Contents
1 Aim
To clarify route for registering service evaluations within the trust, by definition, service evaluation projects should not require formal approval from a research ethics committee.
All service evaluations conducted within the trust, by either internal or external persons, must be registered.
1.1 What is service evaluation?
A service evaluation is a way to define or measure current practice within a service. The results of the service evaluation help towards producing internal recommendations for improvements that are not intended to be generalised beyond the service area. See appendix B for further information on the differences between service evaluation, research and clinical audit.
Service evaluations must be defined using the guidelines set by health research authority (HRA). For further guidance see Is my study research decision tool (opens in new window).
2 Scope
All staff registering research projects conducted within the trust, by either internal or external staff.
3 Link to overarching policy, and or procedure
4 Procedure or implementation
All requests to register a service evaluation should be submitted with approval from the appropriate area manager to proceed with the project.
The area manager will review the evaluation proposal and place on the agenda of the business division or directorate’s governance meeting, it is anticipated that most well developed proposals will be approved, however there may equally be valid reasons not to support evaluation requests, for example, there may already be a high volume of research, audit and evaluations already taking place, the evaluation request may not be logistically supported for example, carry too many risks or not be feasible due to operational demands, workforce commitments, finances and so on.
Business division’s or directorate’s should consider the four ethical principles below as well as the opinion of the area manager, when making a decision about an evaluation approval:
- there is a benefit to existing or future patients or others that outweighs potential burdens or risks
- each patient’s right to self-determination is respected
- each patient’s privacy and confidentiality are preserved
- the activity is fairly distributed across patient groups
Once approved, the evaluation proposal should be submitted electronically to the Research team at grounded.research@rdash.nhs.uk. along with an application for registration (appendix A) The Research team will check that the project falls into the scope of service evaluation (following HRA guidelines) and register the project according to internal agreement and report this to the board via the quality committee.
If the service evaluation request is from an external source, arrangements should be made for appropriate access to the trust; this will vary dependent on the proposed evaluation. The Research team will be responsible for ensuring any checks are made and issuing appropriate letters of access to individuals. Access is granted to clinical areas and confidential data on the understanding that the trust’s policies are adhered to and the trust standards are maintained and protected. If required, the Research team will facilitate an information sharing agreement
The Research team will also update the quality committee (QC), which is a sub-committee of the trust’s board of directors. Reporting is managed by the research panel.
Following completion of the service evaluation, data collection and analysis, the project should be disseminated internally with relevant teams within the trust, thus proactively supporting shared learning.
All service evaluations should result an action plan which will be developed in collaboration with relevant stakeholders and let by a nominated business division or directorate senior staff member or manager.
It is a condition of approval should be that the completed evaluation report is shared with the care group and copied to the Research team.
Following completion, the care group holds responsibility to determine appropriate dissemination and publication. For commissioner-initiated studies, commissioners should ensure the dissemination plan is agreed via the care group from either the director of nursing or medical director.
5 Summary
All service evaluations must:
- have care group agreement
- be submitted to the Research team with appendix A
- be registered by the Research team
- be conducted within the guidelines of the approval
6 Appendices
6.1 Appendix A Registration of service evaluation form
6.2 Appendix B The simple rules
By applying the simple rules below, you will get a reasonable indication of the type of data collection activity you want to embark on and whether you need to use a local policy on the introduction of new treatments and techniques.
6.2.1 Service evaluation
- Incorporates both service or practice development and service or practice evaluation.
- Service or practice development, introduces a change in service delivery or practice for which there is evidence derived from research or other health or social care settings that have already introduced and evaluated the change. New developments should always be evaluated.
- Service or practice evaluation evaluates the effectiveness or efficiency of an existing or new service or practice that is evidence based, with the intention of generating information to inform local decision-making. This type of activity is sometimes referred to as a clinical effectiveness study, baseline audit, activity analysis, organisational audit and benchmarking.
- All service review activity should comply with clinical governance requirements and follow the ethical principles.
- Service or practice development which is concerned with the introduction of new treatments or techniques must follow local policy on introduction of new treatment and techniques.
Also refer to NHS benchmarking network policy.
6.2.2 Research
- Generates new knowledge where there is no or little research evidence available and which has the potential to be generalisable or transferrable.
- All research must comply with research governance requirements.
Also refer to Research governance policy.
6.2.3 Clinical audit
- Measures existing practice against evidence-based clinical standards
- All clinical audit must comply with clinical audit governance requirements
Also refer to clinical audit policy.
This information comes from a document titled ‘A Guide for Clinical Audit, Research and Service Review’. A full copy of the document can be obtained at HQIP guide for clinical audit, research and service review (opens in new window).
Document control
- Version: 3.2.
- Unique reference number: 433.
- Approved by: Corporate policy advisory group.
- Date approved: 29 January 2024.
- Name of originator or author: Research governance manager.
- Name of responsible individual: Research panel.
- Date issued: 12 February 2024.
- Review date: April 2025.
- Target audience: All staff.
Page last reviewed: October 11, 2024
Next review due: October 11, 2025
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