Best Practice Policy

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1 Best Practice Policy Reference No: P_CIG_06 Version: Version 3 Ratified by: LCHS Trust Board Date ratified: 29 th July 2014 Name of originator/author: Name of responsible committee/individual: Deputy Chief Nurse Quality Scrutiny Group Date issued: August 2014 Review date: August 2016 Target audience: All Staff Distributed by Website 1

2 Version Section/Para/ Appendix Best Practice Policy Version Control Sheet Version/Description of Amendments Date Author/ Amended by 1 New LCHS Policy June 2010 C Wylie Policy Statement Titles changes to reflect new organisation January 2012 J Ashby 2 2 Names changed to reflect January 2012 new organisation & renumbered from CIG011a to P_CIG_06 3 Updated lessons learnt process July 2014 J Ashby Deputy Chief Nurse 2

3 Best Practice Policy Contents i. Version control sheet ii. Policy statement Section Page 1 Introduction Rationale Purpose Scope of this Policy 6 2 Definitions NICE Guidance NSFs National Confidential Enquiries and High Level 7 Enquiries 3 Roles and Responsibilities Implementation of NICE Guidance Implementation of National Service Frameworks National Confidential Enquiries and High Level 8 Enquiries 4 Identification of Relevant Documents 8 5 Implementation of NICE Guidance Identifying and Disseminating NICE guidance Implementation 9 6 Implementation of NSFs Identification and dissemination of NSFs Implementation 10 7 Implementation of National Confidential Enquiries and High Level 10 Enquiries 8 Gap Analysis 11 9 Risk Register Ensuring that Recommendations are Acted Upon and Sharing 11 Lessons Learned 3

4 11 Monitoring 11 Appendix 1 NHSLA Monitoring Template 12 Appendix 2 NICE Guidance Process 13 Appendix 3 Process for Lessons Learned 14 Appendix 4 Equality Impact Assessment Test for Relevance 15 Appendix 5 Human Rights Assessment Tool 16 Appendix 6 Audit Tool for Compliance 17 4

5 Best Practice Policy Policy Statement Background Lincolnshire Community Health Services NHS Trust is committed to ensuring that there is a systematic process for implementing, monitoring and evaluating National Institute of Clinical Excellence (NICE) guidance, National Service Frameworks (NSFs), enquiry recommendations and local and national guidance. Statement This policy has been developed to ensure that the Organisation has in place a systematic approach for reviewing the findings and recommendations from NICE, NSFs, National Confidential Enquiries and other high level enquiries. Important lessons can be learnt and patient safety can be improved from sharing events external to the Organisation. This policy sets out how this information is distributed to appropriate personnel to ensure the implementation of recommendations is monitored and that suitable records are maintained. Responsibilities Chief Executive, all Directors, General Managers, Staff Training All new members of staff will be introduced to the Organisation s Procedures for process of NICE, NSFs and Confidential Enquiries during the Organisation s Induction Programme. Dissemination Website 5

6 1.0 INTRODUCTION 1.1 Rationale Lincolnshire Community Health Services NHS Trust is committed to ensuring that there is a systematic process for implementing, monitoring and evaluating National Institute of Clinical Excellence (NICE) guidance, National Service Frameworks (NSFs), enquiry recommendations and local and national guidance. To ensure that lessons are learned across the whole Organisation to ensure high quality of care and patient safety. 1.2 Purpose This policy has been developed to ensure that the Organisation has in place a systematic approach for reviewing the findings and recommendations from NICE, NSFs, National Confidential Enquiries and other high level enquiries. Important lessons can be learned and patient safety can be improved from sharing events external to the Organisation. This policy sets out how this information is distributed to appropriate personnel to ensure the implementation of recommendations is monitored and that suitable records are maintained. This policy sets out how this information is distributed within the Organisation. This policy covers the process from initial identification through to the dissemination, review and implementation of actions required to bring services in line with best practice recommendations. 1.3 Scope of this Policy This policy applies to all staff involved in clinical delivery and clinical redesign. 2.0 DEFINITIONS 2.1 NICE Guidance The Organisation has an obligation to implement guidance issued by the National Institute for Clinical Excellence (NICE). The role of NICE is to provide patients, health professionals and the public with robust and reliable guidance on the current Best Practice. NICE guidance includes: Technology Appraisals guidance on the use of new and existing health technologies (including drugs, medical devices and procedures); Clinical Guidelines guidance on the appropriate treatment and care of patients with specific disease and conditions; Interventional procedures guidance on the efficacy and safety of interventional procedures. Both the Care Quality Commission and NHS Litigation Authority standards and outcomes relate to the implementation of NICE guidance; careful planning for effective implementation to ensure clear processes are in place is a crucial priority for LCHST. NICE guidance is considered alongside other programmes such as the National Service Frameworks (NSFs), local and national guidelines. Planning for implementation of NICE guidance must therefore be incorporated into the commissioning and financial planning frameworks of the Organisation. 6

