Corporate Document Approval Framework

Transcription

1 Corporate Document Approval Framework Author(s) (name and post): Lezli Feeney, Risk Manager Alan Ferguson, Records Manager Version No.: Version 1.2 Approval Date: 18 Jan 2011 Review Date: 17 Jan 2013 the everyday name for Telford and Wrekin Primary Care Trust

2 Document Control Sheet Title: Electronic File Name: Placement in Organisational Structure: Consultation with stakeholders: Equality Impact Assessment: Corporate Document Approval Framework Corporate Document Approval Framework Version 1.2.doc Corporate Records Management and FOI Group (10/11/2010) Risk Manager, Trust Secretary, Risk Management and Clinical Governance Policy Approval Committee (07/12/10) Alan Ferguson 23/12/010 Ref: Corporate Document Approval Framework EIA Dec 2010.doc Approval Level: Audit Committee 18/01/11 Dissemination Date: 19/01/11 Implementation Date: 01/02/11 Method of Dissemination: Directors, Newsflash and Website Document Amendment History Version No. Date Brief Description (including page number as req.) Version 0.1 Draft 12/05/09 Board discussion draft Version 0.2 Draft 23/09/09 Board amendments Version 0.3 Draft 24/11/09 Audit Committee amendments Version 1 09/12/09 Final minor amendments for Board Version /04/10 Clarification and updating of storage and archiving processes Version 1.2 Dec 2010 Amendments and updates to the Groups and Committees responsibilities relating to the Professional Executive Committee, Audit Committee and Quality Assurance Group The formally approved version of this document is that held on the NHS Telford and Wrekin website ( Printed copies or those saved electronically must be checked to ensure they match the current on line version. Page 1

3 Contents 1 Introduction Purpose Responsibilities The Chief Executive Executive Directors, Community Health Services Managing Director and Deputy Directors Document Authors All Staff Risk Manager and Records Manager The Board Committees and Groups Local Documents Corporate Document Template Document Titles Font and Spacing Headings Consultation, Approval, Dissemination, Implementation, Review and Retention Processes Consultation Equality Impact Assessment Document Approval Document Control Sheet and Version Control Dissemination Implementation of Corporate Documents Corporate Document Review Retention, Archiving and Disposal Retrieval Related Documents Dissemination of this Framework Advice and Training Review and Framework Compliance Monitoring Review Compliance Monitoring...13 Page 2

4 10 References Glossary Document Titles Document Sections Definitions...16 Appendix 1: Corporate Approval Flowchart Appendix 2: Corporate Document Development Checklist Appendix 3: Corporate Document Approval Framework Flowchart21 Appendix 4: Example Corporate Document Template Appendix 5: Example Corporate Document Register Appendix 6: Example Corporate Document Publication Checklist32 Page 3

5 1 Introduction Approved corporate documents, including strategies and policies, record the processes by which (NHS T&W) plans and conducts its activities. They are necessary to ensure that the organisation s vision and goals, as recorded in the strategic plan are achieved, that risks to these objectives are adequately mitigated, that legal and regulatory obligations are met and that the organisation s intentions and methodologies are clearly understood by all stakeholders. The control of corporate documents is essential, not only to comply with corporate and clinical governance standards but as an essential means of ensuring standardisation in the provision of safe care across NHS Telford and Wrekin and the successful reduction of risk. 2 Purpose The purpose of this policy is to ensure a structured and systematic approach to the development, review, ratification, dissemination and retention of procedural documents. It establishes a framework that ensures all policies and procedures are: of a consistently high standard, up to date, available to all staff, implemented and complied with, and reviewed at regular intervals. 3 Responsibilities 3.1 The Chief Executive The Chief Executive has responsibility for establishing procedures to ensure the quality of NHS T&W s corporate documents. This framework documents those procedures. 3.2 Executive Directors, Community Health Services Managing Director and Deputy Directors Directors identify the need for a strategy or policy and sponsor its development, approval, dissemination and future review in line with this framework. In the majority of instances development of the documents will be assigned by the director to a document author, who is competent to write the document and is acting within the bounds of their area of responsibility Directors and deputy directors are also responsible for ensuring that corporate documents are distributed to all relevant staff within their directorate and ensuring that staff are aware of their responsibility to read, understand and act upon them in a timely and effective manner. Page 4

