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Management of Policies, Procedures and Guidelines Policy

Policy Date e.g. (2018/21) Policy Version (Draft 6) February 2018 This document remains valid whilst under review

TARGET AUDIENCE (including temporary staff)

People who need to know this document in detail

Authors and owners of policies, procedures and guidelines

People who need to have a broad

understanding of this document

Trust Board, Executive Leadership Team (ELT), Senior leaders, Trust Committee members

People who need to know that this document exists

All staff involved in the development of Trust strategies, policies, procedures and guidelines

Policy Author: Quality Effectiveness Facilitators, Quality Governance

Approved by: Clinical Effectiveness Group Date: Feb 2018

Ratified by: Trust-Wide Clinical Governance Group Date: April 2018

Date of next review:

February 2021

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CONTENTS

Page

Version Control 3

1. INTRODUCTION 4

1.1 Purpose 4

1.2 Scope 4

1.3 Definitions 5

2. DEVELOPMENT PROCESS 6

2.1 Policies & Procedural Documents: Key Information to Include 7

2.2.1 The Consultation Process 8

2.2.2 The Approval Process 9

2.2.3 The Ratification Process 9

2.3 Document Exceptions 10

2.4 Documenting Version Control History 10

2.5 Requirements for Implementing a Policy or Procedural Document 10

2.6 Requirements for Reviewing a Policy or Procedural Document 11

2.7 Document Updates and Alterations 11

2.8 Toolkits, Local Guidelines, Plans and Frameworks 12

3. RESPONSIBILITIES 12

4. ASSOCIATED DOCUMENTS AND REFERENCES 13

5. MONITORING COMPLIANCE 13

6 DISSEMINATION AND IMPLEMENTATION 14

7. CONSULTATION, APPROVAL, RATIFICATION & REVIEW 14

Appendix 1 – Executive Sub Committee Group responsible for policy approval

16

Appendix 2 – Clinical Procedures Approval Groups 17

Appendix 3 – Non-clinical / corporate procedure approval and ratification groups

18

Equality Analysis Impact Assessment Form 19

Ratification Checklist 21

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VERSION CONTROL

Record of Changes

Date Version List of Changes (please state).

21/11/2017 V6 Change of Policy Author

Revised policy template

Change to text in policy

Revised approval and ratification flowcharts

18/06/2018 V6.1

Add info regarding adopted policies

Removed Approval/ Ratification Groups (these will be held centrally by the Quality Effectiveness Team as they are likely to change regularly)

Updated job title

Minor changes to ratification process for documents reviewed within time frame

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1. INTRODUCTION 1.1 Purpose Policies, procedures and guidelines play an essential part in delivering the Trust’s objectives and in maintaining high standards of care.

Policies, Procedures and Guidelines inform the clinical decision making process and provide “best practice” indicators to evaluate current practice. All organisations must have an approved documented process for developing organisation-wide procedural documents as previously outlined in NHSLA Risk Management Standards 2013-14, Standard 1: Governance. It is also acknowledged that locally developed guidelines, based on research evidence and introduced by effective dissemination and implementation strategies, can lead to improvements in health (University of Leeds 1994, Thomas et al 1999). The purpose of this policy is to provide clear guidance on how to write a policy, procedure or guideline and identify the expected standards of Sussex Community NHS Foundation Trust in meeting and complying with policy processes and best practice requirements. 1.2 Scope This policy explains the process of the development, ownership, approval, ratification, distribution, archiving, monitoring and review of documents. This policy does not cover strategies or other corporate documentation, for example clinical pathways, leaflets, agendas, or minutes of meetings. This policy applies to all employees of Sussex Community NHS Foundation Trust. 1.3 Definitions

Policy A national or corporate framework that directs the organisation’s

practice in fulfilling statutory and organisational responsibilities and which is contractually and legally binding for all employees. It is a statement of the standard of provision of service, enabling staff to make correct decisions, manage effectively, and comply with relevant legislation and good working practices.

