policy for the production, approval and implementation of trust … · 2020-06-24 · development,...

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Policies and Procedural Documents: Development, Approval and Dissemination

Version No.: 7.0

Effective From: 28 March 2019

Expiry Date: 28 March 2022

Date Ratified: 26 February 2019

Ratified By: Clinical Policy Group

1 Introduction This policy provides guidance on the development, approval, presentation and monitoring of Strategies, Policies and Procedures within the Trust. This is essential to ensure that safe care is standardised across the Trust. Strategies, Policies and Procedures should be in a standard format, should be dated and should be reviewed at regular intervals. All Trust strategies, policies and procedures must be owned by, and submitted for approval through, a recognised Trust Committee and be notified to the Clinical Governance and Risk Department (CGARD). Strategies, policies and procedures must be developed in accordance with this policy. All strategies, policies and procedures are held electronically in the Policies Database and can be accessed via the Trust’s intranet. Strategies, policies and procedures are also published on the Trust’s web site in accordance with the provisions of the Freedom of Information Act (2000). Well maintained documentation contributes to the quality of patient care and general safety by reducing, as far as possible, the risks of staff working from outdated policies. 2 Policy Scope This policy applies to all members of staff working within The Newcastle upon Tyne Hospitals NHS Foundation Trust who are involved in any aspect of strategy, policy and procedure development. Staff are responsible for ensuring compliance with Trust policies. This document scope covers the development, approval, presentation and monitoring of strategies, policies and procedures as defined in paragraph 5. This policy does not cover principles to be applied to the development of Trust protocols and guidelines, which are covered under the Trust Clinical Guidelines and Protocols Policy.

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3 Aim of the policy This policy provides a system for administering the development, approval and monitoring of documents to ensure that strategies, policies and procedures are:

In line with corporate governance requirements

Clear and consistent in their format, compilation and dissemination

Meet corporate and clinical standards

Promote equality and diversity

Are approved, disseminated and implemented appropriately

Are monitored and reviewed in a regular, structured way. 4 Duties – Roles and responsibilities 4.1 Trust Board

The Trust Board is responsible for implementing a robust system of corporate governance within the organisation. This includes having a systematic process for the development, management and authorisation of strategies, policies and procedures.

4.2 Chief Executive

The Chief Executive is ultimately responsible for ensuring effective corporate governance within the organisation and therefore supports the Trust-wide implementation of this policy.

4.3 Executive Group

The Executive Group is responsible for approving all new strategies, policies and procedures that cover Human Resource issues, and approving all major revisions to such policies and procedures.

4.4 Clinical Policy Group (CPG)

The Clinical Policy Group is responsible for approving all new strategies, policies and procedures that do not cover Human Resource issues, and approving all major revisions to such strategies, policies and procedures.

4.5 Employment Policies & Procedures Consultative Group (EPPCG)

The EPPCG is responsible for consulting on HR policies. 4.6 Clinical Governance and Risk Department (CGARD)

CGARD has delegated responsibility for ensuring an effective, robust system is in place for the development, management and authorisation of all strategies, policies and procedures within the Trust.

CGARD also has responsibility for the archiving of strategies, policy and procedure documents within the organisation.

The Clinical Effectiveness Manager within the Department has overall responsibility for the content of the policies database on both the Intranet. This includes the ongoing development, management and administration of the database.

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4.7 Trust Committees Trust Committees are responsible for agreeing strategies and policies that fall within their remit, prior to CPG / Executive Group approval.

4.8 Authors

The author retains ownership through development, consultation, approval and ratification processes. Responsibility for monitoring and review of the strategy or policy remains with the author after release of the final version to the Clinical Effectiveness Manager, CGARD.

The author must check that the proposed new strategy/policy subject is not already covered by an existing document or guideline, or could not easily be incorporated into an existing document or guideline.

The author must ensure that the strategy/policy is written using the Format of Procedural Documents (see Appendix 1)

The author must ensure that appropriate consultation with expert individuals or groups must take place, to ensure accuracy and adherence with existing Trust procedures, and any legal or regulatory requirements. This process must be documented using the Policy / Procedure Ratification Form (see Appendix 2), or in the case of Strategies the Strategy Ratification Form (see Appendix 8).

When notified that a strategy/policy for which they are responsible is approaching or past its review deadline, it is the responsibility of the author to instigate a review process and update the document as necessary.

4.9 Wards and Departments

It is the responsibility of all wards and departments to make staff aware that new or amended strategies, policies and procedures are available in response to the update notification from CGARD.

Paper copies of Trust strategies, policies and procedures are discouraged, but if wards and departments do keep such copies there must be systems in place to keep these updated and it must be acknowledged that the definitive version is that displayed on the Intranet site.

All new staff should be made aware of how to find and use Trust strategies, policies and procedures during their induction programme as outlined in the Induction Policy.

4.10 All Staff

All staff within The Newcastle upon Tyne Hospitals NHS Foundation Trust are responsible for ensuring that the principles outlined within this policy are universally applied and that they familiarise themselves with all strategies, policies and procedures relevant to their area of work and that they act in accordance with these at all times.


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If users feel that a particular strategy, policy or procedure is no longer relevant or in need of revision they should contact the person responsible for that document so that a review process can be instigated if appropriate - the strategy/policy/ procedure should not be ignored.

5 Definitions 5.1 Policy

A policy enables management and staff to make correct decisions; deal effectively with and comply with relevant legislation, organisational rules and regulatory requirements.

