Policy and Procedural Documents’
Development and Management
Version:
6.1
Bodies consulted:
Lead Managers
Approved by:
Executive Management Team
Date Approved:
8.3.16
Lead Manager:
Governance Manager
Lead Director:
Deputy Chief Executive
Date issued:
Mar 16
Review date:
Jun 21
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Contents
1 Introduction ..............................................................................3
2 Purpose .....................................................................................3
3 Scope .........................................................................................4
4 Definitions ................................................................................4
5 Duties and responsibilities .......................................................5
6 Procedures ................................................................................6
7 Training Requirements ........................................................... 13
8 Process for monitoring compliance with this Procedure ......14
9 References .............................................................................. 14
10 Associated documents......................................................... 14
Appendix A : Equality Impact Assessment .................................15
Appendix B : Terms of Reference, Policy and Procedure SubCommittee .................................................................................... 18
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Policy and Procedural Documents’
Development and Management
1 Introduction
Policies and procedures are intended to provide staff with clear rules and a
process for given situations where some degree of complexity exists or where
requirements for such a policy have been set by an external body. This policy
sets out how the Trust will achieve this. The Trust is committed to reducing
and managing risk and ensuring effective and safe practice. The Trust has a
responsibility to ensure that policies and procedural documents are
developed that:









enable the Trust to deliver its strategic objectives
provide a framework for safe, effective and acceptable practice
Comply with NHS identity guidelines and are standardised in the
Trust format and style
are easily available and comprehensible
follow a clear approval process
promote diversity and do not discriminate in their application
are subject to a formalised review and revision process at
specified intervals of not more than 5 years
are subject to consultation with the trades’ unions with a view
to reaching consensus with the Joint Staff Consultative
Committee (JSCC)
give clarity on the appropriate level of authority for the
approval of different types of policy
For brevity, the term “policy” will be used to denote all document types
throughout this document. For formal definitions, see section 4.
2 Purpose
The purpose of this policy is to ensure that there is a consistent approach to
the processes involved in developing and controlling policy and procedural
documents from inception to review, through to withdrawal and archiving.
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3 Scope
3.1
This policy applies to all policy and procedural documents
developed for Tavistock and Portman NHS Foundation Trust. Lead
managers of existing Trust Policies and Procedures will be required
to ensure that the requirements of this Policy are incorporated into
them when reviewed, and updated.
3.2
All new policy documents are to be developed following the
principles and format laid out within the content of this policy.
3.3
All directorate specific procedures are to be developed in line with
this policy and the director will be responsible ensuring out of date
versions are retained electronically in an archive.
3.4
Regulations agreed with university partners applicable only to
students of that institution or processing of business in relation to
the courses of that institution will be approved by the Director of
the Department of Education and Training/ Dean of Postgraduate
Studies.
4 Definitions
The following definitions are used by the Trust:
A Policy: is a statement of organisational intent in respect of a given issue.
Only the Board of Directors can ratify original policy, other directions
categorised below can be approved at other levels within the organisation
hierarchy (see section 6.4).
A Procedure: is a statement setting out structured steps, which need to be
adhered to, in order for a given task to be completed.
A Protocol: is a statement of rules or parameters associated with a procedure
that are to be followed in a specific situation.
A Guideline: is a statement outlining the evidence directing an action based
upon information issued by a professional or regulatory body or otherwise
informed by legislation or case law.
A Standard: is a statement of a measurable level of performance to be
achieved.
A Standard Operating Procedure (SOP): is a variation to a procedure that
applies in circumstances set out in the SOP. An SOP would be approved at
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the level that it would apply (eg, a director could approve it if the SOP only
applies to that director’s lead areas).
Policy Master Log: this is an electronic list of active and archived Trust-wide
policies.
Regulations: applicable only in the Department of Education and Training
may be named by other institutions as ‘policies’ but the scope of such
documents will be limited to situations agreed jointly by the Trust and the
respective institution as set out in the respective agreement.
Technical Policies: ICT staff and contractors often refer to rules applied
within computer programs and algorithmic decision making as ‘policies’,
however, this should be taken as a technical term and such rules have no
effect outside the given ICT system.
5 Duties and responsibilities
In relation to developing and managing policies within the Trust, the
following key duties have been identified:
5.1
The Board of Directors: is responsible for the ratification of original
Trust policies.
5.2
The Chief Executive: is responsible for ensuring that all staff follow
policies and procedures.
5.3
The Deputy Chief Executive: will monitor compliance with this
procedure and report to the Corporate Governance and Risk work
stream.
