POLICY ON PROCEDURAL
DOCUMENTS
Last Review Date
N/A
Approving Body
Governing Body
Date of Approval
2nd April 2013
Date of Implementation
2nd April 2013
Next Review Date
April 2016
Review Responsibility
Chief of Corporate Services
Version
1.0
REVISIONS/AMENDMENTS SINCE LAST VERSION
Date of Review
March 2013
Amendment Details
The original PCT document has been revised to:
• Reflect the Clinical Commissioning Group
establishment.
• Reflect the Clinical Commissioning Group structure.
CONTENTS
Page
Definitions
4
Section A – Policy
5
1.
Policy Statement, Aims & Objectives
5
2.
Legislation & Guidance
6
3.
Scope
6
4.
Accountabilities & Responsibilities
6
5.
Dissemination, Training & Review
9
Section B – Procedure
1.
Types of Procedural Documents
11
2.
Style and Format of Procedural Documents
11
3.
Development and Approval of Procedural Documents
12
4.
Review of Procedural Documents
12
5.
Dissemination of Procedural Documents
13
6.
Control of Procedural Documents
13
Appendices
A
Template for procedural documents
14
Page 3 of 23
DEFINITIONS
Term
Definition
Approval
The act of approving, of formal agreement.
Policy
A deliberate plan of action adopted or pursued by an
individual organisation to guide decisions and achieve
rational outcomes.
A policy is a statement of intent, describing the approach
or course of action the organisation is taking in respect of
a particular issue. Policies are underpinned by relevant
evidence based procedures and guidelines and enable
management and staff to make correct decisions, work
effectively and comply with relevant legislation and
organisational aims and objectives.
Procedure
A set of step-by-step instructions that describe the
appropriate method for carrying out tasks or activities to
achieve the highest standard possible and to ensure
efficiency, consistency and safety.
Procedural
document
An overarching term for the full range of strategies,
policies and procedures.
Standard
Operating
Procedures
A set of instructions, usually in a clinical setting, for
undertaking a particular task.
Strategy
A long term plan designed to achieve particular goals or
objectives. A strategy is often a broad statement of an
approach to accomplishing these desired goals or
objectives and can be supported by policies and
procedures.
Page 4 of 23
SECTION A – POLICY
1. Policy Statement, Aims & Objectives
1.1.
Procedural documents offer advice, guidance and instruction to staff
within organisations, whether they are in the form of a strategy, policy
or procedure. Establishing a clear system for the management of
procedural documents is a critical component of a transparent risk
management programme and integrated governance.
1.2.
The purpose of this document is to provide guidance to staff leading on
the development of procedural documents. The aim is to ensure that
there are documented, up-to-date, authorised organisation-wide
procedural documents in place which enable the organisation to
achieve its objectives.
1.3.
The aims of this procedural document policy are:
• To ensure that the development and review of strategies, policies
and procedures is commissioned, coordinated and progressed
through appropriate channels.
• To ensure that all procedural documents are produced in a standard
format using a consistent corporate approach.
• To ensure that the dissemination of procedural documents is
coordinated and monitored.
• To ensure that the effectiveness of all procedural documents is
audited, monitored, reviewed and updated routinely.
1.4.
To ensure continuous improvement in risk management, the
organisation has a range of key performance indicators (KPIs) which it
uses for monitoring purposes:
No.
1.
2.
1.5.
Key Performance Indicator
Progress on procedural
document development and
review is reported within the
organisation.
Method of Assessment
Quarterly Governance
Reporting.
Approved procedural
documents are published on
the website.
Website review.
This procedural document will be reviewed 3-yearly, and in accordance
with the following on an as and when required basis:
• Legislative changes
• Good practice guidance
• Case law
• Significant incidents reported
Page 5 of 23
New vulnerabilities
Changes to organisational infrastructure
•
•
2. Legislation & Guidance
2.1.
The following legislation and guidance has been taken into
consideration in the development of this procedural document:
•
NHS Litigation Authority (2007) An Organisation-wide Policy for the
Development and Management of Procedural Documents
3. Scope
3.1.
