An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
NHS Trust
An Organisation-wide Document for the Dissemination,
Implementation and Monitoring of NICE guidance
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
Contents
1
Introduction ............................................................................................................. 4
2
Purpose .................................................................................................................... 4
3
Explanation of Terms ............................................................................................... 4
4
Duties ....................................................................................................................... 5
4.1
4.2
Duties within the Organisation ............................................................................................... 6
Committees and Groups with Overarching Responsibilities .................................................. 6
5
Process for Identifying Relevant Documents .......................................................... 8
6
Process for Disseminating Relevant Documents ..................................................... 8
7
Process for Conducting an Organisational Gap Analysis ......................................... 8
8 Process for Ensuring that Recommendations are Acted Upon Throughout the
Organisation ................................................................................................................... 9
9
Process for Documenting any Decision not to Implement NICE Recommendations
9
10
Equality Impact Assessment ................................................................................. 9
11
Monitoring Compliance with the Document ....................................................... 9
11.1
11.2
12
12.1
13
Process for Monitoring Compliance ....................................................................................... 9
Standards/Key Performance Indicators ................................................................................ 10
References .......................................................................................................... 10
Guidance from Other Organisations ..................................................................................... 10
Associated Documentation ................................................................................ 11
Appendix A - Process Flow Chart for Managing the Dissemination, Implementation
and Monitoring of NICE Guidance ................................................................................ 12
Appendix B - Nominated Committee and Lead Individuals (Example) ........................ 13
Appendix C - Template for an Action Plan Following an Organisational Gap Analysis
(Example) ...................................................................................................................... 14
Appendix D - Template Document for the Dissemination, Implementation and
Monitoring of NICE Guidance ....................................................................................... 15
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
Review and Amendment Log
Version No
Type of Change
Date
Description of change
V.2
Annual review
Mar 2011
Update to section 12 ‘References’
V.2
Amendment
Mar 2011
Addition of amendment log
Addition of example of definition
Addition of examples of associated documents
V.3
Annual review
Mar 2012
Update to section 4 ‘Duties’
Update to include reference to NICE Pathways
Update to Appendix B
V.3
Amendment
Mar 2012
Change to format
contents page
including
automated
Please Note the Intention of this Document
This document has been developed with the aim of providing a model document template.
However, any documentation subsequently produced must follow its own rules and include details
of all the requirements set out in sections 1-13, where relevant. The organisation may use this
template and adapt it to reflect procedures within the organisation or alternatively use a document
already in existence. Whichever approach is used the organisation must ensure it is compliant with
the minimum requirements of the relevant National Health Service Litigation Authority (NHSLA) Risk
Management Standards.
a
To assist the organisation, areas have been identified in the margins where the section
within the template document relates to the minimum requirements for the criterion in the
relevant NHSLA Risk Management Standards.
It is important that the document should follow any pre-existing guidance within the organisation in
relation to style and format of documentation. Please note that a template document entitled An
Organisation-wide Document for the Development and Management of Procedural Documents can
be found on the NHSLA website which may provide the organisation with additional guidance.
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
1
Introduction
This section should state the reason the document has been developed.
A clear process to respond effectively to NICE guidance brings benefits to patients ensuring
that the care provided is both clinically and cost effective. It helps the organisation to meet
standards set by the Care Quality Commission. The process supports the organisation’s
governance framework and provides assurance to the board.
2
Purpose
Within this section the organisation should provide the rationale for the development of the
document. It should include a description of how the organisation intends to ensure that
the process for managing risks associated with the dissemination, implementation and
monitoring of compliance with NICE guidance is managed in the most effective way. As a
minimum the document should include details of each of the minimum requirements within
this process, as identified in the NHSLA Risk Management Standards.
The document must describe the organisation’s whole systems approach to managing NICE
guidance. It must ensure that there are clear procedures in place to inform and support all
those involved in the process.
A process flow chart could also be developed and may be included in the appendices Appendix A.
3
Explanation of Terms
This section should list and describe the meaning of the terms used within the context of this
document.
The following list is a guide only and is not exhaustive:

National Institute for Health and Clinical Excellence (NICE)
An independent organisation responsible for providing national guidance on the promotion
of good health and the prevention and treatment of ill health: www.nice.org.uk.

