Development and Management of Procedural Documents Policy

Transcription

1 Development and Management of Procedural Documents Policy The 5 key messages the reader should note about this document are: 1. Procedural Documents are important within any organisation. They are an essential element in maintaining a safe and effective workforce, and as such all staff need to be aware of and have access to relevant and up to date Procedural Documents. 2. This Policy only applies to Trust Procedural Documents that are policies and procedures (as specified below) and not other document types (such as guidelines, protocols, quality standards, standard operating procedures, care pathways, terms of reference and strategies). 3. Policies are Trust-wide and tell the organisation what is to be done. 4. Procedures describe how a policy is to be implemented and provide a series of activities, tasks or processes which produce the desired outcome. 5. All Procedural Documents should be written in a style which is concise and clear using unambiguous terms and language with abbreviations and specialist terms are explained. You & Your Care Page 1 of 20

2 This document has been approved and ratified. Circumstances may arise where staff become aware that changes in national policy or statutory or other guidance (e.g. National Institute for Health and Care Excellence (NICE) guidance and Employment Law) may affect the contents of this document. It is the duty of the staff member concerned to ensure that the document author is made aware of such changes so that the matter can be dealt with through the document review process. NOTE: All approved and ratified policies and procedures remain extant until notification of an amended policy or procedure via Trust-wide notification, e.g. through the weekly e-update publication or global and posting on the Intranet (Connect). Document Title: Version: Name and Title of Responsible Director/Senior Manager: Name and Title of Author Title of Responsible Committee / Group (or Trust Board): Persons/Groups/Committees Consulted: Procedural Document Compliance Checklist adhered to: Target Audience: Approved by: Development and Management of Procedural Documents Policy 9-10 Final Andy McElligott, Medical Director Darren Shipman, Governance & Clinical Audit Manager Debbie Webster, Deputy Director of Quality & Governance Non-Clinical Policy Ratification Group Policy & Procedure Leads Group Yes Directors Policy authors Senior Managers Policy & Procedure Leads Group Date Approved: 17/11/2015 Ratified by: Non-Clinical Policy Ratification Group Date Ratified: 30/11/2015 Date Issued: 02/12/2015 Review Date: 30/11/2018 Page 2 of 20

3 Frequency of Review: Responsible for Dissemination: Copies available from: Where is previous copy archived (if applicable) Amendment Summary: 3 years Darren Shipman, Governance and Clinical Audit Manager (also responsible for uploading to the Intranet/Connect). Connect on BDCFT Intranet Connect on BDCFT Intranet This is a major revision to the Development and Management of Procedural Documents Policy. The full document has been streamlined with any repetition removed and reference to NHSLA taken out as this is no longer relevant. Although changes are numerous, they do not affect the overall process but make the policy easier to follow hence resulting in more streamlined and effective policy documents. Amendment detail: Amendment number Page Subject Page 3 of 20

4 Contents 1 INTRODUCTION SCOPE DEVELOPING A PROCEDURAL DOCUMENT Identifying the Need Responsibility for Development Author Director/Senior Manager Responsible Specialist Staff Style & Format Version Control Required Sections Title Page (Page 1) Production and Review Details (Page 2) Contents Page Main Body of the Procedural Document Appendices ONCE THE DRAFT PROCEDURAL DOCUMENT IS DEVELOPED Consultation and Communication with Stakeholders Approval and Ratification of the Procedural Document ONCE THE DRAFT PROCEDURAL DOCUMENT IS APPROVED AND RATIFIED Dissemination Implementation Library of Procedural Documents Archiving Arrangements Process for Reviewing a Procedural Document DEFINITIONS Types of Procedural Document Policies Page 4 of 20

5 4.1.2 Procedures Approval of Procedural Documents Ratification of Procedural Documents Assurance Strategic Intents Equality Impact Assessment Training Needs Analysis Policy Coordinators EQUALITY IMPACT ASSESSMENT TRAINING NEEDS ANALYSIS MONITORING COMPLIANCE AND EFFECTIVENESS REFERENCES TO EXTERNAL DOCUMENTS ASSOCIATED INTERNAL DOCUMENTATION APPENDIX A: EQUALITY IMPACT ASSESSMENT APPENDIX B: EQUALITY IMPACT ASSESSMENT (TEMPLATE) APPENDIX C: PROCEDURAL DOCUMENT COMPLIANCE CHECKLIST APPENDIX D: STANDARD PROCEDURAL DOCUMENT TEMPLATE Page 5 of 20