A policy document should be regarded as mandatory, with deviation only in exceptional circumstances, as it sets out a course of action which the Trust expects to be followed.

Trust policies have been formulated and developed to guide staff in their work ensuring their protection and that of service users, in order to minimise risk and maximise safety for all concerned.

5.2 Procedure

Procedures are the practical way in which a policy is translated into action. It is comprised of a set of detailed step by step instructions that describe the appropriate method for carrying out tasks or activities to achieve the highest standards possible and to ensure efficiency, consistency and safety.

5.3 Protocols

A protocol is a formal set of procedures that must be followed on order to achieve specific outcomes or for the management of a specific condition or situation. Protocols define and restrict what must happen under particular circumstances with no flexibility, in contrast to a guideline where there is a little constraint.

5.4 Guidelines

Clinical guidelines are statements of good practice e.g. recommendations on appropriate treatment and care for patients with specific diseases and conditions.

They allow deviation from a prescribed pathway according to the individual circumstances and where reasons can be clearly demonstrated and documented.

“Endorsed” guidelines are, by definition, those which practitioners are encouraged to follow.

5.5 Strategy

A strategy is a high-level plan of action designed to achieve a long-term or overall aim. A strategy usually covers three to five years.

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6 Strategy / Policy / Procedure Development

Every strategy / policy / procedure should be developed in accordance with section 6 of this policy and submitted with the appropriate Policy / Procedure Ratification Form (see Appendix 2) or Strategy Ratification Form (see Appendix 8) to the Clinical Effectiveness Manager, CGARD. Failure to do so will result in a delay in approval and publication on the policies database on the Trust website.

The process for developing and producing strategy / policy / procedure documents is set out in Procedural Document Development and Approval Process (see Appendix 3).

Strategies / Policies / procedures must be produced using the Procedural Document Content and Layout Checklist (see Appendix 4).

Strategies / policies / procedures should be proof-read before being sent for approval and publication.

It is essential that strategies/policies/procedures are distributed to the appropriate expert group(s) for consultation and agreement, prior to approval and publication.

General Principles of Good Practice for Writing Strategies/Policies / Procedures are set out in Appendix 5.

Strategies/policies / procedures must be sent by the author to the Clinical Effectiveness Manager, CGARD, together with the completed Policy / Procedure Ratification Form (Appendix 2) or Strategy Ratification Form (see Appendix 8) for checking, and the completed Equality Analysis Form (Appendix 6). The Clinical Effectiveness Manager will direct appropriate policies/procedures to the Clinical Policy Group, or Executive group (for HR policies), for approval.

An extension period of a maximum of six months is allowable for the finalisation of policies beyond their initial expiry dates. This is to ensure that all appropriate discussion and considerations are had prior to finalisation of the policy.

Once approved the Clinical Effectiveness Manager will ensure that the strategy / policy / procedure is posted on the Trust Intranet.

It is the responsibility of the author to make sure that the process has been completed and the correct document appears on the Trust intranet.

6.1 Preparation

When reviewing documents within the scope of this policy it is important to advise the Clinical Effectiveness Manager so that the process can be logged

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in the policies database as under review. The Clinical Effectiveness Manager will also provide further advice on the development and approval process. All strategies/policies/procedures will remain in DRAFT until final approval by the relevant Trust Committee. Trust Committees are responsible for agreeing strategies/policies that fall within their remit, prior to CPG / Executive Group approval.

6.2 Impact and implications

Consideration must be given to the following during the developmental process:

Impact on other organisations

Implications for other Divisions/departments

Financial implications, fraud and corruption issues

Equality issues

Monitoring

Refer to Procedural Document Development and Approval Process (Appendix 3) for guidance on the process for development.

6.3 Equality Analysis

6.3.1 Introduction

The purpose of Equality Analysis (EA) is to ensure:

a. the Trust complies with its duties under the Equality Act 2010, including the requirement to:

eliminate unlawful discrimination

advance equal opportunity and

foster good relations between those who share a protected characteristic and those who do not. b. the Trust has considered the needs of all people including those

who have the following protected characteristics:

race / ethnic origin

sex

religion and belief

sexual orientation

age

disability

gender reassignment

marriage and civil partnership

maternity and pregnancy

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c. any groups of people with protected characteristics will not be disproportionately advantaged or disadvantaged

d. the Trust makes reasonable changes to policies, strategies or

services, where required to meet the needs of people with protected characteristics and

e. the Trust does not unlawfully discriminate

6.3.2 A quick guide to completing Equality Analysis can be found on the intranet. http://nuth-intranet/cms/SupportServices/EqualityDiversityHumanRights/EqualityAnalysis.aspx

6.3.3 Further advice and assistance

Should you have any queries regarding the completion of the form, please contact;

Equality and Diversity Lead on 0191 2824241 or

Senior Human Resource Manager (Projects) on extension 31362

6.3.4 Following completion of the template

a) Policies and Procedures

Equality Analysis relating to policies should be forwarded with the policy to their parent committee for review and agreement. Following agreement they should be sent electronically together with the policy documentation to the Clinical Effectiveness Manager in CGARD.

b) Strategies and or Service Developments

Equality Analysis relating to strategies or service developments should be forwarded Business Planning Committee Investment Sub Group.

