Policy for the Development and Management of Procedural Documents

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					     POLICY FOR THE DEVELOPMENT AND MANAGEMENT OF
                 PROCEDURAL DOCUMENTS




Version                                       11

Name of responsible (ratifying) Committee     Risk Assurance Committee

Date ratified                                 7 February 2012

Document Manager (job title)                  Head of Risk Management and Legal Services

Date issued                                   9 February 2012

Review date                                   January 2015 (unless requirements change)

Electronic location                           Management Policies
                                              An Organisation-Wide Policy for the Development and
                                              Management of Procedural Documents: NHSLA,
                                              March 2011. www.nhsla.com/Publications/
Related Procedural Documents
                                               NHSLA Risk Management Standards for Acute Trusts:
                                               NHSLA, April 2007 www.nhsla.com/Publications/
                                               Policy, Ratification, Responsible Committees,
Key Words (to aid searching)
                                               Archiving
In the case of hard copies of this policy the content can only be assured to be accurate on the date
of issue marked on the document.

For assurance that the most up to date policy is being used, staff should refer to the version held on
the intranet




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CONTENTS


1.    INTRODUCTION.......................................................................................................................... 5
2.    PURPOSE .................................................................................................................................. 5
3.    SCOPE            .................................................................................................................................. 6
4.    DEFINITIONS .............................................................................................................................. 6
5.    DUTIES AND RESPONSIBILITIES .............................................................................................. 6
6.    PROCESS .................................................................................................................................. 7
7.    STYLE AND FORMAT ................................................................................................................. 8
8.    REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 9
9.    RATIFICATION ............................................................................................................................ 9
10. DISSEMINATION ....................................................................................................................... 10
11. REVIEW AND CONTROL .......................................................................................................... 10
12. ARCHIVING AND RETRIEVAL .................................................................................................. 11
13. EQUALITY IMPACT ASSESSMENT .......................................................................................... 11
14. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
    DOCUMENTS ............................................................................................................................ 11
15. MONITORING THE EFFECTIVENESS OF THIS POLICY ......................................................... 12
16. ASSOCIATED DOCUMENTATION ............................................................................................ 13
APPENDIX A: PROCEDURAL DOCUMENT TEMPLATE ................................................................. 14
APPENDIX B: STANDARD EMAIL FOR DISTRIBUTION OF RATIFIED TRUST PROCEDURAL
   DOCUMENTS ............................................................................................................................ 20
APPENDIX C: TRUST PROCEDURAL DOCUMENT RATIFYING COMMITTEES/GROUPS ........... 21




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QUICK REFERENCE GUIDE
(this could also be a flow-chart if deemed appropriate)

This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.

For quick reference the guide below is a summary of actions required to ensure appropriate
implementation of this policy. 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.

The author must:
   1. First check if the document already exists or if there is a similar one that could be amended or
      revised. This check can be made via the Trust Intranet or the Trust Policy Officer (TPO) on
      ext 7700 3477

    2. Gain approval to develop a new document from the appropriate Committee and, if it is Trust
       procedural document and approval is gained, register it with the TPO. Local procedural
       documents do not need to be registered with the TPO.

    3. Ensure that the right people are consulted and involved, paying particular attention to the
       involvement of patients/service users and staff teams. It may also be appropriate / necessary
       to consult with the Trust solicitors.

    4. Ensure that the needs of any specific group are considered and wherever possible integrate
       policies i.e. separate adult and paediatric policies for the same subject should be avoided.

    5. Ensure the document meets the standard Trust style and formatting requirements as
       described in this policy (a blank template is available on the Trust Intranet site. Home page ->
       Procedural Document and Information)

    6. Ensure the document contains all relevant sections and that they are completed appropriately
       (a checklist is available on the Trust Intranet site. Home page -> Procedural Document and
       Information)

    7. Ensure an Equality Impact Assessment is completed (a blank template is available on the
       Trust Intranet site. Home page -> Procedural Document and Information )

    8. Once the checks and consultation process are complete, forward the document to the
       relevant Committee for ratification, together with the appropriate paperwork

The Committee will:
   9. Provide feedback to the author of the document. If amendments are required these must be
      completed and the document re-submitted to the Committee

    10. Once ratification is gained for Trust procedural documents forward the document to the TPO,
        together with the completed checklist, Equality Impact Assessment and an extract of the
        minutes, to evidence ratification. For local procedural documents, the Committee should
        return it to the local author for processing.

