Self-Review Gap Analysis and Assessor RAG Report
This document is intended for you to complete with details of how you meet the Principles and Requirements of The Information Standard and where
your evidence is to prove that you meet each of the Requirements.
The 6 Principles are the high level assessment areas of The Standard and the Requirements are the details which underpin the Principles, and it is
the Requirements against which the applicants will be assessed.
Once you have completed your Self-Review Gap Analysis, it should be returned to The Information Standard team. They will forward it to your
designated Assessor, who will review it, and provided they believe you are at a suitable level of readiness, will book your External Assessment visit.
This document will then be used by the Assessor as the basis for their RAG (Red, Amber, Green) Report which they complete after your External
Assessment and which details whether or not you have met the Requirements of The Standard and which areas, if any, need improvement.
You will complete the third column of the RAG report and the assessor will complete the fourth and fifth columns when they will identify your RAG
measure for each requirement.
In addition to any comments or evidence you can also attach any supporting documents or information to demonstrate compliance. Any documents
submitted or referred to during the assessment can be provided in either electronic or paper version at the discretion of the applicant.
The Self-Review Gap Analysis is intended to be completed with reference to the detailed guidelines within The Principles and Requirements of The
Information Standard and reference can also be made to The Information Standard Assessor Guidelines if further clarification is required. These are
available on our website, www.theinformationstandard.org together with best practice guides.
The Information Standard team can also offer you further advice if you email them at [email protected] or telephone them on
01256 383 890. Alternatively they can put you in touch with other, similar organisations that have already been through the process themselves and
would be willing to offer you some guidance.
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Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
The Principles and Requirements
Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Organisation Name:
Organisation Detail: (summary of organisation including what you do, how many employees and what kind of information products are produced e.g. leaflets,
online, video etc)
Completed By (individual in Organisation):
Date Completed:
Completed By (Assessor)
Date Completed:
Assessing Body:
Scope of Certification: (e.g The provision of information relating to x y z disease that is aimed at people with x y z disease and/or their carers.)
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Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
The Principles and Requirements
Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
The Principles and Requirements of
The Information Standard
This column is to be completed by the Information
Producer
a) Where is the documented evidence you are using to prove
you meet the Requirements (ie links to the electronic
document, location of hard copy, page and name of
document etc)?
b) How does this prove you meet (or plan to meet) the
Requirements?
This column is to be used by the Assessor –
either during their initial review of the applicant
Gap Analysis and/or for the Assessor RAG
Report.
Red – Requirements have not been met and
must be resolved prior to certification; Amber –
Requirements have not been met and there
must be a plan in place to resolve within 12
months or less; Green – Requirements have
been met.
RAG
This column
is to be used
by the
Assessor to
show if the
Requirements
have been met
R
1.
Information Production - you have a
defined and documented process for
producing high quality information.
You have a documented process for
producing information.
1a.
1b.
All of your public-facing health and care
information within scope follows that
documented process.
1c.
All those involved in the information
production process understand and are
trained to follow your process.
3
A
Attach a copy of your process, which could be illustrated
in a variety of ways from a flow chart with the process
steps described, to a detailed production process
manual.
You could prove it by attaching your checklist which
shows that each time a step is passed, that element is
signed/checked – either manually or electronically.
Demonstrate which of the information products you
produce are in scope of TIS and those which are out of
scope and why.
Show the assessor the list of the team and 3rd parties
who produce information. Prove how those individuals
are aware of their input in the process and their training
(e.g. email, training records or talking to the assessor
directly, either on the assessment day or on the phone).
Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
G
The Principles and Requirements
2.
Evidence Sources - you only use
current, relevant, balanced and
trustworthy evidence sources.
You have checked the most current and
relevant evidence sources.
2a.
2b.
You have referenced your evidence and
signposted people to those references.
2c.
Your organisation has an approved list or
guidelines for evidence sources to support
your information production and these are
reviewed and updated regularly.
