NICE GUIDANCE/QUALITY STANDARDS
POLICY FOR THE ASSURANCE OF IMPLEMENTATION
Version
5
Name of responsible (ratifying) committee
Clinical Effectiveness Steering Group (CESG)
Date ratified
21 January 2015
Document Manager (job title)
Clinical Audit and Assurance Manager
Date issued
13 February 2015
Review date
31 January 2018
Electronic location
Management Policies
Related Procedural Documents
Key Words (to aid with searching)
Policy for the Introduction of New Clinical Procedures,
Interventions and Techniques.
Risk Assessment Policy and Protocol.
NHSLA; Care Quality Commission; Quality Contract;
NICE; Technology Appraisal Guidelines; Interventional
Procedures Guidance; Clinical Guidelines; NICE
Implementation; NICE Compliance; medical device;
diagnostic technique; surgical procedure; Drug,
Intervention; Cancer; Tumours; Clinical Audit;
Monitoring; Governance; Corporate management;
Trust law; Trusts; Technological innovations;
Technology; Drug administration; Drug regulations;
Audit; Review bodies; Performance measurement;
Medical interventions; Medical equipment; Clinical
guidelines; Medical Technologies; Diagnostic
Technologies; Patient Safety; Quality Standards;
Public Health Intervention; NHS Evidence;
Version Tracking
Version
Date Ratified
5
21/01/2015
Brief Summary of Changes
Review/revision updating with new types off NICE
guidance including NICE Quality Standards/ Medical
Technologies Diagnostic Technologies/NICE Safe
Staffing Guidance
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Author
D Williams
Page 1 of 18
CONTENTS
Page
QUICK REFERENCE ......................................................................................................................... 3
1.
INTRODUCTION.......................................................................................................................... 4
2.
PURPOSE ................................................................................................................................... 4
3.
SCOPE ........................................................................................................................................ 4
4.
DEFINITIONS .............................................................................................................................. 4
5.
DUTIES AND RESPONSIBILITIES .............................................................................................. 5
6.
PROCESS ................................................................................................................................... 7
7.
TRAINING REQUIREMENTS ...................................................................................................... 9
8.
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 9
9.
EQUALITY IMPACT ASSESSMENT ............................................................................................ 9
10. MONITORING COMPLIANCE ................................................................................................... 10
Appendices
Appendix A - Baseline Compliance Review TAG .............................................................................. 11
Appendix B - Baseline Compliance Review IPG ............................................................................... 13
Appendix C - Clinical and Cancer Guideline Self-assessment Checklist ........................................... 15
Appendix D - Quality Standards Gap Analysis .................................................................................. 17
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 2 of 18
QUICK REFERENCE
NICE Implementation Flow Chart
New and proposed NICE
guidance received via NICE
alert email


NICE Coordinator to add
guidance to database
Governance leads to make decision to whom to
send guidance.
NICE Coordinator to distribute relevant
documents (BCR) to identified lead.
Identified Lead to review document and return BCR to NICE
Co-ordinator stating their compliance
Relevant to the Trust?
NO
YES
Fully
Compliant
NICE Coordinator
to update database


For inclusion in
report to CESG
Two yearly
review
Partially
Compliant




Identified Lead
ensures audit is
planned on forward
audit plan.
NICE coordinator
to update database
Two yearly review




NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Non
Compliant
Submit action plan to
ensure compliance,
including details of any
business case.
Add to risk register
CSC governance leads
ensure issues are
monitored at CSC
governance meetings
6 monthly review for partial
/ non compliant
For inclusion in report to
CESG.
Page 3 of 18
1. INTRODUCTION
Portsmouth Hospitals NHS Trust (the Trust) has a responsibility for implementing National
Institute for Health and Care Excellence (NICE) guidance in order to ensure that:



Patients receive the best and most appropriate treatment;
NHS resources are not wasted by inappropriate treatment; and
There is equity through consistent application of NICE guidance/Quality Standards.
The Trust must demonstrate to stakeholders that NICE guidance/Quality Standards are being
implemented within the Trust and across the health community. This is a regulatory
requirement which is subject to scrutiny by the CQC. Assurance of compliance is also required
as part of the NHS standard Acute Services Contract.
The Trust is required to comply with its statutory obligations to meet the funding implications of
the recommendations of all NICE Technology Appraisal Guidelines (TAG) within three months
of the date of issue: unless where specifically exempted.
2. PURPOSE
The purpose of this policy is to set out the Trust processes for implementing, monitoring and
reporting progress in relation to NICE guidance and Quality Standards, thus ensuring continual
improvement in the quality of services provided against evidenced best practice standards.
3. SCOPE
This policy applies to all healthcare professionals involved in the clinical management of
patients who receive services from the Trust.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it
may not be possible to adhere to all aspects of this document. In such circumstances, staff
should take advice from their manager and all possible action must be taken to maintain
ongoing patient and staff safety.
4. DEFINITIONS
National Institute for Health and Care Excellence (NICE):
NICE is an independent
organisation responsible for providing national guidance on promoting good health and
preventing and treating ill health.
Clinical and Cancer Guidelines (CGs): give recommendations of good practice based on the
best available evidence and the appropriate treatment and care of people with specific
diseases and conditions. They may focus on any aspect such as prevention, self-care, or
management in primary and secondary care.
Interventional Procedure Guidance (IPG): make recommendations about whether
interventional procedures used for diagnosis or treatment are safe enough and work well
enough for routine use and whether special arrangements are needed for patient consent.
Technology Appraisal Guidance (TAG): provides recommendations on the use of new and
existing health technologies within the National Health Service. Each TAG focuses on
pharmaceutical and biopharmaceutical products, but also includes procedures, devices and
diagnostic agents. This is to ensure that all NHS patients have equitable access to the most
clinically - and cost-effective treatments that are viable.
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 4 of 18
Medical Technologies Guidance (MTG): designed to help the NHS adopt efficient and cost
effective medical devices more rapidly and consistently.
Diagnostic Technologies Guidance (DTG): designed to help the NHS adopt efficient and
cost effective diagnostic technologies more rapidly and consistently.
Patient Safety Guidance (PSG): provides advice on patient safety solutions.
NICE Quality Standards (QS): are a set of specific, concise statements that act as markers of
high quality, cost-effective patient care, covering the treatment and prevention of different
diseases and conditions. Derived from the best available evidence such as NICE guidance and
other evidence sources accredited by NHS Evidence, they are developed independently by
NICE, in collaboration with the NHS and social care professionals, their partners and service
users, and address three dimensions of quality: clinical effectiveness, patient safety and patient
experience.
Public Health Intervention Guidance (PHIG): gives guidance on the promotion of good health
and the prevention of ill health. The guidance may focus on a particular topic (such as
smoking), a particular population (such as schoolchildren) or a particular setting (such as the
workplace).
NICE Safe staffing guidelines
The National Quality Board has set out the immediate expectation of NHS providers in
providing safe staffing levels. This guidance is a comprehensive review of the evidence in this
area and produce definitive guidelines on safe staffing to support local decisions at ward and
organisational level.
Self-assessment Checklist for CGs: is an organisational gap analysis against the guidance
recommendations to enable an action plan to be developed and prioritised to achieve full
compliance.
Organisational Gap Analysis: is a review of actual current practice against the NICE
recommendations, producing an action plan where gaps are identified to align current practice
with the identified best practice recommendations.
Baseline Compliance Review (BCR): is an initial position statement from the specialty clinical
lead, detailing the level of compliance with the published NICE guidance excluding Clinical and