6 3.3 Document Authors Corporate document authors must ensure that documents they write are: compliant with this framework, reflect current best practice, and practical and possible to implement within NHS T&W. They are also responsible for retaining a master (i.e. Word) version of the document which should be stored on a suitable network drive relating to their department. They must maintain a register of all documents they are responsible for, which must include the version number, approval, review and disposal dates - Appendix 5: Example Corporate Document Register. Should a document author change post or leave the organisation ownership of their documents and the relevant document register must be passed to another appropriate member of staff. The Records Manager should be informed of any such changes so that the published corporate document register can be kept up to date. 3.4 All Staff All staff have a responsibility to read, understand and follow all NHS T&W corporate documents at all times and bring to the attention of their line manager any difficulties in achieving or maintaining compliance. 3.5 Risk Manager and Records Manager The Risk Manager and the Records Manager, provide advice regarding compliance with this framework for corporate and local documents. They also conduct compliance monitoring activity (see sections 8 and 9). In addition the Records Manager will also be responsible for: carrying out a check of all corporate documents prior to publishing to the NHS T&W website - Appendix 6: Corporate Document Checklist, maintaining a register of published and archived corporate documents, archiving of corporate documents when newer or replacement documents are approved and published. 3.6 The Board Within NHS T&W ultimate responsibility for the approval of corporate documents lies with the Board. However, responsibility for approval of certain documents is delegated to other committees. The Board retains responsibility for approving: corporate frameworks and strategies, and corporate policies that are required by law, e.g. Health and Safety Policy. Page 5

7 3.7 Committees and Groups Responsibility for approving the following is delegated to: Quality, Performance and Resources Committee (QPR): commissioning policies and procedures, human resources policies, minor amendments to policies previously approved by the Board Human Resources Policy Committee: This sub-committee of QPR reviews human resources policies following staff consultation, including discussion at the Joint Staff Consultative Committee Professional Executive Committee: Reviews and approves, for recommendation to Board, all corporate clinical documents Audit Committee: Reviews and recommends to the Board, for approval, all corporate documents that relate to the organisation s governance including corporate governance, information governance, clinical governance and management of risk, in particular the Risk Management Strategy Risk Management and Clinical Governance Policy Review Committee: This committee, chaired by the Head of Clinical Governance is responsible for the development and review of documents prior to presentation to the Audit Committee for approval. Membership will be selected by the Head of Clinical Governance to ensure that appropriate interested and specialist staff contribute to each document presented for consideration Community Health Services Provider Committee: Reviews and approves provider services operational strategies and policies and procedures Other Community Health Services Committees Quality Assurance Group: All overarching provider policies, codes of practice, guidelines and documents prepared to maintain compliance with the Care Quality Commission and NHS Litigation Authority standards are approved by this group before formal approval by the Provider Committee. In addition this group develops all documents aimed at maintaining patient, public and staff safety, e.g. procedures for the use of medical devices and provider arm health and safety codes of practice and guidelines. It is also the staff consultation forum for health Appendix 1: Corporate Approval Flowchart Page 6