7 2. 2 N S F s NSFs were introduced following the publication of the New NHS and a First Class Service and re-emphasised in the NHS Plan. They are long term strategies designed to improve the quality of specific areas of care and decrease variation across the country. They set standards of care describe service models for the delivery of these standards with milestones and goals and set out methods for monitoring progress with implementation. Examples of NSFs are: Mental Health (1999) Coronary Heart Disease (2000) Older People (2001) Diabetes (2001 & 2003) The Cancer Plan (2005) Long Term Conditions (2005) Chronic Obstructive Pulmonary Disease (COPD) (2008) 2.3 National Confidential Enquiries and High Level Enquiries National Confidential Enquiries are nationally defined audit programmes that ensure learning from serious incidents. The National Institute for Clinical Effectiveness received responsibility for the four Confidential Enquiries from the Department of Health in 1999: Confidential Enquiry into Maternal Deaths (CEMD) Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) National Confidential Enquiry into Preoperative Deaths (NCEPOD) and Confidential Enquiry into Suicide and Homicide by people with Mental Illness (CISH). The Enquiries aim to improve clinical practice through the investigation of deaths in specific circumstances. High level enquiries address similar issues regarding serious incidents that cannot and should not be dealt with through the usual local procedures. 3.0 ROLES AND RESPONSIBILITES 3.1 Implementation of NICE guidance All clinicians and managers are responsible for ensuring that they aware of and implement the relevant NICE guidance for their service. This will include its implementation phase and the monitoring of outcomes. The Chief Executive has ultimate responsibility for the implementation of NICE guidance within LCHST. 7

8 Lincolnshire Community Health Services NHS Trust Quality Scrutiny Group is responsible for monitoring and promoting the implementation of NICE guidance across the Organisation. QSG is monitored by the Quality and Risk Committee. Reports are submitted to the Quality and Risk Committee, Management Committee and LCHST Board. Medicines Management Committee, is a sub group of the Clinical Governance and Risk Committee, and will monitor recommendations made by PACEF. Quality Scrutiny Group will: Review the details, on a monthly basis, any guidance that is released and is relevant to the services provided; Disseminate relevant guidance to service with the audit tool to facilitate implementation; Monitor the implementation and outcomes of audits and patient surveys in relation to the guidance; Oversee the development and implementation of an Evidence Based Practice Strategy (i.e. for the implementation of NICE, NSF and other guidelines) in LCHST. Regarding implementation of NICE guidelines,the committee would have the following responsibilities: Note the dates of release of guidance and action timetable; Identify the specialist group that will take the lead on the analysis and development for each piece of guidance; Final approval and monitoring of the action plan for the implementation of the NICE Guidelines prepared by the Leads; Help in identifying leads for implementation of the action plans; Forward audit tool to the applicable service with NICE Guidance; Monitor the outcomes of the audit and implementation of the guidance. Medicines Management Committee will: Review recommendations from NHSL Primary and Clinical Effectiveness Forum (PACEF) on all medication related NICE guidance; Link with CEPF to ensure all guidance is disseminated appropriately and audit the implementation of relevant guidance. Appendix 1 demonstrates the process for the implementation of NICE guidance. 3.2 Implementation of National Service Frameworks (NSFs) The Chief Executive has ultimate responsibility for the implementation of NSFs and the resultant action plans. This work is currently supported by The Medicines Management lead and The CEP Forum. Additional specific roles may be assigned under the auspices of the CEPF in accordance with the requirements of the individual guidance under review. 3.3 National Confidential Enquiries and High Level Enquiries The Chief Executive shall have overall responsibility for the implementation of National Confidential Enquiries and high level enquiry recommendations. Compliance against enquiry recommendations will be monitored by the Clinical Governance and Risk 8

