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 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.
 n
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.

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 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
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 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, criterion.
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?

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, criterion.
policies) explain how representative
intended users are involved in developing
guidance?
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?
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?
13. (Criterion 3.3) Does the process
documentation explain how the strengths
and limitations of the body of evidence are
assessed and documented?
14. (Criterion 3.4) Does the process
documentation describe the method used
to arrive at recommendations?
15. (Criterion 3.5) Does the process
documentation explain how the health
benefits are measured against the side
effects and risks in formulating
recommendations?
16. (Criterion 3.6) Is the external peer
review process documented?
17. (Criterion 3.7) Is there a documented
process for updating guidance and
maintaining and improving guidance
quality?
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: Rigour of development, 3.1 for
further information on the intent and requirements of this
criterion.
Go to Models of Practice: Rigour of development, 3.2 for
further information on the intent and requirements of this
criterion.
Go to Models of Practice: Rigour of development, 3.3 for
further information on the intent and requirements of this
criterion.
Go to Models of Practice: Rigour of development, 3.4 for
further information on the intent and requirements of this
criterion.
Go to Models of Practice: Rigour of development, 3.5 for
further information on the intent and requirements of this
criterion.
Go to Models of Practice: Rigour of development, 3.6 for
further information on the intent and requirements of this
criterion.
Go to Models of Practice: Rigour of development, 3.7 for
further information on the intent and requirements of this
criterion.
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 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
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 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
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?
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, 6.1 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.
Go to Models of Practice: Editorial independence, 6.4 for
further information on the intent and requirements of this
criterion.