8 3.8 Local Documents Other documents not listed above and which define local procedures, and are not therefore regarded as corporate documents, must also have a suitably qualified author and be approved, reviewed, monitored and archived using locally defined processes that reflect the principles defined in this document. Particular care is needed when establishing processes for the development and approval of documents for joint working teams and that define multiagency policy and procedures. The Records Manager gives advice to all directorates and services to develop these processes. 4 Corporate Document Template All corporate documents should be written using the Corporate Document Template in a concise and clear style without ambiguous terms and language. Subject to the outcome of the Equality Impact Assessment (EIA) consideration should be given to producing the document in relevant languages, Braille and large fonts. Appendix 4: Example of the Corporate Document Template 4.1 Document Titles Corporate document titles should reflect the definitions of the words framework strategy, policy, code of practice, procedure and guidelines given in section 10.1 Document Titles below. 4.2 Font and Spacing The Corporate Document Template requires the use of the Arial font in the following point (pt) sizes and numbering style: Front cover title: Arial, 30 pt, bold Table of Contents: TOC 1 Arial 14 pt bold; TOC 2 Arial 12 pt; tab settings 1 cm and cm; paragraph spacing 6 pt after. Margin settings: Top 2.5 cm, Bottom 2.55 cm, Left 3.00 cm and Right 2.50 cm (use the File Page Set Up margins options) Section headings: Heading 1 - Arial 16 pt, bold; outline numbering 1, 2, 3, 4 etc.; paragraph spacing 12 pt before and 3 pt after; indent 1.27 cm Sub-section headings: Heading 2 - Arial, 14 pt, bold; outline numbering 1.1, 1.2, 1.3, 1.4 etc; paragraph spacing 12 pt before and 3 pt after; indent 1.27 cm Paragraph headings (sub-section of a sub-section): Heading 3 - Arial 12 pt, bold; outline numbering 1.1.1, 1.1.2, 1.1.3, etc; paragraph spacing 12 pt before and 3 pt after; indent 1.27 cm Page 7

9 Text: Arial, 12 pt; paragraph alignment, justified; paragraph spacing 6 pt after; indent 1.27 cm Headers: Arial, 10 pt; border below 0.5 pt line width - <<document title>> on left and on right Footers: Arial, 10 point; border top 0.5 pt line width Filename (use insert field / filename option) on left; page numbering centre; and date and year on right e.g. December Headings Corporate documents must contain as a minimum: 1 Introduction, 2 Purpose, 3 Responsibilities, 4 Procedures / Processes, 5 Related Documents, 6 Dissemination, 7 Advice and Training, 8 Review and Compliance Monitoring, 9 References, and 10 Glossary. For explanations of what each section should contain see 11.2 Document Sections below. Appendices may be included, if required, to expand or explain information contained within the document, or to provide specific guidance or examples to aid compliance. In this framework appendices include: Appendix 2: Corporate Document Development Checklist Appendix 3: Corporate Document Approval Framework Flowchart Appendix 4: Example of Corporate Document Template 5 Consultation, Approval, Dissemination, Implementation, Review and Retention Processes After the preparation of a draft document the author must ensure the processes outlined below are followed: 5.1 Consultation The involvement of relevant stakeholders is essential to the review and development of effective documents. The author has the responsibility to ensure that appropriate staff, expert advisers, staff groups and, where relevant, patients and public and external stakeholders, including the Patients Forum, are consulted about the content of the document. The draft document may be circulated for comment or presented to relevant groups for discussion. A draft watermark must be included in all draft Page 8

10 documents. If documents are circulated for comment deadlines and contact details must be provided. Documents that have Human Resources and Health and Safety implications must be presented to the staff union representatives, through the Joint Staff Consultative Committee. 5.2 Equality Impact Assessment All public bodies have a statutory duty, under the Race Relation (Amendment) Act 2000, to set out arrangements to assess and consult on how their policies and functions impact on race equality. This obligation has been extended to include equality and human rights with regard to age, gender and religion. Therefore, following consultation and prior to submission to the relevant committee for approval, the author must ensure that the document is subject to an Equality Impact Assessment (EIA). A copy of the document and completed EIA should then be submitted to the Equality and Diversity Group so the EIA can be approved. The author may conduct this assessment, using the Equality Impact Assessment Tool if trained to do so. However, it is best practice to conduct the assessment jointly with another trained author, who has not participated in the development of the document. The EIA must be signed off by the director responsible for instigating the development of the document and a copy submitted to the document approving committee. 5.3 Document Approval Following completion of the consultation and EIA and inclusion of all relevant amendments the documents (together with the relevant committee executive summary and EIA) can be scheduled for presentation to the approving committee. The approving committees are listed in section 3 Responsibilities above. 5.4 Document Control Sheet and Version Control Document authors are responsible for document and version control using the front page and Document Control Sheet of the Corporate Document Template. Draft versions must be indicated as such by a watermark and in the version number, e.g. version 1 draft. The first approved version of a document is version 1. Where there is a requirement for minor amendments subversions (i.e. 1.1, 1.2) can be used. The author must retain the current master version and maintain a register of the documents they are responsible for. Appendix 4: Example of Corporate Document Template Page 9