9 Committee, Management Committee and the LCHST Board. Assurance of compliance will be provided to NHS Lincolnshire. 4.0 IDENTIFICATION OF RELEVANT DOCUMENTS LCHST receives a range of reports and guidance that are commonly but not exclusively sent directly to the Chief Executive/Managing Director. Relevant reports and guidance may also be indentified by scanning the Care Quality Commission and Department of Health Websites. NICE guidance, NSFs and enquiry recommendations are dealt with in very different ways throughout the Organisation and the local procedures are outlined for each within this policy. All professionals and managers are expected to scan and be aware of the national agenda for their service area. Information from national documents should inform service developments and changes should be raised in the appropriate forums to ensure awareness is shared throughout the Organisation. 5.0 IMPLEMENTATION OF NICE GUIDANCE 5.1 Identifying and disseminating NICE guidance All NICE guidance is issued via the NICE website on the 25 th of each month. All NICE clinical guidelines will go to the CEPF to decide which pieces are relevant. In turn, leads will be appointed via the CEPF to oversee the implementation of each piece of guidance that has direct relevance as follows: For guidance which relates to an NSF or major disease area, the Clinical Lead for that NSF or disease area will be appointed; The Clinical Governance Manager with a lead for Clinical Effectiveness will be appointed responsibility for NICE guidance requiring a nursing lead; A Therapy Lead will be appointed by CEPF for NICE guidance related to therapy staff; Medicines Management lead will be the lead for guidance in medication. The guidance is reviewed at the Clinical Effectiveness and Policy Forum and then disseminated to the appropriate services. Implementation is monitored through the CEPF and concerns raised to the Clinical Governance and Risk Committee. Appendix 1 demonstrates the process of NICE implementation. 5.2 Implementation QSG will make arrangements to support the dissemination and implementation process where appropriate by: Using suitable communication channels to remind relevant clinicians of new guidance relevant to primary and community care; 9

10 Monitoring NICE implementation by the Organisation; Feeding back monitoring information and/or exception reports to the Clinical Governance and Risk Committee as necessary. It is imperative that NICE guidance is taken into account by clinical services within the Organisation. 6.0 IMPLEMENTATION OF NSF s 6.1 Identification and dissemination of NSF s The publication of a new NSF is received by the Chief Executive. The CEO s office will ensure that details of the NSF are forwarded to the Chief Nurse/Director of Operations who will nominate a lead for all new NSFs and disseminate the appropriate documentation. The nominated lead for each NSF will be responsible for identifying key stakeholders and for coordinating a review of the NSF to identify areas of good practice and current gaps on a self-assessment form. This analysis will be used as the basis for an action plan indentifying action required to implement best practice. NSF action plans will be reported bi-annually to CEPF, who will identify and ensure that recommendations are taken into account within the clinical services. Any areas of concern will be assessed and where indicated by the severity of the identified risk, escalated through the management reporting structure the quarterly quality performance review undertaken by NHS Lincolnshire. See also section 7 related to, risk register below. 6.2 Implementation The implementation of NSFs is managed more locally in the following smaller groups: Stroke Implementation Group Diabetes Strategic Commissioning Group Cardiac Commissioning Group Cancer Partnership (LINCAP) Suicide Prevention and Self-harm Reduction Group Mental Health and Well-being of Children and Young People Workstream Healthy Lifestyle Workstream for Children and Young People These groups conduct an Organisational gap analysis by completing a self-assessment form as to whether the Organisation is complying with each NSF and share information with the relevant providers. These groups will report to LCHST. Any risks in relation to non-implementation will be reflected on Corporate Risk Register. Significant risks will be reported to the Quality and Risk Committee in accordance with the Risk Management Strategy. 10

