Procedural Document
Development Policy
Choice, Responsiveness, Integration & Shared Care
Worcestershire Mental Health Partnership NHS Trust Information Reader Box
Document Type:
Document Purpose:
Corporate Policy
Guidance on how to set out procedural documents and get them
ratified by the Trust
Unique identifier:
TC0029
Title:
Procedural Document Development Policy
Target Audience:
All staff involved in Developing Procedural Documents
Description:
Guidance on content and layout of documents
Superseded Documents:
Ratified by:
Quality Committee
Ratification date:
December 2010
Implementation date:
January 2011
Review period:
3 years
Version update date:
Review date:
Owner:
January 2014
Director of Service Development and Executive Nurse and
Governance Manager
Responsible group:
Senior Management Team
Contact Details:
Governance Manager
The electronic copy of this document is the only version that is maintained.
Printed copies may not be relied upon to contain the latest updates and amendments.
Contents
Page
Section
1
Introduction
2
2
Purpose
2
3
Definitions
2
4
Responsibilities and Duties
3
5
Consultation and Communication with Stakeholders
5
6
Forums with authority to sign off procedural documents
5
7
Forums with authority to ratify procedural documents
5
8
Style of Procedural Documents
5
9
Review Interval
6
10
Format of Procedural Documents
6
11
Development of Procedural Documents
6
12
References
8
13
Associated Documentation
9
14
Guidance
9
Appendix A
Procedural Front Sheet
Appendix B
Equality Impact Assessment Tool
Appendix C
Template Document for the Development of Procedural Documents
1|Page
1.
INTRODUCTION
a. The Trust sees high quality procedural documentation as an essential tool of quality
and governance, that help the trust achieve its strategic objectives, as well as
facilitating the delivery of a consistently high standard of care.
2.
PURPOSE
The purpose is to ensure procedural documents:
meet the trust template and style
meet the trust standards
are easy to understand
are implementable
are as short as possible
are consulted upon
are well researched
are evidence based
reflect the views of stakeholders
avoid duplication
encourage ownership and accountability
are disseminated
are signed off and ratified
are archived
are monitored
are up to date
are reviewed
are accessible
3.
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,
usually have a narrow application and include a series 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 A clinical guideline is an evidence-based overview of treatments and
Guideline 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 The fundamental principle of an Integrated Care Pathway is to make explicit
Pathway the most appropriate care for a particular service user group, based upon the
best available evidence and a consensus view of best practice.
Procedural Within this document, the term Procedural Document is used to refer to all
Document policies, procedures, protocols and guidelines which apply across the Trust
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 individual colleagues; whole departments; specific
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groups; service users and their family and carers; other agencies and single
issue community groups.
Sign Off Formal agreement by a quality working group that the procedural document
meets all required standards and is acceptable to move to ratification
Ratification Final review of a new or revised policy which provides the official authority for
publication and implementation
Working Group A group, reporting to the Quality Committee, with responsibility for ensuring the
development and review of specific procedural documents
Procedural The senior manager with responsibility for the development or review of a
Document procedural document
Owner:
Other Within the definitions section of all procedural documents should be a section
definitions policies should contain that policies should explain terms which are unique to
the particular policy – define a term in the context of that particular policy
4.
Responsibilities and duties
a. Trust Board
i. The Trust Board has overall responsibility for ensuring that the Trust
complies with all legal, statutory, best practice and quality requirements and
for ensuring staff have quality, ratified procedural document to work with.
b. Chief Executive
i. The Chief Executive has ultimate responsibility for quality and governance
including ensuring a process is in place to support good procedural
document management.
c. Directors
i. All directors have responsibilities for ensuring procedural documents within
their portfolio responsibilities meet the needs of the Trust and its staff and
are appropriately implemented.
d. Managers
i. All Managers must ensure their staff are aware of, have read and
understand the implications for their practice, of appropriate procedural
documents.
ii. All Managers must monitor, within supervision, the implementation of
procedural documents and put in place performance management measures
or instigate disciplinary actions where ongoing issues arise.
iii. All Managers have responsibility for ensuring that procedural documents
meet the needs of their staff.
iv. All Managers must ensure that procedural document owners are advised of
any changes in practice, legislation or contacts; or if the document becomes
out of date.
