Policy for the Development and Management of Procedural Documents Caesarean Section by benbenzhou

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Policy for the Development and Management of Procedural Documents Caesarean Section

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									     POLICY FOR THE DEVELOPMENT AND MANAGEMENT OF
                 PROCEDURAL DOCUMENTS




Reference Number                              15.11

Version                                       9

Name of responsible (ratifying) Committee     Trust Procedural Document Group

Date ratified                                 05.02.2010

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

Date issued                                   08.02.2010

Review date                                   January 2013

Electronic location                           Management Policies

Related Procedural Documents                  See section 17 of this policy
                                               Portsmouth Hospitals Procedural Document template
                                               policy guideline policies guidelines guidance procedure
Key Words (to aid searching)                   strategy protocol ratification responsible committee
                                               ratifying archiving archive business continuity hard
                                               copy policy folder
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




Procedural Documents Development and Management Policy. (Review date: January 2013)
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CONTENTS
    QUICK REFERENCE GUIDE ......................................................................................................................... 3
1. INTRODUCTION............................................................................................................................................. 5
2. PURPOSE....................................................................................................................................................... 5
3. SCOPE ............................................................................................................................................................ 6
4. DEFINITIONS ................................................................................................................................................. 6
5. DUTIES AND RESPONSIBILITIES ................................................................................................................ 7
6. PROCESS..................................................................................................................................................... 12
    6.1. Rationale ............................................................................................................................................. 12
    6.2. Evidence Review ................................................................................................................................. 12
    6.3. Identification of Stakeholders .............................................................................................................. 12
7. STYLE AND FORMAT………………………………………………………………………………………………12
8. REFERENCES AND ASSOCIATED DOCUMENTATION............................................................................ 13
9. EQUALITY IMPACT ASSESSMENT ............................................................................................................ 13
10. CONSULTATION .......................................................................................................................................... 14
11. RATIFICATION ............................................................................................................................................. 14
    11.1. Ratification of Trust Procedural Documents........................................................................................ 14
12. DISSEMINATION .......................................................................................................................................... 15
    12.1. Electronic Access ................................................................................................................................ 15
    12.2. Hard Copy Availability ......................................................................................................................... 15
13. REVIEW AND CONTROL............................................................................................................................. 15
14. ARCHIVING AND RETRIEVAL .................................................................................................................... 16
    14.1. Archiving .............................................................................................................................................. 16
    14.2. Retrieval .............................................................................................................................................. 16
15. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS . 16
16. MONITORING THE EFFECTIVENESS OF THIS POLICY .......................................................................... 17
    16.1. Ratification Committees ...................................................................................................................... 17
    16.2. Trust Procedural Document Advisory and Audit Group ...................................................................... 17
17. ASSOCIATED DOCUMENTATION .............................................................................................................. 18
APPENDIX A ........................................................................................................................................................ 19
    Checklist for the Review and Ratification of Procedural Documents and Consultation and Proposed
    Implementation Plan ..................................................................................................................................... 19
APPENDIX B ........................................................................................................................................................ 21
    EQUALITY IMPACT ASSESSMENT ............................................................................................................ 21
APPENDIX C ........................................................................................................................................................ 22
    NHSLA Risk Management Standards – April 2009 ...................................................................................... 22
APPENDIX D ........................................................................................................................................................ 23
    CNST Standards – April 2008....................................................................................................................... 23
APPENDIX E ........................................................................................................................................................ 24
    STANDARD EMAIL FOR DISTRIBUTION OF RATIFIED TRUST PROCEDURAL DOCUMENTS ............ 24
APPENDIX F ........................................................................................................................................................ 25
    TRUST PROCEDURAL DOCUMENT COMMITTEE APPROVAL ............................................................... 25




Procedural Documents Development and Management Policy. (Review date: January 2013)
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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 7701 2431

    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 ->
       Policies)

    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 -> Policies -> Templates)

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

    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 completed

    12. Publish the document, archiving any previous versions as appropriate, and forward the
        document to the Divisional General Managers for appropriate dissemination

    13. Forward the Equality Impact Assessment to the Trust Diversity Advisor




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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

   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 be comprehensive and provide clarity regarding the management of
        both new and revised policies, procedures, protocols, guidelines and standard operating
        procedures.