Cancer Guidelines (CGs).
NICE social care guidelines
The primary role of NICE social care guidelines is to provide recommendations on “what works”
in terms of both the effectiveness and cost-effectiveness of social care interventions and
services.
NHS Evidence: is a service that enables access to authoritative clinical and non-clinical
evidence and best practice through a web-based portal (http://www.evidence.nhs.uk ). It helps
people from across the NHS, public health and social care sectors to make better decisions as
a result. NHS Evidence is managed by NICE.
5. DUTIES AND RESPONSIBILITIES
Clinical Effectiveness Steering Group (CESG)
The CESG has overall responsibility for monitoring the status of NICE guidance/Quality
Standards and receiving a quarterly NICE implementation status report from the Clinical Audit
and Assurance Manager to ensure that, through the appropriate monitoring of that
implementation, the Trust can demonstrate care against best evidence, best practice guidance
to assure the continuous and measurable improvement in the quality of the services provided.
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 5 of 18
Clinical Service Centre Governance Committees (CSCGC)
CSCGCs have the responsibility to ensure that they are aware of NICE guidance/Quality
Standards that impact on their areas and that all action plans to address areas of partial or noncompliance are monitored and added to the CSC Risk Register, escalating any issues of
concern to the CSC Management Team and through their quarterly reports to the Governance
and Quality Committee.
Clinical Service Centre Management Teams (CSCMT)
CSCMTs are responsible for receiving and acting upon any information from the CSCGCs,
concerning barriers to the implementation of NICE guidance/Quality Standards.
Senior Management Team meeting (SMT)
As a sub-group of the Trust Board, SMT will identify if funding is available for NICE related
business cases, ensuring that guidance can be aligned with the Trust planning processes and
that there is appropriate liaison with relevant CCG partners.
Medical Director (MD)
The MD, who also chairs CESG, has delegated responsibility to ensure that NICE
guidance/Quality Standards is appropriately implemented across the Trust and that the Trust
Board is made aware of any issues that may impact upon the organisation’s ability to do so.
CSC Governance Leads
The CSC governance leads will receive details of all new and proposed NICE publications from
the NICE Co-ordinator and will identify relevant leads within the organisation to complete the
initial BCR/Self-assessment checklist or gap analysis as appropriate. The CSC governance
leads will be responsible for ensuring that appropriate and timely action is taken in response to
any issues identified, through the CSC governance structure or by escalation to the CESG.
The CSC governance leads have responsibility to ensure that their CSCs are aware of NICE
guidance/Quality Standards and to ensure that there is robust evidence to give assurance of
implementation of that guidance. They are also responsible for ensuring that any identified
issues of partial or non-compliance are escalated to the CSC Governance meeting and that any
barriers to implementation and compliance, are risk assessed and added to the appropriate
CSC risk register.
Clinical Audit and Assurance Manager
The Clinical Audit and Assurance Manager has responsibility for the operational and day-to-day
implementation of this policy, including the escalation of any identified issues to the CSC
governance leads or CESG. The Clinical Audit and Assurance Manager will ensure that the
CESG receive a quarterly status summary report giving the overall Trust position of compliance
with NICE guidance/Quality Standards.
NICE Coordinator
The NICE coordinator is responsible for the coordination and distribution
guidance/Quality Standards to the CSC governance leads, providing support
relevant staff and assisting the Clinical Audit and Assurance Manager, including
issues identified. The NICE coordinator will also maintain the NICE database
Intranet together with evidence to support compliance or non-compliance.
of new NICE
and advice to
escalating any
on the Trust’s
Identified Leads
The identified leads have responsibility for ensuring that an initial BCR/Self-assessment
checklist or gap analysis review is undertaken for any NICE guideline/Quality Standard for
which they have been identified by the CSC governance leads or CESG as the lead. This will
include utilising implementation and costing tools provided by NICE, to assist in understanding
the financial and clinical impact of the guidance, developing business cases, ensuring that any
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 6 of 18
