Process and methods

13 Implementation support for clinical guidelines

The aim of NICE implementation support is to encourage and promote the uptake of NICE guidance. Priorities identified by the Guideline Development Group (GDG), recommendations identified as having significant resource implications or resulting in a change in practice, and information from stakeholder consultation will inform the focus of the implementation support work for a clinical guideline. Support work may include a range of activities to promote uptake and the provision of practical support tools.

Implementation tools are produced by staff in the implementation programme at NICE. Three leads are involved in developing the tools: the audit lead, the costing and commissioning lead and the implementation adviser. Tools are developed in consultation with:

  • the GDG

  • the National Collaborating Centre (NCC) or the NICE Internal Clinical Guidelines Programme[18]

  • the Centre for Clinical Practice (CCP) Guidelines Commissioning Manager (GCM)

  • the lead from the Patient and Public Involvement Programme.

This chapter outlines the methods and process for developing the implementation tools, and the contributions of the GDG, NCC and CCP to this process.

13.1 Needs assessment, support plan and tools

Each clinical guideline is routinely accompanied by three implementation tools:

  • a baseline assessment tool

  • clinical audit tools

  • a costing report and costing template, or a costing statement.

For each guideline, the implementation adviser analyses the information gathered from the GDG, stakeholders and other sources to carry out a needs assessment, and produces an implementation support plan which details the activities that will be undertaken by NICE to address the key implementation issues. During the needs assessment, the implementation adviser will consult with members of the GDG, the NCC and the GCM. Tailored solutions are then developed according to need.

The tools are described below; for more information see the NICE website.

13.1.1 Baseline assessment tool

The baseline assessment tool is prepared by the audit coordinator. It is an Excel spreadsheet that organisations can use to identify whether they are in line with practice recommended in the guideline, and to help them plan activity to implement the recommendations.

13.1.2 Clinical audit tools

Clinical audit tools are prepared by a clinical audit specialist. They help organisations to carry out clinical audits based on some of the guideline's measurable recommendations. They consist of audit standards, data collection tools and action plans. Some will also be produced as Excel electronic audit tools that provide a basic data analysis and clinical audit report.

13.1.3 Costing tools

Costing tools are prepared by a costing analyst. They are intended to help organisations assess the costs and potential savings associated with implementing the guideline. The costing analyst assesses the recommendations to identify those with the greatest resource impact[19]. NICE usually provides two types of costing tools to accompany a clinical guideline:

  • a costing report, which summarises the estimated national costs and savings associated with implementing the guideline and discusses the assumptions made in reaching this figure

  • a costing template, which allows users to estimate the local impact of implementing the guideline based on their population and to change the assumptions and variables to reflect local circumstances.

Occasionally, implementing the recommendations in a guideline may not be estimated to result in significant additional costs or savings. No costing report or costing template is produced in these cases. Instead, a costing statement is produced that explains why the cost impact is not considered to be significant.

13.1.4 Tailored implementation tools based on the needs assessment

In addition to the implementation tools described above, the needs assessment may identify additional tools that would be useful for addressing specific learning or education needs of staff and organisations. These targeted tools for clinical guidelines are prepared by the implementation adviser. There is some evidence that barriers to uptake of a guideline that are identified in advance can be overcome by designing specific interventions to address them, although it is not always very clear how best to identify the barriers and which particular types of interventions are best for each barrier (Baker et al. 2010).

Where there is an agreed need for specific implementation tools to support recommendations about drugs and prescribing, the implementation adviser will work with the NICE Medicines and Prescribing Centre to produce these materials.

See Into Practice on the NICE website for examples of the types of tailored tools that are produced. These could include:

  • learning and development slide sets

  • clinical case scenarios

  • podcasts

  • training plans

  • online educational tools

  • examples of how NICE guidance has been put into practice

  • shared decision aids.

There might also be signposting to, or 'joint badging' of, resources developed and promoted with other organisations, such as professional or patient groups.

13.2 Developing the implementation tools

The needs assessment and development of the implementation tools usually start during consultation and continue through to publication of the guideline.

13.2.1 Initial involvement during guideline development

At the start of the guideline development process, an implementation team is assigned to work with the NCC and GDG. The team consists of a costing lead, an audit lead and an implementation adviser.

During scoping of the guideline (see chapter 2), the implementation adviser carries out an initial assessment to ensure that all critical stakeholders have registered and starts to record a log of any implementation issues that arise. This log is kept up to date throughout guideline development to inform the development of the implementation support plan.

At GDG meeting 2 or 3, GDG members will be given a general briefing paper from the implementation team explaining its work and future involvement.

At the end of guideline consultation, the costing analyst and the implementation adviser will usually attend a GDG meeting to hear the outcome of the consultation and to consider how this will affect key implementation issues. The costing lead may be given a slot at a GDG meeting to discuss their work.

The GDG may also invite other members of the implementation team to meetings at any time if discussion about other implementation issues is needed.

Volunteers from the GDG are needed to work with the implementation teams. Two members are required to contribute to the development of the costing tools (the 'GDG costing nominees') and two to the development of the implementation support tools (the 'GDG implementation support nominees'). After consultation, the implementation adviser will liaise with the GDG implementation support nominees to discuss the implementation support plan and to agree their level of input into tool development.

13.2.2 Commenting on the draft implementation tools

13.2.2.1 Costing tools

The costing analyst uses the recommendations in the consultation draft of the guideline to identify the potential significant changes in resource use that are likely to arise from implementation of the guideline. This will be based on baseline practice, how practice might change and the effect on resources for the areas identified. This is assisted by input from the GDG, the NCC health economist and costing research.

