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NICE Accreditation: Gap Analysis
NICE Accreditation: Gap Analysis
NICE Accreditation: Gap Analysis
Gap analysis
Gap analysis instructions
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.
Process Implementation
A Documented and robust A Consistent
B Documented B Inconsistent
C Undocumented C None
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"
Next steps
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.
Printing
Worksheets can be printed individually. To print the entire workbook, select "Entire workbook" from the print options.
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Gap analysis Comments Action Required
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1. Is there a documented guidance
development process? NICE accreditation
requires a documented process to give
confidence that a systematic, robust
process is followed.
4. (Criterion 1.1) Does the process Go to Models of Practice: Scope and purpose, 1.1 for
documentation describe how, when and further information on the intent and requirements of this
where to state the overall objective when criterion.
writing each piece of guidance?
5. (Criterion 1.2) Does the process Go to Models of Practice: Scope and purpose, 1.2 for
documentation describe how the clinical, further information on the intent and requirements of this
healthcare or social questions are criterion.
considered in developing the guidance, and
how they will be displayed in the final
product?
6. (Criterion 1.3) Does the process Go to Models of Practice: Scope and purpose, 1.3 for
documentation describe how to ascertain further information on the intent and requirements of this
the population covered by the guidance, criterion.
and the target audience for the guidance?
The process should explain how to identify
these groups in the final product.
7. (Criterion 1.4) Does the process Go to Models of Practice: Scope and purpose, 1.4 for
documentation state that clear further information on the intent and requirements of this
recommendations in reference to specific criterion.
clinical, healthcare or social circumstances
are documented, and how these will be
displayed in the final product?
8. (Criterion 2.1) Does the process describe Go to Models of Practice: Stakeholder involvement, 2.1 for
how to ensure individuals from all relevant further information on the intent and requirements of this
stakeholder groups, including patient criterion.
groups, are involved in developing
guidance?
9. (Criterion 2.2) Is the process Go to Models of Practice: Stakeholder involvement, 2.2 for
documentation or other supporting further information on the intent and requirements of this
information (e.g. meeting minutes, policies) criterion.
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?
10. (Criterion 2.3) Does the process Go to Models of Practice: Stakeholder involvement, 2.3 for
documentation or other supporting further information on the intent and requirements of this
information (e.g. meeting minutes, policies) criterion.
explain how representative intended users
are involved in developing guidance?
11. (Criterion 3.1) Does the process Go to Models of Practice: Rigour of development, 3.1 for
documentation explicitly describe that further information on the intent and requirements of this
systematic methods must be used to search criterion.
for evidence, and provide details of the
search strategy and criteria?
12. (Criterion 3.2) Does the process Go to Models of Practice: Rigour of development, 3.2 for
documentation explain that the reasons for further information on the intent and requirements of this
inclusion or exclusion of evidence identified criterion.
by the evidence review, must be stated?
13. (Criterion 3.3) Does the process Go to Models of Practice: Rigour of development, 3.3 for
documentation explain how the strengths further information on the intent and requirements of this
and limitations of the body of evidence are criterion.
assessed and documented?
14. (Criterion 3.4) Does the process Go to Models of Practice: Rigour of development, 3.4 for
documentation describe the method used further information on the intent and requirements of this
to arrive at recommendations? criterion.
15. (Criterion 3.5) Does the process Go to Models of Practice: Rigour of development, 3.5 for
documentation explain how the health further information on the intent and requirements of this
benefits are measured against the side criterion.
effects and risks in formulating
recommendations?
16. (Criterion 3.6) Is the external peer Go to Models of Practice: Rigour of development, 3.6 for
review process documented? further information on the intent and requirements of this
criterion.
17. (Criterion 3.7) Is there a documented Go to Models of Practice: Rigour of development, 3.7 for
process for updating guidance and further information on the intent and requirements of this
maintaining and improving guidance criterion.
quality?
18. (Criterion 4.1) Does the process Go to Models of Practice: Clarity of presentation, 4.1 for
documentation explain how to ensure that further information on the intent and requirements of this
the recommendations in the guidance are criterion.
specific, unambiguous and clearly
identifiable? Is this evident in examples?
19. (Criterion 4.2) Does the process Go to Models of Practice: Clarity of presentation, 4.2 for
documentation state that within the further information on the intent and requirements of this
guidance different options for the criterion.
management of the condition or options
for intervention are clearly presented? Is
this evident in examples?
20. (Criterion 4.3) Does the process Go to Models of Practice: Clarity of presentation, 4.3 for
documentation state that the date of the further information on the intent and requirements of this
evidence search, the date of publication or criterion.
last update and the proposed date for
review are clearly stated in the guidance? Is
this evident in examples?
21. (Criterion 4.4) Does the process Go to Models of Practice: Clarity of presentation, 4.4 for
documentation specify that the language further information on the intent and requirements of this
and format of guidance should be suitable criterion.
for the specified target audience? Is this
evident in examples?
22. (Criterion 5.1) Does the process Go to Models of Practice: Applicability, 5.1 for further
documentation describe how the information on the intent and requirements of this
implementation of guidance will be criterion.
assisted in each case? For example, by
providing tools and aids? Do you have
examples?
23. (Criterion 5.2) Does the process Go to Models of Practice: Applicability, 5.2 for further
documentation explain that a discussion of information on the intent and requirements of this
potential organisational and financial criterion.
barriers in applying the recommendations
from each guideline should be included?
24. (Criterion 5.3) Does the process Go to Models of Practice: Applicability, 5.3 for further
documentation describe how to include information on the intent and requirements of this
review criteria for monitoring and/or audit criterion.
to assess how the guidance is implemented
among intended users ?
25. (Criterion 6.1) Do you have a process, Go to Models of Practice: Editorial independence, 6.1 for
policies or governance arrangements in further information on the intent and requirements of this
place that ensure editorial independence criterion.
from the funding body?
26. (Criterion 6.2) Does your process, Go to Models of Practice: Editorial independence, 6.2 for
policies or governance arrangements further information on the intent and requirements of this
require you to demonstrate transparency criterion.
about the funding mechanisms for your
guidance?
27. (Criterion 6.3) Do you have a conflicts of Go to Models of Practice: Editorial independence, 6.3 for
interest policy? further information on the intent and requirements of this
criterion.
28. (Criterion 6.4) Do you have processes Go to Models of Practice: Editorial independence, 6.4 for
in place that take into account any further information on the intent and requirements of this
potential for bias in the conclusions or criterion.
recommendations of the guidance?
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 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 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