Policy and Procedural Documents Development and Management

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 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 1 of 18

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 Sub- Committee... 18 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 2 of 18

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. Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 3 of 18

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 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 4 of 18

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 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 5 of 18

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 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 6 of 18

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 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 7 of 18

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 bodies 1 Board of Directors As specified (usually incorporated into policy of procedure) Policy Approval level Directorate or Discipline Management Team** All trust-wide procedures, protocols, guidelines & standards, and reapproval of minor updates to policies 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) formulate a policy, the Trust re-approves may polies introduce a procedure or guidance to indicate how such a directive would be implemented. Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 8 of 18

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: Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 9 of 18

Director initiates development process Policy developer drafts policy and consults Director considers draft approved declined For new policies requiring board approval, this process will take 56-60 days declined Policy Lead checks compliance and comprehension log 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 Leads creates pdf Policy (and procedure etc) approval process Communications adds to intranet Policy Lead completes log and sends final version to policy developer log Director arranges dissemination and training Key Document Data input Process Decision Policy expires Policy Lead logs and prompts review by sending intentions form log Blue -lead directorate Purple -IT Sky -policy coordinator Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 10 of 18

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:- Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 11 of 18

Policy (and procedure etc) renewal process Director initiates process Is the policy still required? no yes Initiate archive arrangement, see section 8 Renewing a policy, or making minor changes will take 7-14 days no Is any change required to the policy? yes Are the only changes mandated by law or regulators? Renewal/ changes can be considered by PASC 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. Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 12 of 18

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 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 13 of 18

N/A 7 Training Requirements 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 Non- Executive 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 documents 2 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. Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 14 of 18

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 characteristics 3 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. Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 15 of 18

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 Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 16 of 18

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. Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 17 of 18

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 Sub- Committee. 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. Policy and Procedural Documents Management and Development, v6.1, Mar 16 Page 18 of 18