The TPO will:
   11. On receipt of a ratified Trust procedural document and accompanying paperwork, ensure all
       references to the document being ‘draft’ are removed and the front sheet is complete.

    12. Publish the document, archiving any previous versions as appropriate, and forward the
        document to the Clinical Service Centre (CSC) Managers for appropriate dissemination



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   13. Ensure the Ratification Documents (including minutes of ratifying committee) and EIA are
       stored securely

Authors of local procedural documents will:
Follow steps 1 -> 9 then …

   14. On receipt of a ratified local procedural document, ensure all references to the document
       being ‘draft’ are removed and the front sheet is complete.

   15. Ensure the document is published and any previous versions are archived in accordance with
       the Schedule of Retention of Documents DoH Health Records Retention Schedule 06.pdf




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 1. INTRODUCTION

     This policy is designed to provide clarity regarding the management and production of both new
     and revised organisational procedural documents, more commonly referred to as policies.

     Well developed, evidence-based and successfully implemented policies will enable staff at
     Portsmouth Hospitals NHS Trust (the Trust) to deliver a high standard of care through
     improvement in quality, safety, efficiency and consistency of practice.

     All Trust policies must follow the standards and format as set out in this document, there can
     be no deviation.

     Any documents developed for local application (e.g. Clinical Service Centre (CSC) and/or
     Department) must follow the appropriate ratification pathway and must comply with this policy,
     as set out in section 9.

     Advice can be sought from the Chair of the Trust Procedural Document Group: Head of Risk
     Management and Legal Services – Ext 7700 6388


 2. PURPOSE

     The purpose of this policy is to:

          Ensure agreed practice is followed throughout the organisation with regards to the
           development of approved documentation.

          Ensure all procedural documents are accessible to all relevant staff.

          Promote consultation to ensure the content of procedural documents supports the highest
           standards of care, are well-researched, evidence-based and reflect the views of
           stakeholders;

          Avoid duplication and ensure there is a genuine need for any new procedural documents;

          Encourage ownership and accountability for procedural document development and
           implementation;

          Achieve a standardised corporate style and format for procedural documents throughout
           the organisation, which supports document management;

          Ensure all procedural documents are accompanied by an implementation plan;

          Clarify the approval and ratification routes of various types of procedural documents;

          Ensure registers and archives of all procedural documents are maintained;

          Ensure compliance with procedural documents is monitored and action taken as required;

          Ensure all procedural documents are up to date and reviewed as necessary.

          Support the claims and complaints management process by ensuring that applicable
           documentation can be retrieved to identify organisational practice at the relevant time.




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 3. SCOPE

     This policy applies to all staff (including voluntary workers, students, locums and agency) within
     the Trust, the MDHU (Portsmouth) and Carillion, whilst acknowledging for staff other than those
     of the Trust the appropriate line management or chain of command will be followed.

     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

     Policy
     A policy can be defined as a high level statement of intent or set of principles with widespread
     application that provides a basis for consistent decision-making and resource allocation.

     ‘Trust’ Policy Documents
     Within this document, the term ‘Trust’ is used to refer to all policies which apply across the
     whole Trust

     ‘Local’ Policy Documents
     Within this document, the term ‘local’ is used to refer to all policies, which only apply to certain
     departments, rather than across the Trust. In most cases, these documents will be approved
     and managed at departmental / Clinical Service Centre (CSC) level.

     Stakeholders
     Stakeholders are those people with an interest in a procedural document and who can usefully
     contribute, comment and agree to the content of the document. They include: specific
     committees, groups or forums, individual colleagues; whole departments; service users and
     their families.

 5. DUTIES AND RESPONSIBILITIES

     Governance and Quality Committee is responsible for receiving an annual policy audit report
     from the Trust Procedural Document Committee and a bi-annual report on the status of Trust
     procedural documents.

     CSC Governance Committee are responsible for providing assurance that policy
     management within the CSC is in accordance with this policy.