The costing analyst updates the draft costing tools when the final draft of the guideline is submitted. The tools are sent to the NCC and the GDG costing nominees 4–5 weeks before publication of the guideline for a 2-week consultation period. Comments are invited on:

  • whether the assumptions made are reasonable

  • the usability of the costing template at a local level.

The NCC and the GDG nominees send their comments back to the costing analyst, with a copy to the GCM.

13.2.2.2 Clinical audit tools

The audit coordinator sends drafts of the audit support tools to the NCC and the GDG for a 2-week consultation period, approximately 9 weeks before publication of the guideline.

The NCC and the GDG send their comments back to the audit coordinator, with a copy to the GCM.

13.2.2.3 Other tailored tools

Other draft implementation tools will usually be sent to the NCC and the GDG for comment around 4–5 weeks before publication of the guideline for a 1-week or 2-week consultation period, depending on the nature of the tool. Advance notice will be given of all timelines. Any delays to the development of the final guideline may reduce these periods.

Comments are invited on accuracy, clarity and whether the tool provides an accurate interpretation of the key messages of the guideline.

13.3 Publishing the implementation tools

When implementation tools are published at the same time as a clinical guideline by NICE, they are downloaded more frequently than if they are published later. Therefore the aim is to publish the implementation tools at the same time as the guideline wherever possible.

Achieving this is dependent on the final signed-off version of the guideline being available with sufficient lead time for development of and consultation on the tools. For some support tools, a later timeline after publication of the guideline may be necessary.

Publication of the tools is announced on the NICE website and in the e-newsletter; the latter is available to everyone who wants to be kept up to date with important developments at NICE.

13.4 Post-publication support

NICE and the NCC may also carry out activities to help users implement a clinical guideline after it has been published. These activities are identified in the implementation support plan (see section 13.1) and may include:

  • speaking at, and encouraging and supporting GDG members to speak at, relevant conferences and events

  • encouraging and supporting GDG members to contribute to or write journal articles about the guideline

  • contributing to or writing journal articles about the guideline

  • speaking about the implementation tools at events

  • supporting workshops and regional events

  • working with the implementation consultants (see section 13.6)

  • providing feedback and encouraging submission of shared learning (see section 13.6)

  • supporting the development of an online educational tool and other educational initiatives, such as incorporating NICE into curricula

  • supporting work to review uptake of the guidance

  • adding a notification on the National Clinical Audit Forum that new NICE clinical audit tools are available, with details of the topics they relate to

  • adding some of the electronic tools to the Clinical Audit Knowledge Exchange database.

13.5 Working with national organisations

The implementation adviser works in partnership with other NICE teams to engage with national organisations and networks. This work might include embedding recommendations from NICE clinical guidelines into other guidelines or initiatives, or encouraging the development of patient information (for example, joint tools with the NHS Blood and Transplant Service to support the organ donation guideline [NICE clinical guideline 135] and a referral tool for suspected autism in adults with the NHS National Institute for Health Research to support the autism in adults guideline [NICE clinical guideline 142]).

The implementation advisers welcome suggestions from GDG members on how to work with national organisations to support the implementation of a clinical guideline.

13.6 Other NICE implementation services and products

NICE also provides a range of services and products to assist NHS and non-NHS clinicians and other practitioners and organisations in the implementation of its clinical guideline recommendations. The following support is available:

  • A field-based team of seven implementation consultants work with organisations to help to put NICE guidance into practice. Each consultant visits NHS, local authority and other organisations in their area, ensuring regular interaction with NICE stakeholders.

  • Web-based examples of how organisations have implemented NICE clinical guidelines are provided on the shared learning database.

  • NICE reports and published articles relating to the uptake of NICE guidance are provided on the 'uptake database' – ERNIE (Evaluation and review of NICE implementation evidence).

  • Commissioning guides are also provided to support commissioners of services. These aid in the local implementation of NICE clinical guidelines through commissioning, and are underpinned by the guidelines. Each commissioning guide:

    • signposts and provides topic-specific information on key clinical and service-related issues to be considered during the commissioning process

    • offers an indicative benchmark of activity to help commissioners determine the level of service needed locally

    • includes an interactive tool that provides data for local comparison against the benchmark, and resources to estimate and inform the cost of commissioning intentions.

Because the guides are focused on services commissioned, they may bring together elements from one or more pieces of NICE guidance rather than focusing on one particular guideline. For example, the commissioning guide 'Biologic drugs for inflammatory disease in rheumatology, dermatology and gastroenterology' brings together the clinical guideline on rheumatoid arthritis (CG79) and several technology appraisals.

13.7 Further reading

Auerback AD, Landefeld CS, Shojania KG (2007) The tension between needing to improve care and knowing how to do it. New England Journal of Medicine 357: 608–13

Baker R, Camosso-Stefinovic J, Gillies C et al. (2010) Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2010, issue 3

Cabana MD, Rand CS, Powe NR et al. (1999) Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 282: 1458–65

Eccles M, Grimshaw J, Walker A et al. (2005) Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. Journal of Clinical Epidemiology 58: 107–12

Michie S, Johnston M, Hardeman W et al. (2008) From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change. Techniques in Applied Psychology: An International Review 57: 660–80.



[18] Information throughout this manual relating to the role of the National Collaborating Centres in guideline development also applies to the Internal Clinical Guidelines Programme at NICE.