6.3.5 No Policy, strategy or service developments will be approved without

the completion of a thorough and meaningful equality analysis. 6.4 Style and format

All Trust strategies/policies/procedures should:

be written in Arial 12;

be justified to the left;

http://policies.app/Quick%20Guide%20to%20Completing%20Equality%20Analysis.docx

http://nuth-intranet/cms/SupportServices/EqualityDiversityHumanRights/EqualityAnalysis.aspx



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include page numbers in the footer of the document in the format Page x of y;

use plain English with explanations of acronyms (go to http://www.plainenglish.co.uk/files/howto.pdf for a guide to plain English);

use flow diagrams where possible; and

avoid the use of block capitals. Block capitals make the text difficult to read because the shapes of words disappear, causing the reader to slow down and study each letter. Ironically, readers tend to skip sentences written in only uppercase.

To highlight information and maintain readability, use bold or italic text.

Avoid underling text for emphasis (in online documents underlining implies a hypertext link)

Hypertext links should be underlined and in blue

Capital letters should be used for referring to formal or specific committees, e.g. Patient, Quality, Risk and Safety Committee. This also applies to the title of individuals, e.g. Director of Finance and Information. Lower case letters should be used for generic reference, e.g. divisional managers, executive directors.

The first page of all approved strategies, policies and procedures must as a minimum include the following information: -

Strategy/Policy/Procedure title

Version number*

Date the strategy/policy/procedure is effective from (dd/mm/yyyy must be specific for legal reasons)* This is the date that the revised strategy/ policy/procedure is posted on the intranet and available to staff

Date ratified

Ratified by (approval committee)

Expiry date (must not exceed 3 years) Items marked * will be allocated by the Clinical Effectiveness Manager.

The following elements must be incorporated into all new strategies/ policies/procedures or revisions of existing strategies/policies/procedures: (N.B. Appendix 1 Format of Procedural Documents provides guidance for the completion of strategies/policies/procedures and the numbering, detailed below, must be followed.)

Section 1. Introduction – this should inform the reader of the rationale for the strategy/policy/procedure and highlight any legislative requirements and current local / national guidance. It should also describe how the strategy/policy/procedure supports the Trust’s stated vision and values.

Section 2. Policy scope – this should detail to whom the strategy/ policy / procedure relates and state the limitations of strategy/ policy/procedure application.

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Section 3. Aim of policy – this should detail the aim or objective of the strategy / policy / procedure

Section 4. Duties - Roles and responsibilities of the following o Trust Board o Chief Executive o Executive Director o Directorate Managers and Directorate Directors o Heads of Department o All staff o The list above is not exhaustive and there may be occasion

where additional stakeholders/specialist personnel with a specific role and or responsibility should be listed.

Section 5. Definitions - List and describe the meaning of the terms used in the context of the document

Section 6. Main body of the policy/procedure – This section will include the main strategy / policy / procedure guidance in relation to the specific issue - all relevant information and steps in the process should be added in as many sub-sections as necessary.

A flowchart detailing the relevant steps within the process should be included as an appendix. This will be of help when monitoring compliance with the strategy / policy / procedure. See section 9 below.

Section 7. Training – This section relates to the organisation’s expectations in relation to staff training. State whether there are training requirements associated with, or from, the strategy / policy/procedure. If the subject is included within Mandatory Training - refer to the Mandatory Training Policy as the training component should be detailed within the Mandatory Training Policy. The Mandatory Training Policy is updated annually and will therefore reflect the most up to date position without having to review the strategy/policy/procedure being updated.

If the subject is not part of the Mandatory Training Policy - Authors are to identify the training requirements relating to the strategy / policy / procedure and detail them within this section. They should also assess the organisational impact of training requirements and discuss any new requirements or changes to existing training programmes with the Education Department (contact: Peter Martin).

Section 8. Equality and diversity - On completion of the equality assessment (see para 6.3 above) the strategy/policy/procedure can contain the following statement: “The 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

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and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed”.

Section 9. Process(s) for monitoring compliance with the policy/procedure. (This section is optional for strategy documents.) Outline the organisation’s process to monitor compliance with the policy / procedure and the effectiveness of processes described within the document. The organisation continually strives to achieve 100% compliance with this policy and its intended outcomes. Where this is not met an action plan will be formulated and agreed by the overseeing committee and reviewed by them until completion. Please see the table below for standards and monitoring arrangements. Advice can be sought from CGARD.

Standards Monitoring and audit

Method By Committee Frequency

This should be the steps that you have described in the process part of the policy for example:

All inpatients will receive an initial EWS score within an hour of admission

This is how are you going to monitor this, for example:

Snapshot random audit

Quality assurance audit

Who will undertake the monitoring:

Infant feeding lead

Who has overall accountability:

CGQ

How often are these carried out:

at least monthly

quarterly

Once you have pulled all the standards out of the policy you then need to put in your outcome standards, for example:

Reduction in the rate of unexpected cardiac arrests

Outcomes may be monitored differently for example:

Review of all incidents of unexpected cardiac arrests

Review of rates and reasons of cardiac arrests

As above As above If this is a review of incidents or complaints etc it should be continuous

Continuously

Annually

The method adopted for monitoring compliance will depend on the policy/procedure type but may include the following:

Sample audits of patients views/experiences

Staff surveys to assess knowledge, implementation and experience of policies

Health and Safety and ward/environmental inspections and audits

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Monitoring adherence to policies via performance management programmes/appraisals

Complaints management audits and trend analysis

Clinical incident reporting analysis

Monitoring staff competencies and compliance with mandatory training

Monitoring of equality and diversity and equality legislation where appropriate

Meeting minutes / other evidence demonstrating effective functioning of arrangements as outlined within the policy.