This policy applies to those members of staff that are directly employed
by NHS Doncaster CCG and for whom NHS Doncaster CCG has legal
responsibility. For those staff covered by a letter of authority / honorary
contract or work experience this policy is also applicable whilst
undertaking duties on behalf of NHS Doncaster CCG or working on
NHS Doncaster CCG premises and forms part of their arrangements
with NHS Doncaster CCG. As part of good employment practice,
agency workers are also required to abide by NHS Doncaster CCG
policies and procedures, as appropriate, to ensure their health, safety
and welfare whilst undertaking work for NHS Doncaster CCG.
4. Accountabilities & Responsibilities
4.1.
Overall accountability for ensuring that there are systems and
processes to effectively manage procedural documents lies with the
Chief Officer. Responsibility is also delegated to the following
individuals:
Chief of
Corporate
Services
(or
equivalent)
Has delegated responsibility for:
• Developing the Policy on Procedural Documents and
maintaining an overview of the corporate procedural
document ratification and governance process.
• Leading the development, review and approval of
governance and risk management procedural documents.
• In the role of Senior Information Risk Owner (SIRO), is
also responsible for managing the development and
implementation of Information Management &
Governance procedural documents.
Page 6 of 23
Chief Nurse
(or
equivalent)
Chief
Finance
Officer
(or
equivalent)
Chief of
Strategy &
Development
(or
equivalent)
Governance
Manager
(or
equivalent)
Has delegated responsibility for:
• Leading the development, review and approval of clinical
procedural documents.
• Leading the development, review and approval of
safeguarding procedural documents.
Has delegated responsibility for:
• Leading the development, review and approval of financial
procedural documents.
Has delegated responsibility for:
• Leading the development, review and approval of
commissioning procedural documents.
Has delegated responsibility for:
• Overseeing and coordinating corporate procedural
document processes, issuing procedural documents to all
Procedural Document Manual Holders, maintaining
appropriate records regarding procedural documents, and
monitoring developments in policy management.
•
Procedural
Document
Authors
Staff
4.2.
Are responsible for ensuring procedural documents
remain up to date and in line with relevant legislation and
guidance. Procedural Document Authors are also
responsible for ensuring new / reviewed procedural
documents are sent through the appropriate approval
process.
Responsibilities of Staff (including all employees, whether
full/part time, agency, bank or volunteers) are:
• Complying with all procedural document of the
organisation.
• Identifying any gaps in procedural documents and
identifying these to procedural document authors /
responsible officers.
Committees and Sub Committees of the Governing Body have
delegated responsibility to approve new procedural documents and
significantly updated procedural documents according to the scheme of
delegation detailed below. These Committees and Sub Committees
should ensure that relevant consultation on planned changes has been
Page 7 of 23
undertaken with relevant groups prior to reaching the approval stage.
The full mapping of each organisational policy to an approving body is
held by the Governance Team. Procedural documents to which only
minor updates have been made may receive Lead Officer approval
from a lead officer in the relevant area as listed under 4.1. above and
will not be required to be reviewed by an Approving Body.
Approving
Body
Type of procedural document
Overarching corporate and planning strategies such as the Single
Integrated Plan and Organisational Development Strategy.
Governing
Body
Procedural documents where there is a legislative or national
requirement for Governing Body approval.
Procedural documents which relate to a significant risk on the
Assurance Framework.
Financial procedural documents.
Governance procedural documents.
Audit
Committee
Overarching procedural documents which fall within the terms of
reference of the Committee. The approval of underpinning
procedural documents may be delegated to sub groups where
considered appropriate.
Human Resources procedural documents.
Remuneration
Committee
Overarching procedural documents which fall within the terms of
reference of the Committee. The approval of underpinning
procedural documents may be delegated to sub groups where
considered appropriate.
Clinical procedural documents.
Quality &
Safety
Committee
Engagement
& Experience
Committee
Safeguarding procedural documents.
Overarching procedural documents which fall within the terms of
reference of the Committee. The approval of underpinning
procedural documents may be delegated to sub groups where
considered appropriate.
Procedural documents relating to engagement, communication,
public & patient experience and equality.
Overarching procedural documents which fall within the terms of
reference of the Committee. The approval of underpinning
procedural documents may be delegated to sub groups where
considered appropriate.
