Shared learning database

Type and Title of Submission


The NICE Way (update 2008)


To standardise the implementation and audit of NICE guidance. To give assurance to the Trust on the implementation and audit of NICE guidance. To manage NICE guidance in a robust and centralised way



Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:


Category(s) that most closely reflects the nature of the submission:

Implementation policy
Terms of reference for implementation team

Is the submission industry-sponsored in any way?


Description of submission


Aim Addenbrookes Hospital has deemed the implementation of NICE guidance best practice, unless the clinical director or service delivery director of a speciality decides otherwise for reasons of clinical judgement/individual patient need or advancement in medicine. A NICE guidance process map has been developed which ensures that guidance is distributed to all appropriate personnel, the implementation of guidance is monitored and audited and suitable records are kept and maintained. An implementation plan template has also been produced to ensure that all necessary areas are covered, this includes financial work-up. These process maps and implementation plans bring standardisation to the process


Objectives 1. A clinical and managerial lead is appointed to all NICE guidance published. 2. Any gaps between NICE guidance and practice must be addressed in an implementation plan written by clinical and managerial leads. A compliance notice is supplied where no gaps exist between NICE guidance and practice. 3. All NICE guidance published is subjected to clinical audit to assess levels of compliance by the clinical lead. All recommendations following audits are documented in an action plan and monitored.


Context The trust decided from the very beginning that NICE would be adopted, that a standard procedure would be developed and that monitoring of guidance through clinical audit was essential. Each guidance is the responsibility of the directorate that it sits within, the clinical directors nominate a clinical lead and the senior managers nominate the appropriate speciality manager to help the clinical lead write the implementation plan. Once an implementation plan is realised or a compliance notice is received then the guidance will be added to the directorates annual audit plan. The overview is maintained in the clinical audit department, the manager of this department reports into the trust clinical governance framework. Reporting is by way of a traffic lighted scorecard.


Results All guidance is being addressed and a clinical and managerial lead has been appointed to each individual guidance. The standardised process lends itself more easily to monitoring, giving the trust a better overview. It is a formalised process. Quarterly scorecards have been developed to inform local governance meetings of progress. Implementing NICE has become part of everyday practice.

Results and evaluation

Monitoring & Evaluation Generic spreadsheets and traffic lighted scorecards have been introduced in order that the implementation and audit of NICE guidance can be monitored. The information held is used for board reports and local reports.

Key learning points

Key learning points Agreement from the board that implementing NICE is a must and that a standardised way is the way forward. Design a process without loop holes. Support clinicians, and when barriers arise, navigate round them, but with a firm understanding that barriers must be overcome. A shift in culture will come with a strong process, clinicians now just see the NICE process as what they do.

View the supporting material

Contact Details

Name:Carol Heesom-Duff
Job Title:Assistant Governance Manager/Head of Clinical Audit
Organisation:Cambridge University Hospitals (Addenbrooke's)
Address:Addenbrooke's Hospital, Hills Rd
Postcode:CB2 2QQ
Phone:01223 216112


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This page was last updated: 26 September 2008

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.