NICE AccreditationGap analysis

Gap analysis instructions

Filling in the self assessment form

Process Implementation

A Documented and robust A ConsistentB Documented B InconsistentC Undocumented C None

Next steps

PrintingWorksheets can be printed individually. To print the entire workbook, select "Entire workbook" from the print options.

The gap analysis is designed to help you view your guidance production processes across all 25 accreditation criteria. It helps you to identify areas that are strong, or in need of improvement or further documentation. The gap analysis should also help you to identify areas where your processes are applied inconsistently, by asking you to look for evidence of implementation within your guidance. In many ways, this mirrors the process used by our Technical Analysts in assessing your application. If you identify any areas you wish to improve, you may find it useful to track your progress by completing the self assessment before and after. This tool should also help you to consider all the relevant points for your application. This assessment is best done after reading the Models of Practice document.

The gap analysis looks at two aspects of guidance production: Process and Implementation. In Process you should consider the processes you have in place, how well they are documented and how robust they are, according to the NICE accreditation criteria. In Implementation you need to consider how consistently your guidance demonstrates that it complies with your processes. We have developed models of practice to help bridge any gaps. These are listed in the ‘Actions’ column and are based on our experience with accreditation. For each column, please select the corresponding letter to indicate your findings, from the options below. The actions box indicates where to look in the Models of Practice if your findings show that there is a gap in process or implementation. The comments section is to used to write in your own notes which evidence the selection you have made and what actions are required.

In the above classifications, a "robust" process can be taken to mean "A process fit for purpose for the type of guidance that you produce, that if followed will ensure the high quality, reliability and trustworthiness of your products in relation to this specific criterion"

The final tab in the workbook will help you interpret your self assessment and work out next steps. Depending on your results and the type of guidance you produce, you may need to modify your process, produce more guidance, or proceed to an accreditation application.

Gap analysis Comments Action Required

1. Is there a documented guidance development process? NICE accreditation requires a documented process to give confidence that a systematic, robust process is followed.

2. Does the process cover all 6 domains? To attain accreditation all applicable criteria within the 6 domains should be considered. The Models of Practice should provide further information on the applicability of criteria to your type of guidance.

3. Are all guidance development processes documented in sufficient detail? In all cases have you ensured that your process is described in enough detail to allow to allow it to be consistently implemented?

4. (Criterion 1.1) Does the process documentation describe how, when and where to state the overall objective when writing each piece of guidance?

Go to Models of Practice: Scope and purpose, 1.1 for further information on the intent and requirements of this criterion.

5. (Criterion 1.2) Does the process documentation describe how the clinical, healthcare or social questions are considered in developing the guidance, and how they will be displayed in the final product?

Go to Models of Practice: Scope and purpose, 1.2 for further information on the intent and requirements of this criterion.

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6. (Criterion 1.3) Does the process documentation describe how to ascertain the population covered by the guidance, and the target audience for the guidance? The process should explain how to identify these groups in the final product.

Go to Models of Practice: Scope and purpose, 1.3 for further information on the intent and requirements of this criterion.

7. (Criterion 1.4) Does the process documentation state that clear recommendations in reference to specific clinical, healthcare or social circumstances are documented, and how these will be displayed in the final product?

Go to Models of Practice: Scope and purpose, 1.4 for further information on the intent and requirements of this criterion.

8. (Criterion 2.1) Does the process describe how to ensure individuals from all relevant stakeholder groups, including patient groups, are involved in developing guidance?

Go to Models of Practice: Stakeholder involvement, 2.1 for further information on the intent and requirements of this criterion.

9. (Criterion 2.2) Is the process documentation or other supporting information (e.g. meeting minutes, policies) clear about how patient and service user representatives are involved in the guidance development? Does the process describe how patients views and preferences are sought in developing guidance?

Go to Models of Practice: Stakeholder involvement, 2.2 for further information on the intent and requirements of this criterion.

10. (Criterion 2.3) Does the process documentation or other supporting information (e.g. meeting minutes, policies) explain how representative intended users are involved in developing guidance?

Go to Models of Practice: Stakeholder involvement, 2.3 for further information on the intent and requirements of this criterion.

11. (Criterion 3.1) Does the process documentation explicitly describe that systematic methods must be used to search for evidence, and provide details of the search strategy and criteria?

Go to Models of Practice: Rigour of development, 3.1 for further information on the intent and requirements of this criterion.

12. (Criterion 3.2) Does the process documentation explain that the reasons for inclusion or exclusion of evidence identified by the evidence review, must be stated?

Go to Models of Practice: Rigour of development, 3.2 for further information on the intent and requirements of this criterion.

13. (Criterion 3.3) Does the process documentation explain how the strengths and limitations of the body of evidence are assessed and documented?

Go to Models of Practice: Rigour of development, 3.3 for further information on the intent and requirements of this criterion.

14. (Criterion 3.4) Does the process documentation describe the method used to arrive at recommendations?

Go to Models of Practice: Rigour of development, 3.4 for further information on the intent and requirements of this criterion.

15. (Criterion 3.5) Does the process documentation explain how the health benefits are measured against the side effects and risks in formulating recommendations?

