Worcestershire Royal Hospital
Establishing an organisational committee to support the implementation of NICE guidance.
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 initial work in setting up this committee has now been completed. We have an approved health economy wide policy, terms of reference and a central database. The committee meets on a monthly basis and is well attended by a wide range of staff, from across the health economy. It was felt that the committee now needed, and was ready, to move forward, to obtain a higher level of knowledge and evidence of implementation and audit. 1. IMPLEMENTATION - Any responses received need to be fully discussed and issues regularly monitored. 2. AUDIT - Audits need to be regularly undertaken, recorded and reported on 3. SHARED LEARNING - There needs to be a regular feedback session open to all staff, so that departments can share learning tips and demonstrate best practice when implementing NICE Guidance.
Reasons for implementing your project
When setting up a committee such as this, the main body of work is putting into place processes, policies and other supporting documentation. Now that this work has been completed, we needed to look more in depth at the responses we receive, ensuring that any issues are followed through, sharing the information we receive across the health economy and putting an audit programme into place.
How did you implement the project
1. IMPLEMENTATION Completed questionnaires now discussed at meetings. Any issues are put into an agreed action plan, and a member of HENIG will work closely with the directorate/department to ensure that issues are worked through and resolved where possible. Where the guidance crosses organisations, a health economy wide questionnaire and action plan will be devised. The central database has been expanded and any evidence to support implementation i.e. changes to clinical guidelines, patient information, business cases, risk assessments etc can be linked to the relevant entry on the database. 2. AUDIT - An audit plan for the year has been devised, and audits are given priority from the directorate or by HENIG depending on the work required for implementation, issues etc. Audits are recorded on the central database, so that each entry will have the implementation information, evidence, audit details and results, in one place. Audits not on list are also carried out by directorate, and they are now given the NICE audit tool to work from. Results are again recorded on the database 3. SHARED LEARNING - Event was held last year, but this focused more on raising peoples awareness of NICE and the importance of implementation. The next event, being held May 2009, is a clinical feedback event, and clinicians are giving short workshop style presentations on specific pieces of guidance, illustrating where the service was prior to NICE, the work that was undertaken to meet the recommendations and where the service is now. Audit results will also be fed back here. This is now an annual event, open to all staff across the health economy. A regular newsletter is published, giving information on guidance that has been published, any news articles, event dates etc and will in future be used to highlight any issues with NICE, highlighted risks, advertise new procedures as a result of NICE etc. The intranet is also used to publish the newsletter, within the NICE pages
The clinical feedback event will be monitored by evaluation forms, given to delegates on the day. Implementation of guidance is monitored through the database, and reports are submitted to HENIG on a monthly basis, highlighting outstanding entries, issues etc.
Key learning points
We had a very clear idea of the committees role and where we would like to be and what we would like to achieve, and then worked to this point. Ensuring that the background work is fully completed and in place, before moving to the next level has been important, as we can now concentrate on the more in-depth issues. Everyone on the committee is supportive of the work and keen and our goal is the same, therefore we are all working towards the same end point. We have also had to be prepared to regularly change paperwork and the database, as more responses were received and it was clearer what needed to be recorded.
NICE & Systems Co-ordinator
Worcestershire Royal Hospital
Is the example industry-sponsored in any way?