Commissioning procedural documents and strategies.
Delivery &
Performance
Committee
Overarching procedural documents which fall within the terms of
reference of the Committee. The approval of underpinning
procedural documents may be delegated to sub groups where
considered appropriate.
Page 8 of 23
5. Dissemination, Training & Review
5.1.
Dissemination
5.1.1. The effective implementation of this procedural document will support
openness and transparency. NHS Doncaster CCG will:
•
•
•
Ensure all staff and stakeholders have access to a copy of this
procedural document via the organisation’s website.
Communicate to staff any relevant action to be taken in respect of
complaints issues.
Ensure that relevant training programmes raise and sustain
awareness of the importance of effective complaints management.
5.1.2. This procedural document is located in the General Policy Manual. A
set of hardcopy Procedural Document Manuals are held by the
Governance Team for business continuity purposes and all procedural
documents are available via the organisation’s website. Staff are
notified by email of new or updated procedural documents.
5.2.
Training
5.2.1. All staff will be offered relevant training commensurate with their duties
and responsibilities. Staff requiring support should speak to their line
manager in the first instance. Support may also be obtained through
their or HR Department. Managers should contact the Governance
Team if there are specific training needs.
5.3.
Review
5.3.1. As part of its development, this procedural document and its impact on
staff, patients and the public has been reviewed in line with NHS
Doncaster CCG’s Equality Duties. The purpose of the assessment is to
identify and if possible remove any disproportionate adverse impact on
employees, patients and the public on the grounds of the protected
characteristics under the Equality Act.
5.3.2. The procedural document will be reviewed every three years, and in
accordance with the following on an as and when required basis:
•
•
•
•
•
•
Legislatives changes
Good practice guidelines
Case Law
Significant incidents reported
New vulnerabilities identified
Changes to organisational infrastructure
Page 9 of 23
•
Changes in practice
5.3.3. Procedural document management will be performance monitored to
ensure that procedural documents are in-date and relevant to the core
business of the CCG. The results will be published in the regular
Governance Reports.
Page 10 of 23
SECTION B – PROCEDURE
1. Types of Procedural Document
1.1.
There are three types of procedural documents to which this procedural
document refers:
• Strategies
• Policies
• Procedures
1.2.
Templates for these documents are appended to this document.
Templates show the minimum required for content headings. Authors
may not remove sections listed within the template.
1.3.
Procedures are the instructions that support the plan outlined in
policies and it is therefore usual that a policy will have a procedure
included as part of the procedural document.
2. Style and format of procedural documents
2.1.
All procedural documents should be written in a style which is concise
and clear using unambiguous terms and language. Consideration
should be given to producing appropriate documents in languages
other than English, dependent on the population groups represented in
the Doncaster area.
2.2.
All procedural documents should be prepared in Microsoft Word using
Arial font, point size 12 with headings of point size 14 and sub
headings of point 12. Left-alignment should be used.
2.3.
The correct organisational logo should be used on all procedural
documents.
2.4.
Paragraphs should be numbered as demonstrated in this guidance.
2.5.
Page numbering should be used in the format “1 of 23” and placed in
the bottom right hand corner.
2.6.
Version control should be observed. When a procedural document is
first being written and is in the draft stage, its version number will be
0.1. If that procedural document is later amended and a second draft
completed, its version number should be changed to 0.2. As soon as
the procedural document has been ratified by a Lead Officer as
identified in paragraph 4.1 or an Authorising Body as identified in
paragraph 4.2, its version number will change to 1.0.
Page 11 of 23
2.7.
A review period for the procedural document must be entered. The set
review period is 3 years, or earlier if legislation/guidance indicates
otherwise.
3.
Development and approval process for new procedural
documents
3.1.
STEP 1: The need is identified for a new procedural document or a
revision to an existing procedural document. A lead author for the
procedural document is identified.
3.2.
STEP 2: The Procedural Document Author informs the Governance
Team, who will advise on the authorising body and provide any
guidance on procedural document development.
3.3.
STEP 3: The Procedural Document Author develops and consults on
the procedural document. It is the responsibility of the Procedural
Document Author to ensure that the relevant people have been
consulted with regard to the procedural document. The Procedural
Document Author should ensure that the procedural document is
assessed for equality impact and, where relevant, consulted upon with
the NHS Local Counter Fraud Specialist.
