Policy for the Development and Management of Policy, Procedures and Guidance Documents
Responsible Directorate:
Corporate Services
Date Approved:
September 2009
Committee:
Governance Committee
Version:
2
Revision Date:
September 2011
Accountable Director:
Director of Corporate Services
Contents Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Policy Statement Introduction Associated Policies and Procedures Aims and Objectives Scope of the policy Accountabilities Style and Format of Procedural Documents The Development of Policy & Procedural Documents (Appendix B) Version Control Identification of and consultation with key stakeholders Equality Impact Assessment 1 Training Needs Analysis. Key Performance Indicators (KPIs) and/or Outcomes Policy approval process Review and Revision arrangements Dissemination Implementation Monitoring Compliance with and the effectiveness of Procedural Documents Document Control and Archiving Arrangements Register of Documents Archiving arrangements Monitoring Compliance with this Procedure for the Development and Management of Procedural Documents
Appendices Policy/procedure template A Flowchart for the development , approval and ratification of policy B documents Equality Impact Assessment Tool C Sign off sheet for dissemination of documents D Stakeholder Consultation Record E
Page 1 1 1 1 2 2 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5
6 10 11 12 13
Policy Statement NHS Kirklees will have a systematic and planned approach to the development of policy and its associated guidance documents. Policy direction is the role of the Board and Directors and policy must be developed at senior manager level and overseen by an accountable Director. Policies will only be developed when there is a clear identified need for them to enable achievement of objectives and standards which would not be possible without written policy and guidance. The supporting guidance to develop documents will ensure that all the appropriate information is included in a standard format that can easily be accessed by PCT staff and that the ratification and review process is clear to all. The PCT’s policy is that all policies and guidance documents should follow the process set out in the attached guidance and must be followed by all PCT staff.
1
Introduction
This document sets out: • • • •
The PCT’s definitions of strategy, policy and guidance The required format of policy and guidance documents Who is accountable and responsible for policy and guidance The process for the development, approval and ratification of documents.
All documents will be managed as set out in the Records Management Policies and guidance. 2
Associated Policies and Guidance
This procedure should be read in accordance with the following PCT policies, procedures and guidance: • 3
Records Management Policies Aims and Objectives
NHS Kirklees aims to have a PCT wide understanding of the terms strategy, policy and guidance and a common approach to the development of policy and management of the associated guidance documents. This will enable the achievement of the following objectives: • •
To manage and control the development of policy To support compliance with the NHSLA Risk Management Standards.
• • • 4
To support compliance with the requirements of the NHS Information Governance standards To support compliance with standards for records management To support compliance with the Care Quality Commission standards. Scope of the Policy
All Trust employees including those on temporary or honorary contracts, bank staff and students who are developing policy, procedural and guidance documents must follow the process set out in this document. Independent Contractors are responsible for the development and management of their own documents and for ensuring compliance with relevant legislation and best practice guidelines. The Trust will provide such advice and support as required. 5 Accountabilities The Board and Senior Management Team The Board and Directors are responsible for setting policy direction. Directors Directors are responsible for the development of policy, procedures and guidance to make sure the technical content is appropriate, evidence based and in line with best practice and is approved, ratified, implemented and registered on the database in line with records management policies. The Director will be accountable for making sure that all documents have been agreed through an appropriate committee and the fact is recorded in the committee minutes. Lead Director The Director of Corporate Services is the lead Director with Board level responsibility for Information Governance and Records Management. Overall day to day responsibility for all aspects of Information Governance is the Assistant Director of Corporate Governance and Risk Management. They will be responsible for ensuring that staff conform to the policy. Corporate Services Manager/Records Manager KCHS They have responsibility to make sure: • • • •
there is a copy of all the PCT’s policies and procedures on the website, the PCT Policy and Procedure database is up-to-date all old documents are archived the Director responsible is aware when documents are due for review
Committee Duties The Governance Committee is the Board sub committee responsible for this policy, its ratification and review as appropriate. Staff who have delegated responsibility from the Director for developing policy, procedures and guidance documents must follow this policy and procedure. 6
Style and Format of Procedural Documents All PCT documents should be written in the corporate style set out in Appendix A in Arial font size 12.
7
The Development of Policy, Procedures and Guidance Documents Refer to flowchart in Appendix B.
8
Version Control Policies, procedures and guidance produced by the PCT must have a version control table. This should appear on the front of the document as set out in the template (Refer to Appendix A). This aids tracking and retrieval of documents and makes sure that all staff are working to the latest document which will be found on the website. The numbering system is as follows: • • • •
9
All drafts should be marked draft The first approved version is V1 Draft revisions should be marked draft The next approved version is V2 Identification of and consultation with key stakeholders
As set out in the flowchart a key element of the process is consultation with stakeholders: • • • 10
SMT must be part of the consultation process for policy development Some policies will need to be considered by the PCT’s partnership forum and HR advice should be sought on whether or not this is required. Remember external stakeholders and where appropriate service users.
Equality Impact Assessment All public bodies have a statutory duty to assess policies for their impact on race, disability, age, sexuality gender and religion. In order to meet these requirements, NHS Kirklees will use an Equality Impact Assessment tool supplied in Appendix C to make an initial assessment.
Further equality impact assessment may be required dependant on this initial screening process. 11
Training Needs Analysis The policy, procedure or guidance must take account of the training needs of staff required to be able to implement the policy, procedure or guidance. Staff groups who require training should be identified including how the PCT will meet the training requirements.
12
Key Performance Indicators (KPIs) or Outcomes The aims and objectives should be reflected in KPIs and outcomes must be identified to monitor the effect of the implementation of the policy, procedure or guidance.