11 5.5 Dissemination Website: Once a document has been approved an electronic copy of the master is sent to the Records Manager. Document authors should also inform the Records Manager of any corporate documents the current document replaces. This is of particular importance if the document supersedes and incorporates a number of previous documents. The Records Manager checks each document received to ensure it follows the format of this framework and has been approved by a named approving committee or the Board - Appendix 6: Corporate Document Publication Checklist. After checking the document the Records Manager will convert it to Adobe pdf format and publish it in the appropriate section of the Policies and Procedures Library on the website. A copy of the document will also be saved to the Policies and Procedures Library on the Halesfield network drive. This will be the primary copy used for archive purposes. The Records Manager will maintain a register of published corporate documents and will ensure that document authors are reminded of review dates three months in advance. The Records Manager will obtain summaries of new and revised policies from authors and send these to the Communications Manager for inclusion in News Flash. The Webmaster and Communications Team provide technical support to the Records Manager. Because documents MUST only be uploaded to the website ONCE only the Records Manager is authorised to upload documents to the Policies and Procedures Library. Therefore web-authors should place a link to relevant documents within this library in their local web pages Document authors should also circulate an electronic copy of the approved version to all relevant directors and line managers for dissemination to relevant staff. This may be done by advising directors and line managers of the location of the document on the intranet. 5.6 Implementation of Corporate Documents Directors and line managers are responsible for ensuring that corporate documents are implemented and compliance maintained. 5.7 Corporate Document Review With the exception of documents that require annual review, e.g. the Risk Management Strategy, all corporate documents should be reviewed by the author within two years of the date of approval. Revised documents should be approved by the relevant committee, as documented in section 3 Responsibilities. Should there be changes in legislation, policy or practice, documents should be reviewed immediately, irrespective of the review date and document authors must remain mindful of this. Page 10

12 5.8 Retention, Archiving and Disposal It is important that corporate documents are retained for the recommended retention period so they can be referred back to, as required 1. Corporate documents published to the NHS T&W website will be in Adobe pdf format and these will be considered to be the primary copy of the document and will be stored by the Records Manager in the Policies and Procedures Library on the Halesfield network drive. When replaced by newer versions, the older version will be archived in the Policies and Procedures Library for the retention periods detailed in the Records Retention and Archiving Policy Corporate documents will be retained for 10 years. The disposal date for corporate documents will be recorded in the register of published corporate documents. The document will be deleted from the network drive once it has reached its disposal date. Corporate documents that form part of employment terms and conditions or form part of some other substantial reason as a basis of an employment claim 3 will be retained for a longer period. These will be archived until at least six years after the last person affected by that policy has left the organisation; or they have reached their 70 th birthday, or have died Specific advice and guidance on these types of documents and any other retention period queries should be obtained from the Records Manager who will consult with the relevant authorities, clarify and agree the actual retention period During the current review of the NHS T&W websites any policies and procedures held on the old website will be reviewed and retention periods agreed by the Records Manager. They will then be stored in the Policies and Procedures Library on the Halsefield network drive Any corporate document that is not held electronically (e.g. documents from previous related organisations) will be retained in hard copy for the specified retention period. Departments are responsible for maintaining a register of these documents and archiving them using the centralised Storage and Archive Service provided by an external supplier. 5.9 Retrieval Archived corporate documents will be held on the Halesfield network filestore in the Policies and Procedures Library. This process will be administered and monitored by the Records Manager. Requests for retrieval of archived corporate documents should be made to the Records Manager. 1 For example, as evidence in legal proceedings 2 Based on the NHS Records Management Code of Practice retention schedules 3 For example, Human Resources and Health and Safety Page 11

