Implementation of National Guidance Policy

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1 Implementation of National Guidance Policy (including NICE, NSFs, NCEs & High Level Enquiries) First Issued by/date May 2009 Issue Version Purpose of Issue/Description of Change Planned Review Date 1 New Policy October 2010 Named Author:- Committee Approved by Date Governance General Policy Group May 2009 Clinical Effectiveness Manager Policy File:- General Policy Impact Assessment Screening Complete: May 2009 Full Impact Assessment Required- No Policy Number GP40 Key Performance Indicators: 1. Number of action plans & baseline reviews returned within the deadline. 2. Results of audits completed. 3. The Health & Clinical Effectiveness Group will receive summary updates from the Local Implementation Team on NSF implementation. 4. The Health & Clinical Effectiveness Group will receive summary updates from the named lead responsible for High Level Enquiry implementation. 1/30

2 CONTENTS PAGE Introduction 4 Purpose 4 Scope 5 Development Process 5 Definitions 5 National Service Frameworks 6 National Confidential Enquiries and High Level Enquiries 6 Model for NICE Implementation and Monitoring within 7 NHS Wirral Roles and Responsibilities 7 NICE Implementation and Monitoring 11 NICE Tracking Speadsheet 11 Baseline Compliance Review and Implementation Record Template 11 Action Plan Development 11 Financial Implications and Costing Guidance 11 Audit Implications 12 NICE Implementation Quarterly Report 13 NICE Implementation Annual Report 13 Model for NSF Implementation 14 Model for National Confidential Enquiries & other High level Enquiries 14 Document Control 14 Archiving Arrangements 14 Process for Retrieving Archived Documents 15 2/30

3 Monitoring Compliance with and the Effectiveness of Procedural Documents 15 References 15 Appendix 1NICE Implementation Process 15 Appendix 2 Process for Monitoring External Provider s Compliance with NICE Guidance 16 Appendix 3 Letters 17 Appendix 4 Baseline Review 19 Appendix 5 Action Plan 23 Appendix 6 Clinical Audit Registration Form 24 Appendix 7 NICE Business Case Pro forma 26 Appendix 8 NSF Implementation Process 28 Appendix 9 Version Control Sheet 30 3/30

4 Introduction 1.0 The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. 1.1 NICE underpins the decision making process of the NHS in reaching a decision as to what new interventions are the most appropriate to use and under what circumstances. Guidance from NICE exists to provide advice to NHS clinicians, commissioners and patients as to those treatments that are clinically and cost effective. Clinicians are not obliged to follow NICE guidance in every case if they feel alternative courses of treatment are more appropriate for an individual patient, though they will need to be able to account through clinical governance arrangements for decisions to depart from NICE guidance. 1.2 NICE does not exist to Kite Mark all the interventions which are introduced for use in the NHS and decisions are taken by Ministers against published criteria as to which products NICE should be asked to assess. Not all new interventions will be referred to NICE for appraisal and for those interventions that are referred there may be time lag whilst NICE guidance is being developed, though the new NICE Single Technology Appraisal process should help to minimise this lag. Therefore, the NHS will have to continue to make informed decisions about the use of the interventions. DOH (2006) 1.3 National Service Frameworks (NSFs) are long term strategies for improving specific areas of care. They are national standards, identifying key interventions and put in place agreed timescales for implementation. 1.4 The National Confidential Enquires make a unique contribution to the governance and development of the delivery of clinical care in the United Kingdom and it is of great importance that their strengths are fully represented within the changing framework of the health care delivery infrastructure. The enquiries exist: To investigate the contribution of deficiencies in care to serious adverse patient outcomes. To identify areas where clinical practice needs to be improved and to make appropriate recommendations for changes that will improve outcomes for patients. 2.0 Purpose 2.1 NHS Wirral is required to provide evidence and assurances of compliance with the Standards of Better Health (DOH 2004) and National Litigation Authority Risk Management Standards and views the implementation of NICE guidance, NSFs, National Confidential Enquiries and other high level enquiries as an essential part of its work. The aim of this policy is to ensure that a robust process for the implementation and monitoring of NICE guidance other National Guidance including NSFs and National Confidential Enquiries are in place for the PCT. 2.2 The policy puts in place the processes to ensure that the PCT implements and monitors National Guidance through strategic planning and organisational dissemination. It also ensures that continual improvements are made and lessons 4/30