Where a committee is nominated to review the policy / procedure compliance then that committee should also be consulted as part of the development and ratification process.

Section 10. Consultation and review When reviewing a strategy / policy / procedure all appropriate subject specific guidance should be taken into account. In addition to relevant subject specific guidance, the requirements of regulatory bodies, e.g. the Care Quality Commission, the NHS Litigation Authority, Health & Safety Executive, and Department of Health must be taken into account and noted within this section.

The involvement of all groups, committees, forums and stakeholders responsible for ensuring the safe and effective implementation of policies and procedures is key to the review and development of effective documents. Stakeholders should be asked to contribute, comment and agree the content of a document before it is passed to the appropriate body for approval. In addition every strategy / policy / procedure needs to be reviewed by the Internal Audit and counter Fraud Service to ensure that is it fraud proofed. To achieve a monthly list of strategies/policies/procedures being reviewed is sent to by CGARD to the Fraud Team, Finance Directorate. A decision will be made by the approving body on the appropriateness of involvement of each group depending on the nature of the strategy/ policy/procedure being developed or reviewed. A list of the persons or groups from whom comments have been invited should be included in this section. The name of the Committee(s) approving the document should be included on the Policy / Procedure Ratification Form (see Appendix 2) or Strategy Ratification Form (see Appendix 8) accompanying the document.

• Section 11. Strategy/policy/procedure implementation (including

awareness raising)

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This should include any specific requirements (in addition to the implementation in accordance with this policy) e.g. staff briefings, newsletters, team brief, divisional meetings.

• Section 12. References - references should be included within the strategy/policy/procedure. The Trust’s preferred referencing methodology is the Harvard method. Documents developed using numerous references should contain a condensed list where possible. It is the author’s responsibility to ensure that references cited within a strategy / policy / procedure are the most recent available.

• Section 13. Associated documentation – should include cross

referencing to any other Trust strategies/policies/procedures which have an impact on the issue.

Multi-agency documents – Where multiagency documents are in use, e.g. Safeguarding Children, related local strategies / policies / procedures must be cross-referenced and be in line with the agreed multiagency document.

6.5 Ratification/approval process

All Trust policies and strategies will have a named individual with overall responsibility for the content of the document and ensuring that it is kept up to date. This will normally be the Chairman of the relevant Trust Committee. They may delegate the tasks involved in the development, ratification and implementation processes, therefore the author may not necessarily be the responsible owner. Consultation should be planned in advance and must include appropriate multi-professional Trust groups prior to ratification. For strategies / policies / procedures which may impact on several staff groups or processes, more than one group may need to be consulted. Only strategies, policies and procedures which have undergone major changes require approval by the Clinical Policy Group (CPG). Documents must not be sent directly to the CPG by the author or committee. a) Policies ratified by the CPG

Ratification Process Part 1

Following consultation the strategy / policy / procedure should be ratified by the responsible Trust committee and then be sent to the Clinical Effectiveness Manager, CGARD, with a completed Policy / Procedure Ratification Form (Appendix 2) or Strategy Ratification Form (see Appendix 8) and Equality Analysis Form A (Appendix 6)

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Part 2 The Clinical Effectiveness Manager will check all relevant sections are completed and identify whether the strategy / policy / procedure should be put forward to the CPG for final ratification. If the strategy/policy/procedure needs to go to the CPG, the document together with the ratification form and Equality Analysis form(s) will be sent by the Clinical Effectiveness Manager. If the policy is approved by the CPG then the minutes of the CPG meeting are circulated to the Clinical Effectiveness Manager as confirmation that the policy can be uploaded to the Intranet/ Internet as appropriate.

b) Ratification of Human Resources (HR) policies

Ratification Process Part 1

The ratification process for Human Resources (HR) policies is different as they are reviewed at HR Heads and then approved to go forward to EPPCG for consultation. If there was a difference of opinion at EPPCG it would go to the Executive Team for a decision/ratification. Electronically signed ratification forms are acceptable if they come directly from the chair of the appropriate committee or a nominated proxy. Part 2 When a policy is agreed at EPPCG, it then goes back to HR Heads of Department for final ratification. In the event the strategy/policy/procedure is rejected pending further amendment. The author is required to consult with the members of CPG or Executive Group / Head of Department during the development process to ensure all objections are dealt with.

6.6 Publication and dissemination of strategies, policies and procedures

Following approval the Clinical Effectiveness Manager has the responsibility of making sure that the strategy/policy/procedure (as approved) appears on the Trust intranet site. The author of the document has a responsibility to check on the intranet that the process has been completed with the final approved documentation.

Notification of all newly published strategies, policies and procedures is by a fortnightly Newsletter distributed to all directors, directorate managers,

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matrons, heads of department and made available on the News Section of the intranet for all staff. All new or updated strategies, policies and procedures will be highlighted on the intranet policy pages. When sending out the Newsletter CGARD request that:

the Newsletter is brought to the attention of all staff without access to Trust e-mail: and

the recipient destroys any previous document or portion thereof held as hard copy.