3.4.
STEP 4: The Procedural Document Author sends the finished and
approved procedural document (see section 4.1 and 4.2 for approving
bodies / lead officers) to the Governance Team, Sovereign House, Ten
Pound Walk, Doncaster, DN4 5DJ.
3.5.
STEP 5: The Governance Team publishes the document on the
organisation’s website and ensures it is advertised to staff.
4.
Review of Procedural Documents
4.1.
Review of procedural documents will be 3 yearly unless legislation /
guidance states otherwise.
4.2.
Procedural Document Authors are responsible for reviewing procedural
documents within their area of responsibility to ensure that they are up
to date with current legislation and within their review date.
4.3.
When a procedural document requires updating or is due to expire, the
Procedural Document Author should undertake the review in
consultation with relevant individuals / approving bodies.
•
If a procedural document is reviewed and there are no changes, the
procedural document coversheet and review sheet should be
updated to reflect that a review has taken place and the procedural
Page 12 of 23
document should be forwarded to the Governance Team as in Step
4 above.
•
If there are only minor changes to a procedural document (e.g.
contact addressses, logos, names/titles, a paragraph inserted,
deleted or amended to bring procedural documents in line with new
guidance which do not affect the intended purpose of the procedural
document) the procedural document coversheet and review sheet
should be updated to reflect that a review has taken place. The
Lead Officer with lead responsibility should then confirm acceptance
of the amendments and the procedural document should be
forwarded to the Governance Team as in Step 4 above.
•
If a procedural document has significant changes then a summary
of the changes should be listed and sent, alongside the procedural
document, to the relevant Authorising Body. Once approved, the
procedural document should be forwarded to the Governance Team
as in Step 4 above.
5.
Dissemination of Procedural Documents
5.1.
The Governance Team at Sovereign House disseminate all procedural
documents as follows:
•
STEP 1: Place the procedural document in Adobe format on the
organisation’s website.
•
STEP 2: Print a single hard copy of the procedural document for
business continuity purposes.
•
STEP 3: Maintain a database of procedural documents in Adobe
format and Word format.
6.
Control of Procedural Documents
6.1.
The Governance Team have overarching responsibility for the control
of procedural documents which will be contained alphabetically within
Procedural Document Manuals:
• Manual 1 – General
• Manual 2 – Employment
• Manual 3 – Clinical
• Manual 4 – Commissioning
• Manual 5 – Multi-Agency Policies
6.2.
The Governance Team will electronically archive all old procedural
documents upon receipt of reviewed documents, maintaining access to
the past library of procedural documents.
Page 13 of 23
SECTION C - APPENDICES
APPENDIX A
TEMPLATE FOR PROCEDURAL DOCUMENTS
Page 14 of 23
TITLE OF PROCEDURAL DOCUMENT
[ARIEL POINT SIZE 22, CENTRED]
Last Review Date
Approving Body
Date of Approval
Date of Implementation
Next Review Date
Review Responsibility
Version
Page 15 of 23
REVISIONS/AMENDMENTS SINCE LAST VERSION
Date of Review
Amendment Details
Page 16 of 23
CONTENTS
Page
Definitions
Section A – Policy
1.
Policy Statement, Aims & Objectives
2.
Legislation & Guidance
3.
Scope
4.
Accountabilities & Responsibilities
5.
Dissemination, Training & Review
Section B – Procedure
1.
[Whatever is relevant to the subject]
2.
[Whatever is relevant to the subject]
3.
[Whatever is relevant to the subject]
4.
[Whatever is relevant to the subject]
5.
[Whatever is relevant to the subject]
6.
[Whatever is relevant to the subject]
Appendices
A
[Whatever is relevant to the subject]
B
[Whatever is relevant to the subject]
Page 17 of 23
DEFINITIONS
Term
Definition
[Term]
[Definition]
Page 18 of 23
SECTION A – POLICY
1. Policy Statement, Aims & Objectives
1.1
Describe the topic of the procedural document, giving a summary of
the background to what the document aims to achieve.