5 learned throughout the year on the process for implementing National guidance within the PCT. Implementing National guidance helps to ensure consistent improvements in people s health and equal access to healthcare. Putting National guidance into practice benefits everyone patients, carers, the public, NHS organisations, healthcare professionals, public health practitioners, policy makers and local authorities. 2.3 It is not acceptable to cite a lack of NICE guidance as reason for not providing a treatment. The PCT is required to have a decision making process in the absence of NICE. Individual cases are heard by the PCT s Health Treatment Panel and local commissioning policies or guidelines are developed where there is a cohort of patients Scope 3.1 This policy is relevant for all NHS Wirral staff. It sets out a systematic process for the PCT that puts the National Institute of Health and Clinical Excellence (NICE) guidance, NSFs and National Confidential Enquiries into practice. 4.0 Development Process 4.1 This policy will be discussed formally at the Health & Clinical Effectiveness Group before review in the General Policy Group. 4.2 The Policy will be ratified by the Integrated Governance Committee before it is disseminated to staff. 5.0 Definitions 5.1 NICE produces four types of guidance Technology Appraisals, Clinical Guidance, Interventional Procedures Guidance and Public Health Guidance. Guidance is published on the fourth Wednesday of the month. This is available on the NICE website ( 5.2 Technology appraisals are recommendations on the use of new and existing technologies. The Secretary of State has directed that the NHS provides funding and resources for medicines and treatments that have been recommended by NICE, normally within three months from the date that NICE published the guidance. 5.3 Core standards C5 (Standards for Better Health, DOH 2004), states that healthcare organisations should ensure that they conform to NICE technology appraisals. 5.4 Clinical guidance provides guidance on the appropriate treatment and care of people with specific diseases and conditions. Implementation of clinical guidelines forms part of the developmental standard D2 (Standards for Better Health, DOH 2004), which states that patients should receive effective treatment and care that conforms to nationally agreed best practice, particularly as defined in NICE guidance. 5.5 Guidance on interventional procedures covers the safety and efficacy of surgical procedures. Core standard C3 (Standards for Better Health, DOH 2004), clearly states that healthcare organisations should protect patients by following NICE interventional procedure guidance. 5/30

6 5.6 Public health guidance provides guidance on the promotion of good health and the prevention of ill health. The implementation of NICE public health guidance will demonstrate that NHS Wirral is committed to improving health in that it meets Core standard C 22 & C 23 as well as the developmental standard D13 (Standards for Better Health, DOH 2004). 6.0 National Service Frameworks (NSFs) 6.1 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. Current NSFs are: Mental Health (1999) Coronary Heart Disease (2000) Older People (2001) Diabetes (2001 & 2003) Long Term Conditions (2005) Chronic Obstructive Pulmonary Disease (COPD) due in 2009 Children, Young People and Maternity Services (2004) 7.0 National Confidential Enquiries and High Level Enquiries 7.1 National Confidential Enquiries are nationally defined audit programmes that ensure learning from serious incidents. 7.2 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 Perioperative Deaths (NCEPOD) and Confidential Enquiry into Suicide and Homicide by People with Mental Illness (CISH) 7.3 The Enquires aim to improve clinical practise through the investigation of deaths in specific circumstances. 7.4 High level enquires address similar issues regarding serious incidents that cannot and should not be dealt with through the usual local procedures. 8.0 Model for NICE Implementation and Monitoring within NHS Wirral 8.1 The model in Appendix 1 sets out NHS Wirral s internal process for Implementing and Monitoring NICE guidance. The blue sections relate to Strategic Planning while the yellow refer to dissemination. 6/30

