Document control policy including policy and guidance template

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1 Document level: Trustwide (TW) Code: GP1 Issue number: 8 Document control policy including policy and guidance template Lead executive Authors details Type of Target audience Document purpose Medical Director- Compliance, Assurance & Learning Policy Support Officer (PSO) Safe Services Department Policy All CWP staff involved in the development of approved policy and guidance s. This policy sets out the standards for the development, consultation, approval, review and control / archive of all Trust approved policy and guidance s. Approving meeting Quality Committee (QC) 07-May-14 Implementation date May-14 followed by an annual review CWP s to be read in conjunction with FR1 Integrated governance strategy Document change history What is different? Appendices / electronic forms What is the impact of change? The process has been updated as a result of the policy survey results from staff and authors and organisational structure changes. This policy has been revised to reflect practice, support staff involved in policy developments and to outline the approval process. Duties and responsibilities sections have been removed and replaced by process flowcharts to prevent duplication. Quick reference flowcharts have been introduced and strategy and SOP have been removed from this process. App 1 The step by step process has been removed and replaced with a quick reference flowchart showing the full development and approval process; App 2 Approved template has been replaced by the revised version as appendix 1; App 3 Addendum template has been removed and not been replaced. Approving groups have overall responsibly for s they approve; Minor changes can be made with quickness and ease; Visual process flowcharts instead of wordy paragraphs (no duplication and support for clinical staff with implementation of policy); Amended template to support the circulation and distributions of updates. To view the s Equality Impact Assessment (EIA) and see who the was consulted with during the review please click here Page 1 of 9

2 Contents Quick reference flowchart Introduction Policy synopsis Policy / guidance process flowchart Definition of approved s Policy definition Guidance definition Process for approved s Consultation Approval Review Standards for CWP approved s Style and format CWP s to be read in conjunction with Appendices and working forms Supporting references Equality Impact Assessment (EIA) Version control Document addendums... 7 Appendix 1 Approved template for policies and guidance s... 8 Page 2 of 9

3 Quick reference flowchart For quick reference the guide below is a summary of actions required. Reviewed Document Author to the PSO alerting of a review PSO to request for background information to enable decision for need for policy development / review Author to PSO for approved template New Document PSO sends to Head of Compliance Authors responds with information PSO to liaise with author to discuss options Confirmed the route of approval and to continue PSO to provide template & current version if required Author writes / reviews content Author sends to PSO to process PSO to Quality Assurance (QA) check the PSO to upload to the discussion board for 2 weeks PSO to close the discussion at the deadline date Author to send final to PSO to process Author considers feedback and updates accordingly PSO to liaise with author providing the feedback received PSO to complete QA / add consultation information Is chairs approval required? PSO to send to approving groups admin lead Approving meeting takes place Author to send PSO final amended Author to follow recommendations from the meeting as minuted Document approved Approved subject to amendments Author to liaise with PSO for the to amend Author to make amends on sent and send back to PSO PSO to provide to the author to make minor amends PSO to send to approving chair for chairs action PSO to send to Head of Compliance for Approval Approved with NO amendments PSO to complete final QA, PDF, add hyperlinks and create appendices and upload to the webiste PSO to communicate to all staff the published Author completes amendments and sends final to PSO Are they minor? Author has identified that amendments are required Is a review required? PSO to contact the author 12 months after implementation and completed annual compliance folow-up PSO to add date to page 1 and log on the database to contact author in 12 months Page 3 of 9