You have provided a balanced account,
reflecting the weight of the available
evidence and clearly identified any
uncertainties or unknowns.
The content, context and quality of the
evidence within your information product
have been checked by a suitable peer
reviewer.
2d.
2e.
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Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Show your assessor the evidence reviews that you
undertook as part of your process and the justification
for including the evidence that you have referenced.
Show how you record the list of evidence sources used
for every information piece – that could be on the
production checklist, your recorded search strategy or as
a page on the website for example. Ensure that your
final products signpost your evidence sources either on
the information piece itself or by giving contact details to
request them.
Show your assessor the guidelines or evidence sources
that have been approved by your organisation and give
a brief overview of who is qualified or has the experience
to approve them.
Explain how you deal with differing views, uncertainties
and unknowns in the evidence references and detail
how you ensure that they are presented in a balanced
manner.
Show your assessor the documentary evidence/email
trail to show that expert peer review has been carried
out by the assigned suitable reviewer(s) and explain why
you consider them to be suitable. Explain how the
reviewers’ comments have been documented and
implemented or if not implemented, record the
justification for why not.
Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
The Principles and Requirements
Information Producer Gap Analysis Evidence / Notes
2f.
If re-using another Information Standard
organisation’s approved information you
must cross-reference that organisation’s
name and state the production or last
review date as well as the date of next
review of the source material.
2g.
If required, you have selected your
sample products for external product
quality check.
This may not be relevant, in which case write n/a in the
green colum. If you do reuse another organisation’s
information, explain how you check the evidence
sourced from other IS organisations. Check that the
evidence references the name of the organisation and
the production or last review date as well as the date of
next review of the source material.
Please select 5 sample products that have gone through
your production system that contain health and or care
information, then provide either links to web pages or
copies of leaflets and complete a Product Sample Cover
Sheet for each which can be found on our website. (You
may not submit re-used information (as in 2f) as one of
your sample products).
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Assessor RAG Report Notes
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The Information Standard Version 2.0 December 2013
The Principles and Requirements
3.
User Understanding and Involvement you understand your users and you
user-test your information.
You know who you are producing
information for and why.
3a.
3b.
You understand their specific needs and
your information products are produced
appropriately for that audience and their
needs.
You have user-tested your information
with the intended audience and you have
taken account of user feedback in the final
product.
3c.
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Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
The target audience description could be outlined on a
production checklist sheet or on a project brief.
You may already have a process in place for ensuring
that you capture and record that information.
The reason that information piece is needed and how
you understood that need could also be recorded in the
same place.
You could show your assessor for example, survey
sheets, returned questionnaires or individual feedback.
The target audience feedback could be gathered via
user groups, forums, questionnaires, patient groups,
surveys or from individuals or friends who fall within your
target audience.
Self-Review Gap Analysis and Assessor RAG Report
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The Principles and Requirements
4.
End Product - you double-check your
end products
You have complied with the required
elements of the Principle 4 checklists
Any conflicts of interest/funding/
advertisement are clearly identified and
explained.
4a.
4b.
4c.
You follow the guidelines for use of The
Information Standard Member Logo and
display of the disclaimer (see Member
Logo Guidelines).
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Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Show your assessor that you have complied with the
Principle 4 checklists.
Explain to your assessor how you deal with any conflicts
of interest/funding/advertisement. This would be
demonstrated on the final product where are any
conflicts of interest/funding/advertisement exist.
The Member Logo Guidelines are available on the
Member area of www.theinformationstandard.org and
the disclaimer is detailed within that document.
Not applicable to applicant members who are yet to be
certified to use The Information Standard logo.
Self-Review Gap Analysis and Assessor RAG Report
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The Principles and Requirements
5.
Feedback - you manage
comments/complaints/incidents
appropriately.
You record comments/complaints/
incidents and have a standard process for
dealing with them.
5a.
5b.
You have a process for ensuring that
information products are updated where
the comments/complaints/incidents deem
it necessary.
