Version Control Procedure
Version:Version 3.0 / Issue Date:
7th June 2004
Responsible Person:
Lyndee Peters
Data Quality Manager / Review Date:
7th June 2005
Approved By:
Terasa Wilkins
Information Manager / DO NOT USE THIS PROCEDURE AFTER THE REVIEW DATE
Contents
1Introduction
1.2Aims
2Version Control
2.1Statutory Changes
2.2Revision
2.3Changes
2.4Audits
3Appendices
3.1Appendix 1 - Policy/Procedure Change Notice form
3.2Appendix 2 – Document History Page
1Introduction
1.1.1Statutory changes are regularly made to the way in which the Trust collects and records patient data onto the Patient Administration System (PAS). These changes must be reflected in all the Trust’s policy and procedure documents as soon as possible.
1.1.2It is essential that staff have the most up-to-date copy of both the policy and procedure documents for each area in which they work. These documents provide detailed instructions on how to record patient activity on the PAS.
1.1.3This document details the method that the Trust has chosen to control this process.
1.2Aims
1.2.1Each department will have the most up-to-date copy of the policy applicable to their department.
1.2.2Each department will have the most up-to-date copy of the procedure for entering patient data onto the PAS.
1.2.3Staff will be confident that they are using the most up-to-date version of either the policy or procedure.
2Version Control
2.1Statutory Changes
2.1.1The PAS Application Manager is responsible for regular meetings with the Data Quality Manager and Information Manager to discuss statutory changes notified via DSCNs (Data Set Change Notices).
2.1.2The Information Manager is responsible for taking these changes to the Data Quality Group for approval. Any changes will be incorporated into the Trust policy and/or procedures and circulated to all departments using the Policy/Procedure Change Notice form (Appendix 1).
2.2Revision
2.2.1Each document has an Issue Date and Revision Date.
2.2.2Each document states on the front page that the document must not be used after the review date has passed. All outdated or discarded policy/procedure documents must be returned to the Data Quality Manager. All outdated or discarded pages must be removed and replacement pages inserted. The Document History page (Appendix 2) must be completed and retained at the front of the document folder to display the history of changes to the policy or procedure.
2.2.3Current policy/procedure documents can be obtained from the Data Quality Manager, ext 6250, email: or via the Trust intranet on the Data Quality Pages.
2.2.4Six weeks prior to review date of the document the Data Quality Manager will send a reminder notification together with a copy of the document for the Responsible Person (as indicated on the front sheet of the document) to review.
2.2.5The Responsible Person must amend the document to reflect any changes that have been made since the Issue date. Amendments must be tracked using the ‘track changes’ function (Word/tools) and returned to the Data Quality manager for review and approval.
2.2.6When a policy or procedure is revised, the Data Quality manager will forward the new version to the Responsible Person(s) who holds a copy of the policy or procedure. A Policy/Procedure Change Notice (Appendix 1) must accompany the reviewed documentation. An updated index Document History page (see 2.3.6) must also be included. The Data Quality Manager will post the new version on the Intranet.
2.2.7The Responsible Person must, by whatever means appropriate (e.g. by delegation to staff member or employment of temporary help), ensure that reviewed documents are copied and placed in each document folder (pink) for that department and ensure discarded documents or pages are collatedremoved and replacement pages inserted.
2.2.8The Policy/Procedure Return form (Appendix 2) must be completed by the Responsible Person and returned to the Data Quality Manager with the outdated document or discarded pages.
2.2.9
2.2.102.2.8Returning the outdated pages provides an assurance that the old pages are no longer in circulation and are destroyed correctly. Completing the Document History page provides an assurance that the old pages have been removed and correct pages inserted.
2.2.11The data quality manager must report back to the data quality group on any documents that have passed the revision date without being updated/reissued.
2.2.9
2.2.10The Responsible Person must explain to the data quality group, any missed document revision/issue dates together with a plan of action
2.3Changes
2.3.1When a major change is made to a Policy document, the Policy must be sent to the Data Quality Group and/or Clinical Management Board for approval prior to distribution.
2.3.2When a change is made to a procedure document, it must be made in conjunction with the Responsible Person as named on the front to the procedure document and must be approved by the Data Quality Manager prior to distribution.
2.3.3When a major change is made to a policy or procedure document prior to the revision date the Responsible Person must complete a Change Notice Form (Appendix 1) and send a copy to the Data Quality Manager for approval at least one week prior to the date of change. All completed Change Notice forms are placed at the front of the policy/procedure folder. The Data Quality Manager will circulate to other Responsible Persons as appropriate. The Responsible Person(s) will ensure all appropriate members of staff update their documents and are aware of the change.
2.3.4When a major change is made to a policy or procedure, the version number must be changed to the next whole number e.g. Version 2.3 changes to Version 3.0.
2.3.5When making a minor change to a policy or procedure, the version number must be changed to the next decimal point e.g. Version 2.3 changes to Version 2.4.
2.3.6The Document History page (Appendix 2) is used by the Responsible Person to record pages/sections that have been updated. The index page will remain at the front of the folder to display the history of changes to the policy or procedure.
2.4Audits
2.3.62.4.1The data quality manager is responsible for a random audit of 10% of all document folders each month, checking that documents within folders are up to date. Results to be reported back to the data quality group.
3Appendices
3.1Appendix 1 - Policy/Procedure Change Notice form
Policy/Procedure Change Notice
Changes have been made to: ______Policy and/or Procedure (Please delete as appropriate)
These changes are effective from: ______
The section(s) that have been changed/added to is:
Section: ______
Change: ______
______
______
______
______
______
______
______
This change to the policy and /or procedure will be incorporated within the revised version of the document. The documents will be revised by:
______
In the meantime, please place this Change Notice at the front of the policy/procedure and ensure all appropriate members of staff are aware of the change.
Data Quality ManagerDate: ______
It is essential that Trust staff are using the most up-to-date policy or procedure documents for recording patient activity on the PAS.
The Trust has a process whereby each document is reviewed on a regular basis and any amendments will be circulated to all applicable policy and procedure folder holders.
Please complete the form to acknowledge that you have received updated pages and enclose with the form the outdated pages.
I confirm that I have received the updated pages, including the front page, and inserted them into applicable policy or procedure that is held in the policy and procedure folder that I hold and have attached the outdated pages.
Name: ……………………………………………………………………………………
Folder Number: ………………………………………………………………………..
Department: …………………………………………………………………………..
Extension Number: …………………………………………………………………
Please return this form and the out dated pages to:
Data Quality Manager, Room AD35, Maple House, East Surrey Hospital.
3.2Appendix 2 – Document History Page
DOCUMENT HISTORY
Remove / Replace With / Name and DateThis sheet must be retained at the
Front of the Document Folder
Version Control Procedure Version 3.0Page 1 of 8