13 There are some archived corporate documents that are not held electronically. These are primarily Human Resource related documents and relate to the organisation prior to the current structure i.e. prior to the Primary Care Trust. Requests for such documents should be made to the Human Resources Manager. 6 Related Documents The following documents contain information that relates to this framework: Risk Management Strategy Risk Register (Assurance Framework) structure and Audit Committee Timetable Equality Impact Assessment tool for conducting assessments and Guidelines for undertaking and producing Equality Impact Assessments (available under the Equality and Diversity section of the NHS T&W website) Records Management Strategy and Policy Records Retention, Archiving and Disposal Policy 7 Dissemination of this Framework Once approved, this framework will be placed in the Corporate Policies and Procedures section on the website and directors, specialist staff, likely to write corporate documents, and line managers advised of its content. The Records Manager will raise awareness of the requirements and content of this framework by liaising with directorates and services. 8 Advice and Training 8.1 Advice in the Use of This Framework Corporate document authors should seek advice from the Risk Manager or the Records Manager regarding compliance with this framework. Bespoke training may be provided as required by document authors. Authors of local documents should seek the advice of the Records Manager. Contact details: Lezli Feeney Risk Manager Halesfield 6 Telford TF7 4BF Tel: lezli.feeney@telfordpct.nhs.uk Alan Ferguson Records Manager Halesfield 6 Telford TF7 4BF Tel: alan.ferguson@telfordpct.nhs.uk Page 12

14 8.2 Training for the Implementation of and Compliance with Corporate Documents Document authors must identify training needs and document its availability within the training section of their corporate document. 9 Review and Framework Compliance Monitoring 9.1 Review This policy will initially be reviewed in six months then annually. The Risk Manager and the Records Manager carry out these reviews. 9.2 Compliance Monitoring Compliance with this framework will be monitored, by periodic audit, as part of the Quality Review Plan element of the Risk Registers (Assurance Framework) and reported within the Audit Committee Timetable. These audits will be conducted by the Risk Manager and the Records Manager. The Records Manager will also carry out checks on corporate documents prior to publishing on the website using the Corporate Document Publication Checklist, Appendix References 11 Glossary NHSLA Risk Management Standards for Acute Trusts Primary Care Trusts and Independent Sector Providers of NHS Care, NHS Litigation Authority, London, 2009 ( oc ) NHS Records Management Code of Practice, Part 1 and 2 Department of Health, 2006 (part 2 revised 2009) ationspolicyandguidance/dh_ Document Titles The following terms should be used in the titles of documents in accordance with their purpose: framework A logical conceptual structure (or skeleton) for organising or developing a complex task or information. In this instance a format for corporate documents. The Learning Development Framework demonstrates how the workforce has access to education, training and development in order for them to fulfil their role effectively. Page 13

15 strategy policy code of practice procedure / protocol care pathway A plan of action designed to achieve a particular goal(s). The Risk Management Strategy documents NHS T&W s approach to ensuring effective risk management throughout the organisation. The Communication and Engagement Strategy describes a vision and an Implementation Plan which will improve involvement of patients and the public in the ongoing delivery and development of health services. A strategy includes the assumption gradual progress will be made towards achieving defined goals. An approach to ensuring best practice throughout the organisation in a particular area of legal or regulatory requirement. The Health and Safety Policy records NHS T&W s principles for ensuring the health, safety and welfare of its staff and all others who are affected by its work. The Bullying and Harassment at Work Policy describes in its Statement of Commitment NHS T&W s principles regarding tolerance in the workplace. A policy provides a structure to operational decisionmaking. A set of written rules which explains how people working in a particular context should behave. The Lone Working Code of Practice defines how NHS T&W staff should behave when working alone. The Records Retention, Archiving and Disposal Code of Practice defines how these activities should be managed to ensure best practice. Managers must ensure that staff are aware of these documents and staff must comply with the practical advice given in them. Variations to the requirements of a code of practice must be documented within a risk assessment. A formally agreed set of practical steps required to complete a task. This includes standard operating procedure. The Pre-employment Checks Procedure documents the steps that must be taken to ensure that the correct checks are undertaken before a member of staff starts work with NHS T&W. A pathway directing the patient s journey based on best multi-disciplinary (integrated) practice and service delivery, approved and endorsed by the specialities and appropriate forums including providers and commissioners. Page 14

