POLICY MANAGEMENT FRAMEWORK

Transcription

1 POLICY MANAGEMENT FRAMEWORK October 2012 Author: Responsibility: Janet Young, Governance and Risk Manager All Staff Effective Date: ctober 2012 Review Date: October 2014 Reviewing/Endorsing committees Approved by Governance and Risk Sub Group Date Ratified by CCG Board Governance and Risk Sub Group 8 October 2012 Not required Version Number 2

2 POLICY DEVELOPMENT PROCESS Names of those involved in policy development Name Designation Janet Young Governance & Risk Manager Names of those consulted regarding the policy approval Date Name Designation Mike Thompson Programme Director, CCG Development Equality Impact Assessment prepared and held by Date Name Designation Base Janet Young Governance & Risk Manager Committee where policy was discussed/approved/ratified Committee/Group Date Status Governance & Risk Sub 8 October 2012 Agreed. Group Equality Impact Analysis Bedfordshire Clinical Commissioning Group is committed to promoting equality in all its responsibilities as commissioner of services, as a provider of services, as a partner in the local economy and as an employer. This policy will contribute to ensuring that all users and potential users of services and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender, reassignment, marriage or civil partnership, pregnancy and maternity, race, religion, sex and sexual orientation. Policy Management Framework Page 2

3 Contents Page 1. Introduction Purpose Definitions 3.1 Policy Procedures Protocol Guidelines Framework Responsibilities 4.1 Role of Authors Role of Executive Directors Role of Corporate Office Role of Governance & Risk Sub Group Role of Endorsing Committees Role of Line Management Role of Staff Policy Template and Content Monitoring Equality Impact Analysis Review and Revision arrangements Ratification Dissemination of Policies Archiving arrangements Monitoring Document replaces References Appendix 1 Policy Ratification Process 11 Policy Management Framework Page 3

4 1 Introduction This document aims to provide a clear framework for policy management that supports staff and external stakeholders to engage in Bedfordshire Clinical Commissioning Group s policy process. The Framework describes the processes for document development, dissemination, implementation, evaluation an review together with document control. It also outlines the associated governance and responsibilities of those involved in the process. 2 Purpose The purpose of this Framework is to ensure that the Clinical Commissioning Group (CCG) meets nationally recognised best practice for the development and management of procedural documents. The Framework applies to all staff. Implementation of this Framework will ensure that: Development of all policies and procedural documents follow a clear system of consultation and ratification. Equality impact assessments are undertaken on all procedural documents in order to meet the organisation s statutory duties. Policies are reviewed at agreed intervals. An effective system for the control of documents, including version control and archiving arrangements, is used throughout the organisation. A process for monitoring compliance with and the effectiveness of procedural documents is established. 3 Definitions 3.1 Policy A policy is a mandatory statement of required action. A policy may be defined as a corporate framework document that enables staff to adopt safe and effective working practice. The document should: Clearly state what will or will not be done Include who it covers Provide reference to any underlining SOPs/guidelines Identify how the policy will be monitored and evaluated, and Ideally be as short as possible. All policies must be ratified by the CCG Board. 3.2 Procedures A procedure may be defined as a process to be followed, often set out as a step-bystep list of actions/instructions that describe the appropriate working method to Policy Management Framework Page 4

5 achieve high standards and ensure consistency and accuracy. Procedures must be approved by an endorsing committee but do not require ratification by the Board. 3.3 Protocol A protocol defines and restricts practice to what must happen. Named individuals, teams or professional groups may be identified within the protocol and they are expected to follow the agreed practice. Protocols must be approved by an endorsing committee but do not require ratification by the Board. 3.4 Guidelines Guidelines define good practice and conduct, usually based on guidance published by national or external agencies using current evidence. The organisation s guidelines should be consistent with national guidance, but may be adapted to reflect local circumstances. They are advisory but should be followed wherever possible. If professional judgement dictates action outside the agreed guidelines, the rationale should be fully documented. Guidelines must be approved by an endorsing committee but do not require ratification by the Board. 3.5 Framework A strategic framework is a set of principles and/or longer term goals that form the basis of making policy and to give overall direction to activities. Framework documents aim to describe organisational responsibilities while policies aim to clearly outline staff responsibilities. Frameworks must be approved by an endorsing committee but do not require ratification by the Board. 4 Responsibilities 4.1 Role of the Author The author is responsible for: Ensuring that a new policy/document is required and does not duplicate national or local work, confirming the need with the relevant committee Ensuring that key stakeholders are consulted with and involved in the development of the document Undertaking the equality impact assessment and keeping a record for audit Following the agreed approval and ratification processes Ensuring that the policy is presented in the agreed template to ensure a corporate appearance Ensuring the approval history is documented on the policy Maintaining the document control record Describing how the document will be monitored for compliance and effectiveness Reviewing the document at the agreed interval Identifying relevant training to support implementation of the policy Policy Management Framework Page 5