7 8.2 Appendix 2 sets out NHS Wirral s process for monitoring the compliance of its external providers with NICE guidance. 9.0 Roles and Responsibilities 9.1 NICE recommends that the most effective implementation models have strong multidisciplinary teams. To be most effective this team should be a decision making body that reports to the Board via the working groups. This team should also serve other functions within the organisation, in addition to implementing NICE guidance. NHS Wirral will adopt the following approach: 9.2 The Health & Clinical Effectiveness Group will take responsibility for the implementation and monitoring of NICE guidance. It will then report to the Patient Safety and Learning from Experience Group to ensure that NICE Guidance is embedded within Clinical Services. Minutes of the Patient Safety and Learning from Experience Group will be forwarded to the Primary Care Management Board. 9.3 The Health & Clinical Effectiveness Group will report directly to the Integrated Governance Committee for strategic monitoring and reporting to the board. 9.4 A member of the Health & Clinical Effectiveness Group is also a member of the PEC and as such they are able to report to that group as appropriate when financial or patient safety issues are identified. 9.5 The Health & Clinical Effectiveness Group will meet monthly to discuss the appropriate distribution of guidance and to support its implementation. It will ensure the following: Consider ways of collaborating across the health economy to aid effective implementation of guidance to avoid duplication of effort Enable effective implementation and monitoring arrangements for NICE guidance implementation including clinical audit Ensure effective forward planning occurs including appropriate financial and training considerations. Act as champions to promote a positive culture for the implementation of NICE guidance and evidence based practice. Ensure compliance with the relevant core and developmental standards C3 Safety domain, C5a Clinical & Cost Effectiveness domain associated with Standards of Better Health. Will act as a forum for the approval of external National and Local Guidance 7/30

8 10.0 National Institute for Health and Clinical Excellence (NICE) Lead 10.1 The Clinical Effectiveness Manager has been identified as the NICE Lead and has overall responsibility for the Implementation and Monitoring of NICE Guidance for the organisation. The Clinical Effectiveness Manager will report to the Head of Governance The Role and Responsibility of the NICE Lead is to; Ensure that robust processes for Implementing and Monitoring NICE guidance are in place for the organisation. Ensure that the relevant clinical staff are aware of NICE guidance that may have an impact on the service that they deliver by updating the clinical effectiveness portal of the intranet Prepare reports for the Integrated Governance Committee, other relevant groups and executive committees Horizon scan future NICE guidance to identify implementation implications As the Guidance is distributed on the fourth Wednesday of each month the Clinical Effectiveness Manager will support the Health & Clinical Effectiveness Group by compiling the agenda. The Health & Clinical Effectiveness Group will discuss the distribution to the appropriate operational lead and implications of the guidance. Once an operational lead has been designated they will receive; A covering letter explaining the process and outlining the necessary timescales. Appendix 3. They will also receive a documentation pack via which will consist of the baseline assessment proforma, the action plan proforma and an audit registration form to be submitted four months after the guidance has been issued within the PCT. Appendices 4, 5 & 6. They will receive a copy of the NICE guidance and support material including the NICE costing tool and NICE audit tool as appropriate The Operational lead will then be added to the audit register If the operational lead does not feel that they are the appropriate lead for a piece of guidance they should inform the Clinical Effectiveness Manager as soon as is reasonably practicable The Clinical Effectiveness Manager will also; Act as the named clinical contact for the organisation 8/30

9 Update the tracker spreadsheet for NICE guidance implementation and monitoring Provide relevant evidence and assurances of compliance with Annual Health Check requirements The Role and Responsibility of the Operational Lead (s) 11.1 As part of the organisations NICE guidance Implementation process an Operational Lead (s) will be identified. There may be a number of Operational Leads depending on the NICE guidance under consideration. The Lead (s) for each specific NICE guidance will be identified 11.2 The Medicines Management Team s Clinical Effectiveness Pharmacist is the operational lead for all technology appraisals involving medicines and will participate in the implementation of all clinical guidelines where there is a prescribing element. In addition to the roles and responsibilities described in section 11.3 the Clinical Effectiveness Pharmacist will: Disseminate relevant guidance to prescribers via the bi-monthly NICE Prescribing newsletter Monitor compliance with NICE guidance involving medicines across the local health economy. Will complete baseline assessments for Technology Appraisals within one month of issue The role and responsibility of the operational lead (S) is to: Disseminate guidance to relevant colleagues in their service and associated services. Work with other leads for NICE guidance and relevant members of staff to complete the Baseline Review and subsequent action plans within 3 months of issue of Clinical Guidelines and Public Health Guidelines thereby ensuring implementation across services within the organisation. If this is not feasible, a negotiated timescale should be agreed with the Clinical Effectiveness Manager. There is a one month deadline for completion of the Baseline Reviews and subsequent action plans associated with Technology Appraisals. The baseline review will act as an organisational gap analysis of individual pieces of guidance. Compile an action plan for implementation with agreed timescales and associated actions to be presented at the Health & Clinical Effectiveness Group for monitoring. 9/30