6 1 INTRODUCTION The rationale for development of this Policy is to ensure an overall standard for the production and implementation of Trust Procedural Documents, i.e. policies and procedures (see Section 4: Definitions). 2 SCOPE The main objectives of this Policy are to: a) Ensure an overall quality standard for the production and implementation of Procedural Documents. b) Ensure that an effective process for Procedural Document development, approval, ratification, implementation and monitoring is in place. c) Provide a standardised template for writing a Procedural Document, which will assist Authors in ensuring that all Procedural Documents include the necessary elements. This approach will also assist those responsible for implementing Procedural Documents by providing a consistent and familiar format. It should be noted that guidelines, protocols, quality standards, standard operating procedures, care pathways, terms of reference and strategies are beyond the scope of this policy and are the responsibility of the relevant service lead. 3 DEVELOPING A PROCEDURAL DOCUMENT When developing a Trust Procedural Document the following process should be utilised. 3.1 Identifying the Need Prior to development of Procedural Documents, the following issues should be considered: Is this an existing Procedural Document and is it still pertinent and required? Are the requirements already included in other ratified Procedural Documents? Does a Procedural Document exist anywhere else, e.g. Royal Marsden / Maudsley Procedure Books, other organisations? Will this Procedural Document safeguard patients / reduce risk? Is any expert support or advice required? What does the literature say? 3.2 Responsibility for Development For each Procedural Document the following responsibilities for developing it will be identified Author Each Procedural Document will be allocated to a named Author. The Author is required to follow the Trust-wide Policy for the Development and Management of Procedural Documents and to ensure review of their Procedural Document is undertaken in a timely manner. Where there are any difficulties in doing so, this should be reported to the Page 6 of 20

7 Director/Senior Manager responsible. The Author will be responsible for forwarding the reviewed Procedural Document for approval and ratification Director/Senior Manager Responsible Every Procedural Document will have a named Director/Senior Manager who will be responsible for: Identifying the Author of the Procedural Document; Ensuring it is developed within the required timescale; Designating the approval and ratification groups/committee for the Procedural Document; and Ensuring it is reviewed and updated in a timely manner by the Author. Procedural Documents that are policies must be linked to a director of the Trust but for all other Procedural Documents this should be the appropriate senior manager Specialist Staff A range of staff with specialist knowledge will provide professional advice and support to Authors and to the group/committee approving the Procedural Document. This support will vary dependant on the Procedural Document content and will be identified by the Author and may include the following non-exhaustive key individuals: Heads of Professions to provide professional advice and support to Authors and to the group / committee approving the Procedural Document. Risk Manager Health & Safety lead(s) Human Resource managers etc. 3.3 Style & Format All Procedural Documents should be written in a style which is concise and clear using unambiguous terms and language with abbreviations and specialist terms explained. The standard Procedural Document template format should be followed wherever possible but is not intended to be restrictive. It is important to ensure that effectiveness and ease of use of the document remain a priority. A Procedural Document Compliance Checklist (see Appendix C) is available to the Author to ensure a uniform approach to its development and management and should be utilised as a source of assurance by them and the Director/ Senior Manager responsible for it to ensure that all requirements are met. The Author must indicate that they have produced the Procedural Document in a manner that is compliant with the Procedural Document Compliance Checklist. Failure to do this will mean that the Procedural Document cannot proceed to approval and ratification. (This requirement was set by the Non-Clinical Policy Ratification Group on 30/11/2015). The following formatting requirements will be met for all Procedural Document and the Author by using the approved Procedural Document template (see Appendix D) will ensure this. Arial font size 12 will be used; Page type set to A4, with margins of 2cm top, bottom, left and right; All documents will include page numbers; and Page 7 of 20

