Trust Policy for Production Of

TRUST POLICY FOR PRODUCTION OF

DRUG THERAPY GUIDELINES

Version / 8
Name of responsible (ratifying) committee / Formulary & Medicines Group
Date ratified / 20 July 2018
Document Manager (job title) / Guidelines Pharmacist
Date issued / 10 August 2018
Review date / 10 August 2020
Electronic location / Clinical Policies
Related Procedural Documents / -
Key Words (to aid with searching) / -

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
8 / 20.07.2018 / Job titles updated. Reference document codes updated to new SOP format. Included comment re: electronic drug information documents. / M. Bennett-Marsden
7 / 16.09.2016 / No changes. / M. Bennett-Marsden
6 / 18.07.2014 / No content changes. Layout and spelling corrections only. / M. Bennett-Marsden
5 / 18.1.2013 / Updated to reflect new guidelines pharmacist role/s / M. Bennett-Marsden

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY

EQUALITY IMPACT SCREENING TOOL

APPENDIX 1: Drug Therapy Guideline Template

QUICK REFERENCE GUIDE

This policy describes the process for the preparation, approval, publication, audit and review of Portsmouth Hospitals NHS Trust Drug Therapy Guidelines.

Drug Therapy Guidelines are developed in order to improve patient safety and limit risk by provision of concise, structured, evidence-based clinical and pharmaceutical information on a range of medicines management topics relevant to the treatment of patients under the care of practitioners working for Portsmouth Hospitals NHS Trust.

Information on relevant adverse incidents will be reported to the specified Guideline Project Manager for action and will be considered in the production of new or revised Drug Therapy Guidelines.

This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

Note: This Policy encompasses all drug therapy guidelines published on the PHT intranet, as well as other PHT-administered electric media (i.e. mobile phone applications).

1.INTRODUCTION

The Policy for the Production of Drug Therapy Guidelines covers the processes involved in the preparation, approval, publishing, audit and review of Portsmouth Hospitals NHS Trust Drug Therapy Guidelines.

2.PURPOSE

The purpose of this policy is to ensure the consistent preparation, approval, publishing, audit and review of Drug Therapy Guidelines.

3.SCOPE

This policy applies to all Portsmouth Hospitals NHS Trust staff involved with the preparation of Drug Therapy Guidelines.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

Drug Therapy Guidelines: Guidance documents (including electronic media controlled by PHT)prepared to assist healthcare staff in the safe prescribing, preparation, control and administration of medicines for specific clinical conditions.

5.DUTIES AND RESPONSIBILITIES

Guideline Project Manager

A member of pharmacy staff will be designated by the Associate Director of Medicines Optimisation & Pharmacy to manage the process of development of a Drug Therapy Guideline, including establishing and leading a Guideline Development Group and ensuring that the requirements of this policy are adhered to.

Guideline Development Group

A group will be established by the Guideline Project Manager to develop the content of the proposed Drug Therapy Guideline including review of evidence and undertaking consultation with intended users of the guideline and other relevant stakeholders. The Guideline Development Group should be multidisciplinary and include members with experience and expertise in the relevant area.

Ratifying body

The PHT Formulary and Medicines Group will be responsible for the approval of Drug Therapy Guidelines.The Guideline Project Manager will submit the draft Drug Therapy Guideline together with the completed form PHPS07001 (see below) detailing the process of development, consultation and preparation of the guideline.

The Formulary and Medicines Group will check that the draft Drug Therapy Guideline

•is based on the best available evidence and is technically accurate

•is not discriminatory along the adult age continuum, unless there is clear evidence for age-defined contra-indication and this is recorded.

•is discriminatory for paediatricsif appropriate;

•has undergone multi-disciplinary consultation with the relevant stakeholders

The Formulary and Medicines Group will record ratification of the Drug Therapy Guidelines in the meeting notes, together with any conditions e.g. agreed minor amendments to be made prior to publication. If more than minor changes are required the Formulary and Medicines Group may request that a revised draft is presented to the committee for ratification. The required amendments will be documented in the meeting notes.