10 Provide relevant evidence and assurances of compliance with the Annual Health Check requirements. Add any non compliance guidance to the relevant service risk register and then assign a risk rating for the Corporate Risk register. Any guidance that is deemed not relevant to the PCT will be placed on the Corporate Risk Register. Should a clinical decision be made that NICE guidance will not be implemented then an exemption report will be requested to support that decision The Role of Commissioners 12.1 Commissioners within the organisation have a responsibility to ensure and offer assurances that they commission and monitor services that are compliant with NICE guidance and other guidance such as NSFs and can supply documentary evidence of that compliance when necessary The role of commissioners is to operate in a strategy that brings change and continuous improvement in services, through service redesign that takes into account best clinical evidenced based practise including NICE guidance Support the Clinical Effectiveness Manager to seek assurances of compliance with NICE Guidance from External providers The Role of Independent Contractors 13.1 To comply with the Healthcare Commission the PCT has taken the following steps to seek assurances that independent contactors are complying with NICE guidance: The Heads of all three Local Health Directorates have agreed that data from GPs can be collected by the Local Health Directorate Analysts to demonstrate compliance with NICE Guidance. The Wirral Dental Modernisation Manger and The Wirral Optometry Advisor are able to attend the Health & Clinical Effectiveness Group The Role of Service Heads 14.1 Is to ensure that they are aware and implement any NICE Guidelines or other relevant Clinical Guidelines that apply to the service that they manage To ensure that they disseminate and encourage evidence based best practise within their service NICE Implementation and Monitoring 15.1 Quarterly and Annual Reports will be produced by the Clinical Effectiveness Manager and members of the Health & Clinical Effectiveness Group, which will inform the Patient Safety and Learning from Experience Group and the Integrated Governance Group of activity relating to the implementation and monitoring of NICE guidance. 10/30

11 15.2 Key Performance Indicators (KPIs) will be identified to assist in the monitoring of NICE guidance implementation NICE Tracking Spreadsheet 16.1 A NICE tracker spreadsheet will be used to monitor all actions related to guidance implementation and will be administered by the Clinical Effectiveness Manager Baseline Compliance Review and Implementation Record Template 17.1 It is proposed to monitor implementation by reviewing current practice against NICE guidance. The Operational Lead (s) will compare current practice against NICE guidance recommendations. The lead (s) will complete a Baseline Compliance Review and Implementation Template (appendix 4). This review is part of the NICE guidance implementation process Action Plan Development 18.1 If changes to current practice are required as a result of the Baseline Review an action plan will be developed, implemented and monitored. The NICE Implementation Action Plan will be agreed at the Health & Clinical Effectiveness Group and reviewed every 6 months until actions are completed Financial Implications and Costing Guidance 19.1 There are possible resource and funding implications for all NICE guidance. However, there are also specific funding implications There is a statutory obligation for PCTs to meet the funding implications of the recommendations of all NICE Technology Appraisals since January 1 st Further to this, the Secretary of State s Directives which came into effect in April 2003 stipulated that PCTs must ensure that funding is made available in such a way as to enable all recommendations to be implemented within three months of the date of issue of the Technology Appraisals (except where specifically exempted) 19.3 From April 2004 a global uplift was added to all Trust s baselines to cover the additional prescribing costs and other cost pressures due to the implementation of the recommendations of Technology Appraisals. For Technology Appraisals which affect secondary or tertiary care, this represents a shift in the responsibility from the PCT to the Trust with whom the services are commissioned for risk managing the financial impact of NICE Technology Appraisals. A small number of interventions are specifically excluded from the national tariff and funding is agreed locally between the PCT and the Trust NHS organisations are expected to do all they can to implement Clinical Guidelines within their current resources. There is no additional funding available for Clinical Guidelines and Intentional Procedures from the Government. 11/30