8 A draft watermark applied to all versions until the final ratified one. 3.4 Version Control All new Procedural Documents will be identified as Version 1-01 meaning version 1 draft 1. A draft number will be added for amended versions developed as part of the consultation, approval and ratification process (e.g. Version 2-02 is version 2 draft 2, etc.) until the Procedural Document is ratified. When Procedural Documents are updated, the Version number will advance (e.g. Version 1 will become Version 2 during its first review). Following the version number it must be stated if this is a production or implemented version of the Procedural Document by stating Draft or Final respectively. 3.5 Required Sections Every Procedural Document will have the following sections in the following order Title Page (Page 1) The Title Page will include the following information: The Bradford District Care NHS Foundation Trust (BDCFT) logo in the top right hand corner. The BDCFT strapline (currently You and Your Care ) and Web address ( in the bottom left corner. The title of the Procedural Document. See Section for the naming convention for Procedural Documents. A concise statement of the 5 key messages for Trust staff arising from the Procedural Document Production and Review Details (Page 2) The second page of the Procedural Document will include the following information (see the Procedural Document Template in Appendix D for guidance on what this entails). Standard Staff Notification for All Procedural Documents Title of the Procedural Document Version Name and Title of Responsible Director/Senior Manager Title of Responsible Group/Committee (Or Trust Board) Persons/Groups/Committees Consulted Procedural Document Compliance Checklist has been adhered to Target Audience Approved By Date Approved Ratified By Date Ratified Date Issued Review Date Frequency of Review Responsible For Dissemination Page 8 of 20

9 Copies Available From Where Previous Version is Archived (If Applicable) Amendment Summary (If Applicable) Amendment detail (If Required) Contents Page There will be a Contents page for each Procedural Document which lists the key sections of it as listed Section of this policy. If the Procedural Document template (see Appendix D) is used then the Contents section can be generated using the heading and sub-heading styles Main Body of the Procedural Document The Main Body of the Procedural Document will have the following sections unless otherwise stated. Introduction Scope Core Content Definitions Equality Impact Assessment Training Needs Analysis Monitoring Compliance and Effectiveness References to External Documents Associated Internal Documentation Appendices Appendices Equality Impact Assessment The Equality Impact Assessment is a standard checklist and statement approved by the Trust s Senior Manager for Equality & Diversity which must be included in all Procedural Documents that are policies as Appendix B Additional Appendices It may be helpful to supplement the Core Content of the Procedural Document with appendices. It is a matter for the personal judgement of the Author as to what is included as Core Content and what is inserted into the appendices. It is suggested that very detailed procedural information, should be referred to in the text and included as appendices or identified as separate documents in the Associated Documentation section to avoid Procedural Documents becoming too lengthy. 3.6 ONCE THE DRAFT PROCEDURAL DOCUMENT IS DEVELOPED Consultation and Communication with Stakeholders Authors will be expected to involve relevant stakeholders, including service users, in the development and review of Procedural Documents. Stakeholders consulted with will be listed on the front sheet of the document. It is expected that policies will include a wider consultation than other Procedures Documents. Consultation on procedures may be limited to specialisms or groups within the Page 9 of 20

10 Trust. For clinical policies all relevant clinical input should be sought including consultation with Heads of Professions relevant to the policy subject. Consideration should be given to the following stakeholders (this list is not exhaustive): Staff groups Service users Carers Unions HR representatives Approval and Ratification of the Procedural Document All Procedural Documents will require approval and subsequent ratification by the appropriate Trust group/committee before they can be implemented and staff expected to adhere to them. The Director/Senior Manager responsible for the Procedural Document will identify the Trust groups and committees that will approve and then ratify it for use. If the Procedural Document is a policy then it must be ratified by one of the following and normally approved by a Trust group which reports to it: Trust Board Quality & Safety Committee Audit Committee Finance, Business & Investment Committee Non Clinical Policy Ratification Group Any other committee with delegated Trust Board Authority The date and source of approval and ratification must be recorded on the second page of each Procedural Document. Matrices outlining responsibilities and dates for approval, ratification and review of Procedural Documents will be maintained via the relevant Policy Coordinator for the appropriate part of the Trust. There will be instances where it is essential to have Procedural Documents which are developed and implemented in partnership with other organisations. In such instances it may not be possible to utilise the BDCFT Procedural Document template and a judgement will be made by the approving group/committee as to the adequacy of the document and any additional internal work required in support its adoption by the Trust. 3.7 ONCE THE DRAFT PROCEDURAL DOCUMENT IS APPROVED AND RATIFIED Dissemination Once a Procedural Document is approved and ratified, the Author is responsible for ensuring a finalised version is made available on the Trust s Intranet ( Connect ) for staff information and reference. They may be supported in doing this by the appropriate Policy Coordinator. Additional measures may be utilised by the Author to disseminate the Procedural Document to Trust staff, e.g. through electronic communications such as the regular Trust s weekly e-update briefing. Page 10 of 20

