MONITORING COMPLIANCE As a minimum the following will be monitored to ensure compliance Element to be monitored Lead Tool Frequency of Reporting Reporting arrangements Acting on recommendations of Compliance and Lead(s) Process for identifying Policy Report to: relevant documents: 100% of Clinical Effectiveness NICE Clinical Audit and Assurance Review of Clinical all published guidance is Annually Steering Coordinator Manager Audit website placed on Clinical Audit website Process for disseminating Policy Audit Report to: relevant documents Clinical Effectiveness NICE Clinical Audit and Assurance Review of NICE Annually 95% of documents will be Steering Group Coordinator Manager spreadsheet disseminated within 14 days of publication Process for conducting an Policy Audit Report to: organisational gap analysis: NICE Clinical Audit and Assurance Review of NICE Clinical Effectiveness Annually 100% of relevant documents Coordinator Manager spreadsheet Steering Group will undergo a gap analysis Process for ensuring that Policy Audit Report to: recommendations are acted Clinical Effectiveness upon throughout the Steering NICE Review of NICE organisation Annually Medical Director Coordinator spreadsheet 95% of recommendations will be implemented within the given timescales Process for documenting any Policy Audit Report to: decision not to implement Clinical Effectiveness NICE recommendations Steering Group 100% of such NICE Review of NICE Annually Medical Director recommendations will have an Coordinator spreadsheet associated rationale and documented Trust Board agreement
MONITORING COMPLIANCE As a minimum the following will be monitored to ensure compliance Element to be monitored Lead Tool Frequency of Reporting of Compliance Reporting arrangements Acting on recommendations and Lead(s) Process for identifying relevant documents: 100% of all published guidance is placed on Clinical Audit website NICE Coordinator Review of Clinical Audit website Annually Policy Report to: Clinical Effectiveness Steering Clinical Audit and Assurance Manager Process for disseminating relevant documents 95% of documents will be disseminated within 14 days of publication NICE Coordinator Review of NICE spreadsheet Annually Policy Audit Report to: Clinical Effectiveness Steering Group Clinical Audit and Assurance Manager Process for conducting an organisational gap analysis: 100% of relevant documents will undergo a gap analysis NICE Coordinator Review of NICE spreadsheet Annually Policy Audit Report to: Clinical Effectiveness Steering Group Clinical Audit and Assurance Manager Process for ensuring that recommendations are acted upon throughout the organisation 95% of recommendations will be implemented within the given timescales NICE Coordinator Review of NICE spreadsheet Annually Policy Audit Report to: Clinical Effectiveness Steering Medical Director Process for documenting any decision not to implement NICE recommendations 100% of such recommendations will have an associated rationale and documented Trust Board agreement NICE Coordinator Review of NICE spreadsheet Annually Policy Audit Report to: Clinical Effectiveness Steering Group Medical Director
NICE%20Guidance%20Policy%20for%20Assurance%20of%20Implementation.docx