12 19.5 There is an expectation within NHS Wirral that departments and directorates will consider and plan in advance for the implications of any NICE Guidance that may impact upon their service NICE have published costing reports for specific guidance that look at the resource impact of implementation The costing method takes into account the most accurate data available and was produced with key clinicians and reviewed by clinical and financial experts. These costing reports will be taken into consideration as part of the NICE implementation process If any financial or resource implications are identified from the baseline assessment and action plan then a business case pro forma (appendix 7 ) will need to be completed. Support for this part of the process will be supplied by the appropriate senior accountant The completed form will firstly need to be sent to the Health & Clinical Effectiveness Group before submission to the PEC and Integrated Governance Group Audit Implications 20.1 In order to ensure that the agreed actions have been taken forward, and to assess the implementation of the guidance, monitoring arrangements should be put in place. The Operational Lead has a responsibility for ensuring the action plan is taken forward and a review date should be agreed with Clinical Effectiveness Manager All guidance will be added to the trusts audit programme for audit planning, completion and reporting. When the Operational Lead has been identified their name will be added to the audit register. The audit team will contact the Operational Lead after four months to discuss and advise, where needed, audit criteria for assessment within the six month issue period. The operational lead will need to complete the appropriate audit registration form as advised by the audit team. (Appendix 6) 20.3 If existing audit information is already available to support compliance then it may not be necessary to complete further audit to demonstrate compliance, e.g. prescribing benchmarking data across PCTs and at practice level. This will need to be discussed with the audit team Other sources of evidence can be used to demonstrate compliance at any time NICE Implementation Quarterly Report 21.1 Quarterly reports to the Integrated Governance Committee will include: NICE guidance relevant to the PCT Baseline Compliance Review results Changes to practice summary of action plans Training implications and actions Audit implications and actions 12/30

13 Financial implications including possible savings Key Performance Indicator achievement and progress Actions taken to manage relevant Risk Register and Risk Assurance Framework additions NICE horizon scan issues 22.0 NICE Implementation Annual Report 22.1 The NICE Annual Report will include: Overview of NICE guidance relevant to the PCT Summary of changes to practice for each guidance Summary of training actions Summary of audit implications and actions Financial implications including possible savings Key Performance Indicator achievement Summary of actions taken to manage relevant Risk Register and Risk Assurance Framework additions NICE horizon scan issues Consideration of success of implementation process 23.0 Model for NSF Implementation 23.1NSF implementation is a requirement of both Standards for Better Health and the NHSLA. In order to comply with these standards the PCT needs to have appropriate systems in place to support and monitor their implementation. Appendix 8 outlines NHS Wirral s process for NSF implementation The Governance Arrangements for newly formed Local Implementation Teams are as follows: It will report directly to PEC and will also inform the Health & Clinical Effectiveness group of its progress by providing summary reports Model for National Confidential Enquiries & other High Level Enquiries 24.1 Reports from National Confidential Enquiries will be sent firstly to the Chief Executive The Chief Executive will then appoint a responsible Director to oversee the implementation of the recommendations of the report The process of implementation should initially begin with an assessment of current practice and identification of any gaps in service or provision of care that are recommended from the enquiry. 13/30

