TRUST POLICY FOR THE PRODUCTION AND MANAGEMENT OF ANAESTHETIC GUIDELINES

Version / 8
Name of responsible (ratifying) committee / Anaesthetic Governance Group
Date ratified / 27 March 2018
Document Manager (job title) / Consultant Anaesthetist
Date issued / 23 April 2018
Review date / 22 April 2021
Electronic location / Clinical Policies
Related Procedural Documents / N/A
Key Words (to aid with searching) / Anaesthetic, anaesthesia, guideline

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
8 / 27/03/2018 / Paragraph 6 – review frequency agreed by Anaesthetic GuidelinesDevelopment Group – usually maximum of three years. / Dr F Bayshev
Dr S Radauceanu
Dr S Roland
7 / 02/03/2016 / Paragraph 10 – new leads for acting on recommendations / Dr F Bayshev
6 / 01/07/2013 / - / F King

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

APPENDIX 1: Template Guideline

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

Template Guideline

Font and format as below

Footer to show guideline title, issue date, version and page x of y on all pages

Portsmouth Hospital NHS Trust logo

TITLE OF GUIDELINE

Introduction

Purpose

Subheading

Author

References

Keywords

Equality Impact Assessment Complete – Yes / No; Date -

Approved by / Date
Ratified by / Date

The guideline must then be submitted to the Anaesthetic Governance Group for ratification

1.INTRODUCTION

The aim of the policy is to aide the production of high quality, user friendly Anaesthetic Guidelines conforming to a set format.

2.PURPOSE

This document outlines the policy to ensure the consistent preparation, approval, publishing, audit and review of Anaesthetic Guidelines for use within Portsmouth Hospitals NHS Trust.

3.SCOPE

Any PHT employee who produces an Anaesthetic Guideline. It will predominantly be used by medical staff for the Department of Anaesthesia.

4.DEFINITIONS

Anaesthetic Guidelines: Guidance documents prepared to assist clinicians, nurses and ancillary staff in the safe management of patients for specific clinical conditions relating to anaesthesia.

5.DUTIES AND RESPONSIBILITIES

Guideline Project Manager/Author:

A member of anaesthetic staff designated, by the Anaesthetic Clinical Directory/Guideline Lead to project manage the process for development of an Anaesthetic guideline.

Anaesthetic Governance Committee will be responsible for the approval of the guidelines developed. They have the responsibility for ensuring adherence to corporate guidance and report via the Chair to the CHAT Governance Committee.

The Anaesthetic Governance Committee must ensure that all guidelines:

  • are based on as up-to-date evidence as possible;
  • are NOT discriminatory along the adult age continuum, unless there is clear reason;
  • have patient consultation in their development if appropriate (e.g. for patient information publication);
  • have undergone the broadest multi-disciplinary consultation, including aspects of equality and human rights.

6.PROCESS

Staff preparing Anaesthetic Guidelines will comply with Appendix 1Template Guidance

Anaesthetic Guidelines will be submitted for approval to relevant Committees prior to submission to the Anaesthetic Governance Group.

Anaesthetic Guidelines will be published on the Portsmouth Hospitals Intranet Website as read or print only documents, protected from amendment by password control.

Anaesthetic Guidelines will be subject to an audit programme as determined by the approval committee. Compliance with recommendations is to be audited at an appropriate period after publication

Anaesthetic Guidelines will be subject to review at a frequency agreed by the Guideline Development Group – usually maximum of three years.

7.TRAINING REQUIREMENTS

It is the Anaesthetic Department’s responsibility to ensure appropriate education and training on new and revised guidelines is available. It will ensure that availability of Anaesthetic Guidelines is highlighted in induction training for all staff.

It is the responsibility of line managers to ensure individuals are released to access the necessary education and training.

It is the responsibility of individuals to up-date their knowledge and practice to maintain corporate standards, as described in the Anaesthetic Guidelines.

8.REFERENCES AND ASSOCIATED DOCUMENTATION

Appendix 1. Template Guideline

9.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

Efficiency

This policy should be read and implemented with the Trust Values in mind at all times.

Anaesthetic Guidelines Production and Management Policy:
Version: 8

Issue Date: 23 April 2018
Review Date: 22 April 2021(unless requirements change)Page 1 of 9

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on Recommendations
Preparation of Anaesthetic Guidelines will be in accordance Appendix 2 / Fidel Bayshev / Audit of Departmental Intranet site / 5 - yearly / Policy audit report to:
  • Anaesthetic Governance Committee
/ Fidel Bayshev, Sue Roland, Stefan Radauceanu
Approval of Anaesthetic Guidelines will be by the committee specified in Appendix 2 / Fidel Bayshev / Audit of Departmental Intranet site / 5 - yearly / Policy audit report to:
  • Anaesthetic Governance Committee
/ Fidel Bayshev, Sue Roland, Stefan Radauceanu
Publication of Anaesthetic Guidelines will be as defined in this policy / Fidel Bayshev / Audit of Departmental Intranet site / 5 - yearly / Policy audit report to:
  • Anaesthetic Governance Committee
/ Fidel Bayshev, Sue Roland, Stefan Radauceanu

APPENDIX 1: Template Guideline

Font and format as below

Footer to show guideline title, issue date, version and page x of y on all pages

Portsmouth Hospital NHS Trust logo

TITLE OF GUIDELINE

Introduction

Purpose

Subheading

Author

References

Keywords

Equality Impact Assessment Complete – Yes / No; Date -

Approved by / Date
Ratified by / Date

EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening
Title of Procedural Document: Trust Policy for the Production of Anaesthetic Guidelines
Date of assessment / 27 May 2018 / Responsible
Department / Anaesthetics
Name of person completing assessment / Dr F Bayshev / Job Title / Consultant Anaesthetist
Does the policy/function affect one group less or more favourably than another on the basis of :
Yes/No / Comments
  • Age
/ No
  • Disability
/ No
  • Gender reassignment
/ No
  • Pregnancy and Maternity
/ No
  • Race
/ No
  • Sex
/ No
  • Religion or Belief
/ No
  • Sexual Orientation
/ No
  • Marriage and Civil Partnership
/ No
If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2
More Information can be found be following the link below

Stage 2 – Full Impact Assessment
What is the impact / Level of Impact / Mitigating Actions
(what needs to be done to minimise / remove the impact) / Responsible Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document: Specialty Governance Committee
Clinical Service Centre Procedural Document:Clinical Service Centre Governance Committee
Corporate Procedural Document:Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

Anaesthetic Guidelines Production and Management Policy:
Version: 8

Issue Date: 23 April 2018
Review Date: 22 April 2021(unless requirements change)Page 1 of 9