11 Where staff do not have access to Connect, managers will ensure that appropriate Procedural Documents are made available within the workplace Implementation It is the responsibility of all Trust employees to ensure that they follow all ratified Procedural Documents that apply to them or the service they provide. Any training required to enable staff to operate according the Procedural Document will be set out in the Training Needs Analysis. The effectiveness of the implementation of the Procedural Document will be monitored as set in the Monitoring Compliance and Effectiveness section Library of Procedural Documents Each Policy Coordinator will be responsible for maintaining a library of Procedural Documents relevant to their area of responsibility and will ensure that this is updated within 1 week of being informed of the ratification of the Procedural Document Archiving Arrangements All Procedural Documents will be archived on the Trust s Intranet ( Connect ). Where staff do not have access to the Intranet, Service Managers are responsible for ensuring that paper copies of Procedural Documents are maintained in an accessible file; these should be replaced by any updated versions, and outdated versions destroyed to avoid confusion / errors Process for Reviewing a Procedural Document At the time of ratification, all Procedural Documents will have an identified review date agreed and entered onto the second page of it. The Author will be expected to ensure that the Procedural Document is reviewed by the agreed review date which will normally be 3 years from the date on which it was last ratified for implementation. The appropriate Policy Coordinator will send reminders to the Author and the Director/Senior Manager responsible to ensure that they are kept aware of this. Where changes have been made to a Procedural Document as a result of a review, these will be included in the amendment section at the front of it. 4 DEFINITIONS All Procedural Documents will, where considered necessary, include a glossary describing the meaning of the terms used in the context of the document. 4.1 Types of Procedural Document For the purpose of this Policy, Procedural Documents are defined as policies and procedures. The terminology employed to distinguish between types of document is often used interchangeably, which can result in some confusion about what they should contain and ultimately their effectiveness. In the context of this document the following definitions are of relevance. Page 11 of 20

12 4.1.1 Policies Policies are Trust-wide and tell the organisation what is to be done. They are philosophically based and reflect the values and strategic intents of the Trust, hence allowing adjustment for changing conditions without making any basic changes in policy. Policies explain why certain things are required and provide a basis for the development of procedures. All policies will be written in line with the BDCFT Development and Management of Procedural Documents Policy. Policies must be ratified via the Non Clinical Policy Ratification Group, a committee or Trust Board (see section 3.6.2). Policies must have as responsible for them: A director of the Trust as the Director/Senior Manager Responsible; A committee of the Trust/Trust Board which will also ratify it; and A Trust group that reports to the responsible committee/trust Board that will approve it Procedures Procedures are Trust-wide and must link directly to a Trust-wide policy. Procedures describe how a policy is to be implemented and provide a series of activities, tasks or processes which produce the desired outcomes. A procedure usually induces a change. All procedures will be written in line with the BDCFT Development and Management of Procedural Documents Policy. The only exceptions to this will be the Infection Control Policy and Procedures and Health and Safety Policy. Due to the large number of procedures required, these will be produced as one document; the main policy will be developed in line with the BDCFT Development and Management of Procedural Documents Policy and will include version control etc. for the whole document. Whilst some procedures may be more relevant in some service areas than others (e.g. technical information and technology procedures) these are still classed as Trust-wide (as they affect the Trust as a whole) and will be developed in line with the BDCFT Development and Management of Procedural Documents Policy. It is noted that, there may be procedures which, whilst they are classed as Trust-wide, need to be restricted in terms of circulation for security reasons. Procedures should be approved by the appropriate professional or service group and ratified by a group to which it reports. 4.2 Approval of Procedural Documents Approval means formally approving the content of the Procedural Document. 4.3 Ratification of Procedural Documents Ratification refers to the act of officially sanctioning the use of the Procedural Document for implementation within the Organisation. 4.4 Assurance Assurance means providing evidence needed to establish confidence among all concerned, that activities are being performed effectively. This includes planned or systematic actions necessary to provide adequate confidence that a product or service will satisfy given requirements for quality. Page 12 of 20