14 24.4 The responsible Director will delegate authority to a named lead of their choice. The named lead will have operational responsibility across the organisation for implementing the recommendations of the enquiry. This process will report to the Corporate Directors Group directly and the named lead will be invited to attend the Health & Clinical Effectiveness Group for operational Support and will be asked to provide summary reports of progress Dissemination of Policy 25.1 This policy will be available for staff via the intranet and in hard copy format in each service area if requested by staff through the Clinical Effectiveness Manager Document Control 26.1 It is the responsibility of the policy author to ensure archive of old versions of policies and ensure distribution of new versions of policies Archiving Arrangements 27.1 Policies need to kept for a minimum of 10 years (DOH 2006 Records Management: NHS Code of Practice) for litigious purposes. It is important that the version of the policy is clearly recorded on the front cover of the policy First issue relates to the organisation which first issued the policy. This is important when NHS organisations change in case of future claim or complaint. In which case, it is the policy in place at the time of an incident which is used to defend a case Process for Retrieving Archived Documents 28.1 When a new version of an existing policy has been distributed for dissemination the team leader or individual responsible for the policy file within each team will need to replace the old policy version for the new one, fill in the version control sheet (Appendix 9 for a worked example) and shred the old copy once instructed to do so by the policy author Monitoring Compliance of This Policy 29.1 The Key Performance Indicators identified on the front of this policy will be used to monitor compliance with this document. It is the responsibility of the author of the policy to ensure that they are a robust test of compliance. The policy content will dictate the monitoring questions to be asked References Standards for Better Health (2004), Department of Health, London. Good Practice Guidance on Managing the Introduction of New Healthcare Interventions and Links to NICE Technology Appraisal Guidance. (2006) Department of Health. Managing the Financial Implications of NICE Guidance (2005) Audit Commission 14/30

15 Appendix 1 NICE Implementation Process The Clinical Effectiveness Manager horizon scans NICE website The Clinical Effectiveness Pharmacist is the Operational lead for drugspecific guidance The baseline assessment will be completed and action plan developed within one month of guidance being issued. NICE Guidance published 4th Wednesday of each month The Health & Clinical effectiveness group will discuss the guidance, its implications and designate an operational lead on a monthly basis. The Operational Lead receives guidance pack from the Clinical Effectiveness Manager. This includes letters and documentary proformas for baseline assessment and planning. The operational lead is also added to the audit register and will be contacted after 4 months by the audit team to discuss audit arrangements for the guidance. Published Guidance is placed on the clinical effectiveness site of the intranet Hard copies of guidance can be requested through the Clinical Effectiveness Manager It is expected that an audit of the guidance would be planned or underway after 6 months post issue of guidance. Appropriate and relevant information is disseminated to prescribers in the NICE Prescribing Newsletter The operational lead has 2 months to assess compliance of CG & 1 month for TA before reporting back to the clinical effectiveness group with completed documentation and evidence of compliance for central archiving in the governance department Gaps in compliance need to be added to relevant departmental risk registers and also need to be added to the organisations main register of organisational risk. Wirral wide issues are monitoredincluding Trust prescribing for PbR exclusions funded by the PCT Quarterly reports of compliance will be reported to the Integrated Governance Committee. The Annual report will be presented to the board via the Integrated Governance Committee. Minutes of the Health & Clinical effectiveness group will be sent to the Patient Safety and Learning from Experience Group for information. Guidance can only be removed from risk registers when action plans are completed and the organisation is fully compliant with the guidance 15/30

16 Appendix 2 Process for Monitoring External Providers Compliance with NICE Guidance NICE Guidance is published on the 4 th Wednesday of each month The Health & Clinical Effectiveness Group will discuss the Guidance The Clinical Effectiveness Manager will check which external providers potentially undertake the procedure that the guidance is applicable to. The Clinical Effectiveness Manager will add this information to the tracking system and will then send out a standard compliance request form to each provider or lead PCT asking for their compliance status on individual pieces of guidance. Providers are contractually required to report non compliance and supply exemption reports. This information will be by archived by the Clinical Effectiveness Manager and then will be forwarded to commissioning. 16/30

17 Appendix 3 Date: Dear.. You have been identified through the organisations Health & Clinical Effectiveness Group as the operational lead for guidance:. Issued on Please find enclosed a copy of the guidance, a baseline assessment proforma and action plan proforma. It is a requirement of NHS Wirral s National Guidance Policy that the above mentioned documentation be completed within a one month period for Technology Appraisals and a two month period for all other guidance starting from the date of issue of the guidance. The documentation should be returned to the Clinical Effectiveness Manager who will archive the information centrally within the governance department. The audit team is aware of your responsibility for this guidance and will contact you in four months time to discuss arrangements for auditing. It is expected that an audit of this guidance should be undertaken within six months of issue of the guidance. Please feel free to contact the Clinical Effectiveness Manager at any time if you need assistance with this task. Please complete the attached acknowledgement letter for Louise Halliday, Clinical Effectiveness Manager. receipt of the guidance and return to Thank you for your time. Yours sincerely Louise Halliday Clinical Effectiveness Manager Telephone ext /30

