IntroductionThe NHS Evidence Accreditation Scheme recognises organisations that demonstratehigh standards in producing health or social care guidance. Evidence users cantherefore have high confidence in the quality of the information. Organisations canpublicly display a seal of approval called an Accreditation Mark for three years after theirprocesses have been accredited. The process for accrediting producers of guidanceand recommendations for practice is described in the process manual1.Accreditation recommendationIt is proposed that the process to produce referral guidelines by the Royal College ofRadiologists (RCR) is recommended for NHS Evidence accreditation. This draftdecision is subject to public consultation before a final decision is made.Background to the guidance producerThe Royal College of Radiologists aims to advance the practice of radiology andoncology, improve public education, and promote study and research through settingprofessional standards of practice. To help achieve these aims, faculty publications areproduced to provide members and Fellows with professional standards and guidance.The RCR has produced the referral guidelines, „Making the best use of clinical radiologyservices‟, for clinicians, radiologists, radiographers and other healthcare professionalsto determine the most appropriate imaging investigations for a wide range of clinicalproblems. They provide practical guidance based on the evidence, together with expertopinion where evidence is lacking or conflicting. 1 http://www.nice.org.uk/nhsevidence/aboutaccreditation/aboutaccreditation.jsp?domedia=1&mid= 27C232A0-19B9-E0B5-D4A11FA899F4C219
SummaryThe Advisory Committee considered that the Royal College of Radiologists referralguidelines demonstrated compliance with 23 of the 25 criteria for accreditation. Theprocesses used by the Royal College of Radiologists to produce the referral guidelinesare clearly documented and robust. Processes are described in the Royal College ofRadiologists „Making the best use of clinical radiology services: the process for the sixthedition 2003 – 2007‟ manual.The Royal College of Radiologists referral guidelines are clearly presented and up todate. A range of Stakeholders, including patients, are involved in developing guidanceand there is a comprehensive peer review process. Systematic methods are used toidentify evidence for developing guidance.Suggestions to further strengthen the Royal College of Radiologists‟ developmentprocesses for the referral guidelines are: showing how the organisational barriers to guidance implementation have been considered adding estimated costs for each investigative technique to the guidance making evidence demonstrating the self funding model for the guidance available on request.This draft decision is now going out for consultation, and the decision will be reviewedby the committee in the light of any feedback received before making a finalrecommendation.David HaslamChair, Advisory CommitteeMarch 2010
Reapplication for accreditationIf accreditation is not granted, guidance from the non-accredited producer will still beavailable on the NHS Evidence site but will not be identified by the accreditation markgraphic.Guidance producers that are not accredited following the accreditation process have theopportunity to reapply from one year after the previous assessment. It is assumed thatthe organisation will have addressed any concerns highlighted in the originalassessment before reapplying. The NHS Evidence team will provide detailed feedbackand advice on areas where improvement is required to meet the criteria in a futureapplication.
Appendix A: NHS Evidence accreditation analysisThe Advisory Committee considered the following analysis of the guidance producer‟s compliance with NHS Evidenceaccreditation criteria, which covers six discrete domains. The full analysis leading to the accreditation decision is shownbelow.Domain Criterion Evidence for meeting the criterion Accreditation decision Does the guidance producer have a policy in place and adhered to that requires them to explicitly detail: 1.1 Overall objective The overall objective is clearly defined and implemented in the referral Criterion met b a b guideline as described in the process manual . In the referral guideline section 1 „Introduction‟ states the overall objective. The clinical questions are clearly defined and implemented in the referral Criterion met 1.2 The clinical, healthcare or b aScope and social questions covered guideline as described in the process manual . In each of the 12 bpurpose sections of the referral guideline a number of clinical / diagnostic problems are indicated. The population and target audience is clearly defined and implemented in Criterion met 1.3 Population and/or target b a audience to whom the the referral guideline as described in the process manual . The patient guidance applies populations for each clinical problem are indicated within the body of the guideline itself and the target audience is indicated in the Introduction section.