The development, ratification and publication of all other Trust procedural documents is detailed in the Trust Procedural Documents Development and Management Policy.

6.PROCESS

The actions to be taken to comply with this policy are described in the Standard Operating Procedure SOP07.001.

All Drug Therapy Guidelines will follow the format specified in this SOP.

The Guideline Project Manager will document the development of the Drug Therapy Guideline on form PHPSF07001 including the sources of information and all references used and the methods used to interpret and assess the strength of evidence for the key recommendations.

In particular there should be an explicit link between major recommendations and the level of supporting evidence.

The methods used to formulate the recommendations will be documented including how the views of stakeholders not on the Guideline Development Group were taken into account.

An equality impact assessment will be carried out and documented in PHPSF07001

Following ratification by the Formulary and Medicines Group the Guideline Project Manager will make any necessary amendments and prepare a final version ready for publishing. This will be passed to the guidelines pharmacist for publishing on the intranet(or other applicable electronic medium) in accordance with SOP07.001.

7.TRAINING REQUIREMENTS

All personnel involved in the development, ratification and publication of Drug Therapy Guidelines must be aware of this policy.

There are no specific training requirements.

8.REFERENCES AND ASSOCIATED DOCUMENTATION

Portsmouth Hospitals NHS Trust Procedural Documents Development and Management Policy.

Portsmouth Hospitals Pharmacy Standard Operating Procedure SOP07.001 (link TBC)

Portsmouth Hospitals Pharmacy Service Form PHPSF07001

9.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Working together for patients

Working together with compassion

Working together as one team

Working together always improving

This policy should be read and implemented with the Trust Values in mind at all times

10.MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY

The Formulary and Medicines Group will ensure that any Drug Therapy Guidelines submitted for ratification comply with the requirements of this policy and may refuse to approve the publication of any Drug Therapy Guidelines that have not been developed in accordance with this policy. The Formulary and Medicines Group will require the submission of PHPSF07001 together with the draft guideline to provide assurance that the Drug Therapy Guideline has been developed (or reviewed, in the case of previously published Drug Therapy Guidelines) in line with this policy.

EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Drug Therapy Guidelines – Production & Management

Date of Assessment

/ 03/07/2018 / Responsible Department / Pharmacy
Name of person completing assessment / M. Bennett-Marsden / Job Title / Pharmacist
Does the policy/function affect one group less or more favourably than another on the basis of :
Yes/No / Comments

/ No

Disability

/ No

Gender reassignment

/ No

Pregnancy and Maternity

/ No

Race

/ No

Religion or Belief

/ No

Sexual Orientation

/ No

Marriage and Civil Partnership

/ No
If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2
More Information can be found be following the link below

Stage 2 – Full Impact Assessment
What is the impact / Level of Impact / Mitigating Actions
(what needs to be done to minimise / remove the impact) / Responsible Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document: Specialty Governance Committee
Clinical Service Centre Procedural Document:Clinical Service Centre Governance Committee
Corporate Procedural Document:Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

APPENDIX 1: Drug Therapy Guideline Template

(Renal/Paed*) Drug Therapy Guideline No Issued: date posted on intranet

TITLE
Subject (alphabetical search)

Introduction

This guidance supports

The objectives of this guideline are

This guideline applies to all (specify any restrictions to patient group)patients under

thecare of practitioners working for Portsmouth Hospitals NHS Trust.

Recommendations

Subheading

Content text …

Key References

Evidence Base

Name, Post manages this guideline (ext XXXX)

See Trust Policy for the Production of Drug Therapy Guidelines

Approved by: Formulary & Medicines GroupDate

Review date: (+2yrs unless otherwise stated)

Page x of y

Control date: insert date that rolls over each day

Trust Policy for the Production of Drug Therapy Guidelines

Version: 8

Issue Date: 10 August 2018

Review Date: 10 August 2020 (unless requirements change) Page 1 of 9