6 In cases where there is more than one author, all contributors should be recorded and a main contact identified on the document. The Group expects the author of a policy or procedural document to involve stakeholders, including service users, in the development or procedural documents where appropriate. Where appropriate, the author should ensure that Staff-side have an opportunity to comment on policies during the development process. 4.2 Role of Executive Directors Directors are responsible for: Ensuring policies are approved and presented to the CCG s Governance and Risk Group for approval and Board for ratification. Ensuring that a replacement main contact is identified should the original author be re-deployed or leave the organisation. 4.3 Role of the Corporate Office The Corporate Office is responsible for: Ensuring the development and management of policies has been undertaken in accordance with this framework Ensuring that the document control record for policies is maintained and that there is a robust archiving system in place Ensuring information regarding new or revised policies is disseminated throughout the Trust. Providing advice to authors regarding the development and management of policies and procedural documents Ensuring the ratified policies and procedural documents are made available on the intranet and the CCG s website Maintaining the system for alerting authors of due review dates. 4.4 Role of the Governance and Risk Sub Group The Governance and Risk Sub Group is responsible for:- Reviewing policies and recommending ratifying the organisation s policies by the Board. Referring policies back to the author for amendment if it does not agree with the decision to approve made by any endorsing committee Seeking assurance that the systems for the development and management of policies and procedural documents are robust and effective. Acting as the endorsing committee for all general Group policies 4.5 Role of the endorsing committees The Lead Author in conjunction with the Endorsing Committee Chair has the responsibility for ensuring that the dates for review are actioned and policies are Policy Management Framework Page 6

7 reviewed within the scheduled review date. The Endorsing Committee Chair is also responsible for ensuring that policies are forwarded to the Governance and Risk Sub Group where recommendation for ratification by the Board will be agreed. 4.6 Role of Line Management Line Managers are responsible for: Ensuring staff are aware of the CCG s policies and of the relevant procedural documents. Implementing any procedural documents for the areas in which they apply. Ensuring any hard copies printed off and held in their office are the current versions appearing on the intranet or the website. 4.7 Role of Staff All staff are responsible for: Ensuring they are aware of Group policies and attending appropriate meetings and/or training events. Ensuring their teams work to these policies. Taking responsibility for ensuring new staff in their teams are aware of policies. Taking responsibility for feeding back on problems with content or implementation of policies. Ensuring that if they confer with a hard copy version of the policy, it is the most up-to-date version appearing on the intranet. 5 Policy Template and Content A policy template can be found on the intranet or is available from the Corporate Office. Some of the headings may not be appropriate for your policy and there maybe additional headings you may wish to use but as a minimum the suggested heading in the template should be considered when developing the content. Keep paragraphs under headings brief and use only one subject per paragraph. 6 Monitoring The NHSLA requirements are that organisations should measure, monitor and evaluate compliance with the minimum requirements within the NHSLA Risk Management Standards. This should include the use of audits and data related to the minimum requirements. The organisation should define the frequency and detail of the measurement, monitoring and evaluation processes. It is therefore necessary for Authors to complete a section on how the policy will be monitored for compliance and effectiveness. Policy Management Framework Page 7