     Trust Procedural Document Group is responsible for providing assurance on the
     effectiveness of this policy and the status of Trust Policies to the Governance and Quality
     Committee, including any necessary recommendations to address identified deficits. The Chair
     of the Group (Head of Risk Management and Legal Services) will also supply advice to the
     author of any procedural document, as required.

     Ratification Committees are responsible for ensuring that the key requirements of this policy
     are met.

     Authors of Trust and Local Procedural Documents are responsible for ensuring that the key
     requirements of this policy are met.

     Clinical Service Centre General Managers (CSC GMs) are responsible for ensuring that
     processes are in place for:

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          The distribution of all ratified Trust procedural documents and raising awareness of newly
           published and amended policies;

          Monitoring adherence with relevant local and Trust procedural documents;

          Enabling staff to access local and Trust procedural documents; and

          Enabling staff to be released for any training required to successfully implement the
           procedural documents.

     Ward and Department Managers are responsible for ensuring:

          That all staff are informed of new and amended Trust and local procedural documents;

          That the quality of reproduced copies is of an acceptable standard.

          Ensuring staff, contractors and others comply with Trust and local procedural documents;
           and

          The receipt and implementation forms are retained locally, in a safe environment and are
           available upon request, for auditing purposes.

     Trust Policy Officer (TPO) is responsible for ensuring the Standard Operating Procedure is
     adhered to.

     Voluntary and Inclusion Manager is responsible for providing advice on the completion of
     Equality Impact Assessments

     All Trust Employees are responsible for ensuring that they:

          Cooperate with the development and implementation of procedural documents;

          Read, comply and maintain up-to-date awareness of procedural documents, as laid down
           in job descriptions and contracts of employment;

          Attend training as required, to familiarise themselves and enable compliance with,
           procedural documents relevant to their role and responsibilities; and

          Raise any queries about implementation of procedural documents with their line manager.

 6. PROCESS

     6.1. Rationale
          The first stage of development is to confirm the rationale by considering the justification
          for the procedural document. As part of the confirmation process a review of existing or
          national procedural documents is essential, to avoid duplication. Where possible, the
          revision of an existing procedural document is preferable to the development of a new
          document. An Intranet search should identify any existing internal procedural documents;
          the TPO can also be contacted and asked to check against the document register.

     6.2. Evidence Review
          To ensure a procedural document includes the most up-to-date and, where possible,
          evidence-based practice, a thorough evidence review should be undertaken. The breadth
          and length of this review will vary depending on the topic of the procedural document.
          Where available, national peer reviewed documents should be used as a starting point.

            Examples of useful resources include:
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                     National Health Service Litigation Authority
                     Department of Health
                     Care Quality Commission
                     National Institute for Health and Clinical Excellence (NICE)
                     Royal Colleges and Professional Bodies
                     Clinical Networks
                     Cochrane Library
                     Medline

           This list is not exhaustive and, where there is little or no evidence, a consensus of opinion
           from those experienced in the field should form the basis of the procedural document.

     6.3. Identification of Stakeholders
          Stakeholders are any individuals and/or groups with an interest in a procedural document
          and who can contribute, comment and agree to the content of that document. The
          relevant stakeholders and their appropriate level of involvement will need to be identified.
          They may be:

                     Individual Colleagues
                     Budget holders
                     Whole departments, which will be directly affected
                     Particular staff groups
                     Trade Unions
                     Staff side representatives
                     Partner organisations
                     Patient groups
                     Individual patients and their families
                     The public

     6.4. Consultation
          Consultation with relevant stakeholders will improve the accuracy and quality of the
          procedural document and facilitate effective implementation when ratified. Consultation
          may be via face-to-face informal discussions, formal meetings, email or paper distribution.

           In order to obtain ratification, submission to the relevant committee must be accompanied
           by evidence of robust consultation. This is provided by completion of the Consultation and
           Proposed Implementation Plan.

           The consultation process for a new or revised/amended procedural document should be
           completed within 3 months of receipt of approval being given for the document.

 7. STYLE AND FORMAT

     All procedural documents should be kept as brief as possible and written in a style which is
     concise and unambiguous. A ‘Quick Reference Guide’ must be used to bring the key sections
     to the attention of the reader.