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6.7 Freedom of Information Act 2000

Trust strategies, policies and procedures are subject to disclosure under the Freedom of Information Act 2000 (FOI). From January 2005 the Act allows anyone, anywhere to ask for information held by the Trust. Although some information will be exempt, e.g. information which is covered by other legislation for example the Data Protection Act. All strategies, policies and procedures are published on the Trust Internet site, unless they cover areas of particular sensitivity as determined by the approving committee in consultation with the policy author. A list of those documents excluded from the Internet will be maintained by CGARD.

6.8 Corporate register of strategies, policies and procedures

The Clinical Effectiveness Manager is responsible for maintaining a database of strategies, policies and procedures in use. All strategies, policies and procedures in operation within the Trust are published on the intranet site.

6.9 Review of strategies, policies and procedures

The responsible owner will make sure that each strategy, policy and procedure is reviewed in accordance with the timescale specified at the time of approval. No strategy, policy or procedure should remain operational for a period exceeding three years without a review taking place. To assist in this process CGARD will send out a reminder 6 months prior to the expiry date. Any staff member, who becomes aware of changes in practice, changes to statutory requirements, revised professional or clinical standards and local / national directives that affect, or could potentially affect, Trust strategies, policies and procedures should advise the responsible owner/author as soon as possible. The responsible owner / author will then consider the need to review the document outside of the agreed timescale for revision.

• Minor changes can be sanctioned by the Chair of the appropriate Trust Committee without recourse to a committee meeting. This is restricted to changes that do not significantly alter practice. (A note of the changes made will be tabled at the next appropriate committee meeting.) The approved document and signed Ratification Form must be submitted to the Clinical Effectiveness Manager for appropriate numbering and actions. The approved document will be issued as a point version, e.g. 1.1. The formal review date will remain the same.

• Major changes - If a review results in major changes to the document,

then the author should complete a Ratification Form and Equality Analysis Form (Appendix 6) and submit them with the revised

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document to the appropriate Trust Committee. Following approval by the appropriate Trust Committee the documentation should be sent the Clinical Effectiveness Manager who will arrange for approval as in paragraph 6.5. Following approval the new version number will be allocated, e.g. version 2.0, and a formal expiry date of 3 years applied unless a shorter timeframe is requested by the author.

• Formal review - no changes The Chair of the appropriate Trust

Committee can sign off the strategy / policy / procedure without recourse to a committee meeting. The approved document should be presented with the Ratification Form as reviewed without amendments, to the Clinical Effectiveness Manager for appropriate numbering and actions. The policy will be issued as a point version e.g. 1.1 and a formal review date of 3 years applied unless a shorter timeframe is requested by the author.

• Where a strategy/policy/procedure cannot be reviewed by the

review date – For example if expected regulations and/or guidance has not been received the responsible owner must approve an extension to the expiry date. A Procedural Document Review – Extension Authorisation Form (see Appendix 7) should be completed and submitted to the Clinical Effectiveness Manager. The expiry date of the document will be extended, but there will be no change to the version number or effective from date. The expiry date will be extended for a maximum period of 6 months.

• Where a strategy/policy/procedure is to be withdrawn - The Chair

of the appropriate Trust Committee signs an Authorisation to Withdraw Procedural Document Form (see Appendix 9) authorising that the Policy is to be archived and stating the reason why.

The “effective date” is the date on which any new version of an approved document is posted on the intranet. The “effective date” will be in the format of dd/mm/yyyy and will therefore show the date that the version in question became live. The “expiry date” is the date beyond which the approved document is not generally deemed to be current. If an approved document is not replaced by this dated it will be deemed to be current until a replacement is posted on the policies database or the document is withdrawn. The “review date” is a date six months prior to the expiry date, at which time the document owner will be notified by CGARD that a review is required to be undertaken.

6.10. Document control and archiving

CGARD will archive all earlier versions of policies, procedures and strategies and save on the Trust Policy Database. The new version will then be added to the live database with the correct version number.

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The Clinical Effectiveness Manager will make sure that copies of earlier versions of all strategies, policies and procedures are archived and stored in line with the Trust Policy Non-Health related Records and Documents Retention Schedules and Schedule of Responsible Officers. All old versions will be retained in the “archive” file accessed through CGARD only.

The date an approved document was withdrawn will be recorded on the Policies database.

7. Training Appropriate staff within CGARD will be trained on this policy, the management of the policies database and the Content Management System (CMS) used to maintain the Trust’s web site. Human Resources Training department will provide advice on Equality Analysis requirements. No other formal training is required in relation to the policy. Staff are advised to contact the Clinical Effectiveness Manager for advice in relation to strategy / policy / procedure development. 8. Equality and diversity The 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 appropriately assessed. 9. Monitoring the compliance/effectiveness of this policy Monitoring compliance with this policy will be the responsibility of the Clinical Effectiveness Manager. This will be undertaken by:

Standard / process / issue

Monitoring and audit


Compliance with Trust procedural document format including: Compliance with; • Style and format • Associated documents • Supporting references

• Monitoring section

Assessing all new and reviewed strategies/ policies/procedures against the ratification form before updating the policies database