        For simplicity, the term ‘procedural document’ will be used throughout, to generically refer to all
        types of document, unless otherwise specified. Please refer to section 4 for definitions.

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

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

        Any documents developed for local application (e.g. Division and/or Department) must follow
        the appropriate ratification pathway and must comply with this policy, as set out in section 11.1.

        For any procedural document that the author considers is not covered by this policy advice
        should be sought from the Chair of the Trust Procedural Document Group: Head of Risk
        Management and Legal Services – Ext 7701 2424


 2. PURPOSE

        The purpose of this policy is to:

        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, which supports
         document management;

        Ensure all procedural documents are accompanied by a comprehensive dissemination and
         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 and;

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




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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 provide a basis for consistent decision-making and resource allocation.

     Procedure
     A procedure can be defined as a standardised method of performing clinical or non-clinical
     tasks. Procedures, including standard operating procedures (SOPs), usually have a narrow
     application and include a serious of actions or detailed instructions to be carried out in order to
     achieve a safe, effective and consistent outcome.

     Protocol
     A protocol can be defined as a rigid statement of practice, which must be adhered to: they allow
     little flexibility or variation and as such are only suitable for certain, very specific, aspects of
     practice where the course of action is universal.

     Clinical Guideline
     A clinical guideline is an evidence-based overview of treatments and diagnostic tests to be
     undertaken in certain conditions. They are designed to provide advice, guidance and direction
     to staff whilst leaving room for professional judgment and adaptation to fit individual
     circumstances.

     Integrated Care Pathway (ICP)
     The fundamental principle of an ICP is to make explicit the most appropriate care for a
     particular patient group, based upon the best available evidence and a consensus view of best
     practice.

     The intention of an ICP is to ensure evidence based care is delivered to the patient by the right
     person at the right time in the right environment, to help reduce unnecessary variations in
     treatment and outcome.

     ‘Trust’ Procedural Documents
     Within this document, the term ‘Trust’ is used to refer to all policies, procedures, protocols and
     guidelines which apply across the whole Trust

     ‘Local’ Procedural Documents
     Within this document, the term ‘local’ is used to refer to all policies, procedures, protocols and
     guidelines which only apply to certain departments, rather than across the Trust. In most cases,
     these documents will be approved and managed at departmental / divisional 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.


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 5. DUTIES AND RESPONSIBILITIES

     Chief Executive
     The Chief Executive has ultimate responsibility for Corporate Governance; including ensuring
     processes are in place to support good procedural document management.

     Trust Board
     The Trust Board has overall responsibility for ensuring that, through good procedural document
     management, the organisation complies with all legal, statutory and good practice
     requirements.

     Governance and Quality Committee
     The Governance and Quality Committee is responsible for ensuring that appropriate action is
     taken to ensure all procedural documents are in date. To fulfill this responsibility the Committee
     will receive bi-annual reports from the Trust Procedural Document Committee.

     Divisional Governance Committee
     Divisional Governance Committees are responsible for providing assurance that policy
     management within the divisions is in accordance with the overarching Trust Procedural
     Document policy

     Strategic Learning and Development Committee
     The Strategic Learning and Development Committee is responsible for overseeing the strategic
     leadership and management of all Trust learning and development activities in order to ensure
     the organisation has a workforce, which is fit for purpose and practice and can meet the
     constantly changing demands of healthcare delivery.

     Trust Procedural Document Group
     The Trust Procedural Document Group is responsible for ensuring appropriate procedural
     documents are in place and for providing assurance to the Governance and Quality Committee
     through the provision of a bi-annual report, 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
     Ratification Committees are responsible for ensuring that:

           Appropriate approval is given, and the appropriate author identified, for the development
            of any new, or the revision of any existing, procedural documents;

           Should the need for any new procedural document be identified, an appropriate author
            is assigned responsibility for development;

           Procedural documents referred to them are assessed against the standards set out in
            this policy and document authors are advised accordingly;

           Procedural documents referred to them comply with any relevant National Health
            Service Litigation (NHSLA or CNST) standard(s);

           Consultation with appropriate stakeholders has occurred and a consensus view
            reached;

           The procedural document is technically accurate and in line with evidence based best
            practice;