Procedure A procedure outlines a method or approach for undertaking a task or process in order to achieve the highest standards possible and to ensure efficiency, consistency and safety. A procedure defines how to follow a course of action.

Guidelines Guidelines are similar to procedures, but provide more generalised advice. They define best practices and conduct, acting in an advisory way.

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Other definitions and abbreviations used within the policy:

Author The document author has delegated responsibility for:

Drafting and circulating documents for consultation with all relevant delegated staff groups and stakeholders, ensuring the document is developed and progressed through to the final ratification stage.

Ensuring that the document is accurate, well researched, evidence based, reflects the views of the stakeholders and is presented in the correct trust format.

Submitting documents to the right specialist staff or groups for consultation and approval, i.e. corporate / specialist committee groups and ensuring that all policies affecting staff have also been consulted via the Joint Consultative Negotiating Committee (JCNC).

Ensuring the approving group completes the Equality and Human Rights Analysis form.

Submitting the completed ratification checklist to the nominated ratification group via the Quality and Effectiveness Facilitators.

Clinical Refers to patient care and treatment.

Corporate Refers to business and organisational responsibilities.

Area Management Team (AMT)

The area management team is formed of the Area Director, Deputy Area Director, Clinical Director, General Manager, Head of Service and Area Heads of Nursing and Governance.

Documents Unless stated otherwise, this phrase refers to policies, procedures and guidelines.

Owner Ownership of all policies and procedures will sit with the executive sub-committee responsible for approving the document and the overall responsibility will sit with the chair of this group. The owner is responsible for ensuring that the policy, procedure or guideline is written in accordance to the needs of the Trust or service and by the most appropriate person. The owner is also responsible for ensuring document implementation is adhered to.

SCFT Sussex Community NHS Foundation Trust.

TWGG Trust Wide Governance Group.

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2. DEVELOPMENT PROCESS

The decision to develop a policy, procedure or guideline must be agreed by an appropriate group or committee (the owner). This includes jointly written policies, procedures and guidelines with external agencies, or as part of a working partnership agreement, or in response to national guidance. The executive sub-committee will have ownership of these documents.

For local service procedures, the owner would be the appropriate Clinical Governance Harm Free Care groups.

Once the need for a document is agreed, the author should research, gather and prepare all the information required to create an accurate document.

The author should ensure that the document has clear objectives and that it states if the development follows legislation, national guidelines, or an identified need within the service or Trust.

The author must agree with the owner that the aims and objectives of the document are achievable within current resources, and that it appropriately links into trust objectives, or other service priorities. Additional resources may require consideration as part of the implementation of any Trust document.

Documents are to be written in consultation with other key stakeholders.

If the policy or procedure requires any training for staff, this is to be identified during the development of the document and appropriate training provided.

The author must ensure that the document is not a duplicate, or covered by any other document locally (i.e. other policies within the Trust) or nationally (i.e. Royal Marsden Manual or other national guidance) and that it does not incur any unapproved costs.

Where there are cost implications, a cost analysis will be required and submitted to the approving forum chair for their consideration.

Prior to drafting the document, the author is to contact the Quality Effectiveness Team to ‘register’ their document. The purpose of this is to avoid duplication of documents within the Trust and to ensure the timely review and monitoring of all policies, procedures and guidelines.

To register a policy or procedure and for further information or support, please contact:

Quality Effectiveness Team Quality Governance Team Bramber Building (B Block) Brighton General Hospital Elm Grove, Brighton, BN2 3EW Tel: 01273 696011 ext. 1104, 3746 or 2958 .

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2.1 Policies & Procedural Documents: Key Information to Include

To ensure that all Sussex Community NHS Foundation Trust (SCFT) documents follow the same corporate style, the document is to be written in accordance with Trust standards; using the Trust’s policy or procedural template available on the Pulse. Guidelines should be written using the procedural template.