e. Procedural Document Owner:
i. Are responsible for ensuring that
ii. approval to develop a new procedural document is gained from an
appropriate Director or Senior Manager
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iii. procedural documents are developed with the involvement of key
stakeholders; consultation with relevant groups and committees and where
appropriate the trust legal advisers
iv. all procedural documents follow the standards and format as set out in this
document
v. where a procedural document forms part of the requirements the National
Health Service Litigation Authority Risk Management Standards the
document meets those standards
vi. an Equality Impact Assessment screening is carried out and, where
appropriate, a full Equality and Impact Assessment
vii. the document is proof read for issues such as spelling, punctuation and
general clarity
viii. prior to ratification the document is watermarked with ‘draft’;
ix. procedural documents are forwarded to the relevant working group for it to
be signed off prior to ratification by the Quality Committee, together with the:
x. Procedural Document Front Sheet completed (Appendix 1)
xi. Equality Impact Assessment completed (Appendix 2)
xii. NHSLA Risk Management Standard compliance statement included, if
required
xiii. amendments as suggested by the working group prior to ‘sign off’ are
undertaken
xiv. reviews of, and amendments to, procedural documents are carried out in a
timely fashion and submitted for ‘sign off’
xv. version updates are carried out in a timely fashion but do not need to be
submitted for ‘sign off’ or ratified by the Quality Committee
f.
Quality Working Groups
i. Quality Working groups are responsible for ensuring procedural documents:
ii. are developed in accordance with the Procedural Document Policy
iii. are developed or updated by an appropriately qualified author identified.
iv. procedural documents referred to them are assessed against the standards
set out in this policy and document authors are advised accordingly;
v. procedural documents referred to them comply with any relevant National
Health Service Litigation risk management standards
vi. consultation with appropriate stakeholders has occurred and a consensus
view reached;
vii. procedural documents are technically accurate; in line with evidence based
best practice and up to date evidence;
viii. an accurate record is kept of discussion and approval of the procedural
documented is recorded in the minutes of the meeting.
ix. processes to enable an audit of compliance with the procedural document
are detailed in the document;
x. agreed procedural documents are forwarded to the Quallity Committee,
together with required accompanying documentation;
g. All Staff
i. All staff, including temporary and agency staff, are responsible for:
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ii. comply with organisational procedural documents and failure to do so may
result in performance measures or disciplinary action being taken.
iii. cooperating in the development and implementation of procedural
documents as part of their normal duties and responsibilities
iv. identifying a need for changes to a procedural document through awareness
of changes in practice, statutory requirements, professional or clinical
standards, local or national directives and advise their line manager
accordingly.
v. identifying their own training needs in respect of procedural documents and
bring them to the attention of their line manager.
5.
Consultation and Communication with Stakeholders
a. Consultation with relevant stakeholders secures ownership and provides an
opportunity to identify and eliminate potential barriers to implementation. The
procedural document owner is responsible for ensuring relevant in-house and
external stakeholders have been consulted during its development and their
comments, which are documented, have been taken into consideration.
b. The Trust places significant importance on working collaboratively with
stakeholders. We recognised the wide range of stakeholders with interests in the
work of the Trust and the valuable contribution they make to our work. We were at
the forefront of the development of the Single Health Equalities forums and have
positive links with Black and Minority Ethnic communities and organisations such as
Deaf Direct. Internally we have advisory groups for all our professions as well as
separate forums for service users, carers and community contacts.
c. Procedural Document Development Front Sheets should describe what groups or
people were involved in the consultation process [see appendix 1].
6.
Forums with the authority to sign off procedural documents
a. Quality working groups must sign off a procedural document prior to it being
submitted for ratification.
7.