5.4
The Trust Policy Lead: is responsible for ensuring that this policy is
adhered to when new polices or procedures are developed and/or
current policies and procedures are reviewed, updated, are
comprehensible, and consistent with other policy documents. The
Lead shall also ensure that controlled numbering for documents is in
place and to arrange for the ratified documents to be available to
staff via the intranet. The Lead will arrange prompts for reviews of
policies by set time intervals, and be responsible for withdrawal and
archiving of all out-dated corporate policies. The Lead shall be the
first point of contacts for general enquiries relating to policies; and
shall provide training and support to policy developers as required.
5.5
Lead Managers: develop policies and procedures based on the best
available evidence and in line with current guidance (e.g. NICE,
NHSLA) and mandatory requirements. The Lead Manager is
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responsible for preparing a proposal for the approval process, and if
approved, for ensuring that it is publicised and understood by staff.
5.6
Executive Management Team: has delegated authority from the Board
of Directors to: approve any document up to the level of procedure
(see diagram in 6.4); or to re-approve any policy that has expired but
does not require substantive change.
5.7
Joint Staff Consultative Committee: is the consultative partnership
body between the Trust and the trades’ unions, which seeks to reach
agreement on polices affecting terms and conditions of employment
5.8
Directors have the responsibility to ensure that arrangements are in
place in their directorate for the implementation of policy; directors
also have authority to develop and approve procedures, guidelines,
protocols, etc where they would affect only their directorate or area
of work on which their directorate leads, these will be administered at
directorate level.
5.9
Line managers: are responsible for ensuring that their staff comply
with applicable policies.
5.10
Director of HR will provide, or arrange for the provision of, advice on
equality and diversity issues for staff and honorary contract holders
that arise during the development and/or implementation of policies.
5.11
Equalities Lead: will provide, or arrange for the provision of, advice on
equality and diversity issues for that arise during the development
and/or implementation of policies (other than for staff, see 5.10).
5.12
Trust Secretary: is available as a source of expertise on corporate
governance in relation to this process.
5.13
All staff: Staff are required to ensure they are aware of the content of
policies relevant to their work and how to access them. It is everyone’s
responsibility to ensure that they are familiar with the policies within
the Trust that apply to them.
5.14
Policy Approval Sub-Committee (PASC) Chair: will oversee the work of
the sub-committee. This is a sub-committee of the Executive
Management Team that considers any renewal of policies that do not
require substantive change. The Terms of Reference for this subcommittee are approved by the Executive Management Team and the
current version is kept by the Policy Lead.
6 Procedures
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6.1
Style and format
All policy documents are to be prepared in the corporate NHS style and
format (see appendix A for items to be included); a pro forma is available
from the policy coordinator.
6.2
Naming documents
For ease of referencing and searching, Lead Managers should choose concise
names that immediately convey the purpose of the document.
6.3
Equality Analysis
The Trust aims to design and implement services, policies and measures that
meet the diverse needs of our services, population and workforce, ensuring
that none are placed at a disadvantage over others. Lead Managers will
make this assessment using the Equality Analysis Tool. , without which the
proposed document cannot be considered. Any issues arising from the
analysis should be referred to the Trust’s Equality Lead. The completed
equality analysis for this document is Appendix B.
6.3
Consultation process
6.3.1 The Lead Manager is responsible for ensuring that appropriate
consultation takes place with relevant staff and other stakeholders
during the drafting of the policy. If the proposed or revised policy
would affect staff terms and conditions then this must include the
Joint Staff Consultative Committee.
6.3.2 In addition to other interested parties, the Policy Lead must approve
all proposals to ensure compliance with this procedure and make
directions to ensure policies make sense and are compatible with other
policies (editing suggestions may also be made) prior to submission for
approval.
6.3.3 All comments received on a draft must be considered by the
nominated policy developer and suggested redrafting should be
incorporated whenever appropriate; however, the decision on
inclusion lies with the Lead Manager. Where substantive comments
have not been included, the Lead Manager should contact the
commentator to explain why their views have not been incorporated
in the final draft.
6.3.4 The Lead Manager should list those consulted on the front cover of
the document in the designated box.
6.4
Ratification/Approval Process
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The appropriate approval authority in respect of proposed policies will
depend on the type of policy or procedure. Final approval would
normally be preceded by consideration at a ‘lower’ level.
Regulatory bodies1
As specified
(usually incorporated into
policy of procedure)
Board of Directors
All trust-wide procedures, protocols,
guidelines & standards, and reapproval of minor updates to policies
Approval level
Management
Team**
Directorate
or
Discipline
Policy
Procedures, protocols, guidelines & standards
applying to a single discipline or directorate
Type of ‘policy’ etc
**The PASC (see 5.13 above) can approve updates to policies on behalf
of the Executive Management Team in situations when substantive
change is not required, see below:
High level approval of policy
The Board of Directors
Approves all policies in the first instance
Management Team
scrutinises proposed policies before submission to the Board; approves all
procedures in the first instance
1
The Trust would not
approve a directive from a regulator, so unless specifically directed to
Policy Approval Sub-Committee (PASC)
re-approves
formulate a policy, the Trust
may polies
introduce a procedure or guidance to indicate how such a
directive would be implemented.