           An accurate record is kept of discussion and approval of the procedural documented is
            recorded in the minutes of the meeting. These minutes must be available upon request;


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           Processes to enable an audit of compliance with the procedural document are detailed
            in the document;

           Ratified Trust procedural documents are forwarded to the TPO, together with required
            accompanying documentation;

                     Checklist for the Review and Ratification of Procedural Documents and,
                      Consultation and Proposed Implementation Plan (Appendix A)
                     Equality Impact Assessment (Appendix B)
                     NHSLA / CNST Risk Management compliance statement, if required
                     Extract of the minutes which evidence the ratification

           Ratified local procedural documents are forwarded to the document author.

     Authors of Trust Procedural Documents
     Authors are responsible for ensuring that:

           Approval to develop a new, or revise/amend an existing, Trust procedural document is
            gained from the appropriate Committee (Appendix F) and, once approval is gained,
            registering the document with the TPO;

           The Trust procedural document is developed with the involvement of key stakeholders
            and consultation with relevant groups and committees. It may also be appropriate /
            necessary to consult with the Trust solicitors. They may be contacted via the Trust Legal
            Services Manager on ext 7701 2421;

           All Trust procedural documents follow the standards and format as set out in this policy,
            there can be no deviation.

           The procedural document includes the mandatory paragraph relating to the ability to
            comply with its requirements in the event of a ‘major incident’.

           They consider whether the procedural document forms part of the requirements of the
            National Health Service Litigation Authority (NHSLA or CNST) Risk Management
            Standards (please refer to Appendices C and D for the details of the standards), the
            Standards for Better Health, and/or other external or legal requirements;

           If the policy is a requirement of the NHSLA / CNST Risk Management Standards, a
            compliance statement must be completed. Please contact the Governance Compliance
            Manager on ext 7701 2469 or the Risk Management Department on ext 7701 2476 for
            further information.

           An Equality Impact Assessment is carried out. If the answers to any of the questions
            from the Equality Impact Assessment are positive (i.e. the answer is ‘yes’) a full Equality
            and Impact Assessment (available from the Equality and Diversity website) must be
            completed or the policy amended such that only a disadvantage that can be justified is
            included. Further advice can be obtained from the Equality and Diversity Department on
            02932 288511

           The Trust procedural document is proof read for issues such as spelling, punctuation
            and general clarity;

           The Trust procedural document is clearly marked ‘draft’;

           The Trust procedural document is forwarded to the relevant Committee for ratification,
            together with the:



Procedural Documents Development and Management Policy. (Review date: January 2013)
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                        Checklist for the Review and Ratification of Procedural Documents and,
                         Consultation and Proposed Implementation Plan (Appendix A)
                        Equality Impact Assessment (Appendix B)
                        NHSLA Risk Management Standard compliance statement, if required

               Any required amendments, as suggested by the ratification committee, are included and
                the procedural document re-submitted; and

               Reviews of, and amendments to, procedural documents are carried out in a timely
                fashion and submitted for re-ratification, as required.

     Authors of Local Procedural Documents (e.g. guidelines or protocols)
     Authors are responsible for ensuring that:

               Approval to develop a new, or revise/amend, a local procedural document is gained
                from the appropriate group. (a ‘group’ could also be a committee or forum).

               The local procedural document is developed with the involvement of key stakeholders
                and consultation with relevant groups and committees. It may also be appropriate /
                necessary to consult with the Trust solicitors. They may be contacted via the Trust Legal
                Services Manager on ext 7701 2421;

               All Trust procedural documents must follow the standards and format as set out in this
                policy, there can be no deviation.

               The procedural document includes the mandatory paragraph relating to the ability to
                comply with its requirements in the event of a ‘major incident’.