Forums with the authority to ratify procedural documents
a. The Trust Board, Quality Committee, JNCC and Adult and Community Service
Departmental Management Team are responsible for ratifying procedural document
that have been signed off by an appropriate working groups
b. Trust Board
i. In most cases, but not all, the Board delegates the approval processes to
other forums.
c. Quality Committee
i. The Quality Committee is a sub-committee of the Trust Board and has
delegated responsibilities with regard to procedural documents and to
provide assurance that effective quality arrangements are in place.
d. Joint Negotiating and Consultative Committee
i. The Joint Negotiating and Consultative Committee is the forum for
consultation and negotiation on Trust wide issues and provides a
mechanism by which issues relating to contracts of employment, terms and
conditions of employment, policies and procedures of staff are discussed
and negotiated.
e. Adult and Community Service Departmental Management Team
i. Where documents need joint agreement with the Local Authority those
responsible for their development must ensure that they are ratified for use
within those agencies are agreed by the Community Service Departmental
Management Team
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8.
Style of Procedural Documents
a. All procedural documents are developed to communicate important information
therefore the plainer the language the easier the communication. Jargon should be
kept to a minimum and where complex professional terms are required an
explanation of the term should be available within the document.
b. All procedural documents will meet the following format standards:
i. pages with 2 cm margins all round [page setup/margins]
ii. spacing both before and after at 6pt [format/paragraph]
iii. line spacing at 1 line [format/paragraph]
iv. main text in Ariel 11pt font [format/font]
v. black font only – except for flow charts etc.
vi. numbered pages [insert/page numbers]
vii. numbered headings and paragraph [format/numbering]
c. Each document should have a front cover and inner cover [completed by the
Webmaster following ratification and prior to publication] that includes:
d. The trust front cover design must include the Trust logo and, where appropriate,
partner agencies; the name of the procedural document. The inner cover should
include the trusts unique identifier; the name of the forum which ratified the
document; the date it was ratified; version update; review interval; the review date;
the owner; the responsible forum [quality working group] and the statement: The
electronic copy of this document is the only version that is maintained. Printed
copies may not be relied upon to contain the latest updates and amendments.
9.
Review Interval
a. This is 3 years from the date of ratification or from the date of the last version
update unless statute dictates a specific time period.
10.
Format of Procedural Documents
a. All procedural documents will in general meet the agreed format by following the
procedural document template [Appendix 3] unless agreed with the Governance
Manager.
11.
Development of Procedural Documents
a. Equality Impact Assessment
i. The Trust aims to design and implement services, policies and measures
that meet the diverse needs of our service, population and workforce,
ensuring that none are placed at a disadvantage over others.
ii. To ensure the Trust discharges its legal and moral obligations to promote
equality of opportunity and good relations, not only between persons of
different ethnic minority groups, but also those of different religious beliefs,
political opinions, age, gender, marital status, sexual orientation, those with
a disability (and those without), and those with or without dependants an
equality impact assessment will be undertaken and where appropriate an
action plan developed.
iii. The Equality Impact Assessment Tool is designed to help you consider the
needs and assess the impact of your policy. (Appendix 2)
iv. As Worcestershire has a relatively small and extremely diverse Black and
Minority Ethnic communities it is not cost effective to translate without
individual needs being identified. For further help in this area please refer to
the Translation Policy [TC0080].
6|Page
b. Document Approval Process
i. These steps should be followed for all new and reviewed procedural
documents:
ii. The procedural document owner nominates an individual or group to prepare
a first draft based on the procedural document template [appendix 3] and
completes an equality and diversity assessment [appendix 2] and procedural
document front sheet [appendix 1]
iii. The first draft is reviewed by the appropriate working group.
iv. The draft is revised prior to any consultation with internal and external
stakeholders being undertaken.
v. The working group receives results of the consultation and a final version is
prepared.
vi. The working group sign off the final version or requests further work prior to
signing it off.
vii. The final version made available to the appropriate forum for ratification.
viii. Following ratification the Webmaster is formally requested to arrange
publication on the intranet and internet.
c. Version Control
i. When a procedural document is ratified the Procedural Document Matrix is
updated to reflect the changes or the new document. This document is
monitored by the Quality Committee.
ii. Small changes are version updates which don’t need the full consultation,
sign off or ratification procedure.
iii. Version updates should be made available to the Governance Manager who
will make the necessary adjustments to the policy matrix and will then pass
the version update to the web master for uploading to the intranet.
d. Process for Reviewing a Procedural Document
i. The Governance Department uses the Procedural Document Matrix to
remind owners and working groups six months before a procedural
document ceases to be in date and requests that the review is undertaken.
e. Dissemination
i. All new and reviewed procedural documents are posted on the Intranet and
Internet and reported in the Quality Report to the Trust Board. Business
Units are advised via email and have the responsibility to cascade
procedural documents to relevant staff members via team meetings and
briefings. In some specific circumstances, as with the Observation Policy,
relevant staff are asked to sign that they have read the policy.
ii. Staff are advised that only the electronic copy of a procedural document is
valid and that paper copies should not be kept. The exception is where they
are used daily and in those circumstances staff are told to renew them from
the intranet regularly.
f.