All policies, procedures and guidelines must contain the following key information:

Title – ensure this reflects the content of the document and contains key words that staff can search for on the intranet.

Purpose – State why the document has been written and what needs, objectives and aims it fulfils.

Scope – State what the policy covers and whether there are any exclusions; e.g. relates or does not relate to staff in particular areas.

Be clear and direct in your writing – All documents must be written clearly, using appropriate language and terminology.

Abbreviations and acronyms – Outline the meaning of an abbreviation the first time it is used and include the meaning in section 1.3 “Definitions” of the policy/procedure template.

Consultation – State who has been consulted in the writing of the document (see section 2.2).

Approval – State which Trust group has formally approved the document (see section 2.3).

Ratification – State which Trust group or Executive Director has formally ratified the document (see section 2.4).

References and associated documents - All documents referred to in the creation of a document must be appropriately referenced using the Harvard Referencing System (author, date, name, and publisher). This section must also list any Trust or national document that it is associated or relevant to the document that is being developed.

Version Control – All documents must be version controlled with changes documented for easy identification (see section 2.6).

Equality Analysis Impact Assessment Form (EHRA) – These are to be completed for all policies, business cases and strategies and must be reviewed every three years, in line with the document review date. The policy author will be required to complete the EHRA included in the policy template and submit this alongside the new or updated policy to the Equality and Diversity inbox for review (sc-tr.equality@nhs.net).

Following agreement by the HR advisors, the form will be signed and a word document of the policy emailed back to the author. The document author should

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expect a response from the Equality and Diversity Team within a two-week period. Once the signed document has been returned to the author, the document can be sent for approval or ratification.

Further to ratification, the author is required to submit the EHRA form along with the document to the Quality Effectiveness Team.

If a document has been amended prior to the review date, the Chair of the approval group must consider the impact this may have to the existing EHRA form. If it is considered that the updated content of the document may affect the existing EHRA form the Equality & Diversity Team are to be consulted.

2.2.1 The Consultation Process

The consultation process is vital to ensure that specialist advisors and key stakeholders, who may be affected by the implementation of the document, have the opportunity to formulate and shape the content.

The document must be evidenced based.

The author of the document must ensure timely submission or circulation of the document to key stakeholders for their consultation, seeking guidance where required.

Key steps to consultation

1. Identify the key decision makers and specialist advisors (i.e. stakeholders, peers, staff groups) who need to be involved in the consultation of the document. This may also include local clinical governance or clinical specialists groups. Seek advice on the aims, objectives and factual content of the document, drawing upon relevant and specialist expertise.

2. Develop, update or amend the document in accordance with the advice and recommendations provided, incorporating feedback or comments, as appropriate.

3. Recirculate the revised document for review following any updates and amendments; noting that a document may go through a number of reviews. If this is the case, be sure to update the version control, altering the version number and recording the purpose of amendment.

4. Formal consultation may be undertaken:

via a group;

virtually (i.e. via use of email as a means of obtaining feedback);

as separate interviews with key parties; or

all of the above.

The following groups or teams must also be included in the consultation process:

Joint Consultative Negotiating Committee – for documents that impact on staff terms and conditions of employment. Any relevant toolkits or proformas should also be completed.

Medicines Management Team – for any documents that refer to medicines or the use of medicines (covering Adults Services, Children & Well-Being Services, at both Trust-wide and local service level). The Medicines Safety & Governance Group will be responsible

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for approving any documents that refer to medicines or the use of medicines. These will be ratified by the Chief Pharmacist.

The Local Counter Fraud Service – for any fraud related policies and procedures (see the Anti-Fraud, Bribery and Corruption Policy).

Where legal implications exist, professional legal advice should be sought by contacting the Quality Governance Team.

Once the consultation is finished and the document is in its final draft, this can be taken through the approval process.