               The content of the local procedural document is evidence-based;

               An Equality Impact Assessment is carried out. If the answers to any of the questions
                from the Equality Impact Assessment are positive (i.e. the answer is ‘yes’) a full Equality
                and Impact Assessment (available from the Equality and Diversity website) must be
                completed or the policy amended such that only a disadvantage that can be justified is
                included. Further advice can be obtained from the Equality and Diversity Department on
                02932 288511

               The local procedural document is clearly marked ‘draft’;

               The local procedural document is forwarded to the relevant group for ratification,
                together with the:

                        Checklist for the Review and Ratification of Procedural Documents and,
                         Consultation and Proposed Implementation Plan (Appendix A)
                        Equality Impact Assessment (Appendix B)

               Any required amendments, as suggested by the ratification group, are included and the
                procedural document re-submitted;

               Once the document is ratified:

            o     A copy of the Equality Impact Assessment is forwarded to the Trust’s Diversity
                  Advisor;
            o     Any reference to ‘draft’ is removed
            o     The document is published
            o     All necessary staff are informed of new and amended local procedural documents.

               All necessary staff are informed of new and amended local procedural documents;

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           Reviews of, and amendments to, existing procedural documents are carried out in a
            timely fashion and submitted for re-ratification, as required.

           An archive of local documents is maintained in a safe environment, in accordance with
            the Schedule for the Retention of Documents DoH Health Records Retention Schedule
            06.pdf and in a manner which enables simple retrieval if required.

     Divisional General Managers (DGMs)
     DGMs are responsible for ensuring that processes are in place for:

           The distribution of all ratified Trust procedural documents and that the quality of
            reproduced copies is of an acceptable standard;

           Monitoring adherence with local and Trust procedural documents;

           Enabling staff to access local and Trust procedural documents i.e. through the Intranet
            or hard copy; and

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

     Ward and Department Managers
     Ward and Department Managers are responsible for ensuring:

           That up-to-date files of relevant Trust and local procedural documents are maintained;

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

           Compliance by staff, contractors and others affected by the scope of 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 Policies Officer
     The Trust Policies Officer is responsible for:

           Ensuring that all references to ‘draft’ are removed from ratified Trust procedural
            documents;

           Ensuring that the front sheet contains;
                  Reference Number
                  Version
                  Name of responsible (ratifying) committee
                  Date ratified
                  Document manager (job title)
                  Date issued
                  Review date
                  Electronic location
                  Related procedural documents
                  Key words

           Ensuring that there is an appropriate header and footer on each page, which states:
                  The name of the document
                  Issue date
                  Version number

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                     Page x of y

           Notifying the DGMs of the issue of all new and revised ratified Trust procedural
            documents through the use of a standard email (Appendix E).

           Publishing the Trust procedural document;

           Forwarding a copy of the completed Equality Impact Assessment to the Trust Diversity
            Advisor;

           Maintaining, in a safe environment, a full and accurate register of all existing and
            pending Trust procedural documents, including document reference numbers, author
            contact details, date of issue and review date;

           Maintaining, in a safe environment, an archive of Trust procedural documents, in
            accordance with the Schedule of Retention of Documents DoH Health Records Retention
            Schedule 06.pdf

           Ensuring an effective system is in place to notify an author 4 months prior to a document
            review being required. The TPO will also copy this communication to the chair of the
            relevant ratification committee;

           Maintaining the Trust Intranet site for Trust procedural documents;

           Maintaining in a safe environment extract of minutes, which confirm the Trust procedural
            document has been ratified;

           Providing the Trust Procedural Document Group with the information necessary for
            production of the bi-annual report to the Governance and Quality Committee;

           Updating the NHSLA evidence template; and

           Providing a source of expertise and advice in relation to the requirements of the Trust
            standards for procedural documents.

     Trust Diversity Advisor
     The Trust Diversity Advisor is responsible for:

           Publication of Equality Impact Assessments;

           Providing advice on the completion of Equality Impact Assessments; and

           Maintaining a database of archived Equality Impact Assessments.


     All Trust Employees
     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




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            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
          and the TPO can 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:

                      National Health Service Litigation Authority
                      Department of Health
                      Healthcare 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


 7. STYLE AND FORMAT

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


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     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’.

     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, May 2007. www.nhsla.com/Publications/


 9. EQUALITY IMPACT ASSESSMENT

     The Trust has a statutory responsibility under the Race Relations (Amendment) Act 2000, the
     Disability Discrimination Act 2005 and the Equality Act 2006 to:

           Identify relevant functions, services and policies;



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           Set out arrangements, including consultation, to assess the likely impact proposed
            policies will have on gender, race or disability; and
           Monitor policies for adverse impact.