The Clinical Effectiveness Manager

Various Ongoing

Compliance with review and expiry dates

Monitoring of database with preparation of a


Risk Management and Assurance

Every two months

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Standard / process / issue

Monitoring and audit


report on outstanding documents

Committee

Compliance with the requirement to archive old versions of approved documents

Audit of archived files


Risk Management and Assurance

Annual

10. Consultation and review of this policy This policy has been reviewed in consultation with the Risk Management and Assurance Committee and Equality and Diversity Lead. 11. Implementation of policy (including raising awareness) This policy will be circulated by the Clinical Effectiveness Manager as detailed within paragraph 6.6 above. The Clinical Effectiveness Manager will also remind the Chairs of the approving bodies of the need to refuse to consider strategies, policies and procedures which have not been submitted with the Ratification Form and Equality Analysis Form, or which do not conform to the standards laid down in this policy. 12. References

1. Freedom of Information Act 2000. London: Stationery Office. Available at www.opsi.gov.uk/acts

2. Race Relations (Amendment) Act 2000. London: Stationery Office. Available at www.opsi.gov.uk/acts

3. Disability Discrimination Act 1995. London: Stationery Office Available at www.opsi.gov.uk/acts

4. Equality Act 2010. London: Stationery Office Available at www.opsi.gov.uk/acts

5. NHS Litigation Authority Risk Management Standards for Acute Trusts 13. Associated documentation This policy relates to all strategies, policies and procedures within the organisation. See also the:

Non-Health related Records and Documents Retention Schedules and Schedule of Responsible Officers

Trust Clinical Guidelines and Protocols Policy

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Appendix 1 – Format of Procedural Documents

The Newcastle upon Tyne Hospitals NHS Foundation Trust

Document Title

Version No.:

Effective From: Full date (e.g. 1 October 2011)

Expiry Date: Full date (e.g. 1 October 2011)

Date Ratified: Full date (e.g. 1 October 2011)

Ratified By: Owning Trust Committee

1 Introduction Top level paragraph text left aligned (not fully justified). 2 Scope 3 Aims 4 Duties (Roles and responsibilities) 5 Definitions 6 Main Body of the document 6.1 Sub Title Second level paragraph text indented, left aligned (not fully justified) 6.2 Sub Title

5.2.1 Sub section

Third level paragraph text indented, left aligned (not fully justified) 7 Training 8 Equality and diversity

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9 Monitoring compliance

Standard / process / issue Monitoring and audit


10 Consultation and review 11 Implementation (including raising awareness) 12 References 13 Associated documentation Appendix 1 – on a new page Appendix 2 – on a new page

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Appendix 2 – Policy / Procedure Ratification Form

Policy / Procedure Ratification Form This form must be used by the author of each new or replacement policy/procedure to detail the ratification process undertaken. Please note that some policies/procedures will need to be submitted to more than one expert group. This document plus the Impact Assessment document and the final version of the policy/procedure as approved via the consultation process should be submitted to the Clinical Governance and Risk Department.

Policy Title:

Policy Author: Job Title:

Brief Synopsis of Policy

Is this a New or Replacement policy? New? Replacement?

For Replacement Policies please quote the exact title and date of the old version.

For Replacement Policies please highlight the main changes in this version, quoting the paragraphs / appendices altered: (bullet points

only):

Does the format of the policy comply with the Trust standard? (see

checklist) Yes No

If the policy relates to patients, have the implications for children and young people been included?

Yes No N/A

If the policy includes children and young people, has the Children’s Services Matron been consulted?

Yes No N/A

Has the policy had an Equality Analysis carried out as required by the Trust Policy?

Yes No

Is there any reason why this policy should be withheld from the Trust web site? (e.g. Child Protection issues, Trust Security)

Yes No

Does the policy contain a compliance monitoring process table at paragraph 9?

Yes No

Please choose the area(s) on the intranet on which this document should appear:

Child Protection Clinical Policies Complaints/Accidents/Incidents Corporate Governance Critical Care Services Drugs Health and Safety Human Resources Infection Control Information and Resource packs Information Governance & PAS Information Technology Nursing Operational Research Governance Waste Management Women's Services

Ratification process – Part 1: (required for all change requests and new policies)

Trust Committee Meeting date/ Chairman’s action

Approved? Yes / No

Name of Chairman

Yes

Final policy version and policy ratification form should now be sent to Clinical Effectiveness Manager, CGARD

Ratification process – Part 2: (required for major changes and new policies)

Group (Please choose from the drop-down list)

Meeting date / Chairman’s action

Approved? Yes / No

Group Chairman’s Signature

Clinical Policy Group N/A

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Appendix 3 Procedural Document Development and Approval Process

Completion of Equality Analysis Process

Identify the policy/strategy/procedure to be assessed

Identify the people that need to be involved in the equality analysis

Review available information about service users and staff experience in relation to protected characteristics using the Trust’s workforce and

evidence fact files.

Do you require any additional information? Are there any gaps in the data, can additional useful

can the date be obtained? Is there additional evidence that you are aware of in relation to your particular service or policy area, e.g.

disease patterns related to ethnicity?

Complete the EA form with trained colleagues and relevant stakeholders where appropriate

Consider how the available evidence applies to your policy strategy or service development.

Consider whether you need to make any changes to your policy,

strategy or service development proposals following full consideration of all the available evidence and the outcome of

engagement.

Consider if your policy or service needs to be promoted in a particular way to ensure it maximizes its potential to support

equality improvement.

Document any necessary changes or actions, who will make the changes and the time.

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Document development process

Author makes any necessary changes to Document

Author checks Document complies with Trust format

Author completes Ratification Form

Author seeks approval from Trust Committee

Document Approved?