     The use of headings to break up the text and the use of flowcharts offer opportunities to
     simplify implementation by ensuring the procedural document can be understood without
     significant time input.

     Authors should refer to section 4 of this policy, to ensure the title accurately reflects the type of
     procedural document and the flexibility in interpretation permitted. For example, if a procedural
     document is ‘guidance’, designed to be adapted for different circumstances, avoid calling it a
     ‘policy’ or ‘protocol’.
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     All procedural documents should be written as follows:

           All policies should follow the template available on the Trust Intranet. Home page ->
            Policies
           All other procedural documents should have:
                    The Trust logo in the top right hand corner
                    Title
                    Introduction
                    Purpose
                    Other headings as required
                    Version
                    Ratified by
                    Date ratified
                    Job title - author
                    Date issued
                    Review date
                    Electronic location
                    An equality impact assessment completed

           The body of the text in all documents should be in font size Arial 11
           Main headings for all documents should be in font size Arial bold 12, but not underlined
           Subheadings for all documents should be in Arial bold 11, but not underlined
           A footer must be included on every page, stating the name of the document, issue date,
            version number and page x of y

 8. REFERENCES AND ASSOCIATED DOCUMENTATION

     Procedural documents must be evidence-based and referenced, wherever possible. Reference
     must also be made to any associated national policies, standards, guidelines, Acts of
     Parliament etc.

     References and associated documents must be checked when reviewing an existing
     procedural document, to ensure they are still current and relevant.

     The following format must be used:

     An Organisation-Wide Policy for the Development and Management of Procedural Documents:
     NHSLA, March 2011. www.nhsla.com/Publications/


 9. RATIFICATION

     The management of risk is underpinned by a robust procedural document structure and it is
     therefore essential that document ratification is achieved in an efficient and timely manner,
     taking no longer than 4 months.


     9.1. Ratification of Procedural Documents
          All Trust and local procedural documents will be ratified by the relevant Trust committee
          or group. Appendix C provides an overview of the main categories of Trust procedural
          documents and the appropriate ratification committee or group. If a procedural document
          does not fit easily within one of these categories, or covers more than one category,
          advice on ratification can be obtained from the Chair of the Trust Procedural Document
          Group: Head of Risk Management and Legal Services – ext 7709 6388
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 10. DISSEMINATION

     In order to ensure procedural documents are implemented in practice and deliver the desired
     outcome, they will not be ratified, and therefore cannot be disseminated, without assurance of
     an effective implementation plan. The Consultation and Proposed Implementation Plan
     provides a simple format to outline the plan and must be appended to all procedural documents
     when submitting to the ratification committee.

     10.1. Electronic Access

            Trust procedural documents
            The TPO will:
                   Publish all Trust procedural documents; and
                   Notify the CSC GMs of the issue of all new and revised procedural documents
                     through the use of the standard email and attach to that email the document

            CSC GMs will ensure that a process is in place for the dissemination of all new or revised
            Trust procedural documents.

            Local procedural documents
            The author will ensure that:

                     They are placed on the Intranet; and
                     A process is in place for the dissemination of all new or revised local
                      procedural documents

            Various routes may be used to inform staff of a new or revised procedural document
            including: email; inclusion in a staff newsletter; posters on notice boards.

 11. REVIEW AND CONTROL

     All Trust and local procedural documents must be reviewed by their authors at least every 3
     years. More frequent review will be required if changes in legislation occur, or new evidence
     becomes available.

     The review, whether it is scheduled or carried out in accordance with a change in legislation or
     evidence-base, should follow the same process as set out in this document for new procedural
     documents.

     The TPO will ensure:

            An effective system is in place to notify an author 4 months prior to a Trust procedural
             document review being required; and
            The correct version of a Trust procedural document is published and the previous
             version archived.

     The author of a local procedural document will ensure:

            An effective system is in place to ensure appropriate and timely review; and
            The correct version of a local procedural document is placed on the relevant section of
             the Intranet and the previous version archived.



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 12. ARCHIVING AND RETRIEVAL

     12.1. Archiving
           The TPO is responsible for maintaining an archive of Trust procedural documents, once
           they have been deemed redundant or superseded by a revised document.