11 7.0 IMPLEMENTATION OF NATIONAL CONFIDENTIAL ENQUIRIES AND HIGH LEVEL ENQURIES Identification, dissemination and implementation The publication of an enquiry is received by the Chief Executive. The Chief Nurse/Director of Operations will nominate a lead to support the review of the guidance; associated gap analysis; generation of an action plan and subsequent implementation of relevant enquiry recommendations. The nominated lead will be responsible for indentifying key stakeholders and co-ordinating a review to identify areas of good practice and current gaps on the identified form. This form will provide the basis for an action plan. The action plans produced as a result of National Enquires will be reported quarterly to the Clinical Governance and Risk Committee. The Clinical Governance and Risk Committee will identify and ensure that any recommendations with regard to patient safety are taken into account within the clinical services they are responsible for. Any risk will be recorded on the Corporate Risk Register if required. 8.0 GAP ANALYSIS A gap analysis is an essential stage in instigating the review and implementation of best practice. It is common to the implementation of NICE guidance; NSF and confidential enquiries. The nominated lead / relevant strategic committee will develop and review the gap analysis, using it to inform an action plan to support final implementation. It is capable of identifying and assessing level of risk, and should be used in conjunction with the Organisational risk assessment matrix to clearly inform the LCHS Trust Board and Organisation stakeholders regarding the priority and resources required to undertake outstanding work. 9.0 RISK REGISTER Organisational risks relating to NSF / NICE implementation should be identified by /to the NSF /NICE lead. The NSF / NICE lead will ensure that the risk is assessed, steps taken to minimise the risk, and where the risk remains at an unacceptable level, that it is added to the LCHST risk register to support review / mitigation of residual risk. Similarly, risk identified in relation to implementation of national confidential enquiries and high level enquiries should be assessed by the nominated lead and considered for inclusion on the Organisational risk register. See the Risk Management Strategy for guidance regarding risk assessment and reporting thresholds ENSURING THAT RECOMMENDATIONS ARE ACTED UPON and SHARING LESSONS LEARNED The implementation of NSFs is mandatory and as such it is the Chief Executive s responsibility to ensure that it is implemented within three months of publication. The Trust ensures that recommendations are acted upon by: Clarifying accountability for implementation; Identifying through gap analysis the scale of the task and anticipated action required to support successful implementation; Co-ordination through the central QSG group / Quality and Risk Committee to enable appropriate discussion regarding necessary resources, to support timely implementation; 11

12 Commitment at a strategic level. Strategic forums drive the agenda, meetings attended by senior staff that has the authority to ensure implementation within their specific work areas; Reliable and auditable dissemination of guidance; Regular reporting, clear accountability. Lessons learned from NICE clinical guidelines, NSFs and enquiry recommendations will be summarised and reported through the Quality and Risk Committee MONITORING QSG will monitor the implementation of NICE guidance and NSFs. An annual audit will be developed to monitor the implementation of NICE guidance. Internal monitoring of Care Quality Commission (CQC) compliance will provide systematic feedback regarding emerging implementation risks. The Quality and Risk Committee will monitor the implementation of enquiry recommendations through review of action plans and exception reports. 12

13 Appendix 1 NSHLA Monitoring Template Minimum requirement to be monitored Implementation of NICE guidance Process for monitoring e.g. audit Responsibl e individuals/ group/ committee Frequency of monitoring/ audit Responsible individuals/ group/ committee for review of results Audit QSG Annual Quality and Risk Committee Responsible individuals/ group/ committee for development of action plan QSG Responsible individuals/ group/ committee for monitoring of action plan Quality and Risk Committee Monitor the achievement of action plans against confidential enquiries Evidence of NSF implementation Audit/ review of action plans Quality and Risk Committee Annual Board Quality and Risk Committee Audit QSG Annual Quality and Risk Committee QSG Board Quality and Risk Committee 13