4 1. Introduction This outlines the requirements to ensure all Trustwide (TW) and Locality procedural s are written, approved, disseminated and reviewed within a robust and safe framework to minimise risk to service users, carers, the public and staff. 2. Policy synopsis This known as GP1 provides an outline of how s / policies are developed, reviewed and approved and includes a template (appendix 1). The detail of the author s role and responsibilities are highlighted within the policy / guidance process flowchart. This process applies to all local and trustwide policies / s and ensures the appropriate consultation and approval processes are followed prior to uploading the s to the website. 3. Policy / guidance process flowchart To view the full policy / guidance process flowchart see the quick reference section above for a summary of actions required. 4. Definition of approved s CWP recognises that there are many different national and local definitions and interpretations of what constitutes a policy and guidance. However, such diversity in interpretation only leads to lack of clarity and confusion. The definitions are outlined below and have been agreed and adopted as workable definitions for use within CWP. For the purpose of this policy these are collectively referred to as s. The type of must be clearly stated by the author i.e. whether the is a policy or guidance. There are four levels of s within CWP these are: Level of Who is this applicable to Examples 1. Trustwide (TW) Localities, clinical service specialities, wards / teams and all corporate services All CWP staff 2. Localities A locality 3. Clinical Service Speciality (CSS) 4. Ward / team A clinical speciality within the locality A ward or team within a locality East locality; however, if the is applicable to 2 localities or more then it is a TW e.g. East and West. Wirral (1 locality) AMH speciality Wirral locality - AMH speciality - Lakefield Ward Clinical Service Specialties (CSS), localities and ward / team procedural s should use this policy as guidance to follow CWP s best practice when producing local policies / guidelines. The level to which the is aimed must be clearly stated within the template (appendix 1). Locality, CSS and ward / team s must not override trust policy. Strategies are not covered as part of this and sit under the responsibility of the Operational Board or Board in line with the corporate governance structure. In order to ensure ongoing effectiveness of policy s it is essential that if any issues arise in relation to the practical implementation of a policy, the Clinical Director / General Manager or ward / team manager, must contact the PSO on to feedback concerns. In addition during the period of the policy if there are any changes to practice, national guidance that staff feel are not reflected within the policy then it is important for this feedback and suggested changes to be communicated. 4.1 Policy definition Policies are Trustwide (TW) and speciality (CSS) s which support staff and are used to enhance safety as part of CWP s framework on quality, risk and performance management. Page 4 of 9

5 A policy is a formal which must be followed by relevant staff. n-compliance with CWP policies will leave the organisation, staff and service users open to unacceptable risk. A policy formally s the CWP approved standard or procedure and may be relied upon for legal purposes. 4.2 Guidance definition Trust guidance s: Provides a recommended process for delivering an outcome, which affects a broad group within a flexible framework; Are informed by national guidelines or best evidence, e.g. National NHS Complaints Regulations; Should remove ambiguity and doubt whilst allowing some degree of professional judgment and local interpretation. 5. Process for approved s 5.1 Consultation Consultation is a key component of the policy development and approval process, it ensures that relevant staff have the opportunity to effectively input their views into policy development and thus supports successful implementation and engagement. All approved s must be available for a period of time on the CWP website discussion board for consultation with the trustwide reading panel. Evidence of the consultation must be recorded on the policy template as per appendix Approval In order to ensure that policy approval is appropriate to the terms of authorisation of the committees, sub committees and groups, the Head of Compliance will provide guidance to the policy author as to the appropriate level of approval that must be sought in line with the corporate governance structure outlined in the Integrated Governance Strategy. The approval must be evidenced in the agenda and minutes of the approving meeting. The chair of the approving meeting can take action and approve s outside of the meeting, in exceptional circumstances: Where the meeting has not been quorate; Where an urgent need for the to be approved (operational / clinical need); Where chairs require members to have further consultation on the following feedback at the meeting. In such cases the chair will arrange for the to be circulated to the group members for comments and ensure that the author receives direct feedback to be considered and then chairs approval is given on the final. Chairs action / approval will be noted at the next available meeting. 5.3 Review It is the Policy Support Office s (PSO) responsibility to annually review all s with the author to view the effective implementation and continued effectiveness of the. Consideration will also be given to any national or local changes that have been effective during the 12 months post approval and a decision made as to whether the policy requires updating. The options are: If a review is not required the compliance follow-up date will be recorded Review NOT required Minor changes required (not procedural changes) Review required by the PSO and noted to contact the author in 12 months. Minor changes required e.g. spelling, grammar, job titles, locations, contact numbers or meeting names etc. The Head of Compliance can approve these amendments at this time and the will be published. If a review is required (procedural changes) the PSO will request the detail behind the changes and start the review process. Page 5 of 9