13 4.5 Strategic Intents Strategic Intents refers to the high level objectives of BDCFT. 4.6 Equality Impact Assessment Equality Impact assessment is an assessment of whether the document treats all groups / individuals equally and fairly. 4.7 Training Needs Analysis Training Needs Analysis is an assessment of the training needed to ensure that staff are able to implement the requirements of the Procedural Document. 4.8 Policy Coordinators Policy Coordinators are those with responsibility for coordinating the process for review, approval and ratification of Procedural Documents within their remit and as outlined in Section 3 of this document. This will include: Human Resources/ Education and Training Quality & Governance/ Clinical/ Nursing & Specialist Services/ Involvement & Equality Information Management & Technology/ Information Governance Finance Estates & Facilities/ Health & Safety Medicines Management Mental Health Act 5 EQUALITY IMPACT ASSESSMENT The Trust has no intent to discriminate and endeavours to develop and implement policies that meet the diverse needs of our workforce and the people we serve, ensuring that none are placed at a disadvantage over others. Our philosophy and commitment to care goes above and beyond our legal duty to enable us to provide high-quality services. Our Equality Analysis and equality monitoring is a core service improvement tool which enables the organisation to address the needs of disadvantaged groups. The aim of Equality analysis is to remove or minimise disadvantages suffered by people because of their protected characteristics. An impact assessment has been undertaken to consider the need and assess the impact of this Procedural Document and is evidenced at Appendix A of this template 6 TRAINING NEEDS ANALYSIS The Trust is committed to high quality targeted training and effective communication to support this policy. The Trust recognizes that training capacity can fluctuate and will depend on resources available. As such based on an assessment of capacity and risk, the training needs analysis will identify the high priority groups for training. The objective of the training to implement this Procedural Document is to meet training to this group over the time frequency stated. The focus of Trust monitoring will be on this group over the agreed period or lifetime of the Procedural Document. Page 13 of 20

14 In relation to this Policy a Training Needs Analysis has not been completed as no formal training is required to enable its implementation. Advice and support is available to Authors via the Deputy Director of Quality & Governance and the appropriate Policy Coordinator. 7 MONITORING COMPLIANCE AND EFFECTIVENESS Criteria There is an effective process for the development, approval and ratification of Trust Procedural Documents. All procedural documents comply with the requirements set out in the Trust Procedural Document template. There is an effective process for archiving Trust Procedural Documents. Evidence identified to indicate compliance with policy Libraries of Trust Procedural Documents maintained by the appropriate Policy Coordinator. The content and format of Trust Procedural Documents match the Trust s Procedural Document template. Libraries of Trust Procedural Documents maintained by the appropriate Policy Coordinator. Method of monitoring, i.e. how/where will this be gathered? Reports to the Trust groups/ committees responsible for oversight of the Procedural Documents. Reports to the Trust groups/ committees responsible for oversight of the Procedural Documents. Reports to the Trust groups/ committees responsible for oversight of the Procedural Documents. Frequency of monitoring Quarterly/ Annually as agreed with group / committee Quarterly/ Annually as agreed with group / committee Quarterly/ Annually as agreed with group / committee 8 REFERENCES TO EXTERNAL DOCUMENTS Lead responsible for monitoring Policy Coordinator appropriate to service. Policy Coordinator appropriate to service. Policy Coordinator appropriate to service. National Health Service Litigation Authority Risk Management Standards providing Community, or Mental Health & Learning Disability Services Equality Act 2010 and the associated Equality Delivery System. 9 ASSOCIATED INTERNAL DOCUMENTATION In respect of this policy, specific related Procedural Documents / Trust documents are: BDCFT Strategic Intents BDCFT Equality Impact assessment Process BDCFT Training and Study Leave Policy This policy also has relevance to all Trust Procedural Documents which can be found on the Trust s Intranet ( Connect ). Page 14 of 20

15 10 APPENDIX A: EQUALITY IMPACT ASSESSMENT (EQIA) Area Response Policy Trust-wide Policy for the Development and Management of Procedural Documents Manager Deputy Director of Quality & Governance Directorate Quality & Governance Date Review date Purpose of Policy To ensure an overall standard for the production and implementation of Trust Procedural Documents Associated frameworks NHSLA e.g. national targets NSF s Who does it affect Target audience : all staff developing procedural documents Consultation process carried out QA Approved by Equality protected characteristic Impact Positive Impact Negative Rationale for response Age Yes This policy supports protection of the equality Disability Yes characteristics in the following ways: Gender Yes Provides a structure for producing policies Reassignment Race Yes which is inclusive and uniform Specifies the requirement to undertake EIA for Religion or Yes all policies Belief Includes a quality assurance approach Pregnancy & Yes Maternity Sex Yes Sexual Orientation Yes Equality Analysis SIGN - OFF Have any adverse impacts been identified on any equality groups which are both highly significant and illegal? Are you satisfied that the conclusions of the EqIA Screening are YES accurate? The Trust will publish a summary of the impact analysis carried out to meet the duty and make this available to the public on the Trust Internet site. Completed by Manager Debbie Webster 24/11/2015 Q A approved Director approved NO Page 15 of 20

