Procedure for the Development of Policies

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Cordelia Loraine Jackson
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SH NCP 04 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: This document provides a step-by-step guide to the development/review of all Southern Health NHS

1 SH NCP 04 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: This document provides a step-by-step guide to the development/review of all Southern Health NHS Foundation Trust policies. Policy for Policy Management, Policy, Policies, Policy Management, Policy Writing, Writing, Policy Handbook, Guidelines, Procedures, Protocols, Patient Group Directions, policy development. All staff involved in the development and review of Trust policies. Next Review Date: June 2020 Approved & Ratified by: Quality Improvement and Development Virtual Policy Group Date issued: Date of meeting: Author: Director: David Batchelor, Compliance Officer & Policy Management Lead Helen Ludford, Associate Director of Quality Governance 1

2 Version Control Change Record Date Author Version Page Reason for Change 03/06/16 David Batchelor 2 Throughout To include improved policy management processes identified in the last 4 years. Title change Reviewers/contributors Name Position Version Reviewed & Date David Batchelor Compliance Officer Version 1 March 2012 Tracey McKenzie Head of Audit and Compliance Version 1 March

3 Quick Reference Guide For quick reference, this page summarises the actions required by this procedure. This does not negate the need to be aware of and to follow the further detail provided in this procedure. Quick guide to policy approval: Policy author writes/reviews policy and sends out final draft for consultation Policy author updates policy following feedback & submits to relevant Expert Group for approval Expert Group reviews policy as per Approval Authorisation Checklist and decision is signed off by the Chair Did the Expert Did the Group Expert approve Group the approve policy? the policy? Expert Group feedback to policy author with required changes Yes No Submit final version to Policy Team with copy of signed Approval Authorisation Checklist and/or minutes of meeting as evidence of approval Policy Team will allocate reference & review date; upload policy onto Trust s public website and staff intranet; and cascade message out to staff through the Weekly Staff Bulletin 3

4 Quick guide to policy review: Does the policy meet the latest legislation, best practice and guidance? Yes No Is the policy still fit for purpose, i.e. does it meet the needs of the Trust? No Review and update policy. Send out for consultation & amend as required Yes Policy Team stating review completed & policy still valid. Submit final version for approval as per Policy Approval Guidance Policy Team will update review page, set new review date & publish on website Policy Team will process as per Policy Approval Guidance 4

5 Contents 1 Introduction 6 2 Identifying the need for a new policy 6 3 What type of document do I need to write? 6 4 Identifying the policy director and author 7 5 Writing the policy What style and format should I write my policy in? Quick reference guide Leadership, Education and Development (LEaD) training 7 needs analysis 5.4 Equality Impact Assessment tool Privacy Impact Assessment Best practice Multi-agency documents 8 6 Consultation 8 7 Approval 9 8 Dissemination 9 9 Implementation 9 10 Monitoring compliance 9 11 Review 9 12 Version control 9 Page 5

6 1. Introduction Good policy management underpins all clinical and non-clinical processes within the Trust to ensure they are consistent, effective and safe. This procedure is designed to assist authors in the development of new or review of existing policies. For the purpose of this procedure, the word policy refers to policies, procedures, protocols, guidelines, Integrated Care Pathways and Patient Group Directions, etc. This procedure should be read in conjunction with the SH NCP 03: Policy for Policy Management. 2. Identifying the need for a new policy The following are indicators of when a new policy is required: An issue has been identified which indicates significant and ongoing risk to people of the organisation and there is no guidance for staff There is no existing policy which covers the suggested topic or if such guidance exists, it is out of date National or other directives indicate a need for local action There is a change to existing national policy which needs to be reflected in local guidance Consideration should always be given to whether there is already a policy in place which could be reviewed to include any new requirements. The need to write a new policy should be agreed by the appropriate Director. 3. Which type of document do I need to write? Prior to writing the policy, the author should consider what type of document they are going to write. The following are offered as definitions to help clarify the differences between various types of document: Policy: Procedure: Protocol: Guidelines: Standards: A set of statements documenting the standards, intentions and/or expectations of how a practice or course of action will be implemented and adopted. It is considered binding and a breach of policy may have contractual consequences for the employee (e.g. the Equal Opportunities Policy). Detailed guidance about how a particular task should be carried out, a step-by-step guide which someone not familiar with the work can follow (e.g. the Complaints Procedure). A formal set of steps to follow in order to achieve a specific course outcome, specifically agreed for designated staff. Any deviation from the protocol is acceptable if this can be justified and the rationale for doing so documented in the service user s records. Systematically developed, evidence-based statements that assists in decision-making about appropriate healthcare for specific clinical conditions. Statements specifying a required level of performance for the purpose of monitoring or auditing. 6

