Template for the Development of Procedural Documents

TEMPLATE FOR THE DEVELOPMENT OF PROCEDURAL DOCUMENTS

Instructions on how to complete the policy document template are written through this template in blue italics – please ensure you delete these instructions before the policy document is finalised and put forward for ratification.

DOCUMENT CONTROL:
Version: / Insert version number – check previous version with Policy and Standards Officer
Ratified by: / Insert name of committee/group with authority to approve this policy – check policy for development and management of procedural documents – page 7
Date ratified: / Insert the date the policy was approved by the approving committee/group
Name of originator/author: / Insert the job title (not the name) of the document author
Name of responsible committee/individual: / Insert the name of the committee/group responsible for this document i.e. implementation and monitoring.
Date issued: / The Policy and Standards Officer will complete this box on the day the policy is loaded onto the website.
Review date: / Insert the month and year the policy is due for review – usually this will 3 years from the ratified date unless otherwise agreed.
Target Audience / Insert an overview of who this document is for i.e. clinical or non clinical staff, all staff, managers etc.

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CONTENTS

SECTION PAGE NO

1. / INTRODUCTION / Insert relevant page numbers
2. / PURPOSE
3. / SCOPE
4. / RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES
5. / PROCEDURE/IMPLEMENTATION
5.1 / Insert Sub Headings as required
6. / TRAINING IMPLICATIONS
7 / MONITORING ARRANGEMENTS
8. / EQUALITY IMPACT ASSESSMENT SCREENING
8.1 Privacy, Dignity and Respect
9. / LINKS TO ANY ASSOCIATED DOCUMENTS
10 / REFERENCES
11 / APPENDICES
1. / INTRODUCTION
2. / PURPOSE
3. / SCOPE
4. / RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES
5. / PROCEDURE/IMPLEMENTATION
6. / TRAINING IMPLICATIONS

There are three choices regarding training implications so choose the one that applies to this document and delete the others:

Option 1 - Trust training implications model template

Use this formatbelow where specific training needs are identified - see section 5.2.8 of the policy for development and management of procedural documents on page 14/15.

POLICY TITLE
Staff groups requiring training / How often should this be undertaken / Length of training / Delivery method / Training delivered by whom / Where are the records of attendance held?
DO NOT USE THE TERM “AD HOC” / Electronic Staff Record system (ESR)

Option 2 – Trust Standard Training Statement

Where no specific training needs are identified Insert the following standard statement and adapt as required – see section 5.2.9 of the policy for development and management of procedural documents on page 14/15.

“There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents: (INSERT LIST OF ROLES WHO NEED TO BE FAMILIAR WITH THE DOCUMENT) and any other individual or group with a responsibility for implementing the contents of this policy).

As a Trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through: (ENTER AWARENESS RAISING METHODS TO BE CONSIDERED, examples below.)

A number of a variety of means such as;

Team Brief / Weekly Newsletter
Trust wide mail drop / Trust wide email
Team meetings / Special meetings
One to one meetings / Supervision / Group supervision
Posters / Practice Development Days
CPD sessions / Local Induction

Option 3 – For NHSLA Policies Only

Policies which are required to have their Training Needs Analysis (TNA) monitored for the NHS Litigation Authority are managed separately from other policies. All policies which have a training requirement above that of simple awareness raising will require a TNA to be completed using the table below.

However, the NHSLA related policies will have the TNA table stored in the Mandatory Risk and Safety Training Policy suite rather than in the policy itself. For all other policies, the TNA table will be entered directly into section 6 of the policy.

For all NHSLA policies, a copy of the TNA is to be sent to the Head of Learning and Development PRIOR TO ratification by the relevant committee.

For NHSLA related policies, the following paragraph is to be entered in section 6.

The Training Needs Analysis (TNA) for this policy can be found in the Training Needs Analysis document which is part of the Trust’s Mandatory Risk Management Training Policylocated under policy section of the Trust website.

7. / MONITORING ARRANGEMENTS
Area for Monitoring / How / Who by / Reported to / Frequency

A model template for the monitoring section of procedural documents is shown above and must be completed for all documents.This section must set out how implementation of the procedural document will be monitored.