            The author of a local procedural document is responsible for ensuring a system is in
            place for archiving the document, once it has been deemed redundant or superseded by
            a revised document.

     12.2. Retrieval
           Any member of staff who requires a copy of an archived Trust procedural document
           should contact the TPO on ext 7700 3477

            Any member of staff who requires a copy of an archived local procedural document
            should contact the author of the current document.

 13. EQUALITY IMPACT ASSESSMENT

     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.

 14. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
     PROCEDURAL DOCUMENTS

     The effectiveness in practice of all procedural documents should be routinely monitored
     (audited) to ensure the document objectives are being achieved. The process for how the
     monitoring will be performed should be included in the procedural document.

     The details of the monitoring to be considered include:

           The aspects of the procedural document to be monitored through the use of standards
            or key performance indicators (KPIs). Where the policy relates to an NHSLA standard,
            as a minimum, the minimum requirements of the NHSLA must be monitored to ensure
            compliance;

           The methodology for monitoring e.g. spot checks, observation audit, data collection;

           Frequency of the monitoring e.g. quarterly, annually, to include the timeframe for
            performing and reporting;

           The designation (job title) of who will have responsibility for monitoring and reporting on
            compliance;

           The committee or group who will be responsible for receiving the results and taking
            action as required. In most circumstances this will be the committee which ratified the
            document.




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  15. MONITORING THE EFFECTIVENESS OF THIS POLICY
       As a minimum the following will be monitored to ensure compliance


                                                                                     Frequency of
                                                                                                                                               Lead(s) for acting on
   Element to be monitored               Lead                     Tool                 Report of           Reporting arrangements
                                                                                                                                                recommendations
                                                                                     Compliance
100% of Trust polices are in
accordance with the following
requirements:
 Style and format
                                     Head of Risk
 Definitions                                           Audit of Trust-wide Policy                                                         Head of Risk Management and
                                   Management and                Database                           Policy audit report to:
 Consultation process                                                                                                                             Legal Services
                                    Legal Services
                                                                                       Annually        Governance and Quality Committee    (as Chair of Trust Procedural
 Ratification process             (as Chair of Trust
                                                         Spot Checks on Local                                                               Document Group) / Owner of
 Review arrangements                 Procedural
                                                                                                                                                  relevant policies
                                   Document Group)       Procedural Documents
 Control      of     documents,
  including archiving
 Associated Documents
 Supporting References
 100% of polices are current        Head of Risk
                                                                                                                                           Head of Risk Management and
  and valid.                       Management and       Audit of Trust-wide Policy                  Report to Governance and Quality
                                                                                      Bi-annually                                                 Legal Services
                                    Legal Services              Database                            Committee




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                                                                                                                                                        Version 4. ???
                                                                                                                                                                Page 12 of 21
 16. ASSOCIATED DOCUMENTATION

     An Organisation-Wide Policy for the Development and Management of Procedural Documents:
     NHSLA, March 2011. www.nhsla.com/Publications/

     NHSLA Risk Management            Standards    for   Acute    Trusts:   NHSLA,   April   2007
     www.nhsla.com/Publications/




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APPENDIX A: PROCEDURAL DOCUMENT TEMPLATE




                                TITLE OF DOCUMENT




Version

Name of responsible (ratifying) committee

Date ratified

Document Manager (job title)

Date issued

Review date

Electronic location

Related Procedural Documents

Key Words (to aid with searching)




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CONTENTS




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QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.

For quick reference the guide below is a summary of actions required. 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. The quick reference can take the form of a list or a flow chart, if the latter would more easily
explain the key issues within the body of the document

    1.

    2.

    3.

    4.

    5.

    6.

    7.

    8.

    9.




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 1. INTRODUCTION

     Introduce the policy to the reader.


 2. PURPOSE

     Purpose of the document including the rationale for development.

     Briefly outline the objectives and reasons for the procedural document.


 3. SCOPE

     To whom the document applies.


     ‘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

     List and describe the meaning of the terms used in the context of the document.

 5. DUTIES AND RESPONSIBILITIES

     Detail the duties, accountabilities and responsibilities (including level) of Directors, individuals,
     specialist staff, departments and committees.


 6. PROCESS

     Detail the process to be followed.