16 guidelines Practical advice about how to achieve best practice in an area of work where there is permissible flexibility. Guidelines on the Removal of Footwear When Visiting Clients at Home advised staff of safe practice when asked to remove footwear when entering a client s home Document Sections Title Introduction Purpose Responsibilities Name of the document clearly reflecting its purpose (see 11.1 above). The words used in the title should make it readily identifiable on the website. A brief resume of the background to the document and why there is a need for it. This should include the laws, regulations and best practice that the document seeks to comply with. A description of the rationale for the document, including its objectives. This should explain who the policy is aimed at: including; the staff, e.g. all staff, particular teams or posts, who should operate within it; people who may be affected by its operation, e.g. patients in general or particular client groups; the degree it applies to nonemployees of NHS T&W, e.g. contractors and temporary staff from agencies. It might be appropriate to specify areas specifically not covered. If these are covered by other documents this should be stated. A statement of the accountability and responsibility, within the parameters of the document, of: Staff at all levels including, where relevant the Chief Executive and specialist advisory staff, Committees and groups including, where relevant, the Board. Procedures/ Processes Related Documents Precise details of the procedures to be followed to achieve compliance with the document, e.g. exactly what staff must do. There may be a number of procedural / process sections. A list of other NHS T&W documents that relate to the document or need to be used in conjunction with it. This list may need to include documents belonging to partner organisations, particularly if the document relates to the work of joint teams. Page 15

17 Dissemination Advice and Training Review and Monitoring References The process for disseminating the document, to the website, directors, managers, the wider staff and, if relevant, other stakeholders. Where advice in the implementation and interpretation of the document may be sought. Specific training needs to ensure the effective implementation of the document, how this training will be delivered and if relevant by whom. Explanations of when the document will be reviewed and how compliance with it is monitored. A record of all documents used in the development of the document including relevant legislation, Department of Health and other external regulations and guidance. Reference can be made here to any other associated relevant policies or documents. References must be recorded in the format below and outlined in the Corporate Document Template. Book: Surname, first name title, publisher, city of publication, year of publication, (ISBN) (web location (if available on the internet)) Magazine article: Surname, first name article title title of publication, volume number, date, web location (if available on the internet) Glossary A list of definitions and explanations of words, terms or abbreviations used in the document where these aid understanding. These sections may be combined or separated in documents, but authors must ensure that each item above is appropriately and clearly reflected Definitions Term / Abbreviation Corporate Document CQC DoH Local Document Definition / description Organisational wide documents that support NHS T&W s integrated governance and demonstrate compliance with legislation and regulative requirements. Care Quality Commission Department of Health Directorate or service specific documents that define local procedures and demonstrate compliance with best practices and relevant standards (see section 3.8). Page 16

18 Term / Abbreviation Master NHSLA NHS T&W Primary Standards Definition / description The approved original (MS Word format) version of the document that the author retains. NHS Litigation Authority The approved version of the document (Adobe portable document format - pdf) published on the NHS T&W Website and retained for the recommended retention period. A required level of quality approved by a nationally recognised regulatory bode e.g. Care Quality Commission, NHS Litigation Authority Page 17

19 Appendix 1: Corporate Approval Flowchart Board Professional Executive Committee PEC Audit Committee Quality Performance and Resources Committee QPR Provider Committee Risk Management and Clinical Governance Policy Review Committee Human Resources Policy Committee Quality Assurance Group QAG Joint Staff Consultative Committee JSCC Equality and Diversity Group (this group approves all Equality Impact Assessments) Page 18

20 Appendix 2: Corporate Document Development Checklist The following checklist will assist in the development of corporate documents: Rationale and Responsibility Why is the particular corporate document required? Ensure it does not duplicate local or other local organisational work. Is the document being developed in accordance with or related to regulation and / or legislation? Give details: Who is responsible for co-ordinating the ongoing development, implementation and review of the document? Development, Engagement and Consultation Who are the key stakeholders and groups involved in the development / engagement / consultation process? Consider who the document applies to. Ensure relevant expertise is used. Include service users or a wider public group where applicable. Is this document related to other corporate documents? If yes please list: Content and Evidence Base Identify clear, focussed objectives, outcomes. Identify what type of source e.g. research, expert opinion, clinical consensus, patient views. Relevant reference documents / sites. Ensure the document is factually accurate, evidence based and referenced. Is the document based on a national document? If yes, is the local information needed? List relevant documents: Page 19

