Shared learning database

Royal Cornwall Hospitals NHS Trust
Published date:
September 2009

This submission outlines the development of a robust central process within an Acute Trust to identify and manage all national guidance and alerts received in the Trust. A central working group, the Guidelines & Alerts Steering Process (GASP) group, was set up to review all types of guidance and alerts received. The GASP working group meets monthly (shortly after the publication of NICE guidance) and its role is to: identify clinical and managerial leads; review responses received on level of compliance; and escalate any major issues identified (exception reporting) through the appropriate channels. The group's membership includes representatives from Clinical Effectiveness, Pharmacy, Medical Devices and primary care and is chaired by the Acting Medical Director (Quality & Safety).

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 primary aim of introducing this process was to improve patient care by the successful dissemination and implementation of NICE guidance and the management of any risks associated with non-compliance. The process aimed to: improve the level and type of response from clinicians; provide a workable exception reporting process; appropriately target all clinicians who may be involved in the implementation of NICE guidance; and improve centralised recording and reporting. 1)To identify and target all clinicians who may be involved in implementing specific NICE guidance and improve links with partner organisations (e.g. PCT). 2)To ensure that a robust process is in place in order to provide assurance to the Trust that NICE guidance is being dealt with appropriately. 3)Provide a forum for any issues relating to implementation of NICE guidance to be discussed and escalated as required (exception reporting). 4)To make clinicians aware of forthcoming NICE guidance and to prompt them to identify any implementation issues that may arise.

Reasons for implementing your project

Prior to the implementation of the GASP working group individual NICE guidance was reviewed by the Medical Director and/or the Clinical Effectiveness Co-ordinators (CECs), a clinician was identified and sent the guidance for a response on level of compliance/implementation and this response was recorded by the CECs. After the appointment of an Assistant Medical Director for Governance, who has since taken on the role of Acting Medical Director (Quality & Safety), it was felt that a more robust process needed to be initiated to gain a Trust-wide view on compliance with guidance. A lot of work had been done to reduce the number of 'position unknowns' against NICE guidance but a formal process was needed to ensure guidance was targeted successfully and there was an effective forum where people could take any concerns and issues.

How did you implement the project

1)At the GASP meeting the most appropriate clinician(s) is identified to provide a response on relevance and compliance. Where a guideline has implications across several specialties (e.g. Clinical Guidelines) a separate questionnaire is sent to each identified area and the responses combined and reported back to the next GASP meeting. Identification of Specialty Governance Leads has helped the process by identifying key people who can disseminate information through their specialty. 2)The implementation and exception reporting questionnaires were revised, following discussion at GASP and feedback received from clinicians, before they were rolled out. 3)As the questionnaire send out is targeted to the appropriate clinician(s) across all relevant specialties a broader picture of compliance is attained. 4)A formal system is in place for non-responses where, after an agreed amount of time and discussion at GASP, the Acting Medical Director contacts the lead clinician(s) to follow up the non-response. 5)Barriers to implementation have been highlighted at GASP meetings and escalated to the appropriate committee for action. This has enabled clinicians to see a value in active participation in the process. For example some of the guidance relating to head injury could not be fully implemented as there was a lack of a CT scanner in the Emergency Department. This issue had been raised before but had not been fully dealt with. A report on this issue was received at GASP, escalated by the Acting Medical Director to the Governance Committee where any outstanding issues were resolved and a scanner is due to be commissioned by the end of the year. 6)A formal exception reporting process has been developed where risks are identified and placed on the Divisional risk register by the identified lead. The exception report is taken to the Governance Committee for approval/acceptance and can be informed to the Board through the integrated performance Board report.

Key findings

1)The GASP working group provides an annual report to the Governance & Assurance Committee and quarterly Divisional reports on the compliance information held centrally are sent to the Divisional Management teams. 2)The GASP working group constantly reviews the process for dissemination and recording implementation and makes changes as required if issues arise. 3)Audit requirements arising from TAs are added to the Trust Audit & Outcomes Programme and monitored through communication with the Specialty Clinical Audit Leads, with annual reporting on progress to the Governance & Assurance Committee. 4)Areas of major concern in the implementation of TAs are reported to the Board through the integrated performance Board report.

Key learning points

1)Having the backing and active involvement of a senior clinician (in our case the Acting Medical Director) has helped disseminate the process, encouraged clinician buy-in (which is essential) and is a great help in the follow up of non-responses. 2)A clear governance structure in clinical areas helps identify routes of effective communication and follow up. 3)Being able to show clinicians that any barriers to implementation they may identify will be discussed, escalated through the organisation and if possible, resolved has helped improve responses and increase the reputation of the process. 4)Sending implementation questionnaires to the different specialties covered by the recommendations (e.g. for specific sections within Clinical Guidelines) has helped with gaining a more accurate overall picture of compliance as well as encouraging people to respond, as they are only being asked about recommendations specific to their area. 5)To prevent any confusion it needs to be made clear which topics/recommendations people are expected to respond to and which other specialties/departments have received the request for information. Although this has made the tracking of responses more complicated and requires time in combining the responses received, it does give all specialties a chance to comment on the implications of implementation to their area. This has been especially well received by our Therapies and Imaging departments. 6)Having a PCT representative on the GASP group has helped with communication across the organisations and provides access to information/feedback on issues relating to drug implementation through cross-community pharmacy groups.

Contact details

Mandy Bryant
Clinical Effectiveness Co-ordinator
Royal Cornwall Hospitals NHS Trust

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