partner organisations. This process will take account of the NICE costing templates where available and costing estimates produced elsewhere. Any financial implications arising from the implementation of NICE Guidance will be fed into the planning process where financial implications have not been assessed; the responsibility of performing a financial assessment will be allocated at BDG during action plan approval.

7.3 The Assessment Process 7.3.1 When reviewing any new guidance it is essential to identify the gap between

recommended practice and current practice. The wide ranging nature of the baseline assessment means that it should be undertaken by an appropriate group within the specific service affected.

7.3.2 The baseline assessment is then measured against the guidance and the resultant assessment and action plan should initially be discussed with the Clinical Effectiveness Committee and then, if required, submitted to BDG or Corporate Decisions Team. Advice on this should be sought from the Clinical Effectiveness Committee. The action plan may include proposals for staff training and development and where appropriate, an assessment of resource implications. It should include milestones, responsible officers and dates for completion. Example report Templates are shown in Appendix 1.

7.4 Organisational Non-Compliance 7.4.1 Organisational Non-compliance reflects that the current practice/service

provided does not follow NICE Recommendations, and that there are no plans to change practice to achieve compliance. Where services/groups feel there are valid clinical reasons for non-compliance with NICE Recommendations, robust clinical evidence should be submitted to the Clinical Effectiveness Committee.

7.4.2 Organisational Non-compliance which falls short of the NICE recommendations

whether for clinical or financial reason should be considered as a risk and included on the Corporate Risk Register, in addition to department or other risk registers. The reporting of non-compliance will usually be made to the Clinical Effectiveness Committee, Business Delivery Group and also Trust Quality and Performance Committee and Corporate Decisions Team by the usual reports.

7.4.3 Where areas consider themselves to be non-compliant because their practice exceeds NICE Recommendations, this should be evidence to the Clinical Effectiveness Committee and no entry on the risk register will be necessary.

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7.5 Partial Compliance 7.5.1 Partial Compliance is where current practice does not fully follow NICE

Recommendations at the time of assessment, but there will be an action plan to achieve compliance and document the stages towards full implementation. Guidance will be recorded as partially compliant on the NICE database and reports until the action plan is fully implemented.

8 Guideline Training 8.1 The nominated lead Clinician will have the responsibility for developing and

implementing the training and education that if required to support individual NICE Guidance. This training can take many forms depending on the level of change to practice. Frequently training will consist of team briefings where guidance and policy should be discussed rather than formal training sessions. Where training is required this should be included in the implementation plan and reported quarterly.

9 Implementation Process 9.1 Guidance Leads will identify the key stakeholders who need to be involved in

the implementation process. The implementation period will be defined based on the action plan and agreed by the BDG.

9.2 Decisions not to implement relevant guidance will be recorded via the minutes

of the BDG, the minutes of the Clinical Effectiveness Committee and in the Trust NICE reporting system.

10 Monitoring Guidance Implementation 10.1 The Clinical Effectiveness Committee will provide monitoring reports to the

Quality and Performance committee on all extant NICE Guidance. 10.2 All actions rated as Moderate to High will be monitored against agreed

milestones

10.3 The implementation plan and evidence of progress being made against it are critical elements in the process. Updates are required at scheduled updates to the Clinical Effectiveness Committee. These updates should clearly document whether the action point’s responsible officer is working towards implementation or the reasons for non-implementation.

11 Identification of Stakeholders 11.1 This is an existing policy under review with only minor changes that do not

relate to operational and/or clinical practice therefore does not require the full consultation process.

North Locality Care Group

Central Locality Care Group

South Locality Care Group

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North Cumbria Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

12 Equality and Diversity Assessment 12.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has

undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

13 Training (see Appendix B) 13.1 Professionally registered staff should have an awareness of this policy, e.g.

through local cascade. 13.2 Specific guidance and training available from Clinical Audit department for staff

with specific needs, e.g. training on completing a NICE baseline assessment.

13.3 Organisational awareness of new NICE Guidance is increased through the Chief Executive’s bulletin, Clinical Effectiveness e-bulletin and local cascade where relevant.

13.4 Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link:

http://nww1.CNTW.nhs.uk/services/index.php?id=3796&p=2780 14 Policy Implementation 14.1 This revision is minor only and the process described in the policy is largely

implemented, therefore an implementation timetable of 6 months would be expected.

15 Fraud Bribery and Corruption 15.1 In accordance with the Trust’s CNTW(O)23 – Fraud, Bribery and Corruption

Policy, all suspected cases of fraud and corruption should be reported

http://nww1.ntw.nhs.uk/services/index.php?id=3796&p=2780

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immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

16 Fair Blame 16.1 The Trust is committed to developing an open learning culture. It has endorsed

the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

17 Associated Documents

CNTW(O)01 Development and Management of Procedural Documents Policy

CNTW(O)23 Fraud, Bribery and Corruption Policy

CNTW(O)52 Clinical Audit Policy

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Dawn Oliver May 2019 May 2022 Trust Wide

Policy to be analysed Is this policy new or existing?

CNTW(C)27 - NICE Guidelines Policy – V05 Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

The Trust is committed to ensuring that there is a systematic, effective and efficient process for implementing, monitoring and evaluating NICE guidance.

Who will be affected? e.g. staff, service users, carers, wider public etc

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability

Sex

Race

Age

Gender reassignment

(including transgender)

Sexual orientation.

Religion or belief

Marriage and Civil Partnership

Pregnancy and maternity

Carers

Other identified groups Potential workforce implications

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How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through standard policy process procedures

How have you engaged stakeholders in testing the policy or programme proposals?

Through standard policy process procedures

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Appropriate policy review author

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

Does not unlawfully discriminate against equality target groups

Advance equality of opportunity

Promote good relations between groups

What is the overall impact?

Addressing the impact on equalities

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Dawn Oliver Date: May 2019

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Appendix B Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

No

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

No

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc.

Please identify the risks if training does not occur

No

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

n/a

Is there a staff group that should be prioritised for this training / awareness?

n/a

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning

n/a

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

n/a

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Appendix B

Communication and Training Needs Information

Training Needs Analysis

Staff / Professional Group Type of Training Duration of Training

Frequency of Training

Should any advice be required, please contact: - 0191 245 6777 (internal 56777- Option 1)

Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link

http://nww1.CNTW.nhs.uk/services/index.php?id=3796&p=2780

http://nww1.ntw.nhs.uk/services/index.php?id=3796&p=2780

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Appendix C Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

CNTW(C)27 - Trust-wide Implementation Monitoring and Coordination of National Institute of Health and Clinical Excellence (NICE) Guidance Policy - Monitoring

Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

1. Each new piece of NICE or other national guidance is assessed for applicability to the Trust and the decision documented.

1. Clinical Effectiveness Committee

2. Audit of NICE implementation using NICE guidance registers and minutes

3. Annual

CEC / Q&P (annual)

2. Each NICE guideline Lead Clinician to provide information on implementation of the respective guideline within the trust


2. Update Report review

3. Annual

Clinical Effectiveness Manager to CEC (Annual)

3. Any identified deficiencies in gap analysis including deviances and variances to be included in the risk register



3. Annual

Clinical Effectiveness Manager to CEC/ Q&P Annual

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CNTW(C)27 - Trust-wide Implementation Monitoring and Coordination of National Institute of Health and Clinical Excellence (NICE) Guidance Policy - Monitoring

Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

4. Progress on the implementation of compliance with NICE guidance



3. Annual

Clinical Effectiveness Manager to Q&P (Annual)

Clinical Effectiveness Manager to Corporate Decisions Team (Annual)

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out