2.2.2 The Approval Process Approval of all Clinical and Non-Clinical Policies will sit with the Committees / Groups with allocated ownership of documents Approval of Procedures will sit with the Clinical or subject Specialist Group who have ownership of the procedure Approval of Standard Operating Procedures (SOP’s) i.e. service specific documents, will be managed in service by the document owner. These documents are required to be approved by local service governance groups. The Chair of each approval group or committee will have access to a list of all Policy and Procedural documents for which they are responsible. The Quality Effectiveness Team hold a centralised list of all documents and allocated approval groups. Please note the following: Sections 1 – 4 of the Ratification Checklist must be completed and submitted with the document for approval. The approval group must ensure that the document is the final draft, with all sections complete, formatting correct and that the appropriate stakeholders have been consulted. The Equality Analysis Impact Assessment Form is to be completed for all policies to ensure that the authors of a policy have assurance on the assessment of the potential for their document to discriminate on any of these grounds; alternatively, any positive impact of the document should be included. For more information and support on undertaking an EHRA, please contact the Equality and Diversity Lead. The outcome of approval must be documented in the group meeting minutes, outlining reasons for non-approval, if applicable. The group will be responsible for notifying the author of their decision. Once a document has met approval, it can be taken through the ratification process.

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2.2.3 The Ratification Process All policies Following approval, all policies must be submitted to either the Trust Wide Governance Group (TWGG), Joint Consultative and Negotiating Committee (JCNC) or Executive Committee for ratification. The ratification checklist must be completed and submitted along with the policy document to the administrator of the meeting. Please note that that ratifying group will be sighted on the ratification checklist only and will not review the content of the approved policy. Clinical Procedures Following approval, the Clinical Effectiveness Group (CEG) will ratify Clinical Procedures. The ratification checklist must be completed and submitted along with the document, to the administrator of CEG. Non-Clinical and Corporate procedures Following approval, the Chair of the group or committee responsible for approving the document will ratify Non-Clinical and Corporate procedures. Outcomes of ratification are to be recorded in the committee / group meeting minutes along with any reasons for non-approval, if applicable. The group will be responsible for notifying the approval group/ author of their decision. The Chair will also be responsible for ensuring the ratification tool is completed and that the Quality Effectiveness Team are informed. Standard Operating Procedures (SOP) Following approval, SOP’s are to be ratified by the Area Clinical Governance and Harm Free care Group. If these documents are required to be accessible on the Pulse, services should contact the Quality Effectiveness Team Terms of Reference for Groups and Committees involved in the approval and ratification process must clearly state their responsibility within ‘Scope of Decision Making’. Adopted Policies or Procedures Documents adopted from an external organisation must be reformatted into SCFT template and submitted in full for formal approval and ratification. The name of the organisation from which the policy was adopted from must be credited in the ratification checklist. 2.3 Document Exceptions Agreement and approval by the relevant group or committee is required for any exceptions to the approval and ratification process. These exceptions must be recorded and the Quality Effectiveness Team notified.

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Requests to change approval or ratification process for any policy must be agreed by the Trust Wide Governance Group. Requests to change the process for clinical procedures must be agreed by CEG and the Clinical Specialist Group responsible for approving the document. Requests to change the process for non-clinical and corporate procedures must be agreed by the Subject Specialist Group responsible for approving the document.

2.4 Documenting Version Control History

Version numbers are required for all documents. These are to be updated each time the document is reviewed or amended. A record of the changes must also be identified within the version control comments box for the purpose of an audit trail.

2.5 Implementation of a Policy and procedures

The implementation date of the policy or procedure is the date on which it has been ratified. Following ratification, all new and revised documents must be sent to the Quality Effectiveness Team who will publish the document on the Pulse.

Managers must ensure that any new and updated documents are cascaded accordingly to staff.

Nb: Where policy appendices include templates for operational use, i.e. form, checklist or letter, authors are responsible for circulating these to applicable services. The Quality Effectiveness Team can also provide copies in Microsoft Word format.