16 11 APPENDIX B: EQUALITY IMPACT ASSESSMENT (TEMPLATE) Area Policy Manager Directorate Date Review date Purpose of Policy Associated frameworks e.g. national targets NSF s Who does it affect Consultation process carried out QA Approved by Response Equality protected characteristic Age Disability Gender Reassignment Race Religion Belief Pregnancy Maternity Sex or & Impact Positive Impact Negative Rationale for response Sexual Orientation Equality Analysis SIGN - OFF Have any adverse impacts been identified on any equality groups which are both highly significant and illegal? Are you satisfied that the conclusions of the EqIA Screening are accurate? The Trust will publish a summary of the impact analysis carried out to meet the duty and make this available to the public on the Trust Internet site. Completed by Manager Q A approved Director approved Page 16 of 20

17 12 APPENDIX C: PROCEDURAL DOCUMENT COMPLIANCE CHECKLIST Insert title of document being reviewed 1. Title Is the title clear and unambiguous? Is it clear whether the document is a policy or procedure? 2. Rationale Are reasons for development of the procedural document stated, e.g. in the Introduction or Scope sections? 3. Development Process Is the method described in brief e.g. in the Introduction or Scope sections? Are people involved in the development identified, e.g. in the Production and Review Details (page 2)? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users, e.g. in the Production and Review Details (page 2)? Have the requirements of the following been taken into account where applicable: Mental Health Act Mental Capacity Act Care Programme Approach (CPA) Guidance 4. Content Is the objective of the document clear, e.g. in the Scope section? Is the target population clear and unambiguous, e.g. in the Scope section? Are the intended outcomes described, e.g. in the Core Content section? Are the statements clear and unambiguous? Are any amendments compared to a previous version of the document summarised or where appropriate listed in more detail, e.g. in the Production and Review Details (page 2)? Yes/No/ Unsure Comments Page 17 of 20

18 Insert title of document being reviewed The Trust is transitioning services to agile working: please consider and include implications for agile workers and the management of agile within all policies and procedures. 5. Evidence Base Is the type of evidence to support the document identified explicitly, e.g. in the References to External Documents, Associated Internal Documentation sections and Appendices? Are key references cited? Are the references cited in full? Are supporting documents referenced? 6. Approval and Ratification Does the document identify which committee/group will approve it, e.g. in the Production and Review Details (page 2)? If appropriate have the joint Human Resources/Staff Side Committee (or equivalent) approved the document, e.g. in the Production and Review Details (page 2)? Does the document identify which committee/group will ratify it, e.g. in the Production and Review Details (page 2)? 7. Dissemination and Implementation Is there an outline/plan to identify how this will be done, e.g. in the Production and Review Details (page 2)? Does the plan include the necessary training/support to ensure compliance, e.g. in the Training Needs Analysis section? 8. Document Control Does the document identify where it will be held, e.g. in the Production and Review Details (page 2)? Have archiving arrangements for superseded documents been addressed, e.g. in the Production and Review Details (page 2)? Yes/No/ Unsure Comments Page 18 of 20

19 Insert title of document being reviewed Yes/No/ Unsure Comments 9. Process to Monitor Compliance and Effectiveness Are there measurable criteria, standards or KPIs to support the monitoring of compliance with and effectiveness of the document, e.g. in the Monitoring Compliance and Effectiveness section? Is there a plan to review or audit compliance with the document e.g. in the Monitoring Compliance and Effectiveness section? 10. Review Date Is the review date identified, e.g. in the Production and Review Details (page 2)? Is the frequency of review identified? If so is it acceptable, e.g. in the Production and Review Details (page 2)? 11. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the document, e.g. in the Production and Review Details (page 2)? Author Approval The Author should complete, sign and date this Procedural Document Compliance Checklist then share it with the Responsible Director/Senior Manager. Author Date Signature Responsible Director/Senior Manager The Responsible Director/Senior Manager should complete, sign and date this then share it with the Responsible Director/Senior Manager. If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation s database of approved documents. Name Date Signature Page 19 of 20

20 13 APPENDIX D: STANDARD PROCEDURAL DOCUMENT TEMPLATE The standard Procedural Document Template, is available through BDCFT Connect on the A to Z of Policies> Corporate Policies and Procedures> Quality and Governance page ( Page 20 of 20