Shared learning database

Salford Royal NHS Foundation Trust
Published date:
September 2009

This submission describes SRFTs process for dissemination of NICE guidance. The process and assurance mechanism ensures that the Trust has comprehensive documentation of the applicability of NICE guidance to the services it delivers. It explains the processes used to ensure clinical audit evidence of compliance is forthcoming.

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

At the beginning of 2008 the Trust realised that its system of disseminating NICE guidance and the methods used for ensuring compliance and providing Board assurance required revision. There were gaps in the assurance process. The aim was to streamline the process, develop a group, the Clinical Guidance Steering Group, with overarching responsibility to review all issued national guidance, delegate to named clinical leads and seek audit evidence of compliance. It was set up to ensure a functioning management process that would enable the Trust to have comprehensive records of applicable guidance, that audit projects were planned to provide Board assurance of compliance and that clinicians had support with implementation of guidance. 1) To ensure timely dissemination of new guidance 2) To develop and maintain an accurate recording system 3) To ensure clinical audit evidence of compliance

Reasons for implementing your project

The original system was that NICE TAs and CGs were assessed and discussed at Medicines Management Group and assigned a clinical lead where appropriate. Documentation of clinical leads, applicability of guidance, any correspondence was kept on an Excel spreadsheet and updated as appropriate. NICE IPGs were assessed at a different group led by a surgeon. There was no documentation available. The Trust required a new, more effective mechanism with thorough recording processes and senior Trust personnel with responsibility for ensuring the process functioned well. A new policy was written and approved by Clinical Effectiveness Committee. This policy incorporates all national guidance (NICE, NSFs, NCEPOD etc). The Clinical Audit Managers role was extended to include National Guidance Management. On formation of the Clinical Guidelines Steering Group a Trust-wide gap analysis was performed. This aimed to identify gaps and secure evidence of assurance for all national guidance back to 2003.

How did you implement the project

The gap analysis highlighted concerns that had arisen. The new system (now 18 months on) has shown that:- 1) The new process ensures consideration and timely dissemination where appropriate to key Trust personnel 2)The Trust has a comprehensive recording system for all national guidance and its applicability to the services provided 3)Clinical audit evidence has been forthcoming and specialties are planning audits against NICE guidance into their forward plans 4)Barriers are mainly in the form of securing audit evidence

Key findings

1) Spreadsheet of NICE guidance updated monthly as guidance is issued 2) A record of all communication regarding dissemination of NICE guidance is updated as appropriate 3)Areas of concern are highlighted to the Clinical Guidance Steering Group and Clinical Effectiveness Committee 4)Clinical audits are identified and planned providing specialty forward plans 5)All guidance back to 2003 has been issued to clinical leads with a request to review the guidance, plan audits 6)Bi-annual reports from the Clinical Guidance Steering Group are presented to Clinical Effectiveness Committee and the PCT

Key learning points

1) A dedicated national guidance manager is essential for the process to function 2)Support from senior Trust personnel such as the Medical Director is essential 3)Excellent communication is vital for success 4)Imparting the message to clinicians that this is not just a tick-box exercise is essential to obtain co-operation 5)Provision of adequate support services for clinicians eg Clinical Audit Team is essential 6)Ensure that discussion, evaluation and monitoring of adherence to national guidelines is on all specialty/directorate agendas 7)Streamline systems and processes as much as possible so as to minimise demand put on already busy clinicians 8)Maintain a sense of humour!

Contact details

Mrs Karen Powell
Clinical Audit & National Guidance Manager
Salford Royal NHS Foundation Trust

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