2.6 Requirements for Reviewing a Policy or Procedural Document All documents must be periodically reviewed to ensure that they are up-to-date with any national guidance, legislation or organisational change that may affect the content or staff. It is the owner’s responsibility to ensure that the relevant author reviews the policy within the set timescale. The maximum period for this is three years. If the original author is no longer responsible for the document (i.e. they are no longer in post or their duties having changed), it will be the responsibility of the owner to re-allocate the document to an appropriate author to review. Approval groups are to include document reviews in their annual programme of work and inform ratification groups of their timescales for ratification. The Quality Effectiveness Team will send reminders to the owner and the chair of the approving group three months in advance of the review date.

2.7 Document Updates and Alterations

Where an in-date document requires change, the following actions are to be taken:

Minor changes (to be made within the document review period)

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If minor revisions have been made to the document following ratification or review, then it is not necessary to re-submit the document through the approval and ratification process.

The author can make the amendments and list these changes, along with the date in the ‘comments/changes’ box, in the version control table. The approval group must be informed of the minor changes and minute that this has occurred.

Examples of minor changes include: typing errors, change of job titles, updates to telephone numbers and any other minor changes which do not impact on the context of the document, or significantly impact on staff.

Major changes (to be made within the document review period)

If changes to the document are major, i.e. those which will alter the context of the document, impact on staff or introduce new legislation, the author must re-submit the document (in an updated template if required) for formal approval and ratification. The EHRA form must also be reviewed and submitted for agreement.

A summary of the changes are to be included in the ‘comments / record of changes’ box of the version control table, along with the date in which these changes were made. The document must then be submitted to the Quality Effectiveness Team for uploading onto the Pulse.

Due for review (following the three-year period)

When a document is due for review, it must go through the formal approval and ratification process regardless of the level of change required. The EHRA form must be reviewed and re-submitted for agreement before submitting for approval.

The Quality Effectiveness Team will be responsible for reporting on the above.

3. RESPONSIBILITIES

The Chief Executive has overall responsibility for ensuring that the organisation has the appropriate policies, procedures and guidelines in place, which follow best practice and comply with all relevant legislation.

The Executive Directors are members of the Trust Board and are responsible for ensuring the appropriate process is followed for the management of policies, procedure and guidelines. Executive Directors may delegate some of their authority to various Trust groups or sub-groups.

The document owner is responsible for ensuring:

A suitable person acting within the bounds of his/her area of responsibility has written the document.

The document has a justifiable reason for being developed, or is still required.

The content is in line with the Trust’s vision, values and strategic goals.

The author is aware of the appropriate consultation, approval and ratification process.

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The document has been submitted to the appropriate consultation groups, specialists or stakeholders.

The document has followed process prior to approval.

Responsibility for the document is included within the Terms of Reference of the approving group.

The document author is responsible for ensuring the development and progression of the policy to its final ratification stage, including:

Ensuring the document has been created using the appropriate Trust template and formatting.

Ensuring that the document is submitted to the appropriate specialist advisors or groups for consultation, approval and ratification.

Ensuring that the content of the document is accurate, appropriately researched, evidence-based and reflects the views of stakeholders.

The document meets SCFT formatting and branding guidelines.

The Quality Effectiveness Team are responsible for the following:

Updating and maintaining the central Policies and Procedural Documents database.

Maintaining electronic ‘control copies’ of all policies and procedures held within the Trust, including an archive of policies and procedures (these are held for a minimum of 10 years after they have expired or been superseded).

Providing advice and support to authors in carrying out their required tasks.

Ensuring that all policies and procedures are written using the correct template.

Reminding and supporting owners and relevant groups / committees to review their policies and procedures prior to the expiry review date.

Updating and uploading information onto the Policies and Procedures page of the Pulse.

Service Managers / Team Leaders are responsible for promoting and implementing the document, ensuring:

Staff are aware of the existence of new or reviewed documents and that theye are accessible to them.

A record is maintained and updated to reflect that staff have read and understood the policies and procedures relevant to their role.