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The main stages are:

The Lead Manager is responsible for the document and will lead on
ensuring the policy meets the requirements of this policy prior to
submitting it for approval

The Policy Lead ensures that the policy is compliant with this policy
and will invoke whichever approval process is indicated above

The Policy Lead will ensure that the approved policy is catalogued and
published on the Trust intranet
This process from is set out in the diagrams below:
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Director initiates
development
process
Policy developer
drafts policy and
consults
Director considers
draft
declined
For new policies
requiring board
approval, this
process will take
56-60 days
approved
declined
log
Policy Lead checks
compliance and
comprehension
Approval process
(see policy)
approved
approved
Policy developer
updates format to
comply with
NHSLA rules (if
required)
Renewing a
policy, or
making minor
changes will
take 7-14
days
Policy Lead completes front
sheet + removes red text
Policy (and procedure
etc) approval process
Policy Leads creates pdf
Communications adds to
intranet
Policy Lead completes log
and sends final version to
policy developer
log
Key
Document
Process
Director arranges
dissemination and training
Data
input
Blue -lead directorate
Purple -IT
Sky -policy coordinator
Policy expires
Policy Lead logs and
prompts review by sending
intentions form
Decision
log
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6.5
Decision
The approval process is the same for each decision making body
a) The responsible director shall propose the policy to the entity
indicated in 6.4 (refer to the secretary of the body in question to
ascertain deadlines and any other procedural requirements)
b) Members of the entity consider the proposal and make a decision
whether to approve.
c) The decision is recorded by the secretary
d) The Policy Lead shall ensure that the outcome is communicated to the
Lead Manager.
Publication, dissemination and implementation
6.5.1 Once a policy has been approved, the master copy of the policy will be
retained by the Policy Lead, who will give the policy a version number
and arrange for a ‘pdf’ version to be accessible from the Trust’s
website. The version number will appear on the front of the
document and in the footer.
6.5.2 Access to policies is via the Trust’s website and this will be promoted at
induction and on INSET days.
6.5.3 Managers are responsible for ensuring that their staff comply with
policies
6.5.4 The Policy Lead will highlight new and updated changes to Trust-wide
policies on the ‘what’s new’ section of the Intranet as appropriate.
6.6
Review and revision arrangements including version control
The Policy Lead will make arrangements to remind policy authors 3
months before the policy expires that review is due. If a review is
indicated sooner (eg if there have been legislative, or other guidance
changes prompting the need for a review) then the lead for that
policy should initiate the review.
6.6.1 Policies that require minimal change, or change specified by law or
regulators (see section 5.4) will be put into effect without consultation
and processed from the approval stage as set out in the diagram in
below:-
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Director initiates
process
Policy (and procedure
etc) renewal process
Renewing a
policy, or
making minor
changes will
take 7-14 days
no
Renewal/
changes can be
considered by
PASC
Is the policy still
required?
no
yes
Initiate archive
arrangement, see
section 8
Is any change
required to the
policy?
Are the only changes
mandated by law or
regulators?
yes
yes
no
no
Are the changes
substantive?
no
Are the changes
limited to minor
errors or
clarifications?
yes
yes
Approval process
as indicated by
the level of policy
(see section 6.4)
Changes can be
made by the
Policy Lead
For policies
requiring board
approval, this
process will take
56-60 days, less
for approval at
other levels
6.6.2 Any trivial changes that do not affect the meaning of the document,
eg spelling, grammar, pagination, phrasing, etc, can be made by the
Policy Lead at any time.
6.6.3 If amendments are required then the footer on the amended version
should indicate the date of the update, and the updated version
should be substituted for the previous version on the Trust’s intranet.
6.6.4 Version control will administered by the Policy Lead and recorded in
the master log.
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6.7
Archiving arrangements
The policy co-ordinator will archive all old version of policies and procedures
in a dedicated folder on a Trust server. These documents will be retained in
a “pdf” format and indexed by document number, date of version and full
title. Policies approved at directorate level shall not be archived centrally
unless there is a legal requirement so to do.
Policy Lead
receives form from
lead director
Is the policy
obsolete?
no
Initiate renewal
process, see
section 7
yes
Archive pdf
Delete word
version from file
Remove version
from intranet
Update master log
end
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7 Training Requirements
N/A
8 Process for monitoring compliance with this Procedure
The Policy Lead will monitor the implementation of this procedure and make
status and progress reports to the Executive Management Team, highlighting
exceptions from good practice and overall performance by the lead directors,
and will be responsible for monitoring any action plan agreed to address
deficits.