21 Approval Has an Equality Impact Assessment been completed on the document? This must be completed before the document is submitted for final approval. What group(s) will approve this document? Final approval must be by a NHS T&W group or committee with the relevant authority to approve corporate documents. Are there other groups that need to be involved in the approval process e.g. specific subject matter experts? Dissemination and Implementation How will the document be disseminated to the relevant staff / groups? Who are the key people involved in the dissemination and implementation? How long will the dissemination process take? Is any training required? Consider linking with induction training, continuous personal development and clinical supervision as required. Are there any previous version / out of date documents that need to be removed from circulation? Review and Compliance Monitoring When does the document need to be reviewed? Who will carry out the review and monitoring? Ensure document authors maintain their own register of corporate documents to assist in this process. Who will be involved in the review and compliance monitoring? List: Has a relevant review and compliance monitoring process been identified? Consider developing assurance tools e.g. processes and checklists. Is all current content still relevant? Check for new evidence based best practice to be incorporated into the document. Re-approve document and archive old versions. Page 20

22 Appendix 3: Corporate Document Approval Framework Flowchart Need for corporate document identified Agreement by sponsoring Director Assigned to Document Author Draft Document Created Consultation with relevant stakeholders (see section 5 - Corporate Document Approval Framework Policy) Equality Impact Assessment completed Document edited/approved Electronic copy to Records Manager * Dissemination Process - directors and line managers cascade to relevant staff (electronic copy sent out or just a link to the document on the website) Relevant training arranged / delivered Review and Compliance Monitoring process Retention and Archiving process *Corporate Document should only be uploaded once to website. The Records Manager will publish them in the Policies and Procedures Library. Web authors should place a link from their local web pages to the relevant document in the Policies and Procedures Library Page 21

23 Appendix 4: Example Corporate Document Template Note: The following pages are an example of the Corporate Document Template. The actual template is available on the NHS T&W website under the Policies and Procedures section. Page 22

24 <<Document Title>> Author(s) (name and post): <<Name, Post>> Version No.: <<e.g. Draft 1>> Approval Date: Review Date: the everyday name for Telford and Wrekin Primary Care Trust

25 Document Control Sheet Title: Electronic File Name: Placement in Organisational Structure: Consultation with stakeholders: Equality Impact Assessment: Approval Level: <<Document Title>> <<File name Document Title>> <<directorate, service, function>> <<individuals, staff groups, committees, external stakeholders and dates>> <<confirmation and reference details of Impact Assessment carried out e.g. Race, Disability, Gender Equality, Health Inequalities, Mental Capacity>> Board Dissemination Date: <<date document is disseminated >> Implementation Date: <<date document takes effect>> Method of Dissemination: <<website, directors, managers, stakeholders>> Document Amendment History Version No. Date Brief Description (incl. page no.) << e.g. Draft 1>> The formally approved version of this document is that held on the NHS Telford and Wrekin website ( Printed copies or those saved electronically must be checked to ensure they match the current on line version. Page 24

26 Contents 1 Introduction Purpose Responsibilities The Chief Executive Executive Directors, Community Health Services Managing Director and Deputy Directors Specialist Staff Line Managers All Staff The Board Committees and Groups Processes Process Process Process Process Process Related Documents Dissemination Advice and Training Advice Training Review and Compliance Monitoring Review Compliance Monitoring References Glossary...6 Appendix 1 - <<Appendix Title>>...7 Page 25

27 1 Introduction <<Paragraph>> <<Paragraph>> 2 Purpose <<Paragraph>> bullet point, bullet point, bullet point, bullet point, and bullet point. 3 Responsibilities 3.1 The Chief Executive The Chief Executive has responsibility for. 3.2 Executive Directors, Community Health Services Managing Director and Deputy Directors Specialist Staff bullet point, bullet point, and bullet point. 3.4 Line Managers All Staff 3.6 The Board Page 26

28 3.7 Committees and Groups <<Paragraph Title: <<Paragraph Title: <<Paragraph Title: <<Paragraph Title: 4 Processes 4.1 Process 4.2 Process 4.3 Process 4.4 Process <<Appendix 1: Appendix Title>> 4.5 Process <<Appendix 2: Appendix Title>> Page 27