Technology appraisals
Recommendations on the use of new and existing medicines and treatments within the NHS.

Medical technologies evaluation programme
Medical technologies guidance is designed to help the NHS adopt efficient and cost effective
medical devices and diagnostics more rapidly and consistently.

Interventional procedures
Guidance which evaluates the safety and efficacy of such procedures where they are used
for diagnosis or treatment.

Clinical guidelines
Recommendations based on the best available evidence on the appropriate treatment and
care of people with specific diseases and conditions.
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance

Public health guidance
Recommendations on the promotion of good health and the prevention of ill health.

NICE quality standards
NICE quality standards are a set of specific, concise statements that act as markers of highquality, 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.

NICE Pathways
NICE Pathways is an online tool for health and social care professionals that brings together
all related NICE guidance and associated products in a set of interactive topic-based
diagrams. Visually representing everything NICE has said on a particular topic, the pathways
enable people to see at a glance all of NICE's recommendations on a specific clinical or
health topic.

NHS Evidence
NHS Evidence, provided by NICE, is a free service supporting the information needs of
frontline staff working in health and social care. Users can access a comprehensive evidence
base, including systematic reviews, accredited guidance and patient information. The web
portal provides access to more than 170 reliable sources simultaneously including the
National Institute for Health and Clinical Excellence, British National Formulary and the
Cochrane Library: www.evidence.nhs.uk

NHS Litigation Authority
The NHSLA is a Special Health Authority, and is part of the NHS responsible for handling
negligence claims made against NHS bodies in England: www.nhsla.com

Care Quality Commission (CQC)
Independent regulator of health and social care in England: www.cqc.org.uk
a
4
Duties
It is expected that the organisation will have nominated or appointed an individual or
individuals to coordinate and report on the dissemination, implementation and monitoring
of NICE guidance. This person(s) is often known as ‘the NICE manager’ and will often do this
as part of their clinical governance role.
The document should also include an overview of the responsible committee, management
lead, individual and departmental roles and levels of responsibility for the dissemination,
implementation and monitoring of NICE guidance. The following list is for guidance only and
is not exhaustive.
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
4.1
Duties within the Organisation
Give an overview of the roles, responsibilities and accountabilities for the
implementation of the organisation’s process for the dissemination, implementation
and monitoring of NICE guidance. It should not be a detailed explanation of
processes. The following list is a guide only and is not exhaustive:
Chief Executive
This section should state that the chief executive is ultimately accountable for the
implementation of this organisation-wide process.
Nominated/Appointed Lead for the Dissemination,
Monitoring of NICE Guidance (NICE Manager)
Implementation and
This section should identify the post holder who is the nominated/appointed lead
person for the dissemination, implementation and monitoring of NICE guidance.
This section should detail the duties and how the post holder will fulfil those,
including time-scales where appropriate.
This post holder’s duties may include a responsibility to:

horizon scan and forward plan in relation to NICE guidance;

disseminate guidance to key groups;

coordinate implementation and action plans (including financial plans);

ensure uptake is monitored/compliance is audited;