13
Policy Approval Process The Director is responsible for making sure policy is approved by a Board sub committee and ratified by the Board.
14
Review and Revision Arrangements Unless stated on the document itself, all policy and procedures will be reviewed at least on a 3-yearly basis, but may be reviewed more regularly, for example following a change of practice or the receipt of new professional, regional or national legislation or guidance. The 3 year period commences from the ratification date. It is the responsibility of the Director and the committee who approved the document to monitor if a review is required before the 3 year period has elapsed. All reviews and revision to any policy, procedures, and guidance document must follow the processes described in this document.
15
Dissemination The Director is responsible for making sure the documents are disseminated as set out in Appendix D.
16
Implementation Implementation of the policy must include undertaking the training or support identified within the training needs analysis.
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Monitoring Compliance with and the Effectiveness of policies, procedures and guidance documents The Director is responsible for putting in place systems and processes which enable the PCT to demonstrate the effectiveness and compliance with the policy, procedure or guidance.
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Document Control and Archiving Arrangements Must be in line with the PCT’s Records Management Policy.
19
Register of Documents The Director must make sure a copy of the ratified documents are sent to the Corporate Services Manager and KCHS Records Manager for inclusion on the PCT corporate records database for policies, procedures and guidance. The Corporate Services Manager is responsible for making sure all policy, procedure and guidance documents are on the PCT website.
20
Archiving Arrangements The Corporate Services Manager is responsible for archiving the old documents in accordance with the Records Management Policies. This procedure requires that a register is maintained regarding where archived documents are stored and how to retrieve them from storage.
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Monitoring Compliance with this Procedure for the Development and Management of Policy, Procedural and Guidance Documents The Corporate Policy Group will be responsibilities for monitoring compliance with this procedure.
Appendix A PCT Template for a Policy, Procedure or Guidance
Name of Policy/Procedure/Guidance
Responsible Directorate: Date Approved: Committee: Version: Revision Date: Accountable Director:
Contents
Section
Appendices
Page
Policy Statement NHS Kirklees…
1.
Introduction
Overview of the purpose of the document and its particular context. 2.
Associated Policies, Procedures and Guidance
This policy/procedure should be read in accordance with the following PCT policies, procedures and guidance: • • • 3.
Name Name Name Aims and Objectives
Outline the aim, objectives, why do we need this? 4.
Scope of the policy/procedure
Who does the policy apply to? Usually the text below will apply. All Trust employees including those on temporary or honorary contracts, bank staff and students who are developing policy, procedural and guidance documents must follow the process set out in this document. Independent Contractors are responsible for the development and management of their own documents and for ensuring compliance with relevant legislation and best practice guidelines. The Trust will provide such advice and support as required. 5.
Accountabilities & Responsibilities
Set out an overview of the Director, Management, individual, departmental and committee duties including levels of responsibility for document development. Include expectations regarding consultation/involvement of key stakeholders 6.
Other headings as appropriate to the document The following headings must also be included as set out below.
X.
Equality Impact Assessment must be carried out on Policy and considered for all other documents This policy has been assessed for the potential adverse impact as set out in Appendix C. On initial screening the policy has not/has identified an impact (delete as appropriate). Where some impact has been identified this should be described and what action the PCT will take.
X.
Training Needs Analysis This should indentify staff groups who may/will need training and how the PCT will meet this training need.
X.
Monitoring Compliance with this policy/procedure
Details must be given regarding how, and at what intervals, compliance with this document will be monitored/assessed. A link must be made to the Key Performance Indicators and outcomes of the document. • • • X.
Monitoring arrangements for compliance and effectiveness including frequency i.e. audit, review, etc. Responsibilities for conducting the monitoring/audit. Process for reviewing results and ensuring improvements in performance occur. References
Provide evidence base for the documents with up-to-date references. be referenced appropriately, eg Harvard. X.
Documents should
Appendices
Need to include: Definitions - List and describe the meaning of the terms used in the context of the document if considered necessary. Stakeholder involvement – List key stakeholders consulted/involved in the development of the document and give detail of the feedback received. Equality Impact Assessment Tool – to be completed. Sign off sheet regarding dissemination of procedural documents – to be completed.
<<End of document template>>
Appendix B Flow Chart Board sub committee, SMT or Director decides policy is required
Director oversees development of policy for technical content
Policy is sent to -
Policy group to make sure it meets corporate requirements
SMT and other stakeholders for comments
Policy amendments made
Policy is sent to appropriate committee for approval
Board is informed of policies approved to ratify the process
Appendix C: Equality Impact Assessment Tool Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race • Ethnic origins travellers)
2. 3.
4. 5. 6. 7.
(including
gypsies
and
Comments
No No
• Nationality
No
• Gender
No
• Culture
No
• Religion or belief
No
• Sexual orientation including lesbian, gay and bisexual people
No
• Age
No
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action?
No n/a
No n/a n/a n/a
For advice in respect of answering the above questions, please contact Director of Corporate Services.
Appendix D Sign Off Sheet regarding Dissemination of Procedural Documents To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.
Title of Document:
Policy for the development and management of policy, procedures and guidance documents
Lead Director:
Director of Corporate Services
Date Approved:
September 2009
Where approved:
Governance Committee
Dissemination Lead:
Director of Corporate Services
Placed on Website:
December 2009
Review Date:
September 2011
Appendix E
Stakeholders name and designation SMT Governance Committee
Date feedback requested 17/09/09 17/09/09
Detail of feedback received
Date feedback received
Action taken