Domain Criterion Evidence for meeting the criterion Accreditation decision The recommendations are clearly linked to specific clinical circumstances Criterion met 1.4 Guidance includes clear b a recommendations in in the referral guideline as described in the process manual . reference to specific clinical, healthcare or social circumstances Does the guidance producer have a policy in place and adhered to that means it includes: b The production of the referral guideline includes individuals from relevant Criterion met 2.1 Individuals from all relevant stakeholder stakeholder groups including patients as described in the process manual groups, including patient a groups, in developing . In the guideline there is an „Acknowledgements‟ section which names guidance both individuals and consultation groups involved in the guideline production process.Stakeholderinvolvement b The production of the referral guideline includes patient‟s views as Criterion met 2.2 Patient and service user a representatives and described in the process manual . The guidance producer provided seeks patients views and preferences in developing evidence that the opinions of lay representatives were sought during the guidance production of its guidance. b 2.3 Representative intended Intended users are involved in the development of the referral guideline Criterion met users in developing described in the process manual . a guidance. Does the guidance producer have a clear policy in place that:Rigour of
Domain Criterion Evidence for meeting the criterion Accreditation decisiondevelopment 3.1 Requires the guidance Systematic methods were used to search for evidence on which the Criterion met producer to use b referral guideline is based and the search strategy detailed as described systematic methods to a in the process manual . Further information regarding the dates of search for evidence and provide details of the searches can be found in the evidence tables of the e-guideline. search strategy 3.2 Requires the guidance The inclusion and exclusion criteria are defined in the production of the Criterion met producers to state the b a referral guideline as described in the process manual . The information criteria and reasons for a for this process is found in section 6.2 of the process manual . inclusion or exclusion of evidence identified by the evidence review 3.3 Describes the strengths The strength and limitations of the evidence are defined in the production Criterion met and limitations of the b a of the referral guideline as described in the process manual . The body of evidence and guidance producer‟s response is documented in section 6.2 of the process acknowledges any areas a of uncertainty manual . In addition the evidence grading system documented by the guidance producer in its response to criterion 3.2 shows that this criterion is met. b 3.4 Describes the method The method used to arrive at recommendations in the referral guideline Criterion met used to arrive at a are explained as described in the process manual . The guidance recommendations (for producer‟s chosen methodology is the Delphi technique. example, a voting system or formal consensus techniques like Delphi consensus)
Domain Criterion Evidence for meeting the criterion Accreditation decision 3.5 Requires the guidance The risks versus health benefits are considered in the production of the Criterion met producers to consider the b a referral guideline as described in the process manual . All of the health benefits against directives noted in this submission effectively state that given the choice of the side effects and risks in formulating two or more dose levels of radiation the lowest practicable should always recommendations be used. b 3.6 Describes the processes The peer review process used in the production of the referral guideline Criterion met of external peer review a is clearly defined as described in the process manual . The peer review a process is documented in section 6.5 of the process manual . 3.7 Describes the process of The process of updating and maintaining guidance quality is observed in Criterion met updating guidance and b a the referral guideline as described in the process manual section 6.6. maintaining and improving guidance quality Does the guidance producer ensure that: bClarity and 4.1 Recommendations are All recommendations in the referral guideline are specific, unambiguous Criterion met specific, unambiguous a and clearly identifiable as described in the process manual . Thepresentation and clearly identifiable recommendation grading system is documented in section 2 of the a process manual .
Domain Criterion Evidence for meeting the criterion Accreditation decision 4.2 Different options for the Different options for the management of radiological conditions are clearly Criterion met management of the b presented in the referral guideline as described in the process manual . a condition or options for Each specific condition has a number of different treatment options intervention are clearly presented indicated where these treatments are available. 4.3 The date of search, the All dates of search, update and proposed date for review are documented Criterion met date of publication or last as described in the process manual . a update and the proposed date for review are clearly stated b 4.4 The content of the The content of the referral guideline is suitable for its target audience as Criterion met guidance is suitable for a described in the process manual . Some of the language within the the specified target guidelines is technical particularly in the „Comments‟ section. However the audience. If patients or service users are part of intended audience for these referral guidelines is clinicians, radiology this audience, the practitioners and healthcare organisations so the technical language language should be within the guidelines is acceptable. appropriate. Does the guidance producer routinely consider:Applicability 5.1 Publishing support tools Support tools are published to aid implementation of the referral guideline Criterion met to aid implementation of b by the Royal College of Physicians. The e-guideline and format of the guidance print version assist in implementation because of their ease of use.
Domain Criterion Evidence for meeting the criterion Accreditation decision 5.2 Discussion of potential The guidance producer provided an overarching discussion of potential Some uncertainty organisational and barriers in applying its recommendations. It also stated that the inclusion financial barriers in of information regarding the cost effectiveness of each investigation for applying its recommendations each diagnostic or imaging problem is not thought to be helpful. It is acknowledged that due to the wide range of clinical problems investigated this criterion would be difficult to meet on a case by case basis. However, a generalisable comparison of costs for different types of investigation technique may be helpful in the choice of investigation. In its feedback, the guidance producer provided further explanation as to why costs were not included in its guidance. This shows that the financial b aspects of using the referral guideline have at least been considered. However, it did not address the potential organisational barriers to implementation of its guidelines. This therefore remains an area of uncertainty. b 5.3 That their guidance is The referral guideline is current and audit of the uptake and use of this Criterion met current, with review guideline is undertaken. Examples were supplied that demonstrate the criteria for monitoring RCR encourages local level audits and engages with users of the and/or audit purposes within each product. guidance to monitor uptake and outcomes from these local level audits. Does the guidance producer:Editorial
Domain Criterion Evidence for meeting the criterion Accreditation decision bindependence 6.1 Ensure editorial The referral guideline is editorially independent from the funding body. Criterion met independence from the All groups involved in the guideline production are independent of the funding body College and all work carried out by the Delphi panels, the guidelines working party and the Editorial Group is done on a voluntary basis. 6.2 Demonstrate The process document and example guidance do not provide details of Some uncertainty transparency about the how the funding is achieved. In its response to criterion 6.1 the guidance funding mechanisms for producer stated that “all editions of „Making best use of clinical radiology its guidance services‟ have been produced solely by the RCR under a funding model through which the sales from one version fund the development of the next edition”. In its feedback the guidance producer reiterated that the funding model followed was one in which the sales income from the current version of the guideline funds the development and production of the next version. No further information was provided to confirm this. Therefore this criterion is still assessed as uncertain. 6.3 Record and state any Conflicts of interest are stated and recorded as described in the process Criterion met potential conflicts of a manual . There is a conflicts of interest policy in place which can be found interest of individuals on the website. involved in developing the recommendations
Domain Criterion Evidence for meeting the criterion Accreditation decision b 6.4 Take account of any The referral guideline production minimises bias via a combination of the Criterion met potential for bias in the composition of the GDG, declaration of interests, stakeholder consultation conclusions or a and review, as described in the process manual . recommendations of the guidancea Making the best use of clinical radiology services: the process for the sixth edition 2003 – 2007‟ (process manual).b Making best use of clinical radiology services, sixth edition. Referral guidelines.