relevant guidance is disseminated appropriately within the Trust and or specialty, where the
guidance impacts, liaising with other relevant stakeholders.
The identified leads are also responsible for formulating a robust action plan to address any
areas of partial or non-compliance and sharing these with the CSC governance leads for
monitoring at the CSCGC. Where declarations of partial or non-compliance are made the
identified lead will undertake a risk assessment and escalate that assessment to the CSCGC
for consideration of placement on the CSC or trust risk register.
In addition, the identified leads will ensure that audits of relevant NICE guidance/Quality
Standards are added to the specialty rolling annual audit plans and that those audits are
registered with the Clinical Audit Department (CAD) and undertaken to timescale.
Healthcare Professionals
All healthcare professionals are responsible for ensuring that they familiarise themselves, and
comply with, the requirements of this policy and the associated Policy for the Introduction of
New Clinical Procedures, Interventions and Techniques.
Healthcare professionals are also expected to take NICE guidelines into account when
exercising their clinical judgement. The guidance does not, however, over-ride the responsibility
of healthcare professionals to make decisions appropriate to the circumstances of each patient,
in consultation with the patient. Where treatment is given outside of the guidelines, healthcare
professionals must fully document the reasons for non-compliance in the patient’s medical
records.
5.1: Trust Pharmaceutical Services
5.1.1
5.1.2
5.1.3
5.1.4
Director of Medicines Management and Pharmacy will receive NICE guidance and
identify if guidance is relevant to the Trust or if the Clinical Commissioning Groups
(CCGs) are required to be involved. They will ensure an outline business case is
developed in conjunction with the CSC pharmacist for submission to the relevant
committee. All business cases will include a requirement for regular audit.
Formulary Interface Pharmacist will liaise with the NICE coordinator to ensure the
relevant database is kept updated.
Formulary and Medicines Group (FMG) will review guidance that impacts the Trust
and escalate any business cases to SMT if the cost impact is likely to be greater than
£20,000. Guidance will also be referred to the Area Prescribing Committee for noting
and to approve any changes to the Portsmouth District Prescribing Formulary. The
FMG will report progress on any NICE related medicine reviews to the Governance
and Quality Committee via their bi-annual report.
Area Prescribing Committee (APC) will review all guidance that affects both the
Trust and the CCGs and will record any action arising; this includes updating of the
District Prescribing Formulary or confirmation that no action is required. If a business
case is approved by the APC and / or the financial impact to the Trust is greater than
£20,000, the APC will inform the SMT.
6. PROCESS
6.1 Identifying and disseminating relevant documents
6.1.1 The NICE Coordinator will receive the monthly alert sent by NICE each month.
6.1.2 Within 14 working days following publication the NICE coordinator places the newly
issued guidance onto the NICE database, therefore ensuring it is available to all
members of staff through the clinical audit intranet.
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 7 of 18
6.1.3
Within 14 working days, the NICE coordinator forwards the guidance to all CSC
governance leads, to enable an identified lead to be appointed.
6.1.4
The NICE coordinator forwards to the identified lead the appropriate BCR/Selfassessment checklist or gap analysis review forms for completion (Appendix A, B, C,
D); to ensure an initial position statement of compliance, within the spirit of the
guidance/Quality Standard is received into the CAD.
6.2 Conducting an organisational gap analysis
6.2.1
The identified lead will undertake an organisational gap analysis by completion of a
BCR/Self-assessment checklist or gap analysis review and forward that analysis to
the CAD. The identified lead will also produce an action plan with timescales to
ensure full compliance is achieved.
6.2.2
The NICE Coordinator will update the NICE database and if any area of partial or
non-compliance is reported, the NICE coordinator will inform the identified lead that
a risk assessment is required.
6.2.3
The Clinical Audit and Assurance Manager will escalate any identified issues or
barriers to implement to the CESG.
6.3 Ensuring that recommendations are acted upon throughout the organisation
Once the organisational gap analysis has been completed by the identified lead, the Trust
has the following process in place to ensure that recommendations are acted upon
Relevant to the Trust?
NO
YES
NICE Coordinator
to update
database
Fully
Compliant