maintain a database of organisational responses to NICE guidance; and

produce regular board reports.
Further Duties within the Organisation
This could include: medical director; committee leads; committee secretaries and
could be supported by a table in the appendices - see example at Appendix B.
All Staff
This section should define the responsibilities of all staff. It should emphasise the
individual responsibilities of all staff in relation to complying with the objectives of
the organisation.
4.2
Committees and Groups with Overarching Responsibilities
Trust Board
For effective implementation of the Organisation-wide Document for the
Dissemination, Implementation and Monitoring of NICE Guidance there must be
active support from the most senior members of the organisation. Organisations
should detail how the chief executive and the nominated directors are to gain
assurance that this document is being implemented within the organisation. There
must be effective cooperation at all levels of the organisation in order for this
process to be successful.
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
Accountable Committee for the Dissemination, Implementation and Monitoring of
NICE Guidance
This section should identify the committee/group (normally the board or clinical
governance committee) which will have overall accountability for the dissemination,
implementation and monitoring of NICE guidance. The section should include:

how this committee/group links with all the other relevant committees;

the role of this committee/group with regards to ensuring continuous
development of this document;

the role of this committee/group with regards to receiving summary reports;

how this committee/group communicates both up to board level (if it is not
the board fulfilling this function), and down to the local management levels;
and

how this committee/group facilitates organisational learning and
improvement as a result of the dissemination, implementation and
monitoring of NICE guidance.
It would be considered good practice for the organisation to develop terms of
reference for all committees/groups including accountability, responsibility,
authority, membership (including identified co-opted members and deputies)
meeting schedule, quorum etc.
Responsible Committee for the Dissemination, Implementation and Monitoring of
NICE Guidance
This section should describe the duties and responsibilities of the committee/group
for the dissemination, implementation and monitoring of NICE guidance. This group
may be nominated/appointed by virtue of their position but it should be multidisciplinary in nature with representation of all professions. The committee/group
will:
V.3

work with the NICE manager to provide overall coordination, planning and
monitoring of guidance implementation;

identify appropriate clinical leads for each specific NICE guidance to work
with the NICE manager; this could be supported by a table in the
appendices;

ensure an organisational gap analysis takes place when NICE guidance is
issued;

review and agree dissemination and implementation plans, and consider if
the identified action is adequate and appropriate;

review and agree plans to monitor uptake/audit implementation of NICE
guidance;

monitor progress against agreed dissemination, implementation and audit
plans;
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
b
5

establish links with other organisations in the local health community to
reduce duplication and facilitate joint planning; and

ensure that activities in relation to the implementation of NICE guidance
achieve compliance with the standards of other bodies (for example Care
Quality Commission).
Process for Identifying Relevant Documents
This section should detail how horizon scanning will take place and how decisions will be
made as to whether new NICE guidance is relevant to the organisation. It should also
identify the process for recording decisions not to implement NICE guidance.
Resources that may help are:
6

NICE forward planner Link

NICE email bulletins Link

NICE Pathways Link

NHS Evidence Link
Process for Disseminating Relevant Documents
This section should detail how guidance will be disseminated to both individuals and
groups/committees within the organisation.
Resources that may help are:
c
7

NICE slide sets Link

NICE quick reference guides for clinical guidelines (can be downloaded from the
same website page as the NICE guideline). From October 2011, for new or reviewed
clinical guidelines, quick reference guides will be replaced by information on the
relevant NICE Pathway Link.
Process for Conducting an Organisational Gap Analysis
This section should detail how the organisation will assess NICE guidance in relation to
current practice to determine where actions are needed to implement the
recommendations within the guidance. The process should describe how an action plan is
developed. This could be supported by a template for an action plan – see example at
Appendix C.
d
NICE produce a range of support tools that can help with this activity including costing and
baseline assessment. These resources are available at:
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
NICE service planning Link

NICE baseline assessment tools Link
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8
Process for Ensuring that Recommendations are Acted Upon Throughout the
Organisation
This section should detail how action plans are monitored and how this is then evaluated
through the use of clinical audit or measuring uptake through routinely collected data. It is
not expected that audit is undertaken in relation to every piece of NICE guidance. The
document should detail how topics are prioritised and audit results are acted upon.
Resources that may help are:
d
9