     The Trust also identifies and addresses and adverse impact related to:
         Sexual orientation
         Gender reassignment
         Religion and/or belief

     To fulfill this responsibility an Equality Impact Assessment must be completed and published on
     the Equality and Diversity website on the intranet for each new and revised procedural
     document.

     The Equality Impact Assessment is designed to:

           Identify where certain groups are excluded from any service
           Help identify direct or indirect discrimination
           Assess if there may be any adverse impact on particular groups
           Assist in considering alternative measures that might address that adverse impact
           Help mainstream equality in all documents and practices

     The completed Equality Impact Assessment must accompany the procedural document when it
     is submitted for ratification and once the document is ratified must be forwarded to the Trust
     Diversity Advisor for publication.

     A blank template can be found on the Trust Intranet. Home page -> Policies -> Templates

     Additional information and advice on Equality Impact Assessments can be found on the Trust
     Intranet. Home page -> Departments -> Equality and Diversity, or by contacting the Diversity
     Advisor on 02392 288511.

 10. CONSULTATION

     Consultation with relevant stakeholders (see section 6.3) 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.

 11. 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.


     11.1. Ratification of Trust Procedural Documents
           All Trust and local procedural documents will be ratified by the relevant Trust committee
           or group. Appendix F 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,


Procedural Documents Development and Management Policy. (Review date: January 2013)
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           advice on ratification can be obtained from the Chair of the Trust Procedural Document
           Group: Head of Risk Management and Legal Services – ext 7701 2424

 12. 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.

     12.1. Electronic Access

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

           DGMs 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.

     12.2. Hard Copy Availability
           Ward and Departmental Managers are responsible for ensuring that:

                     Each ward, clinical area and department has a set of files containing relevant
                      Trust procedural documents and/or that staff have immediate access to
                      electronic copies; and
                     The set of files is kept up-to-date with the correct version of any procedural
                      document relevant to their area and all redundant/superseded documents
                      removed

           Authors of local procedural documents are responsible for ensuring that:

                     Their local documents are included in the hard copy files maintained by the
                      ward and departmental managers; and
                     Those documents are the latest version and all redundant/superseded
                      documents are removed

 13. 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.




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     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.

 14. ARCHIVING AND RETRIEVAL

     14.1. 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.

     14.2. Retrieval
           Any member of staff who requires a copy of an archived Trust procedural document
           should contact the TPO on ext 7701 2431

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

 15. 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;



Procedural Documents Development and Management Policy. (Review date: January 2013)
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            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.

            How actions will be undertaken where deficiencies in compliance are identified (ie.
             through action plans which include timescales); and

            How learning from the monitoring/audit will be disseminated to others within the
             organisation (organisational learning).

 16. MONITORING THE EFFECTIVENESS OF THIS POLICY

     16.1. Ratification Committees

            The ratification committees have a role to play in monitoring the effectiveness of this
            policy. The committees should ensure that a Checklist for the Review and Ratification of
            Procedural Documents and a Consultation and Proposed Implementation Plan (Appendix
            A) has been completed.

            If non-compliance is identified, the procedural document will not be published and the
            document returned to the author.

     16.2. Trust Procedural Document Group

            Audits
            The Group will undertake bi-annual audits of Trust procedural documents and spot
            checks on local procedural documents to monitor compliance and ensure that:

                  Trust procedural documents held on the Intranet are current and in the correct
                   format;
                  The system for the review of Trust procedural documents is operating effectively
                   and all policies are reviewed within agree time scales;
                  All new Trust procedural documents are ratified within 4 months of approval for
                   development;
                  All revised/amended procedural documents are re-ratified within 4 months of
                   approval for review


            Reporting
            The Trust Procedural Document Group will provide a bi-annual report to the Governance
            and Quality Committee. As a minimum this report will contain information on

                  Trust procedural documents which have been ratified in the preceding six months;
                  Trust procedural documents which are coming up for review but no action has
                   been taken;
                  The time from registration to ratification of new Trust procedural documents;
                  The time from notification of a required review of an existing Trust procedural
                   document, to review and ratification;
                  Spot checks on local procedural documents;
                  The audit of effectiveness of the Trust Policy on the Development and
                   Management of Procedural Documents; and
                  Any required recommendations to address any identified deficits in the process

            The Governance and Quality Committee will receive the bi-annual report and take
            appropriate action as recommended by that committee.