7 Patient Group Directions (PGDs): Codes of Practice: Codes of Conduct: Pathway: Provide a legal framework to enable non-medical practitioners to supply and administer medicines in the absence of a qualified prescriber. Laid down specifications of standards which have to be met within a legal framework. Standards laid down which have to be adhered to by members of that profession or a specified group. A systematic plan and follow up for a service user focused care programme. 4. Identifying the policy director and author The Director agreeing the need for a policy will be the policy director. The policy director should identify the appropriate author, support the implementation of the policy and ensure that the necessary resources are available for the implementation of the policy. 5. Writing the policy 5.1 What style and format should I write my policy in? The author is responsible for ensuring that the policy is developed in line with this procedure and SH NCP 03: Policy for Policy Management to ensure that all Trust policies are written in a consistent way. All policies are to be written using the Trust s standardised policy template. All other documents (e.g. guidelines, protocols, procedures) are to be written using the Trust s standardised procedure template. In addition to the requirements of the templates, the following must also be adhered to when writing a policy It should be clear as to which division/service(s) the document applied. Other associated documents and supporting references should be clearly referred to Abbreviations must only be used after being written in full for the first time The body of the text should be in font size Arial 11 Subheadings for all documents should be in Arial bold 11, but not underlined All policies should be written in plain English (For guidance on Plain English http// All documents must remain watermarked as DRAFT until they have been approved by the appropriate Expert Group All policies must have a Leadership, Education and Development (LEaD) training needs analysis, an equality impact assessment tool and supporting policy implementation plan. 5.2 Quick reference guide A quick reference guide summarising the actions required by the policy should be included on page 3 of every policy. 5.3 Leadership, Education and Development Training Needs Analysis Where applicable, policies must include a Training Needs Analysis (TNA). This is particularly important for new policies. If there are no training requirements, this should be clearly documented in the policy. 7

8 Assistance to complete this can be obtained from the Leadership, Education and Development (LEaD) Team. The TNA tool is included in the policy template. 5.4 Equality Impact Assessment Tool An Equality Impact Assessment (EIA) tool is aimed at improving the quality of service provision by ensuring that individuals and teams think carefully about the likely impact of their work on different communities or groups. Assistance with the completion of the EIA tool is available from the Trust s Equality and Diversity Team. Policies without a completed EIA cannot be approved. 5.5 Privacy Impact Assessment If your policy relates to any information governance issues (e.g. technology to record/process information, information sharing processes) a Privacy Impact Assessment will be required. Please refer to SH IG 29: Privacy Impact Assessment Procedure and template. For advice please hp-tr.informationassuranceteam@nhs.net 5.6 Best Practice A literature review should be undertaken to ensure a policy includes the most up-todate and evidence-based practice. Examples of useful resources include Department of Health Care Quality Commission National Institute for Health and Clinical Excellence Royal Colleges and Professional Bodies Cochrane library NHS Employers EU directives The Royal Marsden Manual 5.7 Multi-agency documents Where the author of a multi-agency policy is a Trust employee, the use of the Trust s template and development process will be actively encouraged. It is recognised, however, that where the lead author is employed by one of the partnership organisations, the template and review process is outside of the Trust s control. Multiagency policies must still be approved as per the arrangements set out in this procedure. 6. Consultation Once the policy has been drafted, the author should send it to a diverse sample of the target audience for comments. Consultation should last for at least 2 weeks. As a minimum, all policies should be sent to: Leadership, Education and Development (LEaD) team to consult on training needs associated with the policy The Trust s Counter Fraud Specialist to identify any fraud implications Equality and Diversity team to ensure the equality impact assessment has been carried out correctly 8

9 Following a comprehensive consultation, and once any amendments have been made, the policy should be submitted to the appropriate expert group for its approval. 7. Approval Policies will be received and approved by the relevant expert group. If you are unsure of which expert group to seek approval from, please contact the Policy Management Team. The expert group approving the policy should examine and sign the policy off against the Trust s policy approval checklist. The policy cannot be published for use until the Policy Management Team have received confirmation from the chair of the expert group of its approval. 8. Dissemination Once the Policy Management Team have received confirmation of approval, they will upload the policy to the Trust s public website and staff intranet and cascade a message out to staff through the weekly staff bulletin. 9. Implementation To overcome historic problems associated with ensuring all policies are implemented appropriately, it is important that directors and authors give consideration to what needs to happen to get a policy embedded into practice. Policy authors should develop an implementation plan as part of the policies development. Policies without an implementation plan should not be approved by the expert group. 10. Monitoring compliance The effectiveness in practice of all policies should be routinely monitored to ensure the documents objectives are being met. The process for how the monitoring will be performed should be included in the policy and a proforma has been developed as part of the policy template. 11. Review All policies must be reviewed by their authors at least every 4 years. More frequent review will be required if changes in legislation occur, or new evidence becomes available. All new policies, however, must be reviewed within months of issue to ensure they are working effectively. It is the responsibility of the author to diarise the review date. Reminders will be sent to the author from the Policy Management Team 6 months in advance of the review date. A quick reference guide to reviewing a policy is available on page 4 of this procedure. 12. Version control The current version of the policy will be made available by the Policy Management Team on the Trust s public website and staff intranet. 9

10 The Policy Management Team maintain a library in word format of the latest and all historic versions. The archive will be available to assist the investigation and resolution of complaints, claims and incidents. 10

Policy Management Framework

Policy Management Framework University Secretariat Approved by UMT 08/11/2016 1. Purpose The Policy Management Framework establishes a standard and principles for policy development, approval, implementation