Author sends Document, Equality Analysis and

Ratification Form to CGARD

Yes

No

CGARD

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CGARD checks Document complies with

Trust format and that Ratification and EA forms )

received.

C.P.G. / EPPCG approval required?

CGARD submits

Non-HR policies to CPG and HR submit HR policies to HR Heads.

CGARD create pdf document.

Document added to intranet .

Document to be shown on

web site?

CGARD add Document to Web Site.

No

Yes

Yes

Author

All present and correct?

Yes

Approved ? Yes No

No

Document complies with Trust format and that

Ratification and ) received.

CGARD create pdf document.

to be shown on web site?

to Web Site.

No

Yes

Yes

Author

All present and correct?

Yes

Yes No

No

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Appendix 4 – Procedural Document Content and Layout Checklist Title:

Font & Page Layout

Arial size 12, left aligned – not fully justified

UNLESS the use of specific tables or illustrations precludes this

A4 portrait, normal margins (2.54cm)

UNLESS the use of specific tables or illustrations precludes this

Spell check

No underlining unless a hypertext link

If necessary emphasise word by using bold, italics or alter font

No blank pages or series of cover pages / contents lists

Footer

Footer contains page numbers in the format Page x of y

Titles

Name of the Trust in the centre at the top of document, in bold sentence case

Followed by:

Document Name, centred, bold, sentence case (no Policy Nos. e.g. Operational Policy 20)

Version No, Effective and Expiry Dates Table

Version No, Effective and expiry date table present under title

Expiry date present – no more than 3 years from Effective Date

Paragraphs

Document includes all the necessary paragraphs

Section Headings and paragraph numbering

Are all section Headings in bold text

Are all paragraphs or key points numbered correctly as sub sections

Monitoring and Review

Monitoring and Review table present and complete

Ratification and Impact Assessment Checklist

Is there a completed / signed Ratification Form present

Has an Equality Analysis been correctly completed

If all of the above are checked as OK the document should be sent to the Clinical Effectiveness Manager, CGARD

If the Ratification Form has been completed by the responsible Trust committee and indicates that only minor changes have been made the revised document can be added to the database.

If, however, there have been major changes, or this is a new Strategy/Policy/Procedure, it will need to be submitted to the Clinical Policy Group or Executive Group for approval prior to being added to the database.

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Appendix 5

General Principles for Writing Strategies / Policies / Procedures

1. Strategies/policies/procedures are to be produced to a standard format as outlined in

Appendix 2, which defines the style to which strategies/policies/procedures should

comply.

2. The intended audience should be targeted and it should be ensured that anyone who

reads the document will be able to understand it.

3. The information should be presented in a logical, sequential order.

4. The content of each strategy/policy/procedure should comply with all relevant legal and

statutory requirements, NHS guidance and policy in force at the time of writing or review

and should reflect evidence based best practice.

5. Consider what relevant strategy/policy/procedure documents already exist in the Trust

and cross-reference where appropriate to avoid duplication.

6. A summary or introduction at the beginning of each strategy/policy/procedure outlining

the aims of the strategy/policy/procedure and its application should be included.

7. The possibility of patient groups with the production of strategy/policy/procedure should

be considered.

8. Ensure that what is proposed does not make it impossible or unreasonably difficult for

people to make use of any service that is being proposed or provided due to their age,

gender, disability, language or race. The needs of people from diverse cultural or

religious groups and general health and safety issues are to be considered.

9. Be aware that under the Freedom of Information Act there will be open access to your

document by the general public and on the Internet.

10. Be aware that the strategy/policy/procedure document will be viewed electronically and

good practice to view in this format is:

Do not underline words or headings for emphasis, instead use bold text or italics to

show emphasis - underlining in electronic documents generally denotes that the text

is a hyperlink that can be clicked with the mouse button to jump to another document

or another part of the same document.

Do create hypertext links to referenced documents available on the Intranet or the

web (and preferably show the link underlined in blue) so that the referenced

documents can be opened easily on line: the links will be preserved when your

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document is converted into Adobe pdf format. Links to Trust strategies/policies or

guidelines should be dynamic links.

Do not have a series of cover pages, contents lists and/or blank pages at the

beginning of the document, which takes a while to load up and click past before the

user gets the heart of the documents message.

Do include the page number on each page in the format Page x of y.

Include appropriate references, acknowledgements and any appendices at the end of

the document.

Appendix 6

The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 2. Name of policy / strategy / service:

Policies and Procedural Documents: Development, Approval and Dissemination

3. Name and designation of Author:

Steve Stoker; Clinical Effectiveness Manager

4. Names & Designations of those involved in the impact analysis screening process:

Steve Stoker; Clinical Effectiveness Manager; Lucy Hall Equality and Diversity Lead

5. Is this a: Policy x Strategy Service

Is this: New Revised x

Who is affected: Employees x Service Users x Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted

from your policy)

This policy provides a system for administering the development, approval and monitoring of documents to ensure that strategies, policies and procedures are:

In line with corporate governance requirements

Clear and consistent in their format, compilation and dissemination

Meet corporate and clinical standards

Promote equality and diversity

Are approved, disseminated and implemented appropriately

Are monitored and reviewed in a regular, structured way.