6 All meeting groups within the corporate governance structure with review and implementation responsibilities for policy / guidance s will receive a chairs report from the Head of Compliance detailing the outcomes of the annual reviews. The report will also incorporate the annual monitoring information relating to the process / that has been undertaken at that point. There are a number of ways in which a can be monitored, including: Audit of the processes outlined within the trustwide ; Progress report against an implementation plan outlined within the TW ; A survey conducted to assess the impact of the TW ; Review of incident / performance data to assess the effectiveness of the TW. If a author leaves the trust the responsibility of the review of the transfers to the post holder s successor, unless the post is not replaced, it is then the responsibility of the appropriate sub-committee / committee to reassign responsibility to another individual. All s remain in force and current until they are replaced or removed by the formal processes - even if the timeframe for review has elapsed. 6. Standards for CWP approved s 6.1 Style and format All s must be in the agreed / approved format as per appendix 1. To facilitate ease of reading and understanding, authors should have a definitions section, outlining the meaning / explanation of any terms used in the context of the. A flowchart must be incorporated after the opening introduction to visually show the detail of the steps within the, this should include: The staff that are involved; Timeframes / deadlines of the process (where required); Appendices / forms / other CWP s required to be used / read in conjunction with; Systems used and reporting / escalating routes (where required). All appendices need to be referenced throughout the content of the and may be highlighted to assist the reader. 6.2 CWP s to be read in conjunction with Document authors may signpost readers to relevant associated ation to prevent duplication of information; these s should be incorporated within the flowchart process and may be highlighted to assist the reader. These s are to be recorded on the front page of the, including codes and full titles. 6.3 Appendices and working forms All appendices / working forms need to be referenced as part of the process throughout the. The PSO will create the downloadable version of the working form for staff access. To create additional clinical forms within the electronic health record systems e.g. Caretes, please contact the PSO on for support and guidance re the process for approval. NB. In order to address the risks associated with dual record keeping, additional paper versions of clinical forms should only be created as a last resort and been agreed with the Head of Compliance before created. 6.4 Supporting references Any source used within the context of the must be referenced within the references table and contain the following information: date, author, title and publisher. Page 6 of 9

7 6.5 Equality Impact Assessment (EIA) All s must have an initial EIA undertaken. This assessment will be conducted by the author and must be completed as per appendix 1. Where an adverse or negative impact on equality group(s) has been identified during the initial assessment process a full EIA should be conducted. For further information or support contact the HR department. 6.6 Version control To aid version control, all s should be saved with a file name as follows: code, title and issue number e.g. GR3 Risk management policy Issue 4. The PSO will format the titles of all final issues including archived versions. It is an individual responsibility for all staff to keep up to date with policy development and review and to view the policy synopsis when issued via CWP essential. Paper versions of s / working forms should not be retained and all s should be accessed via the desktop policy icon on all CWP computers. Webpage favourites can also be saved to visit regularly accessed s and forms, for more guidance please contact the Policy Support Officer (PSO) on All footers have the following text displayed: Do not retain a paper version of this, always view policy / guidance s from the desktop icon on your computer. 7. Document addendums An addendum is an urgent addition to a, subsequent to its approval and distribution and is only appropriate when an immediate update is required, for further information please contact the PSO on Page 7 of 9

8 Appendix 1 Approved template for policies and guidance s Lead executive Authors details Type of Target audience Document purpose Policy / guidance title Document level: Code: Issue number: Approving meeting Implementation date followed by an annual compliance review Date CWP s to be read in conjunction with Document change history What is different? Appendices / electronic forms What is the impact of change? Training requirements Document consultation East locality Wirral locality West locality Corporate services External agencies Financial resource implications External references 1. Equality Impact Assessment (EIA) - Initial assessment / Comments Does this affect one group less or more favourably than another on the basis of: - Race - Ethnic origins (including gypsies and travellers) - Nationality - Gender - Culture - Religion or belief Page 8 of 9

9 Equality Impact Assessment (EIA) - Initial assessment / Comments - Sexual orientation including lesbian, gay and bisexual people - Age - Disability - learning disabilities, physical disability, sensory impairment and mental health problems Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Is the impact of the likely to be negative? - If so can the impact be avoided? - What alternatives are there to achieving the without the impact? - Can we reduce the impact by taking different action? Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? What is the level of impact? Page 9 of 9

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