NICE audit support Link

NICE service planning Link
Process for Documenting
Recommendations
any
Decision
not
to
Implement
NICE
This section should detail the process for recording reasons guidance has been judged to not
be applicable. These decisions may be recorded in the organisation’s risk register or other
similar document as well as at the patient level through patient records which can be
audited. These decisions should be reviewed periodically as changes or provision of new
services may lead to previously inapplicable guidance becoming relevant to the organisation.
Resources that may help are:

10
NICE baseline assessment tools Link
Equality Impact Assessment
The organisation should identify who will undertake the Equality Impact Assessment which is
required to consider the needs and assess the impact of this document in accordance with
the Organisation-wide Document for the Development and Management of Procedural
Documents. The Equality Impact Assessment Tool found at Appendix E of the Organisationwide Document for the Development and Management of Procedural Documents could be
completed and form part of the body of the document, but as a minimum a statement
should be included within the document to demonstrate that an Equality Impact Assessment
has been carried out and that the document does not discriminate, highlighting any areas of
good practice or risk areas requiring attention.
e
11
Monitoring Compliance with the Document
11.1
Process for Monitoring Compliance
This section should identify how the organisation plans to monitor compliance with
the Organisation-wide Document for the Dissemination, Implementation and
Monitoring of NICE Guidance.
As a minimum it should include the
review/monitoring of all the minimum requirements within the NHSLA Risk
Management Standards. The following list is a guide to issues which could be
considered within this section and should be added to where appropriate:
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
Who will perform the monitoring?

When will the monitoring be performed?
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11.2

How are you going to monitor?

What will happen if any shortfalls are identified?

Where will the results of the monitoring be reported?

How will the resulting action plan be progressed and monitored?

How will learning take place?
Standards/Key Performance Indicators
This section could contain auditable standards and/or key performance indicators
(KPIs) which may assist the organisation in the process for monitoring compliance.
12
References
This section should contain the details of any reference materials reviewed in the
development of the procedural document.
Listed below are some useful sources of reference material:
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12.1
Guidance from Other Organisations

Darzi, Lord (2008) High Quality Care For All: NHS Next Stage Review Final Report

Department of Health website provides further information: www.dh.gov.uk.

Health Service Circular 2003/011 The interventional procedures programme:
working with the National Institute for Clinical Excellence to promote safe
clinical innovation (2003)

Chief Medical Officer Annual Report Learning how to Learn: Compliance with
Patient Safety Alerts in the NHS (2005)

National Quality Board: NICE Quality Standards (2010)

The NHS Constitution: The NHS belongs to us all (2010)

Health Foundation (2009) Rising to the challenge: Using evidence about what works
to improve quality and save money

National Institute for Health and Clinical Excellence (NICE) website provides the full
list of NICE guidance, quick reference guides, resources to support implementation,
and further information: www.nice.org.uk.

Legal Context of NICE guidance (2004)

How to change practice (2010)

How to put NICE guidance into practice: A guide to implementation for
organisations (interim) (2011)
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13
Associated Documentation
This section should provide a cross reference to any other related organisational procedural
document(s).
The following list is a guide only and is not exhaustive:
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
Audit