7. Does this policy, strategy, or service have any equality implications? Yes x No

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

8. Summary of evidence related to protected characteristics

Protected Characteristic Evidence i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

The policy includes Equality Analysis and guidance on completing EA EDHR Mandatory Training

Potential discrimination addressed through EA

These will be identified through EA

Sex (male/ female) As above

As above

As above

Religion and Belief As above

As above

As above

Sexual orientation including lesbian, gay and bisexual people

As above

As above

As above

Age As above

As above

As above

Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

As above

As above

As above

Gender Re-assignment As above As above As above

Protected Characteristic Evidence i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Marriage and Civil Partnership As above

As above

As above

Maternity / Pregnancy As above

As above

As above

9. Are there any gaps in the evidence outlined above. If ‘yes’ how will these be rectified ?

No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery

System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement No

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education?

No

PART 2

Name:

Date of completion:

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)

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Appendix 7

Procedural Document Review – Extension Authorisation Form

Document title:

Document version:

Name of author:

Current review date: (usually six months before expiry date)

Current expiry date:

Proposed extension date: (no longer than 6 months):

Reasons for proposed extension (please give full details of reason for the request for an extension e.g. new

legislation expected with date)

Requested by:

Name:

Title: Date:

Approved by: (Chair of appropriate Trust Committee)

Name:

Signature:

Committee: Date:

Please submit this form to the Clinical Effectiveness Manager, CGARD.

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Appendix 8

Strategy Ratification Form This form must be used by the author of each new or replacement strategy to detail the ratification process undertaken. Please note that some strategies will need to be submitted to more than one expert group. This document plus the final version of the strategy as approved via the consultation process should be submitted to the Clinical Governance and Risk Department.

Title:

Author: Job Title:

Brief Synopsis:

Is this New or a Replacement? New? Replacement?

For Replacements please quote the exact title and date of the old version.

For Replacements please highlight the main changes in this version, quoting the paragraphs / appendices altered: (bullet points only):

Is there any reason why this document should be withheld from the Trust web site? (e.g. Child Protection issues, Trust Security)

Yes No

Please choose the area(s) on the intranet on which this document should appear:

Child Protection Clinical Policies Complaints/Accidents/Incidents Corporate Governance Critical Care Services Drugs Health and Safety Human Resources Infection Control Information and Resource packs Information Governance & PAS Information Technology Nursing Operational Research Governance Waste Management Women's Services

Ratification process – Part 1: (required for all changes and new Strategies)

Trust Committee Meeting date/ Chairman’s action

Approved? Yes / No

Name of Chairman

N/A

Final version of the strategy and this ratification form should now be sent to the Clinical Effectiveness Manager, CGARD

Ratification process – Part 2 (required for major changes and new Strategies)

Group (Please choose from the drop-down list)

Meeting date / Chairman’s action

Approved? Yes / No

Group Chairman’s Signature

Clinical Policy Group N/A

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Appendix 9

Authorisation to Withdraw Procedural Document

Document title:

Document version:

Name of author:

Current review date: (usually six months before expiry date)

Current expiry date:

Reasons for withdrawing document (please give full details of reason for the request for withdrawing

the approved document e.g. incorporation into another policy, or legislative requirement)

Requested by:

Name:

Title: Date:

Approved by: (Chair of appropriate Trust Committee)

Name:

Signature:

Committee: Date:

Please submit this form to the Clinical Effectiveness Manager, CGARD

The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: __10 January 2019________________ 2. Name of policy / guidance/ strategy / service development / Investment plan/Board Paper:

Policies and Procedural Documents:Development, Approval and Dissemination

3. Name and designation of author:

Mr S Stoker, Clinical effectiveness Manager

4. Names & Designations of those involved in the impact analysis screening process:

Risk Management and Assurance Committee

5. Is this a: Policy Is this: Revised Who is affected: Employees 6. What are the main aims, objectives of the document you are reviewing and what are the intended outcomes?

(These can be cut and pasted from your policy)

This policy provides a system for administering the development, approval and monitoring of documents to ensure that strategies,

policies and procedures are:

• In line with corporate governance requirements

• Clear and consistent in their format, compilation and dissemination

• Meet corporate and clinical standards

• Promote equality and diversity

• Are approved, disseminated and implemented appropriately

• Are monitored and reviewed in a regular, structured way.

7. Does this policy, strategy, or service have any equality implications? No

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

The policy applies to all staff across the Trust equally.

8. Summary of evidence related to protected characteristics Protected Characteristic

Evidence What evidence do you have that the Trust is meeting the needs of people in all protected Groups related to the document you are reviewing– please refer to the Equality Evidence within the resources section at the link below: http://nuth-vintranet1:8080/cms/SupportServices/EqualityDiversityHumanRights.aspx

Does evidence/engagement highlight areas of direct or indirect discrimination? For example differences in access or outcomes for people with protected characteristics

Are there any opportunities to advance equality of opportunity or foster good relations? If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

This Trust applies to all staff equally. No

Sex (male/ female)


Religion and Belief


Sexual orientation including lesbian, gay and bisexual people


Age


http://nuth-vintranet1:8080/cms/SupportServices/EqualityDiversityHumanRights.aspx

http://nuth-vintranet1:8080/cms/SupportServices/EqualityDiversityHumanRights.aspx

Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section


Gender Re-assignment


Marriage and Civil Partnership


Maternity / Pregnancy


9. Are there any gaps in the evidence outlined above? If ‘yes’ how will these be rectified?

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement No

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education?)

PART 2 Name of author:

Mr S Stoker

Date of completion

10 January 2019

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)