18 Dear Louise I am writing to confirm my acceptance of guidance.. Issued on.. I can confirm that the required baseline assessment is underway and that it will be completed in Signed Please return to: Louise Halliday Clinical Effectiveness Manager 2 nd Floor Admin Block St Catherine s ext 3971 mailto: 18/30

19 Appendix 4 NHS Wirral NICE Implementation Baseline Review To be returned on completion to Louise Halliday; Clinical Effectiveness Manager wirral.nhs.uk Telephone: ext 3971 TYPE OF GUIDANCE ISSUE NUMBER. DATE PUBLISHED.. GUIDANCE TITLE.. NAME OF OPERATIONAL LEAD What is current this guidance? local practise in relation to Yes No Please add details or comments Are the recommendations already reflected in current policies, procedures and protocols? Do the opinions of local experts indicate that the guidance is being implemented? Is there any data available that indicates or proves that the guidance is being followed? Has a small survey been undertaken to obtain a snapshot of current practice? What is the current status of this guidance? (please circle) Notes Fully Partially Not Implemented What are the clinical implications of Implementing this guidance? Are major changes in practise required? Are there any potential barriers to implementing this guidance? Are there any capacity or resource issues associated with the changes required? Delete as capacity etc inc in finance section ie repeated Has an assessment of the impact on prescribing been made? Is there a need to update protocols etc? Are there any training needs for staff? 19/30

20 Are there any potential clinical risks associated with implementing or not implementing this guidance? Have the clinical implications for the implementation of this guidance been raised with with the relevant planning group? Is patient expectation likely to be high? e.g. from publicity or where previously treatment was unavailable Is there any information that should be made available to the public? Are there any other implications not considered above?( if yes, please state) e.g. on length of Stay What are the financial implications of implementing this guidance? Are there any capacity or resource issues associated with the changes required? Has a financial assessment of the impact on prescribing been made? For secondary care impact- is this within tariff or specifically excluded? Will there be any other potential costs or savings? Are there any potential financial risks associated with implementing or not implementing this guidance? Have the financial implications for the implementation of this guidance been raised with the relevant planning group? Are there any other implications not considered Above? (if yes, please state) Answer the following to ensure you have a robust monitoring process Have you agreed a process for monitoring the above action plan at regular intervals? Are you able to monitor implementation through Existing data sources? Do you need to build into the audit programme system for monitoring the implementation of this guidance? Has this proforma been shared with all other relevant groups and organisations? Do you have a date set to discuss progress of action plan at the Health & Clinical Effectiveness Group? Have any major issues raised been fed back to Directors or a separate business plan developed? Have all the monitoring issues been included in your action plan? In the event of a declaration of partial or non compliance please attach a risk rating to the assessment and place it on your risk register. 20/30

21 The following Risk Matrix should be used to calculate the potential risk to the service and organisation. Likelihood Consequence Insignificant Minor Moderate Major Catastrophic Certain Likely Possible Unlikely Rare Risk Profile Grading Level/Management of Risk In terms of grading the risks the following categories are then applied. Green Low Risk Amber High Risk Red Extreme Risk Immediate Action required. Risk Rating. 21/30

22 IMPLICATIONS AND RECOMMENDATIONS FOR PLANNING NICE IMPLEMENTATION Title of Guidance Document No. Stage of NICE Appraisal Final appraisal document Date published Final guidance Date of any previous guidance Evidence Summary Views Regarding Local Implications (refer to attached checklist) Recommendations No action required (eg confirms current practice) Requires completion of formal action plan Other- please state Suggested Responsibility to Co-ordinate Action Plan (Group or individual) Timescales (Note: where Action Plans are necessary completion should be within 2 months of guidance being published) Recommendations completed by (individual or group); Date 22/30