Procedural Documents Development and Management Policy. (Review date: January 2013)
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 17. ASSOCIATED DOCUMENTATION

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




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                                                                                            APPENDIX A

               Checklist for the Review and Ratification of Procedural Documents and
                           Consultation and Proposed Implementation Plan
To be completed by the author of the document and attached when the document is submitted for ratification: a
blank template can be found on the Trust Intranet. Home page -> Policies -> Templates

                                      CHECKLIST FOR REVIEW AND RATIFICATION
                                                                             YES/NO
               TITLE OF DOCUMENT BEING REVIEWED:                                           COMMENTS
                                                                               N/A
1      Title
       Is the title clear and unambiguous?
       Will it enable easy searching/access/retrieval??
       Is it clear whether the document is a policy, guideline, procedure,
       protocol or ICP?
2      Introduction
       Are reasons for the development of the document clearly stated?
3      Content
       Is there a standard front cover?
       Is the document in the correct format?
       Is the purpose of the document clear?
       Is the scope clearly stated?
       Does the scope include the paragraph relating to ability to comply,
       in the event of a infection outbreak, flu pandemic or any major
       incident?
       Are the definitions clearly explained?
       Are the roles and responsibilities clearly explained?
       Does it fulfill the requirements of the relevant Risk Management
       Standard? (see attached compliance statement)
       Is it written in clear, unambiguous language?
4      Evidence Base
       Is the type of evidence to support the document explicitly
       identified?
       Are key references cited?
       Are the references cited in full?
       Are associated documents referenced?
5      Approval Route
       Does the document identify which committee/group will approve it?
6      Process to Monitor Compliance and Effectiveness
       Are there measurable standards or KPIs to support the monitoring
       of compliance with the effectiveness of the document?
7      Review Date
       Is the review date identified?
6      Dissemination and Implementation
       Is a completed proposed implementation plan attached?
7      Equality and Diversity
       Is a completed Equality Impact Assessment attached?




Procedural Documents Development and Management Policy. (Review date: January 2013)
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                                                                                                       APPENDIX A
                                                                                                                  cont……

              Checklist for the Review and Ratification of Procedural Documents and
                          Consultation and Proposed Implementation Plan

                             CONSULTATION AND PROPOSED IMPLEMENTATION PLAN
Date to ratification committee
Groups /committees / individuals involved in the
development and consultation process




Is training required to support implementation?




If yes, outline plan to deliver training




Outline any additional activities to support
implementation




Individual Approval

If, as the author, you are happy that the document complies with Trust policy, please sign below and send the document,
with this paper, the Equality Impact Assessment and NHSLA checklist (if required) to the chair of the committee/group
where it will be ratified. To aid distribution all documentation should be sent electronically wherever possible.

Name                                                                                  Date


Signature

Committee / Group Approval

If the committee/group is happy to ratify this document, would the chair please sign below and send the policy together with
this document, the Equality Impact Assessment, and NHSLA checklist (if required) and the relevant section of the minutes
to the Trust Policies Officer. To aid distribution all documentation should be sent electronically wherever possible.

Name                                                                                  Date


Signature


If answers to any of the above questions is ‘no’, then please do not send it for ratification.




Procedural Documents Development and Management Policy. (Review date: January 2013)
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                                                                                            APPENDIX B

                                       EQUALITY IMPACT ASSESSMENT
To be completed by the author of the document and attached when the document is submitted for
ratification: a blank template can be found on the Trust Intranet. Home page -> Policies -> Templates

Title of document for assessment
Date of assessment
Job title of person responsible for assessment
Division/Service



                                                     Yes/No                      Comments
Does the document affect one group less or more favourably than another on the basis of:

   Race

   Gender (including transgender)

   Religion or belief

   Sexual orientation, including lesbian, gay and
    bisexual people

   Age (for HR policies only)

   Disability – learning disabilities, physical
    disabilities, sensory impairment and mental
    health problems
Does this document affect an individual’s human
rights?
If you have identified potential discrimination,
are the exceptions valid, legal and/or justified?




