Shared learning database

2gether Foundation Trust
Published date:
February 2011

This submission relates to the formation of the NICE Action Group (NAG) within the working age adults service unit of the 2gether Foundation Trust. A need had been identified for a formal process to be determined for managing actions resulting from recommendations made within NICE guidance audit reports. In addition, communication of NICE guidance information needed to be addressed; how could communication channels be utilised more efficiently to ensure NICE guidance information was communicated to all staff and embedded into day to day working practice?

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To determine a robust process for the continuous improvement of NICE guidance compliance within the working age adults service unit of the 2gether Foundation Trust. 1) To determine an overall process for the review, assignment, implementation and monitoring of audit recommendations and subsequent actions to ensure continuous improvement of practices and patient care. 2) To identify effective communications channels within the working age adults service unit to ensure that information on all relevant NICE guidance is disseminated to all members of staff and embedded into day to day working practice.

Reasons for implementing your project

The 2gether Foundation Trust has a robust process in place for managing NICE guidance and disseminating the guidance to service unit leads. The Trust determines an annual NICE guidance audit plan and all mandatory and contractual guidance is audited on a three year cycle, unless a need is identified for it to be audited more frequently. The corporate level management of NICE guidance works well, but it was identified that the management of audit recommendations and the dissemination of guidance information to staff could be improved. The Trust wanted to ensure that processes were being continuously improved as a result of effective learning gained from audit recommendations. The NAG Group was formed within the working age adults service unit to ensure that all audit recommendations were being addressed and that any actions and improvements to practice were communicated effectively. The Trust also wanted to ensure that all staff had an increased knowledge of NICE guidance in general, and that it could be related to general workplace practices.

How did you implement the project

A proposal for the management of NICE guidance was presented to the working age adults Management Board (WAMB) in February 2010 by the Matron Manager. The proposal detailed the formation of a multi-disciplinary group to consist of the National Guidance Manager, NICE leads and lead professionals within the working age adults service unit. The group was led by the working age adult NICE leads. Terms of reference were produced which detailed that the purpose of the group was to provide a forum to discuss NICE audit recommendations, determine the actions that needed to be implemented, and monitor that effective implementation had taken place. In addition the purpose of the group was to disseminate all relevant information to all staff members within the service unit to improve awareness of the guidance and ultimately working practice and patient care. During the initial meetings a retrospective exercise was carried out, looking at audits from the last two years for which recommendations had been made, but no actions had been determined. Actions were determined and an action log produced and communicated to the working age adults Delivery Committee who are responsible for implementing actions. Communication channels have also been extensively discussed during the meetings. Shortened versions of the initial presentation were given at various steering meetings, forums, and locality cabinet meetings. The group have also produced their first quarterly NAG Newsletter which has been disseminated to staff via 'News In Brief' (a trust-wide e-mail newsletter), and via Team Leaders. The initial NAG Newsletter gave a background about NICE guidance and details of the NAG group, in addition to asking for volunteers to act as NICE champions and giving useful contact information and links.

Key findings

The formation of the NICE Action Group has been really successful in the working age adults service unit. The members of the NAG group have taken on the responsibility of managing and communicating information on NICE guidance and have done so in a positive and proactive manner. The formation of the group has increased interest, knowledge and discussion. The group has also provided a forum for discussing more general issues within the Trust and how these can be managed - the issue of having multiple action plans (SI's, complaints, risk register, NHSLA) which more than likely cover actions relating to key themes is one - the action plans are all managed independently and joint working needs to be seriously considered to eliminate duplication of effort. The action log produced within the first couple of meetings is regularly reviewed and actively progressed. All audits completed since the initial meeting have also had recommendations reviewed in the same manner. The NAG group meets bi-monthly, and the action log has been reviewed during each meeting and progress discussed. It is available to all staff on the Intranet. The action log has been presented at a recent consultant psychiatrists meeting and positively received. The quarterly newsletter has been circulated Trust wide, and discussions have taken place within the Governance meetings for other strategic service units about setting up a similar group following the success of the working age adults group. In addition, a variety of other communication options are being explored. E-learning packages are currently being investigated, as is the production of short, simplistic, eye catching 1 page summaries for audits.

Key learning points

- A similar process could be developed in other service units. - Professional leads are more receptive to managing NICE guidance than originally thought - increased ownership of NICE guidance has resulted in increased interest, knowledge and discussion. - Professional leads are ideally placed at knowing how to effectively communicate information. - Innovative ideas raised during the meetings have Trust wide application.

Contact details

Judith Quartermaine
National Guidance Manager
2gether Foundation Trust

Secondary care
Is the example industry-sponsored in any way?