Monitoring provides assurance that prescribed systems are working and involves collecting information that will help answer questions about the Trust’s systems, including:

- Are we managing the risk?

- How well are we doing?

- Are we doing the things we said we should?

- Are we making a difference in doing those things?

It is important that the frequency and detail of the monitoring process is specified and that it can realistically be achieved.

8.EQUALITY IMPACT ASSESSMENT SCREENING -

The policy author will need to complete an Equality Impact Assessment Screening Tool as part of the development or review of the procedural document. The EIA Tool is attached as a separate document to the policy template – see appendix 1. If you require any advice on completing the EIA you can contact Diane Ekins, Equality and Diversity Lead. You must send the EIA and a copy of the draft policy to the Diane Ekins for approval before the policy is put forward for approval by the authorised committee/group. Record this consultation on the checklist and tracking document (see appendix 2).

The following statement and link is to be added to Section 8 and the EIA Screening Tool will be published on the Trust’s Equality and Diversity webpage.

The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website clickhere

8.1Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.
As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). / Indicate how this will be met
You must consider any issues regarding the content of this policy in relation to privacy, dignity and respect and detail how these will be met.
If there are no issues identified please state:No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court
Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. / Indicate How This Will Be Achieved.
All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)
You must consider any issues regarding the content and implementation of this policy in relation to the Mental Capacity Act and detail how these will be met.
If there are no issues identified please state:

Once the policy document has been completed and you have consulted with the relevant people you must notify the relevant administrator of the approving committee/group that the document needs to be presented to the next meeting for ratification.

The committee/group will need an electronic copy of the following documents usually a week in advance of the meeting: a completed cover sheet, the policy document with track changes if reviewed, a copy of the approved Equality Impact Assessment Screening Tool and a completed copy of the checklist and tracking document – see below. The policy author is usually expected to present the policy document for approval unless alternative arrangements have been made.

9. / LINKS TO ANY ASSOCIATED DOCUMENTS
This section should provide details of any documents which are referred to at any point in the document, in order that the user can refer to these for further guidance as required.
10 / REFERENCES
References provide an evidence base for procedural documents. The Harvard style will be used to provide a uniform approach to referencing, as set out in the policy for development and management of procedural documents on page 18
11 / APPENDICES
Insert any appendices to the policy here i.e.
Appendix 1 – [title of document]

PROCEDURAL DOCUMENT CHECKLIST AND TRACKING DOCUMENT

Document Title: / Insert the title of the document being developed or under review
Category of Procedural Document : / Which procedural document category will the document be linked to i.e. Clinical, Infection Control, Finance etc
Name of Originator/Author: / Insert the name and title of the document author(s)
Accountable Director: / Insert the name of the accountable director for document
Name of Responsible Committee / Insert the name of the committee responsible for approving the document.
Members of Authorship Group (where relevant):insert the name(s) of the people involved in the development or review of the policy – this can be individuals and/or a group.

Names

/ Titles
Please provide details of the consultation process (i.e. Individuals/groups consulted): insert the names/job titles of the people who have been consulted in the development or review of the policy – see section 5.4.4 of the policy for development and management of procedural documents on page 19.
Group or Individual / Date requested and method / Comments made / Were amendments made in response to the comments? If not, explain why

This checklist must be completed and given to theapproving committee/group to confirm that the policy document has been developed/reviewed in accordance with thepolicy for development and management of procedural documents. If there are any reasons why the process has not been followed please indicate this is the comments section.