23 Appendix 5 NICE IMPLEMENTATION ACTION PLAN To be returned to the Clinical Effectiveness Manager, 2nd Floor Admin Block St Catherine s Birkenhead Title of Guidance Document No. Stage of Guidance Final guidance Final guidance document Date published Date of any previous guidance Recommendation Action needed to comply Resource needed to comply Who is responsible Training & Education? When will it be achieved? Monitoring & Feedback Date Completed: Review Date: 23/30

24 Appendix 6 Clinical Audit Registration Form All staff must complete a registration form when conducting a clinical audit. Details will be held on the PCT audit activity database required for Standards for Better Health targets. 1. Project Lead Name Job Title Department/Service Contact Details 2. Audit Title 3. Anticipated start date Duration 4. Reason for Audit (tick all that apply) NICE guidance Recurrent/common problem National Service Framework Potential problem Evidence based guidance Re-audit Service development Prescribing PCT priority High cost/high risk Care pathway Complaints Compliance Incident reporting Variation in practice Controls Assurance 5. Aims/Objectives 6. Methods 24/30

25 Questionnaire Focus Groups Interviews Case/patient notes Other (specify) 7. Will the audit involve contact with patients? Yes No If yes, at what stage Planning and design as part of satisfaction surveys, patient questionnaires letter to patients 8. Do you plan to disseminate the results of the audit? Yes No If yes, where Team meeting PCT meeting (please state) Other (please state) 9. Do you require any help from the clinical audit team? Yes No If so, please specify design/planning stage Database design Analysis of results Report writing Please return this form to Sarah Peacock, NHS Wirral, Admin Block, 2 nd Floor, St Catherine s, Church Road, Birkenhead CH42 0LQ. OR Thank You 25/30

26 Appendix 7 NICE Business Case Pro forma To be returned to the Clinical Effectiveness Manager, 2 nd Floor, Admin Block, St Catherine s NICE: Title of Guidance.. Type of Guidance Date of Publication. Operational Lead name. Outline the recommendations coming from the document: 26/30

27 Background: This should include any information to assist in the understanding of the guidance. Including for example: Prevalence and incidence of the condition Catchment population Changes to work practise Process: Endeavour to describe: What is required to implement the guidance? Who will be responsible for implementation? Where it is undertaken? How will implementation happen? 27/30

28 Are there any implications to patients or the organisation if the guidance is not adopted?... Finance: Consider the financial impact of the guidance Can the requirements of the guidance be absorbed into current practise? If additional funding is required for implementation, clearly identify the additional costs which will be incurred: Existing Extra Total Cost( ) Cost( ) Cost( ) Cost description WTE (A) (B) (A+B) Direct costs Staff costs etc Non pay costs Stationery Medical/surgical disposable etc Support costs AHP services Equipment maintenance Total support costs (B) Total all recurrent costs (A+B) Capital costs Cost Specialist equipment Office costs IT equipment Furniture Total capital cost (Note: Identification of additional costs does not guarantee funding). Signature of Senior Accountant: Date: Signature of Operational Lead: Date: 28/30

29 Appendix 8 NSF Implementation The Clinical Effectiveness Manager will identify when new NSFs have been issued and will inform Strategic Partnerships of their release. Strategic Partnerships will designate a named person to lead on the implementation of the new NSF. It will be the role of the designated lead to establish a Local Implementation Team of relevant stake holders to initially assess the content and impact of the guidance and to identify any gaps in current provision of care. The Local Implementation Team will have strategic responsibility for the Implementation of new Guidance and will assign working subgroups as necessary depending upon the nature of the guidance. The Local Implementation Team will report to PEC. The designated lead will be invited to attend the Health & Clinical Effectiveness Group meetings to inform the group of progress towards implementation. 29/30

30 Appendix 9 Version Control Sheet Completed example Version Number Date of Removal Author Name Status Live/outdated Shredded Yes/No Replacement Number Comments Signature 2copies 1 12/09/07 Louise Halliday Outdated Yes 2 removed 30/30

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