Implementation of Procedural Documents
i. Business Units are responsible for identifying any training requirements or
support etc. that is required prior to a procedural document being
implemented within the unit.
g. Library of Procedural Documents
i. Current and archived procedural documents are held in a data warehouse
linked to the intranet by Folding Space software providing a robust system
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for tracking, version control, and audit. The responsibility for this lies with the
Web Master.
h. Archiving Arrangements
i. When a new procedural document is uploaded onto the intranet, the old
version is archived with a date range showing when it was valid to and from
for easy referencing later should there ever be a query.
i.
Process for Monitoring Implementation and Compliance
i. Prior to ratification the owner and the working group are responsible for
ensuring only procedural documents that meet the standards within this
document will be signed off.
ii. Following ratification the Governance Department will provide a monitoring
report to the monthly Operational Quality Group highlighting any divergence
from this document. Short falls will be reported to the procedural document
owner for rectification. The Operational Quality Group will monitor the
agreed actions and will advise all owners of any learning.
NHSLA Criteria
Lead
Monitoring
Frequency
Before ratification:
Before ratification:
Review
Each version
After ratification:
After ratification:
After ratification:
Governance
Manager
Report
Monthly
Governance
Manager
Report
Monthly
Committee
The organisations approved
document which describes the
process for developing
organisation-wide procedural
documents must include a
description of the following
requirements:
Style and format
An explanation of any terms
used
Consultation process
Ratification process
Review arrangements
Control of documents, including
archiving
Associated documents
Supporting references
The process for monitoring
compliance with the above
j.
Before ratification:
Procedural
document owner
Before ratification:
A Working Group
After ratification:
Operational Quality
Group
Operational Quality
Group
Openness
i. All documents referred to in this policy will be made available to the general
public in accordance with the requirements of the Freedom of Information
Act 2000. Owners, reviewers and responsible Working Groups must ensure
that it has been scrutinised for information that would fall within the Data
Protection Act 1998 or the Freedom of Information exemptions.
k. Policy validation
i. This policy is ratified for use by the Trust:
ii. The Governance Manager is the designated owner with responsibility for
ensuring an appropriately skilled professional will lead the development
and/or review of the policy in line with timescales set by the Work Group
work plan
iii. The Information Quality Working Group is the group whose work plan
identifies their responsibilities with regard to the development and/or review
8|Page
of the policy, monitoring compliance and signing off the policy within agreed
timescales prior to ratification by the Quality Committee.
12.
References
a. Health & Safety at Work Act 1974: Health & Safety Executive, HMSO (General duties of
Employers and Employees. Requirement that employers assess and manage risks to health
and safety)
b. Human Rights Act 1998: Cabinet Office, HMSO (Rights and freedoms protected under the
European Convention on Human Rights.)Management of Health & Safety At Work
Regulations 1999 (Details of how employers must manage health and safety e.g. undertake
risk assessments, appoint competent people, arrange appropriate information and training).
c.
Freedom of Information Act 2000: Cabinet Office, HMSO (Allows anyone to ask for
information held by organisations, although some information, such as patient identifiable
information, is exempt.)
d. Mental Capacity Act 2005: Cabinet Office, HMSO (To protect people who are not able to
make their own decisions. Clarifies who can take decisions, in which situations. Enables
people to plan ahead for a time when they may lose capacity.)
e. Equality Act 2006: Cabinet Office, HMSO (Provisions on Human Rights, and discrimination
on grounds of race, religion or belief, sex or sexual orientation; amends the Disability
Discrimination Act 1995.)
13.
Associated Documentation
a. Data Protection Act and Guidance
b. Freedom of Information Act and Guidance
14.