Checklist for the Review and Approval of Procedural Documents / Yes/No/
Unsure / Comments
1. / Title
Is the title clear and unambiguous?
Is it clear whether the document is a strategy, policy, procedure, framework, guideline, protocol or standard operating procedure?
2. / Rationale
Are reasons for development of the document stated?
Is this an NHSLA policy document?
If yes, has it been checked for compliance against the minimum requirements set out within the criterion?
3. / Development Process
Was the document reviewed before the agreed review date expired?
If not please state reason for delay?
Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?
Is there evidence of consultation with relevant stakeholders and users detailed in the tracking document?
Have the following been considered as part of the development of this document:

• Mental Capacity Act
• Privacy, Dignity and Respect
• Safeguarding
• Fraud
• Infection Control
• Training requirements
• Other relevant documents

4. / Content
Is the scope of the document clear?
Is the target population clear and unambiguous?
Is the policy written in a style which is concise and clear?
Is the policy written in the approved template?
Is the policy formatted in Arial Font size 12?
Is the document referenced using the Harvard reference system?
Is the document numbered using the page x of y convention?
5. / Introduction
Does this section introduce the topic and include references to and applicability of any relevant legislation, national policy guidance, external agency recommendations, definitions and explanation of terms used?
6. / Purpose
Does this section outline the objectives and intended outcomes of the process/system being described?
7. / Scope
Are the target audience and activities covered by the document clearly stated?
8. / Responsibilities, Accountabilities and Duties
Does this section provide an overview of the individual, departmental and committee duties including levels of responsibility for document development?
9. / Procedure/Implementation
Does this section detail the actual procedural guidance?
If lengthy, is it presented in subsections to make it easier for the user to refer to?
10. / Training Implications – where training needs have been identified has either:
A training needs analysis has been completed;
The Trust Mandatory Risk Management Training statement added; or
Where training is not required details of how staff will be made of the policy and its implications for their working practice.
Has the Head of Learning and Development reviewed the TNA?
11. / Process for Monitoring Compliance
Are there measurable standards to support monitoring compliance of the document?
Is there a plan to review or audit compliance with the document?
Has any plan to use clinical audit been discussed with the Clinical Audit Department and included in the Trust Clinical Audit Forward Programme?
12. / Equality Impact Assessment Screening
Has an Equality Impact Assessment been completed as part of the document development/review process?
Has the EIA been approved by the Trust Equality and Diversity Lead?
Have any privacy, dignity and respect issues been identified within the document and does the document indicate how these will be met?
13. / Mental Capacity Act Statement
Have the provisions of the Mental Capacity Act been considered and any issues identified addressed within the document?
12. / Links to any associated documents
Are local/organisational supporting documents referenced?
If the document details any associated documents are these referenced in section 9?
13. / Referencing
Is the type of evidence to support the document identified explicitly?
Are key references cited?
Are the references cited in full using the Harvard referencing style?
14. / Approval/Ratification
Does the document identify which committee/group is responsible for ratification of the document?
If appropriate, have the joint Human Resources/staff side committee (or equivalent) approved the document?
Has the policy been checked by the Clinical Effectiveness Lead (clinical documents) or Policy and Standards Officer (non-clinical documents) – refer to appendix 4.
15. / Dissemination and Implementation
Is there an outline/plan to identify how this will be done
Does the plan include the necessary training/support to ensure compliance?
16. / Document Control
Is the correct version number recorded on the policy?
Is the document control box completed accurately?
Is the review date identified?
17. / Overall Responsibility for the Document
Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?
Date document presented to Trust Policy Review Panel / Insert the date when the policy document was presented to the Policy Review Panel
Outcome
Detailthe outcome i.e. was the policy approved, approved subject to recommendations or not approved?
Recommendations: / Completed by / Date
If approved subject to recommendations please state each of the changes required, the action taken, who by and the date completed.
Date document presented to Trust Committee/Group with delegated responsibility for ratification / Insert the date when the policy document was presented to the approving committee/group
Outcome
Detailthe outcome i.e. was the policy ratified, ratified subject to recommendations or not ratified. / Ratified / Ratified subject to recommendation / Not ratified (provide reason)
Recommendations: / Completed by / Date
If ratified subject to recommendations please state each of the changes required, the action taken, who by and the date completed.

Following the ratification of a policy document:

Once the policy document has been approved and any agreed changes made you must ensure that it is returned to the committee/group administrator who will forward the completed document to the Policy and Standards Officer who will upload it to the Trust website and notify staff through the weekly bulletin.

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