29 5 Related Documents The following documents contain information that relates to this policy: 6 Dissemination <<list of related corporate and local documents that should be considered in conjunction with this document.>> <<list of related corporate and local documents that should be considered in conjunction with this document.>> This policy will be disseminated by the following methods: Directors: Website: News Flash article: Awareness raising by <<specialist staff>>: 7 Advice and Training 7.1 Advice 7.2 Training 8 Review and Compliance Monitoring 8.1 Review 8.2 Compliance Monitoring 9 References Book: Surname, first name title, publisher, city of publication, year of publication, (ISBN) web location (if available on the internet) Magazine article: Surname, first name article title title of publication, volume number, date, web location (if available on the internet) Page 28

30 10 Glossary/Definition Term / abbreviation Explanation Page 29

31 Appendix 1: <<Appendix Title>> Page 30

32 Appendix 5: Example Corporate Document Register It is recommended that Corporate Document Registers are created in MS Excel as the database functionality is ideal for this type of use. Below are key headings to be used. Document authors may want to add additional columns relevant to their directorates or services. Key Document Title Document Type Version Status Author Post / Role Directorate / Service Approval Date Approving Group EIA Date Review Date Disposal Date File location Link Website Link Comments Page 31

33 Appendix 6: Example Corporate Document Publication Checklist The following checks must be completed before a Corporate Document can be published on the (NHS T&W) website. Document Title: Author:. Department:... Approval Date: Role: Location: Review Date: Front Cover: 1. NHS T&W Logo correct size and positioning? Yes No 2. Clear and relevant document title including type of document? Yes No 3. Document author and post / role? Yes No 4. Version Number? Yes No 5. Approval Date? Yes No 6. Review Date? Yes No 7. NHS T&W strap line present? Yes No Comments (continue on additional page if required) Document Control Sheet Check that all sections have been completed in particular: 8. Filename includes version number? Yes No 9. Are key stakeholders and groups identified in the Consultation with stakeholders section? Yes No 10. Has an Equality Impact Assessment been completed and recorded? Yes No 11. Approval Level? Yes No 12. Are the Dissemination and Implementation dates completed? Yes No Comments (continue on additional page if required) Page 32

34 Document Layout, Formatting and Style: 13. Does the Header include: a. Document title? Yes No b. Organisation details? Yes No 14. Does the Footer include: a. Filename (including version number)? Yes No b. Page numbering? Yes No c. Date in correct format? Yes No 15. Is Arial font used throughout the document? Yes No 16. Are the recommended font sizes used? Yes No 17. Are there any inconsistencies in: a. Heading styles? Yes No b. Font style and sizes? Yes No c. Headings and paragraph indent? Yes No d. Heading and Paragraph spacing? Yes No e. Bullet numbering style, size and positioning? Yes No Comments (continue on additional page if required) Document Sections/Content are the following sections included or covered in other sections: 18. Introduction a brief resume of the background and need? Yes No 19. Purpose is the rationale for the document clear? Yes No 20. Responsibilities is there a clear hierarchy of accountability and responsibility? Yes No 21. Procedures / Processes are the details of procedures / processes clear? Yes No 22. Related Documents relevant NHS T&W documents? Yes No Page 33

35 23. Dissemination a. Is there a clear description of the dissemination process? Yes No b. Has a briefing article been created summarising the key points covered by the document? Yes No 24. Advice and Training is it clear who can provide advice and are specific training requirements detailed? Yes No 25. Review is it clear when the document will be reviewed and by who? Yes No 26. Compliance Monitoring is it clear who will carry out the monitoring and how this will be done? Yes No 27. References are all references listed complete? Yes No 28. Glossary does this cover relevant definitions and abbreviations used throughout the document? Yes No 29. Appendices are these relevant and clearly identified? Yes No Comments (continue on additional page if required) Previous Published Versions of Document: 30. Does this document supersede or replace any existing documents that are now out of date and / or need to be withdrawn? If Yes please list below. Yes No Document Name(s) and Version number (s) - include authors details as required: Website Location(s): 31. If Yes in 30, has the document(s) been recorded as closed in the document register and retention periods confirmed? Yes No Comments (continue on additional page if required) Check Completed by: Published on Website (date):. Post:. Page 34