Appendix B: BibliographyAppendix B lists the additional information taken into account in the analysis andconsidered by the Committee.Document name Description LocationMaking the best use of Process manual Not publicly available.clinical radiologyservices: the process forthe sixth edition 2003-2007Making the best use of Guideline assessed as Not publicly available.clinical radiology evidenceservices: referralguidelines (Sixth edition,2007)
Appendix C: Advisory Committee members, externaladvisers and NHS Evidence accreditation teamNHS Evidence Advisory Committee MembersThe NHS Evidence Advisory Committee operates as a standing advisory committee ofthe Board of the National Institute for Health and Clinical Excellence (NICE). TheCommittee provides advice to the Institute on a framework for accrediting sources ofevidence that should be recognised as trusted sources of information for the NHS. TheChair of the Committee is appointed by the Institute‟s Board and the meetings areconducted by the Chair or in his/her absence the vice chair. The current Chair is DavidHaslam. A full list of the Advisory Committee membership is available on the NICEwebsite3. The members have been appointed for a period of 18 months. This may beextended by mutual agreement to a further term of 3 years and up to a maximum termof office of 10 years.The decisions of the Committee are arrived at by a consensus of those memberspresent. The quorum is set at 50% of committee membership. The Committee submitsits recommendations to the Institute‟s Guidance executive which acts under delegatedpowers of the Institute‟s Board in considering and approving its recommendations.Committee members are asked to declare any interests in the guidance producer to beaccredited. If it is considered that there is a conflict of interest, the member(s) isexcluded from participating further in the discussions. A list of the committee memberswho took part in the discussions for this accreditation decision appears below. 3 http://www.nice.org.uk/nhsevidence/nhseac.jspRoyal College of Physicians Stroke guideline: Draft Accreditation Report Page 16 of 18
Title Name Surname Role Organisation Clinical Development & Calderdale & Huddersfield Mr Richard Brownhill Nurse Practitioner NHS Trust & Kirklees PCT NHS Alliance (GP and Dr Brian Fisher General Practitioner national patient/public lead) Professor David Haslam National Clinical Advisor Care Quality Commission Health Education , Senior Lecturer in Child Research and Dr Monica Lakhanpaul Health / Consultant Development Unit Paediatrician (HERADU), University of Leicester Professor of Paediatric The Peninsula College of Professor Stuart Logan Epidemiology Medicine School of Health and Professor of Health Professor Jon Nicholl Related Research Services Research (ScHARR) Stockton on Tees Dr Carl Parker PEC Chair Teaching PCTAdvisory Committee Deputies Title Name Surname Role Organisation Deputising for Head of Knowledge Sharing North East Strategic Ms Lynda Cox Stephen and Learning Health Authority Singleton NHS Information Ms Parul Desai Director of Population Health Centre Mark Davies Social Care Institute Ms Julie Robinson Project Information Officer Amanda for Excellence (SCIE) EdwardsExternal Advisers for Royal College of Radiologists referral guidelinesaccreditation applicationCheryl Harding-Trestrail, Locality Commissioning Manager (West),NHS Southampton City, Southampton, UKDr Frances Burnett, Associate Medical Director-Practice Governance, Consultant AdultPsychiatrist (Community), Hertfordshire Partnership Foundation Trust, Hertfordshire, UKRoyal College of Physicians Stroke guideline: Draft Accreditation Report Page 17 of 18
NHS Evidence accreditation team for Royal College of Radiologistsreferral guidelines accreditation applicationStephanie Birtles, Accreditation Technical Analyst, NHS Evidence, National Institute forHealth and Clinical Excellence, Manchester, UKDr Paul Chrisp, Associate Director Accreditation, NHS Evidence, National Institute forHealth and Clinical Excellence, Manchester, UKRoyal College of Physicians Stroke guideline: Draft Accreditation Report Page 18 of 18