Shared learning database

East & North Hertfordshire NHS Trust (current role at Royal Free London NHS Foundation Trust)
Published date:
November 2014

The Gap Analysis/Action Plan tool is an Excel spreadsheet template that can be customised with NICE guidance recommendations and quality statements, enabling specialist leads to identify gaps in service and to assess compliance levels, and risks associated with non-compliance.
The template has been pre-formatted so that compliance and risk are RAG rated (Red, Amber, Green): a reporting system commonly used by NHS Trusts. The Gap Analysis/Action Plan provides a tool for clinical leads to record, in narrative form, comparison of current services against best-practice, and to plan and monitor continuous service change/improvement.

Information and data from GAAPs inform the Trust's senior clinical and operational management teams, for strategic planning, clinical governance and risk management. The GAAP also provides evidence of completed and planned service improvements for commissioners and the CQC.

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 provide a standard tool and framework to ensure a consistent approach across the Trust to evaluate and monitor NICE, and other evidence-based, best practice guidance and its implementation. Objectives:
- To create an action plan for the implementation of service change/improvements to meet NICE, and other evidence-based best practice, guidance, within a framework for risk management.
- To support compliance with regulatory bodies eg DH, CQC, NHSE.
- To support the delivery of the Trust's strategic aims, and vision to strive for excellence and continuous improvement.

Reasons for implementing your project

The catchment population for our Trust is approx. 600,000.
I was appointed as Senior Clinical Effectiveness Facilitator in July 2010, as part of the Clinical Audit and Effectiveness team. The Trust's monitoring system for NICE then included monthly notification of published NICE guidance to Specialties, and recording of responses on relevance and compliance onto an Excel spreadsheet.
My appointment coincided with the publication of the new Government's white paper: 'Equity and excellence: Liberating the NHS' (DH, Jul 2010), which stated that 'Quality Standards, developed by NICE, will inform the commissioning of all NHS care and payment systems. Inspection will be against essential quality standards'. It also confirmed that NICE were expecting to publish 150 Quality Standards by July 2015. These findings, together with the December 2010 NHS Operating Framework 2011-12 established the link between NICE Quality Standards, quality outcomes indicators and the NHS Outcomes Framework 2012-13. The Trust therefore required a robust clinical effectiveness process, to ensure the recording and monitoring of all relevant NICE guidance, including NICE Quality Standards and their supporting clinical guidelines.

Development of the Gap Analysis/Action Plan:
A 'Baseline compliance and action plan', word document, was introduced in July 2010 and I designed an Access database based on collecting the compliance form data. This was populated for all NICE guidance activity in the Trust, to 2010 and ongoing.

In 2012 an 'Assessment and Action Plan' Excel template was introduced, using the NICE baseline assessment as a model. Completion of the Assessment by Specialty clinical leads, and completion of the action plan; also clinical audit against services found to be non or partially compliant, became a Trust mandatory requirement.
I subsequently submitted the first management reports from the database to Divisional Boards, and Risk and Quality committee. Management requested that the reports should include risk assessment, and also show action plan implementation.

The current Gap Analysis/Action Plan spreadsheet format was finally developed by early 2013, to include RAG rating for compliance, and risk grade. A six-monthly action plan update process has also been introduced, to routinely update GAAPs until full planned implementation is reached.

How did you implement the project

The Baseline compliance review form and associated reports have been developed over the last 3 years, following feedback from 'service users' ie Consultants reviewing services against NICE guidance, and management or committee members requiring further information.

The barriers experienced in implementing the new clinical effectiveness process, and gaining completion of the Gap Analysis/Action Plans have been resistance to change, and changing the old perception of NICE as 'just guidance'.

Raising awareness across a large organisation, such as an NHS Trust, that the position of NICE has been escalated to becoming part of the NHS regulatory framework, and that NHS Trusts should pay attention and implement NICE guidance as far as possible has been a challenge.
There were no specific costs incurred, however it has taken approx. 3 years of continuous education, and development of the reporting and monitoring process, to reach the current position.

Key findings

The development of the Clinical Effectiveness GAAP tool, and its usefulness as a tool for planning actions to implement service improvements, has been evidenced by successful business cases based on completed GAAPs, that have resulted in eg additional consultants, specialist nurses and/or equipment. They have also supported the recent reconfiguration of the Trust's hospital services and buildings, e.g. the Hip Fracture service model, designed in line with NICE guidance.

Presentations at audit meetings, and monthly notifications to clinical and nursing leads and managers, have raised awareness that Quality Standards and their quality measures are drawn on by NHSE and local commissioners (CCGs) as quality indicators in the NHS outcomes and payment framework. This has raised awareness across the Trust of the importance of evaluating services against NICE guidance quality statements and supporting clinical guideline recommendations. The GAAP tool is customised with the NICE guidance standards/recommendations, prior to sending to clinical leads, which has increased responsiveness in its completion.

Summary clinical effectiveness status reports, showing all NICE guidance requiring a GAAP and those completed requiring update on actions implemented, are presented six monthly within Specialty audit meetings. New NICE guidance and newly completed GAAPs are shared in the audit meetings to ensure all specialty clinical and nursing/midwifery staff are aware of service standards and planned change. The GAAP has been used in recent multidisciplinary, and cross-sector working groups, including e.g. Community, Mental Health, and Public Health: examples are NICE guidance such as Hip fracture, Obesity CG43/QS in development, and the new Physical Activity quality standard.

Key learning points

When designing a new reporting and monitoring system, including the form templates, ensure you seek feedback from key clinical leads/senior consultants and management.
Discuss with your clinical audit/effectiveness/quality improvement colleagues, and with those from other Trusts, and use any network meetings, eg East of England Clinical Audit and NICE Network. The NICE Implementation leads, and the NICE Conferences are also good sources of knowledge and information sharing.

Pilot your reports with a 'friendly' specialty or division initially, and make any changes. If possible, implement by face to face meetings with key clinical managers or leads who will cascade a positive message. If implementation is broader, send a customised presentation to introduce the report, emphasising that the time taken to complete the report is worthwhile, stating what it can do for them - i.e. support any business case to give them the quality of service they want, support CQUINs etc. When writing to leads for completion of the form, include the key selling points, as well as the regulatory and Trust requirements. State exactly what will happen to the document after completion, and the support you can offer in escalating high risks etc.

Emphasise at the request to the clinical lead, that the customisation of the GAAP with the NICE standards or recommendations enables quicker and easier completion and monitoring. It also provides a baseline for future clinical audit.

Contact details

Fiona Kennedy
Compliance and Audit Manager
East & North Hertfordshire NHS Trust (current role at Royal Free London NHS Foundation Trust)

Is the example industry-sponsored in any way?