GUIDANCE
a. A few words to help you
i. This template has been designed to develop policy documents which are
readable and contain statements which encourage compliance. Please
follow the format. [Appendix 3]
b. What is a procedural document?
i. It is an approved Trust procedural document, which mandates or constrains
actions that will not frequently change and sets a future course. It ensures
compliance with overarching principles, legislation or professional guidance
and helps to reduce organisational risk
c. A few tips and hints
d. Procedural document must not be huge as they become unreadable. They should
be focused on WHAT the organisation wants to do; WHO is responsible and HOW
the organisation will check that it’s done.
e. Avoid unnecessary wordage. Be specific. Think of this as an instruction manual to a
new member of staff who needs to know what to do, without reading the complete
works of Shakespeare.
f.
To quote a colleague: “If I go fishing and I want to know how to fish I don’t need a
lengthy description of the biological structure and life cycle of the maggot nor do I
need to know the composition of the flora and fauna on the river bank! I just need to
know where to pop in the hook, how to cast, how to reel in and a good spot to sit in
safety.”
g. Avoid writing aspirational documents. The processes described are meant to be
implemented and our insurers [NHS Litigation Authority] will require evidence that
the statements we make in a policy are actually done in practise.
h. Avoid writing lots of “padding“. The document you write will be scrutinised to check
for essential content in relation to external assessments and may remove content
which is not directly necessary. Be focused.
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Appendix 1
Procedural document development front sheet
The Quality Working Group, which ‘signs off’ a document, is responsible for ensuring that a front sheet is completed in full
and attached to the document before forwarding it for ratification by the Quality Committee or other agreed forum. Any
document received by an agreed forum without the front sheet will be returned to the Owner and will not be added to the
agenda until returned with the front sheet fully completed
Worcestershire Mental Health Partnership NHS Trust Information Reader Box
Document Type:
e.g. Clinical Policy etc..
Document Purpose:
e.g. Best practice guidance
Unique identifier:
CP or TC Number
Title:
The name of the policy
Target Audience:
e.g. Nurses, managers etc…
Description:
Small description about the document
Superseded Documents:
Ratified by:
Which committee
Ratification date:
The date ratified
Implementation date:
The date implemented
Review period:
Always 3 years unless statutory timeframe
Version update date:
Date policy was version updated
Review date:
Time from ratification or version update
Owner:
Title
Responsible group:
Governance group name
Contact Details:
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Appendix 2
EQUALITY IMPACT ASSESSMENT FORM (EIAF)
SECTION ONE: SCREENING/PRIORITISING FOR FULL IMPACT ASSESSMENT
Name of the Function or Procedural Document:
Section 1
If any of these
are relevant
box below (for
the equality
area) continue
with screening.
If it does not
apply add x and
cease the
process.
Which of the 3
parts does it apply
to (if any)
1. Eliminating
discrimination
2. promoting equal
opportunities

or
x
3. Promoting good
community
relations
Is there
evidence or
reason to
believe that
some groups
could be
differently
affected?
Which groups
are affected?
1
2
0-2 None or
little
Is there any public
concern that the
function or procedural
document is being
carried out in a
discriminatory way?
3-4 Some
0-2 None or little
5-6
Substantial
3-4 Some
How much
evidence do
you have?
3
Priority
(add
columns
3 and 4)
5-6 Substantial
4
5
RACE
RELIGION/BELIEF
DISABILITY
GENDER
AGE
SEXUAL
ORIENTATION
HEALTH
INEQUALITIES
HUMAN RIGHTS
Section 2: Action Plan
Section 3: Outcome of full Impact Assessment
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Appendix 3
Procedural Document Template
Contents
Section
1
Introduction
2
Purpose
3
Definitions
4
Roles and Responsibilities
a. Trust Board
b. Chief Executive
c. Executive Directors etc.
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1.
INTRODUCTION
a. This section should give an overview as to why the subject is a key priority within the
organisation
b. Why do we want to develop this policy, are there any key drivers [legislation, national
priorities, best practise etc.]
c. Think about the benefits to the organisation, service users and review bodies
d. Be aware of the opportunities for proactive risk management and risk minimisation
e. Keep it short, two or three sentences
2.