8 7 Equality Impact Analysis Equality Impact Analysis (EIA) is a statutory duty of the Race Relation (Amendment) Act 2000, Disability Discrimination Act 2005 and Gender Equality Duty It requires all public bodies to assess any existing or potential adverse impact of their policies, procedures, functions and services on ethnic groups, disabled people and people of different gender (female/male/transgender), and how this impact is to be minimised. The duty is likely to be extended to different age groups, sexual orientation, and religion or belief. Additional support can be obtained from the Equality and Diversity Lead. The EIA need not form part of the policy document itself. A standard statement can be found within the policy template (and printed below). A copy of the full EIA should be sent to the Corporate Office to be held centrally. Bedfordshire Clinical Commissioning Group is committed to promoting equality in all its responsibilities as commissioner of services, as a provider of services, as a partner in the local economy and as an employer. This policy will contribute to ensuring that all users and potential users of services and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender, reassignment, marriage or civil partnership, pregnancy and maternity, race, religion, sex and sexual orientation. 8 Review and revision arrangements The author has the responsibility of ensuring that policy is reviewed and re-ratified within the set review date of the policy. The author will be sent a reminder by the Corporate Office three months before the due review date. All policies and procedural documents should be reviewed at least every three years. Where appropriate, the author may set a shorter review date at one or two years. In some cases an annual review may be required. A review may also need to take place due to new legislation or guidance being received. Revisions should be undertaken when the document requires updating and before the set review date. Where the revisions are significant and the overall policy is changed, the author should ensure the revised document is taken through the standard consultation process. The whole document will need to be submitted to the Governance and Risk Sub Group with an appropriate cover sheet outlining the changes made in order to seek ratification by the Board. Where the revisions are minor, e.g. amended job titles or changes in the organisational structure, it is not necessary to submit the policy in its entirety to the Governance and risk Sub Group. A short report explaining how the policy was revised is acceptable. A full copy of the amended policy will, however, be required to Policy Management Framework Page 8

9 be sent to the Corporate Office by the Author for uploading onto the website and intranet. 9 Ratification For policies which may impact on several staff groups or processes, more than one reviewing group/committee will need to be consulted. This process should be documented on the Policy Development Process. Once the policy has been to a reviewing and endorsing committee, the final policy version should be sent electronically to the Corporate Office who will arrange submission to the Governance and Risk Sub Group. A copy of the Equality Impact Assessment form will be requested at the same time. The Governance and Risk Sub Group must function in accordance with its terms of reference and be quorate. The Group will review the policy and convey its recommendation for ratification to the Board in the form of a report. Final ratification of the policy will be by the Board. Once ratified, the Corporate Office will contact the author and request a final electronic version with the front page updated and the words draft deleted. 10 Dissemination of Policies Ratified policies will be uploaded onto the Intranet and Website. A database of CCG policies has been developed which contains all current policies and procedural documents. Authors will be reminded when the review date is imminent. 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. To achieve this, staff should be strongly discouraged from photocopying or printing policies unless necessary to ensure that the Intranet version is the definitive version and that there are no uncontrolled copies within the CCG. Staff will be informed via the Group s internal newsletter when a new policy is available on the intranet/website and Senior Managers/Directors should ensure policies are disseminated and implemented appropriately throughout their Directorate and discussed at Directorate Team Meetings and Team briefs 11 Archiving Arrangements An electronic version of each policy is held by the Corporate Office and when replaced will be archived within the policy archive. Archiving will take place by the Corporate Office once the final version of the new document is available. To obtain a copy of the archived policy, contact should be made with the Corporate Office. Policy Management Framework Page 9

10 12 Monitoring The Corporate Office will scrutinise the style and format of policies sent to them and where necessary return any document to the author for alteration. The Corporate Office will also through the document development process monitor the consultation and ratification process of each policy. The policy author will be sent a reminder by the Corporate Office three months before the due review date that the policy requires reviewing. 13 Document Replaces NHS Bedfordshire Policy for the Development, Approval and Dissemination of Trust Policies and Procedural documents May References Race Relation (Amendment Act 2000) Policy for the development, approval and dissemination of Trust Policies and Procedural Documents May 2011 Policy Management Framework Page 10

11 Appendix 1 POLICY RATIFICATION PROCESS EXISTING POLICY REVIEW TRIGGERS Review date pending in 3 months Amendments to, or new legislation and guidance Learning from incidents Public or patient feedback NEW POLICY TRIGGERS New legislation New guidance External Agency Requirement Learning from incidents Learning from risk assessments Review Existing Policy Research New Policy Appropriate training developed if necessary Lead post identified Reviewing Committee/Group ACTION Draft policy developed and produced in CCG style and format Reviewed for potential to discriminate Policy implementation plan developed Race Equality self assessment questionnaire completed CHECKS Relevant stakeholder group consulted? Reflects best practice? Meets statutory and legal responsibilities? Based on most up-to-date legislation or guidance? Governance & Risk Sub Committee for approval (or ratify clinical policies as approved by Patient Safety & Quality Committee) Ratification by CCG Board Author to send final version to corporate office Policy placed on Internet and website Communication to staff via staff newsletter Policy Management Framework Page 11

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