If the answers to any of the above questions is ‘yes’ you will need to complete a full Equality Impact
Assessment (available from the Equality and Diversity website) or amend the policy such that only an
disadvantage than can be justified is included. If you require any general advice please contact staff
in the Equality and Diversity Department on 02392 288511




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                                                                                                                                         APPENDIX C

                                                     NHSLA Risk Management Standards – April 2009
Standard
                         1                             2                            3                        4                           5
   
Criterion                                       Competent &                       Safe                    Clinical                Learning from
                    Governance
                                             Capable Workforce               Environment                  Care                    Experience

   1        Risk management strategy          Corporate induction         Secure environment       Patient identification       Incident reporting

               Policy on procedural            Local induction of
   2                                                                       Sickness absence         Patient information         Raising concerns
                    documents                   permanent staff

                 Risk management               Local induction of
   3                                                                      Safeguarding adults            Consent                   Complaints
                   committee(s)                 temporary staff

            Risk awareness training for   Supervision of medical staff                            Clinical record-keeping
   4                                                                       Moving & handling                                         Claims
                senior management                in training *                                           standards

   5         Risk management process      Risk management training         Slips, trips & falls    Transfer of patients           Investigations


   6               Risk register            Training needs analysis       Inoculation incidents   Medicines management               Analysis

               Responding to external
                                                                         Maintenance of medical
   7        recommendations specific to    Medical devices training                                 Blood transfusion             Improvement
                                                                          devices & equipment
                  the organisation

                  Clinical records
   8                                        Hand hygiene training        Harassment & bullying        Resuscitation            Best practice - NICE
                   management

                Professional clinical                                                                                       Best practice - NSFs, NCEs
   9                                      Moving & handling training     Violence & aggression       Infection control
                    registration                                                                                              & High Level Enquiries

                                          Supporting staff involved in
   10           Employment checks          an incident, complaint or             Stress            Discharge of patients           Being open
                                                     claim



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                                                                                                                                              APPENDIX D

                                                                  CNST Standards – April 2008
 Standard
    
                          1                            2                              3                              4                          5
 Criterion
     

                                            Emergency Caesarean
     1        Risk Management Strategy                                   Pre Eclampsia & Eclampsia        Clinical Risk Assessment    Postnatal Information
                                                  Section

                                                                                                             Booking & Missed          Transfer of the Sick
     2               Leadership                   Auscultation            Assisted Vaginal Delivery
                                                                                                              Appointments                  Newborn

               Organisation of Staffing
                                                                                                           Patient Information &
     3       Levels (Midwifery & Nursing   Electronic Fetal Monitoring        Perineal Trauma                                         Newborn Examination
                                                                                                                Discussion
                        Staff)

               Organisation of Staffing                                                                                              Immediate Care of the
     4                                     Care of Women in Labour         Brachial Plexus Injury             Screening Tests
               Levels (Obstetricians)                                                                                                Newborn Post-Delivery

               Organisation of Staffing
     5         Levels (Anaesthetists &          Use of Oxytocin           Obstetric Haemorrhage              Handover of Care          Newborn Feeding
                     assistants)

                 Policy on Guideline         Attending Emergency
     6            Development &              Department & Hospital       Venous Thromboembolism              Maternal Transfer       Neonatal Resuscitation
                    Management                    Admission

                  Maternity Records                                                                       Systematic Approach to      Referral when a Fetal
     7                                             Recovery                Pre-Existing Diabetes
                    Management                                                                                  Training             Abnormality is Detected

               Incidents, Complaints &
     8                                      High Dependency Care                  Obesity                       Skills Drills        Concern about the Baby
                       Claims


     Those criteria shaded in red are mandatory criteria and maternity services must demonstrate compliance with these to pass the assessment.


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                                                                                        APPENDIX E

     STANDARD EMAIL FOR DISTRIBUTION OF RATIFIED TRUST PROCEDURAL
                              DOCUMENTS



To: Divisional 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




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                                                                                      APPENDIX F

     TRUST PROCEDURAL DOCUMENT COMMITTEE APPROVAL


              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 Steering Group

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                      Finance Committee

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




Procedural Documents Development and Management Policy. (Review date: January 2013)
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