PURPOSE OF POLICY
a. Give an outline of the objectives and intended outcomes of the process described in
your document
b. Keep it short, no more than a small paragraph
c. Consider the use of bullet points
3.
DEFINITIONS
a. This section should provide definition of the terms that are unique to this policy – use
key terms only as the list is only a guide and does not need to be exhaustive
4.
RESPONSIBILITIES AND DUTIES
a. The section should include an overview both strategic and operational roles of the
responsible executives, committees, work groups, management leads, specialist leads,
individuals and departments, all of whom have a responsibility at different levels for the
management, operation and monitoring of the topic discussed.
b. These sections describe what people SHOULD do and how the organisation is assured
that they DID do it.
5.
Trust Board
a. Include the responsibilities the Trust Board has for this policy and how they will be
informed and ultimately assured that the system is working effectively.
b. The Trust Board is responsible for:
c. Setting policy for the organisation through powers delegated to relevant committees;
d. Ensuring policy is implemented through agreed management arrangements;
e. Ensuring they are alerted to relevant issues arising that may affect policy
6.
Chief Executive
a. This section should explain how the Chief Executive is ultimately responsible for the
process of managing and responding to this subject and will state if and how that
responsibility is delegated.
b. The Chief Executive is responsible for:
c. ensuring that arrangements are in place so that employees are fully aware of their
statutory, organisational and professional responsibilities and that they are fulfilled;
d. ensuring that the arrangements in support of policy are fully implemented through
inclusion in Business Unit Performance Reviews;
e. In order for this responsibility to be effectively discharged, Executive Directors and
senior colleagues will have specific delegated responsibility to support the Chief
Executive in this process.
7.
Directors
a. Roles and responsibilities of the nominated director(s) for this policy
b. Directors must ensure:
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c. strategic development and implementation of policy, corporately and within their areas
of control;
d. the appropriate assessment and management of risks;
e. effective delegation of responsibilities within their areas of control;
f. effective support for managers’ decisions and recommendations in terms of the
provision of appropriate resources;
g. a framework is in place to ensure that staff are adequately skilled and experienced to
safely undertake their work;
h. necessary reporting procedures are in place;
i. a framework is in place to monitor compliance with policy.
8.
Management Structure
a. The roles and responsibilities of managers and staff involved in the process should be
documented next. Be specific and avoid vague statements. This section should include
a description of post holder’s specific duties relating to the implementation of the policy.
Think about responsibilities flowing from one level to another and remember not
everyone is responsible for the same thing.
9.
Business Unit Leads
a. The roles and responsibilities of Business Unit leads involved in the process should be
documented. This section should include a description of their specific duties relating to
the implementation of the policy.
10.
Senior Managers
a. The roles and responsibilities of senior managers (locality managers, specialist
managers, departmental managers, corporate and clinical managers), involved in the
process should be documented. This section should include a description of their
specific duties relating to the implementation of the policy.
11.
Ward and Team Manager (Inpatient and Community)
a. As above in relation to the ward and team managers level of responsibility
12.
Individual members of staff
a.
13.
This section should define the responsibilities of individual employees
Medical Staff
a. As above
14.
Other
a. As above – other staff may include specialist staff who have a supporting role to play in
assisting in the implementation of the policy such as infection control staff etc.
b. The organisation may have a nominated lead in relation to the subject, if so their role
should be described here [For example falls and safeguarding leads]
15.
WORKING GROUPS AND COMMITTEES
a. This section should identify the working group or committee which will have overall
responsibility for the management of the subject covered in the policy. The section
should describe how the working group or committee ensures that the organisation can
be assured that this policy is implemented, monitored, managed and any issues of
concern are addressed.
b. Think about how information will be passed through the layers of the organisation. This
section should include:
c. How this group links with all the other relevant working group and committee. How do
they receive information and at what frequency
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d. The role the working group or committee has in ensuring continuous development and
review of this policy
e. The role the working group or committee has receiving and reviewing summary reports
or considering if an identified action is adequate and appropriate
f. How does the working group or committee facilitate organisational learning and
improvement?
g. Where does the working group or committee receive its information from and where
does it report to and to what frequency. Describe how and how often it reports up or
down to other levels of the management structure. Example – up from Quality
Committee to Trust Board or down Business Unit Quality Forum to ward and team
managers.