Go to Models of Practice: Rigour of development, 3.5 for further information on the intent and requirements of this criterion.

16. (Criterion 3.6) Is the external peer review process documented?

Go to Models of Practice: Rigour of development, 3.6 for further information on the intent and requirements of this criterion.

17. (Criterion 3.7) Is there a documented process for updating guidance and maintaining and improving guidance quality?

Go to Models of Practice: Rigour of development, 3.7 for further information on the intent and requirements of this criterion.

18. (Criterion 4.1) Does the process documentation explain how to ensure that the recommendations in the guidance are specific, unambiguous and clearly identifiable? Is this evident in examples?

Go to Models of Practice: Clarity of presentation, 4.1 for further information on the intent and requirements of this criterion.

19. (Criterion 4.2) Does the process documentation state that within the guidance different options for the management of the condition or options for intervention are clearly presented? Is this evident in examples?

Go to Models of Practice: Clarity of presentation, 4.2 for further information on the intent and requirements of this criterion.

20. (Criterion 4.3) Does the process documentation state that the date of the evidence search, the date of publication or last update and the proposed date for review are clearly stated in the guidance? Is this evident in examples?

Go to Models of Practice: Clarity of presentation, 4.3 for further information on the intent and requirements of this criterion.

21. (Criterion 4.4) Does the process documentation specify that the language and format of guidance should be suitable for the specified target audience? Is this evident in examples?

Go to Models of Practice: Clarity of presentation, 4.4 for further information on the intent and requirements of this criterion.

22. (Criterion 5.1) Does the process documentation describe how the implementation of guidance will be assisted in each case? For example, by providing tools and aids? Do you have examples?

Go to Models of Practice: Applicability, 5.1 for further information on the intent and requirements of this criterion.

23. (Criterion 5.2) Does the process documentation explain that a discussion of potential organisational and financial barriers in applying the recommendations from each guideline should be included?

Go to Models of Practice: Applicability, 5.2 for further information on the intent and requirements of this criterion.

24. (Criterion 5.3) Does the process documentation describe how to include review criteria for monitoring and/or audit to assess how the guidance is implemented among intended users ?

Go to Models of Practice: Applicability, 5.3 for further information on the intent and requirements of this criterion.

25. (Criterion 6.1) Do you have a process, policies or governance arrangements in place that ensure editorial independence from the funding body?

Go to Models of Practice: Editorial independence, 6.1 for further information on the intent and requirements of this criterion.

26. (Criterion 6.2) Does your process, policies or governance arrangements require you to demonstrate transparency about the funding mechanisms for your guidance?

Go to Models of Practice: Editorial independence, 6.2 for further information on the intent and requirements of this criterion.

27. (Criterion 6.3) Do you have a conflicts of interest policy?

Go to Models of Practice: Editorial independence, 6.3 for further information on the intent and requirements of this criterion.

28. (Criterion 6.4) Do you have processes in place that take into account any potential for bias in the conclusions or recommendations of the guidance?

Go to Models of Practice: Editorial independence, 6.4 for further information on the intent and requirements of this criterion.

Next Steps

The relative importance of each criterion depends upon the type of guidance you produce. There are some general trends however that we have observed during the accreditation programme that will help you to interpret your self-assessment. Please note this information is for illustrative purposes only, and does not guarantee a particular outcome.

If you have any reds (C) in the process column.Experience has shown that guidance producers with either a lack of a documented process, or a process which appears not to be fit for purpose in one or more areas, are unlikely to achieve accreditation. You may wish to consider improving the relevant processes and/or documentation as identified in the self assessment before applying. Particular attention should be paid to any criteria where there is no documented process. Please note that evidence of implementation may also be required if significant changes are made.

If you have mostly yellows (B) in the process column or a cluster of yellows (B) focussed on a particular theme.If your processes require a wide range of minor amendments, you could take the opportunity to revise your process in all areas before applying, concentrating on the areas you judge most important for your type of guidance. In this case you may also need to develop new guidance to demonstrate implementation of your new process.

If you identify a number of issues around one specific theme, it depends on whether this is a critical issue for your type of guidance. If it is, you are unlikely to achieve accreditation without modification of your process, and producing new guidance to demonstrate implementation of the new process. If you judge the area to be less important for your type of guidance and you wish to apply, be sure to explain your thinking in the application form. It may be that criteria in this area are not applicable to your type of guidance.

If you have a small number of yellows (B) in the process column or yellows (B) scattered around the implementation column

You may well be ready to apply for accreditation and we would encourage you to apply. Overall it depends how the weaker areas of your process or implementation relate to the type of guidance you produce. If for example you produce clinical guidelines comparing treatments and recommending a course of action, criteria related to utilising the best available evidence and weighing up risks and benefits will be very important; so weaker processes in these areas may harm your chances of a successful application.

In general, shortcomings in implementation are easier to fix than problems in the process. Provided you are happy with your process, you need to ensure that all guidance you produce follows the process consistently. Make a note of anything you do to improve quality assurance, and any modifications to your process that this entails.

If you would like to find out more about accreditation or discuss any issues raised in the gap analysis in more detail, please email accreditation@nice.org.uk