9 References
The Race Relations Act 1976 (as amended by the Race Relations
(Amendment) Act 2000)
The Disability Discrimination Act 1995 amended 2005
Promoting Equality and Human Rights in the NHS - A Guide for NonExecutive Directors of NHS Boards (2005) Department of Health
NHSLA (2007) template ‘An Organisation-wide Policy for the Development
and Management of Procedural Documents
10 Associated documents2
Risk Management Strategy and Policy
Procedure for Patient information
Corporate and DET Records Procedure
2
For the current version of Trust procedures, please refer to the intranet.
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Appendix A : Equality Analysis for Policies and Procedures
Completed by
Position
Date
The following questions determine whether analysis is needed
Yes
No
Does the policy significantly affect service users, employees or
the wider community? The relevance of a policy to equality
depends not just on the number of those affected but on the
significance of its effect on them.
Is it likely to affect people with particular protected
characteristics3 differently?
Is it a major policy, significantly affecting how Trust activity is
delivered?
Will the policy have a significant effect on how partner
organisations operate in terms of equality?
Does the policy relate to functions that have been identified
through engagement as being important to people with
particular protected characteristics?
Does the policy relate to an area with known inequalities?
Does the policy relate to any equality objectives that have been
set by the Trust?
Other?
If the answer to all of these questions was no, then the assessment is complete.
If the answer to any of the questions was yes, then undertake the following analysis:
Yes
No
Comment
3
Age, disability, gender reassignment, marriage/ civil partnership, pregnancy & maternity, race,
religion and belief, sex, sexual orientation.
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Do policy outcomes and
service take-up differ
between people with
different protected
characteristics?
What are the key findings
of any engagement you
have undertaken?
If there is a greater effect
on one group, is that
consistent with the policy
aims?
If the policy has negative
effects on people sharing
particular characteristics,
what steps can be taken
to mitigate these effects?
Will the policy deliver
practical benefits for
certain groups?
Does the policy miss
opportunities to advance
equality of opportunity
and foster good relations?
Do other policies need to
change to enable this
policy to be effective?
Additional comments
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Appendix B : Policy and Procedure Amendment Sub-Committee
Terms of Reference
1.
Constitution
1.1 The Executive Management Team hereby resolves to establish a subcommittee of the Executive Management Team to discharge the duty in
section 6.6 of the Development and Management of Policy and
Procedural Documents Procedure. This sub-committee has no executive
powers other than those delegated in these terms of reference.
2.
Sub-Committee management
2.1 Membership of the sub-committee shall be tailored to the discussion, it
will include core members and another director as follows:
2.1.1
Deputy Chief Executive (Chair)
2.1.2
Governance Manager (Policy Lead)
2.1.3
Trust Secretary
2.1.4
One additional member selected from the Executive
Management Team for each policy/procedure approval (see 2.2)
2.2 The additional member of the committee will be selected from the
Executive Management Team to form the sub-committee for each
decision (see 2.1.4). The selection of the additional member will reflect
their area of responsibility and experience. A director cannot approve
their own policy/procedure. When considering clinical policies, the
member selected will be a registered clinician. The selection of the
additional member will be made by the Governance Manager on behalf
of the Sub-Committee Chair.
2.3 The Governance Manager will also provide management support and
will keep a record of the sub-committees decisions.
2.3 It is the responsibility of the Chair to determine the most effective way
to deliver on the terms of reference.
2.4 Meetings will take place virtually, eg by email, unless otherwise directed
by the Chair.
2.5 An ‘action tracker’ logging decisions and actions to be taken will be
kept by the secretary.
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3.
Authority
3.1 The Sub-Committee is authorised by the Executive Management Team
to investigate any activity within its terms of reference. It is authorised
to seek information it requires from any employee, and all employees
are directed to co-operate with any request made by the SubCommittee. The Sub-Committee is authorised to obtain outside legal
advice or other professional advice and to secure the attendance of
outsiders with relevant experience if it considers this necessary.
4.
Duties
4.1 The sub-committee shall consider updates to policies and procedures as
requested and required.
4.2 Consultation with stakeholders on amendments is only required if the
changes would be substantive, or would affect the original intention or
scope of the policy, but would be good practice in all cases.
4.3 Policies or procedures that require minimal change, or change dictated
by national policy change or law do not require re-ratification by any
other body.
5.
Other Matters
5.1 At least once every two years the sub-committee will review its own
performance, constitution and terms of reference to ensure that it is
operating at maximum effectiveness and recommend any changes it
considers necessary to the Executive Management Team.
6.
Reporting
The decisions of the sub-committee will be formally recorded by the Policy
Lead who shall draw the attention of the Executive Management Team to
any issues in record of the decisions that require discussion or executive
action.
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