1.2
The aims of this procedural document are:
•
•
•
•
To ensure continuous improvement, the organisation has a range of key
performance indicators (KPIs) which it uses for monitoring purposes:
No.
1.
2.
Key Performance Indicator
Method of Assessment
This procedural document will be reviewed 3-yearly, and in accordance
with the following on an as and when required basis:
• Legislative changes
• Good practice guidance
• Case law
• Significant incidents reported
• New vulnerabilities
• Changes to organisational infrastructure
2. Legislation & Guidance
2.1.
The following legislation and guidance has been taken into
consideration in the development of this procedural document:
•
List legislation and guidance.
3. Scope
3.1.
This policy applies to those members of staff that are directly employed
by NHS Doncaster CCG and for whom NHS Doncaster CCG has legal
responsibility. For those staff covered by a letter of authority / honorary
contract or work experience this policy is also applicable whilst
undertaking duties on behalf of NHS Doncaster CCG or working on
NHS Doncaster CCG premises and forms part of their arrangements
with NHS Doncaster CCG. As part of good employment practice,
Page 19 of 23
agency workers are also required to abide by NHS Doncaster CCG
policies and procedures, as appropriate, to ensure their health, safety
and welfare whilst undertaking work for NHS Doncaster CCG.
4. Accountabilities & Responsibilities
4.1.
Overall accountability for ensuring that there are systems and
processes to effectively [what the procedural document aims to do] lies
with the [job title e.g. Chief Officer]. Responsibility is also delegated to
the following individuals:
[Job title]
or
equivalent]
Staff
Has delegated responsibility for:
• Xxxxxxx
• Xxxxxxx
• Xxxxxxx
Responsibilities of Staff (including all employees, whether
full/part time, agency, bank or volunteers) are:
• Xxxxxx
• Xxxxxx
5. Dissemination, Training & Review
5.1.
Dissemination
5.1.1. The effective implementation of this procedural document will support
openness and transparency. NHS Doncaster CCG will:
•
•
•
Ensure all staff and stakeholders have access to a copy of this
procedural document via the organisation’s website.
Communicate to staff any relevant action to be taken in respect of
complaints issues.
Ensure that relevant training programmes raise and sustain
awareness of the importance of effective complaints management.
5.1.2. This procedural document is located in the
[General/Employment/Clinical/Commissioning/MultiAgency] Policy
Manual. A set of hardcopy Procedural Document Manuals are held by
the Governance Team for business continuity purposes and all
Page 20 of 23
procedural documents are available via the organisation’s website.
Staff are notified by email of new or updated procedural documents.
5.2.
Training
5.2.1. All staff will be offered relevant training commensurate with their duties
and responsibilities. Staff requiring support should speak to their line
manager in the first instance. Support may also be obtained through
their HR Department.
5.3.
Review
5.3.1. As part of its development, this procedural document and its impact on
staff, patients and the public has been reviewed in line with NHS
Doncaster CCG’s Equality Duties. The purpose of the assessment is to
identify and if possible remove any disproportionate adverse impact on
employees, patients and the public on the grounds of the protected
characteristics under the Equality Act.
5.3.2. The procedural document will be reviewed every three years, and in
accordance with the following on an as and when required basis:
•
•
•
•
•
•
•
Legislatives changes
Good practice guidelines
Case Law
Significant incidents reported
New vulnerabilities identified
Changes to organisational infrastructure
Changes in practice
5.3.3. Procedural document management will be performance monitored to
ensure that procedural documents are in-date and relevant to the core
business of the CCG. The results will be published in the regular
Governance Reports.
Page 21 of 23
SECTION B – PROCEDURE
THIS SECTION CAN FOLLOW ANY LAYOUT SUITED TO THE SUBJECT
MATTER, PROVIDING THE CONVENTIONS IN THE “POLICY ON
PROEDURAL DOCUMENTS” ARE FOLLOWED
Page 22 of 23
SECTION C – APPENDICES
THIS SECTION CAN FOLLOW ANY LAYOUT SUITED TO THE SUBJECT
MATTER, PROVIDING THE CONVENTIONS IN THE “POLICY ON
PROEDURAL DOCUMENTS” ARE FOLLOWED
Page 23 of 23