16.
MONITORING IMPLEMENTATION
a. This section should identify how the organisation plans to monitor compliance with the
policy. It should describe how we will know that things are being carried out in the
manner described within the document. Who is responsible for this and what will we do
with our findings. This section links with the responsibilities and duties section which
describes what post holders are supposed to do. Here, we are monitoring that it is
being done.
b. As a minimum this section should include the review/monitoring of all the minimum
requirements within the NHSLA Risk Management Standards. The following list is a
guide to issues which could be considered within this section and should be added to
where appropriate:
c. What are the monitoring arrangements and methodologies to check for compliance, i.e.
it might be an audit, a report, a review, a check on data base figures etc.
d. Who is responsible for conducting the monitoring? The responsibility might or might not
be shared between more than one post holder or department.
e. At what frequency will it be done, i.e. quarterly on a rolling basis etc.; avoid saying
“regularly” as it doesn’t mean anything in this context – be specific.
f. What will be the process for reviewing the results and ensuring improvements in
performance occur. This section should state who gets the results i.e. post holders,
working groups etc. and it should say what they are supposed to do with the
information
g. You should insert a monitoring grid in to describe the monitoring process. Here is an
example which takes into account the minimum requirements within the NHSLA risk
management standards which apply to selected policies
NHSLA Criteria
Lead
Monitoring
Frequency
Committee
The sections below will
contain all the
requirements of the
NHSLA risk management
standards in relation to this
policy. These are things
we must include in the
policy and must evidence
that we do a selection of
them in practise
Who takes
the lead
responsibility
for the
different
parts of the
criteria
How do we monitor
that this is done –
might be by an
audit , a periodic
check of figures , a
report or a review
etc
How often is
this done?
Monthly or
annually?
Which working
groups etc. are
involved and
which
committee
oversee
[Clinical Risk or
Health and
Safety etc .]
17.
KEY PERFORMANCE INDICATORS
a. If appropriate, this section could contain auditable standards and/or key performance
indicators which may assist the organisation in the process for monitoring compliance
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18.
PRACTICE DEVELOPMENT AND SERVICE IMPROVEMENT
a. This is a standard statement and will be included in all policies:
b. The Worcestershire Mental Health Partnership is committed to ensuring its workforce is
confident, competent and capable. The Practice Development and Service
Improvement Team [PD&SIT] develop a yearly training prospectus which describes the
courses on offer, to whom they are aimed, how often they need to be updated and how
to make a booking. The training prospectus can be accessed via the Intranet and
internet.
c. Attendance Monitoring
d. If a person is registered to attend a course and does not attend the information is
registered with the PD&SIT will notify the person’s line manager of the non-attendance.
It is the responsibility of the line manager to ensure staff attends appropriate statutory,
mandatory and essential training.
19.
POLICY VALIDATION
a. This is a standard statement and will be included in all policies:
b. All policies ratified for use by the Trust contain the following information:
c. A designated owner with responsibility for ensuring an appropriately skilled
professional will lead the development and/or review of the policy in line with
timescales set by the Work Group work plan
d. A Working Group, whose work plan identifies their responsibilities with regard to the
development and/or review of the policy, monitoring compliance and signing off the
policy within agreed timescales prior to ratification by the Quality Committee.
20.
EQUALITY IMPACT ASSESSMENT
a. All policies require an equality impact assessment, and where that assessment
identifies equality issues and action plan, to ensure the Trust meets its requirements
within equality legislation. [see assessment tool in appendix 2]
21.
REFERENCES
a. This section should contain the details of any reference materials used in the
development of the document.
22.
ASSOCIATED DOCUMENTATION
a. This section should provide a cross reference to any other Trust procedural documents
that are available on the Intranet [not national or external documents].
1.
APPENDICIES
a. This may contain a wide variety of things such as forms, checklists
b. Standard Operating Procedures – also known as GUIDANCE or PROCESSES or
PROCEDURES
c. This section can be added if the document needs to go into more detail about the
specific processes to go through in order to implement the document - how to do it
guide. If you have properly described the responsibilities and duties of all involved, this
section may not always be necessary.
d. Flow charts are useful here.
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