Shared learning database

Royal Wolverhampton Hospitals NHS Trust
Published date:
October 2008

Reviewing our process to support the implementation of NICE guidance at the Trust.

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

The aim of this current piece of work was to review the effectiveness of the process that we had implemented and to determine what level of assurance could the Trust gain that the NICE guidance has been implemented within the Trust. 1. Assess the what evidence would be available to prove that NICE is implemented within the organisation to satisfy the Healthcare Commissions Standards for Better Health 2. Propose actions that will ensure a more robust level of assurance for Standards for Better Health.

Reasons for implementing your project

1. The initial implementation of the new process brought significant rewards in that, the Trust knew where it stood with regards to the implementation of published NICE guidance. There was concern that the organisation was basing its level of assurance on clinical lead statements without seeking further evidence. I felt that we needed a more robust means of proving appropriate implementation of NICE guidance. Clinical audit of implemented NICE guidance is encouraged and each Directorate must undertake a clinical audit project on one piece of implemented NICE guidance each year to assess the level of compliance to the standards. The Healthcare Commission clinical audit projects, based on NICE guidance, were all completed. This only provided limited assurance on the level of NICE implementation. 2. The NICE database was ideal for what we needed three years ago, but, it does not allow for constant review of the level of implementation and risk rating. This again relied solely on clinical lead statements. If clinical audits showed that the NICE guidance was not implemented fully despite the assurance of the clinical lead, the risk rating did not change to reflect reality, therefore, the assessment was inaccurate 3. There was also no way of attaching documents to the individual pieces of NICE guidance. For Clinical Guidelines, there were completed grids, proformas, policies, audit projects and protocols that would need to be added, but the database did not allow for that. 4. An ongoing issue since the development of the policy was how we gain assurance from the individual GP practices. The new process had not considered how we risk score the GPs as a whole when there are so many individual practices. There was no means of collating the implementation status of the 100 plus practices against the 300 plus NICE guidance.

How did you implement the project

1. To gain assurance, it was proposed that each Directorate would undertake 3 yearly clinical audit projects on each piece of implemented NICE guidance. For Clinical Guidelines, with many recommendations, the audit could cover individual sections, not the whole document. Once there are two consecutive audits showing compliance, the guidance will be removed from the audit programme. If a risk issue arises relating to that particular guidance, it will go back on the audit programme. 2. Develop a new database that will meet the current and future needs of both Trusts. This involves developing a risk score that accurately reflects the level of implementation. This means that guidance will not be compliant until a clinical audit project had been undertaken and the results show full compliance. In reality this means that when the current guidance is transferred to the new database, without a compliant audit report to accompany it, it will become an amber risk instead of the green that it is currently. The risk ratings will change to reflect audit results or other assessments. 3. The database has also been developed so that all of the evidence pertaining to a piece of NICE guidance can be attached to the individual NICE guidance. This means that anyone within any of the Trusts within the city can look at a particular NICE guidance and see all of the history / evidence for that piece of guidance in one place. Collecting evidence for external assessments like NHSLA, Standards for Better Health and other national bodies will now be a lot easier with only one place to go for evidence to prove assurance / compliance. 4. To facilitate the determination of GP compliance a web based tool is in the process of being developed. This will mean that each individual GP practice can respond to each piece of relevant guidance and, if it is designed correctly, will allow a constant assessment of compliance from the currently, poorly measured, GP practices.

Key findings

1. After this piece of work was completed, the Internal Auditors undertook a planned piece of work around gaining evidence to support the statements. Twenty guidance were chosen with responses and the auditors went to the clinical leads to collect evidence to support the statements on the proformas. The auditors struggled to find evidence within the clinical areas to support the statements and provide assurance. 2. I spoke to the auditors regarding the lack of evidence and they made 2 recommendations; a) Change the risk rating to reflect the differing levels of assurance b) Build clinical audit into the assurance process. I wrote the paper outlining these exact measures to go to the Trust Level Governance Committee (Quality and Safety) the week before the Internal Audit was undertaken, where it was unanimously supported by Divisional and Director representatives.

Key learning points

1. I think that, when implementing changes to a process, it is important to go back and evaluate the effectiveness of the changes made. Changes that detract from the effectiveness of the process need to be addressed at the earliest opportunity. 2. Working with colleagues from other Trusts has been vital to the success of this project. I would not have achieved such a positive outcome, if I had worked in isolation.

Contact details

Sandra Rider
Trust Governance Standards Lead
Royal Wolverhampton Hospitals NHS Trust

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