Validated at CSCGC
Included in the quarterly
report to CESG
Two yearly review by
identified lead, to ensure
the guidance remains of
no relevance to the Trust





Partially
Compliant

Compliance validated by
CSCGC
NICE Coordinator
updates database
Identified lead ensures
that audit of compliance
forms part of the rolling
annual audit plan,
registered with the CAD
Results of audit
forwarded to the CAD, to
update the database
NICE Coordinator will
also ensure that two
Implementation
yearly monitoringPolicy
reviews
are undertaken for this
guidance.
NICE Guidance/Quality Standards
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)






Non
Compliant
The identified lead produces an action
plan to achieve compliance
NICE Coordinator updates database
The action plan is forwarded to CSC
Governance Lead
CSC Governance
Leads ensure that
YES
issues are discussed at CSCGC and
ensures that any partial/non-compliance
is placed on CSC/trust risk register,
together with the action plan
Risk Registers are monitored at CSCGC
to ensure progress against action plans
Any barriers to progress will be escalated
to CSC Management Team
CSC Governance Leads will feedback to
CAD on a monthly basis.
Page 8 of 18
6.4 Recording of any decisions not to implement NICE guidance/Quality Standards
6.4.1
The identified lead undertakes a BCR/Self-assessment checklist or gap analysis
review in consultation with colleagues. Any decision not to implement and why, is
referred to CESG.
6.4.2
The decision not to implement, and why, is validated by the CESG
6.4.3
The identified lead will ensure that any risk posed by non-implementation is
assessed and placed on the CSC risk register, as necessary.
6.4.4
The Medical Director will escalate any decisions not to implement NICE
guidance/Quality Standards to the Trust Board.
6.4.5
Once the board validates the non-implementation, any associated risks will be
escalated to the Trust Risk Register.
6.4.6
The NICE Coordinator will contact the identified leads on a six monthly basis in order
to determine whether there are any changes in the decision not to implement the
guidance. The NICE coordinator will then update the database accordingly.
7. TRAINING REQUIREMENTS
There are no specific training requirements associated with this procedural document. Advice
and guidance can be sought from CSC Governance Leads or the NICE coordinator on
extension: 7700 5992.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
External
CQC Essential Standards
Interventional procedures programme process guide (http://www.nice.org.uk/Process Guide).
Interventional procedures programme methods guide (http://www.nice.org.uk//Theinterventional-procedures-programme-methods-guide).
Department of Health, Health Service Circular HSC 2003/011 www.dh.gov.uk
How to put NICE guidance into practice www.nice.org.uk
Internal
Policy for the Introduction of New Clinical Procedures, Interventions and Techniques
Risk Assessment Policy and Protocol
Clinical Audit Policy
9. EQUALITY IMPACT ASSESSMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 9 of 18
10. MONITORING COMPLIANCE
As a minimum the following will be monitored to ensure compliance
Element to be monitored
Process
for
identifying
relevant documents: 100% of
all published guidance is
placed on Clinical Audit
website
Lead
Tool
NICE
Coordinator
Review of Clinical
Audit website
NICE
Coordinator
Review of NICE
spreadsheet
Process for conducting an
organisational gap analysis:
100% of relevant documents
will undergo a gap analysis
NICE
Coordinator
Review of NICE
spreadsheet
Process for documenting any
decision not to implement
NICE recommendations
100%
of
such
recommendations will have an
associated
rationale
and
documented
Trust
Board
agreement
Reporting arrangements
Acting on recommendations
and Lead(s)
Policy Audit Report to:
Process for disseminating
relevant documents
95% of documents will be
disseminated within 14 days
of publication
Process for ensuring that
recommendations are acted
upon
throughout
the
organisation
95% of recommendations will
be implemented within the
given timescales
Frequency of Reporting
of Compliance

Annually
Clinical
Effectiveness
Steering Group
Clinical Audit and Assurance
Manager
Policy Audit Report to:
Annually

Clinical
Effectiveness
Steering Group
Clinical Audit and Assurance
Manager
Policy Audit Report to:
Annually

Clinical
Effectiveness
Steering Group
Clinical Audit and Assurance
Manager
Policy Audit Report to:

NICE
Coordinator
Review of NICE
spreadsheet
Annually
Clinical
Effectiveness
Steering Group
Medical Director
Policy Audit Report to:

NICE
Coordinator
Review of NICE
spreadsheet
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Annually
Page 10 of 18
Clinical
Effectiveness
Steering Group
Medical Director
Appendix A
NICE – TECHNICAL APPRAISAL GUIDANCE
BASELINE COMPLIANCE REVIEW (BCR)
Title:
TAG NO:
Clinical Service Centre:
Issue Date:
Specialty:
Review Date:
As an initial assessment of this guidance, do we generally comply with the
spirit of this guidance?
Fully Compliant
Partially
Non Compliant
Not Relevant to PHT
Please supply evidence below to support this conclusion, this may be tested by
various methods including audit. (This may be an opportunity to add this to your
forward audit plan)
NAME:
POSITION:
DATE:
For office use only:
Signed:
Dated:
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 11 of 18
Appendix A (cont.)
Dear Dr
Technical Appraisal Guidance No. & Title
You were identified by your Governance Lead as the most appropriate person to review this
latest guidance.
Please find attached a Baseline Compliance Review in respect of this new NICE TAG, issued
{full date}.
In the spirit of the guidance please identify if this is relevant to the Trust, complete the Baseline
Compliance Review and return to us by {date}. We understand it is not always possible to meet
this deadline, if this is the case please give us an estimation of when a decision can be made.
Please note that implementation of NICE Technical Appraisals are mandatory within 3 months of
publication unless otherwise directed by NICE/DOH.
<< attachments – BCR form
The NICE guidance and additional information can be accessed through the NICE website, the
direct link to this NICE Guidance is:<< hyperlink direct to TAG on www.nice.org.uk >>
Please do inform us immediately if you consider you are not the most appropriate person to
complete this, if possible please give details of whom we should address this to.
However, if this guidance is relevant to yourselves and you feel it is relevant to another specialty,
please can you inform us.
If you would like any further clarification, please do not hesitate to contact me.
Thank you for your assistance.
Yours sincerely
NICE Coordinator
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 12 of 18
Appendix B
NICE - INTERVENTIONAL PROCEDURE GUIDANCE
BASELINE COMPLIANCE REVIEW (BCR)
Title:
IPG NO:
Clinical Service Centre:
Issue Date:
Specialty:
Review Date:
As an initial assessment of this guidance, do we generally comply with the
spirit of this?
Fully Compliant
Partially*
Non Compliant*
Not Relevant to PHT
Please supply evidence below to support this conclusion, this may be tested by
various methods including audit. (This may be an opportunity to add this to your
forward audit plan)
NAME:
POSITION:
DATE:
For office use only:
Signed:
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Dated:
Page 13 of 18
Appendix B (cont.)
Dear Dr
Interventional Procedure Guidance No. & Title
You were identified by your Governance Lead as the most appropriate person to
review this latest guidance.
Please find attached a Baseline Compliance Review in respect of this new NICE IPG,
issued {full date}.
In the spirit of the guidance please identify if this is relevant to the Trust, complete the
Baseline Compliance Review and return to us by {date}. We understand it is not
always possible to meet this deadline, if this is the case please give us an estimation
of when a decision can be made.
<< attachments – BCR form
The NICE guidance and additional information can be accessed through the NICE
website, the direct link to this NICE Guidance is:<< hyperlink direct to IPG on www.nice.org.uk >>
Please do inform us immediately if you consider you are not the most appropriate
person to complete this, if possible please give details of whom we should address
this to.
However, if this guidance is relevant to yourselves and you feel it is relevant to
another specialty, please can you inform us.
If you would like any further clarification, please do not hesitate to contact me.
Thank you for your assistance.
Yours sincerely
NICE Coordinator
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 14 of 18
Appendix C
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 15 of 18
Appendix C (cont.)
Dear Dr
Clinical Guidance No. & Title
You were identified by your Governance Lead as the most appropriate person to
review this latest guidance.
Please find attached a Self Assessment checklist in respect of this new NICE Clinical
Guidance, issued {full date}.
In the spirit of the guidance please identify if this is relevant to the Trust, complete the
Self Assessment checklist and return to us by {date}. We understand it is not always
possible to meet this deadline, if this is the case please give us an estimation of
when a decision can be made.
<< attachments – Self assessment checklist
The NICE guidance and additional information can be accessed through the NICE
website, the direct link to this NICE Clinical Guidance is:<< hyperlink direct to CG on www.nice.org.uk >>
Please do inform us immediately if you consider you are not the most appropriate
person to complete this, if possible please give details of whom we should address
this to.
However, if this guidance is relevant to yourselves and you feel it is relevant to
another specialty, please can you inform us.
If you would like any further clarification, please do not hesitate to contact me.
Thank you for your assistance.
Yours sincerely
NICE Coordinator
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 16 of 18
Appendix D - Quality Standards Gap Analysis
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 17 of 18
Appendix D (cont.)
Dear
As you may be aware the NICE Quality Standard relating to ________________ has now
been issued.
As you have been identified as the most appropriate lead for this standard, I would be most
grateful if you could complete the attached gap analysis form and return by ___________ at the
latest. This will then be presented and discussed at the Clinical Effectiveness Steering Group
meeting on the ____________.
ADD GAP ANALYSIS
ADD FULL STANDARD
Many thanks and kind regards
NICE Co-ordinator
NICE Guidance/Quality Standards Implementation Policy
Version 5
Issue Date: 13 February 2015
Review date: 31 January 2018 (unless legislation changes)
Page 18 of 18