All superseded documents are deleted or disposed of to ensure staff do not refer to historical information, or out of date documents.

All staff have a contractual responsibility to comply with Trust documents, laws and regulations, apply best practice in order to maintain standards and prevent fraud, bribery and corruption.

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4. ASSOCIATED DOCUMENTS AND REFERENCES

NHSLA Risk Management Standards 2013-14

A Practical Guide to Policy Making, OFMDFM(NI), 2011

BMJ,Clinical Practice Guidelines (University of Leeds 1994, Thomas et al 1999)

5. MONITORING COMPLIANCE

The Quality Effectiveness Team will be responsible for monitoring and reviewing this document, along with the effectiveness of the document process.

Policies and the process for documents may also be audited by other agencies, such as the Care Quality Commission (CQC) or as part of an annual audit programme.

6. DISSEMINATION AND IMPLEMENTATION

It is the responsibility of Heads of Service, Clinical Leads and Senior Managers to ensure that this policy is disseminated to all staff and implemented appropriately in accordance with professional standards and codes of conduct.

Staff must be made aware of all policies, procedures and guidelines relevant to them and how they can be accessed. This may form part of local induction.

This policy will be uploaded onto the Trust’s Policies and Procedures page of the Pulse. New and recently updated policies and procedures will be circulated monthly.

7. CONSULTATION, APPROVAL, RATIFICATION & REVIEW

The following people and groups have been involved in the consultation of this policy:

Interim Head of Quality Governance

Equality and Diversity Lead

Clinical Effectiveness Group

Trust Wide Governance Group

Quality Effectiveness Team

The Clinical Effectiveness Group is responsible for approving this policy.

The Trust Wide Governance Group is responsible for ratifying this policy.

This Policy will be reviewed every three years by the Quality Effectiveness Team or on an ad-hoc basis as required.

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Equality and Human Rights Analysis (EHRA)

Title(s): Management of Policy, Procedures and Guidelines

Aims: Policies, Procedures and Guidelines inform the clinical decision making

process and provide “best practice” indicators to evaluate current

practice. All organisations must have an approved documented

process for developing organisation-wide procedural documents

Evidence

Please summarise any evidence about how the work

may impact people either positively or negatively

specifically linked to their characteristics.

E.g. performance or survey data; focus groups; PALS; incident reviews; NICE guidance; research; good practice; demographic data

Mark an ‘X’ in the columns for as many characteristics as are relevant

Mark ‘X’ relevant characteristics

Age

Dis

abili

ty a

nd C

arer

s

Rac

e

Rel

igio

n or

Bel

ief

Sex

Preg

nanc

y or

Mat

erni

ty

Gen

der R

eass

ignm

ent

Sexu

al O

rient

atio

n

Oth

er (e

.g. A

rmed

For

ces)

Positive impacts: x x x x x x x x x

Negative impacts:

Equality Analysis

Please evaluate how the work may impact people with protected characteristics to meet the three

aims (A-C) below, referencing any evidence identified above. If an aim is not relevant to your

work, please explain why.

Aim A. Eliminate discrimination – Please evidence if the work could unlawfully

discriminate:

Include who is discriminated (e.g. disabled adults) and how. Include detailed reasons if it is lawful

N/A

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Aim B. Advance equality of opportunity – Please evidence if the work:

Minimises disadvantage – Does the work address any poorer outcomes for particular protected groups?

Meets different needs – Does the work meet different protected groups’ social, cultural or other needs?

Encourages participation – Does the work target under-represented groups to increase involvement?

N/A

Aim C. Foster good relations – Please evidence if the work:

Tackles prejudice – Does the work increase contact between groups to reduce negative attitudes?

Promotes understanding – Does the work educate people about groups to change negative attitudes?