You communicate with the complainant to
inform them how their point has been
addressed.
You have a documented moderation
policy to manage all forms of user
generated content.
5c.
5d.
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Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
This could be done via a simple
comments/complaints/incidents document which details
the date, comments/complaints/incidents, contact
details, communication and resolution of the
comment/complaint/incident. You may already have one
which would serve this purpose.
Show your assessor your complaint/feedback process
and an example of where changes have been made
based on feedback, if relevant.
Show your assessor your complaint/feedback process
and an example of communication between yourselves
and the complainant, if relevant.
Show your assessor a copy of your moderation
policy/statement outlining what is/isn’t acceptable and
how you control the user generated content as well as
indicating where user generated content is available.
Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
The Principles and Requirements
6.
Review - you review your products and
process on a planned and regular
basis.
You have an information product review
process as part of your information
production system.
You have a planned review schedule for
your information products as per their
review dates.
You have a version control and archiving
process in place.
6a.
6b.
6c.
You regularly review your information
production process and update it, if
required.
6d.
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Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Demonstrate there is a process for reviewing and
updating information products (including back-catalogue
products) to the same standard as for new products.
The planned review dates for each product could be
entered onto a review calendar or schedule (maximum
review period of 3 years).
Confirm, with documentary evidence, that a version
control process is being used for electronic and/or hard
copies of documents.
Confirm the process for archiving information products
(after year 1, for a minimum of 4 years from the initial
production date) and how the archived information will
be managed. For example, when will archived
documents be destroyed/deleted and how will electronic
documents be backed up.
Explain how you regularly review the production process
or will be conducting this in the future.
Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
The Principles and Requirements
Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Appendix A – Principle 4 Checklists
These checklists are designed to ensure that you comply with your production processes when you produce individual products.
The System Checklist
This checklist is designed to help you and the assessor double-check that the
key elements of The Information Standard have been implemented on each
product.
Evidence
You must be able to demonstrate to the Assessor that each of these points has
been implemented for each information product – you could cross-reference
other documents, you may choose to incorporate these elements into your own
production checklist/product or you could use this checklist. It is not mandatory
to complete this as a separate checklist for every product, but you must be
able to provide the evidence if asked, to prove that each point has been
addressed for every product.
1. The needs and diversity of the target audience have been identified and met,
with consideration given to the health literacy levels of the audience.
2. The evidence is up-to-date and has been derived from appropriate sources.
The evidence is presented in a clear manner, reflecting the weight and quality of
the evidence and it is clear where there is little or no evidence.
3. User feedback has been sought, assessed and included as appropriate.
4. Product has been peer reviewed by a suitable person.
5. Product has been proofread for grammar, spelling and punctuation.
6. Product is designed according to the organisation’s style guide, where
appropriate.
7. Product is designed to be accessible by the target audience (as far as
budgets allow).
8. Product has been approved for publication by final authorised approvers.
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Self-Review Gap Analysis and Assessor RAG Report
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The Principles and Requirements
Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Appendix A – Principle 4 Checklists continued
The Final Product Checklist
This checklist outlines the elements that are required on a final product.
Evidence
Each of these should be evident on every information product. This checklist
does not need to be completed for every information product but it must be
evident from the product itself that these elements have been complied with.
1. Product features the production or last review date as well as the date of next
review.
2. Product is in plain language, is free from spelling or grammatical errors and
free from medical or social care jargon; medical terms are explained where
necessary.
3. Sources of evidence are clearly signposted where appropriate.
4. The Information Standard logo is displayed correctly for certified
organisations.
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Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
The Principles and Requirements
Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Any other comments
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Self-Review Gap Analysis and Assessor RAG Report
The Information Standard Version 2.0 December 2013
The Principles and Requirements
Information Producer Gap Analysis Evidence / Notes
Assessor RAG Report Notes
RAG
Assessor summary and next steps
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The Information Standard Version 2.0 December 2013