 7. TRAINING REQUIREMENTS

     Specify all training requirements for all levels of staff, how frequently the training should take
     place, how it is to be delivered, and where appropriate by whom. If the document is linked to
     Essential Training a cross reference to the Trust’s Training Matrix needs to be made in this
     section.

     Include within this section any processes for following up those who fail to complete the
     training: this needs to be in line with any learning and development policies and include a cross
     reference to such policies.

 8. REFERENCES AND ASSOCIATED DOCUMENTATION

     Procedural documents must be evidence-based and referenced, wherever possible.
     References could include any associated national policies, standards, guidelines, Acts of
     Parliaments.
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     References and associated documents must be checked when reviewing an existing
     procedural document, to ensure they are still current and relevant.

     The following referencing format must be used:

     An Organisation-Wide Policy for the Development and Management of Procedural Documents:
     NHSLA, May 2007. www.nhsla.com/Publications/

 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


     All policies must include this standard equality impact statement. However, when sending for
     ratification and publication, this must be accompanied by the full equality screening assessment
     tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
     Documentation




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 10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

     This document will be monitored to ensure it is effective and to assurance compliance.




            Minimum requirement      Lead              Tool          Frequency of         Reporting arrangements        Lead(s) for acting on
               to be monitored                                         Report of                                         Recommendations
                                                                      Compliance
                                                                                      Policy audit report to:
                                                                                      
                                                                                      Policy audit report to:
                                                                                      
                                                                                      Policy audit report to:
                                                                                      

     The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
     achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.

     The details of the monitoring to be considered include:

           The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
           The lead for ensuring the audit is undertaken
           The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
           Frequency of the monitoring e.g. quarterly, annually;
           The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required. In
            most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on the Trust
            Intranet Trust Intranet -> Policies -> Policy Documentation
           The lead(s) for acting on any recommendations necessary
        .




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(Review date January 2015 (unless requirements change)
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APPENDIX B: STANDARD EMAIL FOR DISTRIBUTION OF RATIFIED TRUST
PROCEDURAL DOCUMENTS




To: CSC General Managers


Dear Colleagues

RE: Insert Title of Document

Please find attached a copy of the above recently revised/developed* procedural document.
I should be grateful if you would ensure:

   Withdrawal     of      any     paper     copies   of    the    previous     document       entitled
    …………………………………............., dated ………………… (delete if new document)
   Appropriate distribution of the attached document throughout your division.
   That processes are in place so that staff can access the document: either electronically or in hard
    copy.

Yours sincerely




Trust Policies Officer




Development and Management of Procedural Documents: Version 4 9 February 2012
(Review date January 2015 (unless requirements change)

                                                                             Page 20 of 21
APPENDIX C: TRUST PROCEDURAL DOCUMENT RATIFYING COMMITTEES/GROUPS


              POLICY CATEGORY                                   RATIFICATION BODY

Full Board approval required                      Trust Board

Blood Related Procedural Document                 Hospital Transfusion Committee

Clinical Procedural Document – Nursing            Nursing & Midwifery Advisory Committee

Clinical Procedural Document – Medical            Clinical Directors Forum

Education and Training Procedural Document        Learning and Development Team

Emergency Preparedness Procedural Document        Major Incident Planning Committee

Health & Safety Procedural Document               Health & Safety Committee

Human Resources Procedural Document               Human Resources Policy Group

Infection Control Procedural Document             Infection Control Management Committee

Information Governance Procedural Document        Information Governance Steering Group

Financial Procedural Document                     Trust Board

Medicines Related Procedural Document             Formulary and Medicines

Medical Devices Procedural Document               Medical Devices Management Committee
Procurement Related Procedural Document           Director of Procurement and Commercial
                                                  Services; and Director of Finance and
                                                  Investments
Research Governance Procedural Document           Research and Governance Committee

Resuscitation Related Procedural Document         District Resuscitation Committee

Risk Management Procedural Document               Risk Assurance Committee


This list is not exhaustive: any advice can be obtained from the Chair of the Trust Procedural
Advisory and Audit Group: 7700 6388




Development and Management of Procedural Documents: Version 11 9 February 2012
(Review date January 2015 (unless requirements change)

                                                                                      Page 21 of 21

				
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