Risk register

Communications

Risk assessment

Risk management process

Improvement
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Appendix A - Process Flow Chart for Managing the Dissemination, Implementation
and Monitoring of NICE Guidance
Organisation to develop Process Flow Chart
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Appendix B - Nominated Committee and Lead Individuals (Example)
Role in NICE process
Member of committee/group
Lead individual
Executive lead
Trust Board
Medical director
NICE manager
Multidisciplinary NICE group
(Coordinator)
NICE manager
Pharmacy representative
Multidisciplinary NICE group
Head of pharmacy
Medical representative
Multidisciplinary NICE group
GP
Nursing representative
Multidisciplinary NICE group
Nurse consultant
Allied health professions
representative
Multidisciplinary NICE group
Patient representative
Multidisciplinary NICE group
Finance representative
Multidisciplinary NICE group
Management accountant
Secretary to multidisciplinary
NICE group
Multidisciplinary NICE group
Clinical governance
administrator
NICE clinical lead (surgery)
Ad-hoc member of
multidisciplinary NICE group
NICE clinical lead
(cardiovascular)
Ad-hoc member of
multidisciplinary NICE group
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Appendix C - Template for an Action Plan Following an Organisational Gap Analysis
(Example)
Recommendation
(detail all
Compliance
recommendations
from the guidance)
(Yes/No/Partial)
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Action
Required
March 2012
Responsibility
and
Timescales
Monitoring
Arrangements
Date Action
Completed
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
Appendix D - Template Document for the Dissemination, Implementation and
Monitoring of NICE Guidance
NHS Trust
An Organisation-wide Document for the Dissemination,
Implementation and Monitoring of NICE guidance
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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Contents
1
Introduction ........................................................................................................... 18
2
Purpose .................................................................................................................. 18
3
Explanation of Terms ............................................................................................. 18
4
Duties ..................................................................................................................... 18
4.1
4.2
Duties within the Organisation ............................................................................................. 18
Committees and Groups with Overarching Responsibilities ................................................ 18
5
Process for Identifying Relevant Documents ........................................................ 18
6
Process for Disseminating Relevant Documents ................................................... 18
7
Process for Conducting and Organisational Gap Analysis ..................................... 18
8 Process for Ensuring that Recommendations are Acted Upon Throughout the
Organisation ................................................................................................................. 18
9 Process for Documenting any Decision Not to Implement NICE
Recommendations ........................................................................................................ 18
10
Equality Impact Assessment ............................................................................... 18
11
Monitoring Compliance with the Document ..................................................... 18
11.1
11.2
12
12.1
13
Process for Monitoring Compliance ..................................................................................... 18
Standards/Key Performance Indicators ................................................................................ 18
References .......................................................................................................... 19
Guidance from Other Organisations ..................................................................................... 19
Associated Documentation ................................................................................ 19
Appendix A
Analysis Report Template ..................................................................... 19
Appendix B
Checklist for the Review and Approval of Procedural Documents ...... 19
Appendix C
Version Control Sheet ........................................................................... 19
Appendix D
Plan for Dissemination .......................................................................... 19
Appendix E
Equality Impact Assessment Tool ......................................................... 19
Examples of the Checklist for the Review and Approval of Procedural Documents, Version Control
Sheet, Plan for Dissemination and the Equality Impact Assessment Tool can all be found within the
Organisation-wide Document for the Development and Management of Procedural Documents on
the NHSLA website.
Appendix B in the Organisation-wide Document for the Development and Management of Procedural
Documents contains a flowchart to assist with the process for the creation and implementation of
procedural documents.
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Review and Amendment Log
Version No
V.3
Type of Change
Date
March 2012
Description of change
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An Organisation-wide Document for the Dissemination, Implementation and Monitoring of NICE Guidance
1
Introduction
2
Purpose
3
Explanation of Terms
4
Duties
4.1
Duties within the Organisation
4.2
Committees and Groups with Overarching Responsibilities
5
Process for Identifying Relevant Documents
6
Process for Disseminating Relevant Documents
7
Process for Conducting and Organisational Gap Analysis
8
Process for Ensuring that Recommendations are Acted Upon Throughout the Organisation
9
Process for Documenting any Decision Not to Implement NICE Recommendations
10
Equality Impact Assessment
11
Monitoring Compliance with the Document
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11.1
Process for Monitoring Compliance
11.2
Standards/Key Performance Indicators
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12
References
12.1
13
Guidance from Other Organisations
Associated Documentation
Appendix A
Analysis Report Template
Appendix B
Checklist for the Review and Approval of Procedural Documents
Appendix C
Version Control Sheet
Appendix D
Plan for Dissemination
Appendix E
Equality Impact Assessment Tool
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