NICE Accreditation

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.

Filling in the self assessment form

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.

Process
A Documented and robust
B Documented
C Undocumented

Implementation
A Consistent
B Inconsistent
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

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.

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?
26. (Criterion 6.2) Does your process,
policies or governance arrangements
require you to demonstrate
transparency about the funding
mechanisms for your guidance?
27. (Criterion 6.3) Do you have a
conflicts of interest policy?

Go to Models of Practice: Editorial independence, 6.1 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.

Go to Models of Practice: Editorial independence, 6.2 for

further information on the intent and requirements of this
criterion.

Go to Models of Practice: Editorial independence, 6.3 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