N/A

Human Rights Analysis

Mark ‘X’ against the relevant rights which are safeguarded (+) or breached

(−) by the work:

+ −

Article 2. Right to life (e.g. The Deteriorating Patient policy, DNACPR or Clinical competencies)

Article 3. Prohibition of torture, inhuman or degrading treatment (e.g. Consent or Safeguarding)

Article 5. Right to liberty and security (e.g. Deprivation of Liberty or Restrictive Interventions)

Article 8. Right to respect for private and family life, home and correspondence (e.g. Confidentiality, health records, carer involvement, correspondence or staff leave)

Article 9. Freedom of thought, conscience and religion (e.g. End of Life Care or Prescribing)

Article 10. Freedom of expression (e.g. Patient information or Raising Concerns policy)

Article 12. Right to marry and found a family (e.g. Pregnancy testing procedure)

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Monitoring

Please describe how any impacts will be monitored: (e.g. annual policy review, audit,

performance metric)

Policy will be reviewed every three years,

Outcome

Choose the final outcome(s) a-d of the analysis with an ‘X’ and explain the reasons in the space

below:

X (a) Continue the work EHRA form has been completed with no noted complication.

(b) Change the work

(c) Justify and continue the work

(d) Stop the work

Please score any risks to equality or human rights below and update your risk register:

Consequence score:

x Likelihood score:

= Equality and Human Rights Risk Score:

Assurance Statement: I have reviewed the evidence with rigour and an open-mind and am

satisfied there has been due regard to the need to eliminate discrimination, advance equality

of opportunity and foster good relations, and there is compliance

with Section 149 of the Equality Act 2010.

Analysis Lead(s) names: Amanda Feest, Quality & Effectiveness Facilitator Naomi Bonetti OD & Inclusion Facilitator

Date: 20/02/2018 02/07/2018

Ratifying committee / body: TWGG Date: 05/04/2018

Reviewer (office use): Decision: Date:

Improvement Plan

Description of actions Date Person How will this be delivered?

Add more rows if necessary

Send this form along with your main paperwork for consultation to sc-tr.equality@nhs.net.

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RATIFICATION CHECKLIST Trust Wide Governance Group

Agenda Item: The meeting administrator should be able to provide this

Policy Title: Management of Policies, Procedures and Guidelines

Purpose: Ratification

Checklist for Ratification

1. Reason for Review:

Reason for the Policy review: Review date due or expired.

2. Summary

Please give a brief overview of the following: The Policy explains the process of the development, ownership, approval, ratification, distribution, archiving, monitoring and review of documents. Policy has been updated with new SCFT process.

3. Format

Has the standard SCFT template been used?

Yes Comments:

4. Consultation

Name Group Member Response Y/N

TWGG CEG Interim Head of Quality and Governance Quality Effectiveness Team Equality and Diversity Lead

Y

5. Dissemination/Implementation Process

The policy will be available on The Pulse

6. Cost/Resource Implications

Does this policy/procedures have any cost and/or resource implications?: No

Please provide details of the cost/resource implications: e.g. training, equipment, additional staff

None identified.

Has this been agreed by the accountable Director? N/A

Name Job Title Date

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N/A

7. Approval

Please state the name of the Group that has approved this document?

Name: Clinical Effectiveness Group (Virtual Approval)

Date of Group Approval: Date: February 2018

8. Equality Analysis

Has the Equality Impact Assessment been completed?

Yes Comments

9. Review

Please state the timescale for review: 3 years.

DECISION OUTCOME AND RECOMMENDATIONS

For completion by the Chair of the Group or Committee considering ratification.

Is the Committee / Group satisfied and assured that due process has been followed in order to produce or review the Policy?

Yes Comments:

Is the Committee / Group satisfied and assured with the consultation on the Policy?

Yes

Comments:

Does anybody (Group or individual) else need to be consulted prior to ratification?

No

Please state who:

Other Comments

Outcome:

Was the Policy Ratified?

Yes

Other comments:

Including strengths and good practice.

Additional actions required for ratification:

Must be SMART

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Signed: Richard Quirk

Medical Director and TWGG CHAIR

Date: 5 April 2018