14 Appendix 2 NICE GUIDANCE PROCESS New This NICE Guidance is a standing Agenda item on the Clinical Effectiveness and Policy Forum which meets on a monthly basis. Guidance that is relevant is discussed at this meeting and the Forum identifies which areas of the service the guidance relates to. NICE The Clinical Governance Manager (lead for clinical effectiveness post meeting, forwards a Guidance Alert to each Clinical Governance Manager for each business unit that guidance has been identified as relevant to their service area by the Forum. They are requested to complete and return the alert to the Clinical Effectiveness Facilitator within a given timeframe. NICE Guidance Alert is completed by the service manager who confirms whether it is relevant to their service area and if so indicating whether this guidance is presently implemented and the audit criteria is to be undertaken. (lead Once this NICE Guidance Alert has been completed by the Clinical Governance Manager for clinical effectiveness) this is forwarded to the Clinical Governance Manager (lead for clinical effectiveness) who logs the information detailed in the NICE Guidance Alert on to an Excel spreadsheet. Completed Reminder s are forwarded to Clinical Governance Managers who do not respond within the given timeframe for receipt of the completed alert. Clinical Audits and Patient Satisfaction Surveys are monitored and reviewed by the Clinical Effectiveness and Policy Forum which is held on a monthly basis 14

15 To be disseminated to all staff via newsletter. 15

16 Appendix 4 Equality Impact Assessment Test for Relevance Race, Religion/Belief, Disability, Gender, Age and Sexual Orientation Name of the Policy:...Best Practice Policy What you are trying to achieve in this service/policy/function (Write short notes to explain the policy) This policy has been developed to ensure that the Organisation has in place a systematic approach for reviewing the findings and recommendations from NICE, NSFs, National Confidential Enquiries and other high level enquiries. Important lessons can be learnt and patient safety can be improved from sharing events external to the Organisation. This policy sets out how this information is distributed to appropriate personnel to ensure the implementation of recommendations is monitored and that suitable records are maintained. 2. Which population groups the policy intended to benefit and how? All patients, This policy has been developed to ensure that the Organisation has in place a systematic approach for reviewing the findings and recommendations from NICE, NSFs, National Confidential Enquiries and other high level enquiries. Important lessons can be learnt and patient safety can be improved from sharing events external to the Organisation. This policy sets out how this information is distributed to appropriate personnel to ensure the implementation of recommendations is monitored and that suitable records are maintained. 3. Related policy areas that may be affected by changes in this policy Clinical audit policy 16

17 Appendix 5 Human Rights Assessment Tool The Human Rights Act, which came into force in October 2000, incorporates into domestic law the European Convention on Human Rights to which the UK has been committed since Section 6 of the Human Rights Act makes it unlawful for a public authority to act in a way, which is incompatible with a Convention right. The underlying intention of the Act is to create a Human Rights culture in public services. To be completed and attached to any policy document when submitted to the appropriate committee for consideration and approval. Yes/No Comments 1. Will it affect a person s right to life? no 2. Will someone be deprived of their liberty or have their security threatened? 3. Could this result in a person being treated in a degrading or inhuman manner? 4. Is there a possibility that a person will be prevented from exercising their beliefs? 5. Will anyone s private and family life be interfered with? no no no no If the answer is yes to any of the questions on the proforma can the policy be amended to avoid impacting upon Human Rights? If not, please refer it to the Director of Corporate Affairs to enable legal advice to be sought before proceeding. 17

18 Appendix 6 Audit Tool for Policy Compliance Audit Tool for Policy Document Compliance (Compliance Audit to be undertaken by Heads of Services/Managers) Service Area: Head of Service/Manager: Policy Title: Communication/Dissemination: Are all staff within the service aware of the policy document? *Yes/No (please delete as appropriate) If no, please identify issues and action plan to resolve: Compliance with the Policy Document Are all staff fully compliant with the policy document? *Yes/No (please delete as appropriate) If no, please identify issues and action plan to resolve: Does the policy document need revision in light of the compliance audit undertaken? *Yes/No (please delete as appropriate) If yes, please state the areas for review and revision: 18

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