POLICY ON PROCEDURAL DOCUMENTS

(1)

POLICY ON PROCEDURAL DOCUMENTS

Last Review Date July 2019

Approving Body Executive Committee

Date of Approval November 2019

Date of Implementation November 2019

Next Review Date July 2022

Review Responsibility Associate Director of HR and Corporate Services

Version 3.2

(2)

REVISIONS/AMENDMENTS SINCE LAST VERSION

Date of Review Amendment Details

March 2013 The original PCT document has been revised to:

 Reflect the Clinical Commissioning Group establishment.

 Reflect the Clinical Commissioning Group structure.

July 2016 Refresh of policy to reflect the changed CCG governance structure which applied from 1 June 2016.

Policy:

 Remove Section 1.5 which is duplicated in Section 5.3.2.

 Update section 2.1 with the good practice guidance on which the policy is based.

 Section 4.1 – refresh responsibilities of Chiefs of Service to further clarify responsibilities.

 Section 4.2 – refresh list of Committees to reflect the new Committee structure and their updated terms of reference.

 Section 5.1.1. – remove obsolete reference to complaints.

Procedure:

 Section 3.4 – Update address/postcode.

June 2019  Chief of Corporate Services amended to Associate Director of HR and Corporate Services

 Chief of Strategy and Delivery amended to Director of Strategy and Delivery.

September 2019  Legislation and Guidance (new section 2)

 Equality Impact Assessment (new section 5)

 Procedural Document Authors, amended to Document Authors.

 Equality Impact Assessment Template (new Appendix D).

May 2020  Changes made to the template for ‘Policy on Procedural Documents’.

(3)

DEFINITIONS

Term Definition

Approval The act of approving, of formal agreement.

Policy A deliberate plan of action adopted or pursued by an individual organisation to guide decisions and achieve rational outcomes.

A policy is a statement of intent, describing the approach or course of action the organisation is taking in respect of a particular issue. Policies are underpinned by relevant evidence based procedures and guidelines and enable management and staff to make correct decisions, work effectively and comply with relevant legislation and organisational aims and objectives.

Procedure A set of step-by-step instructions that describe the appropriate method for carrying out tasks or activities to achieve the highest standard possible and to ensure efficiency, consistency and safety.

Procedural document

An overarching term for the full range of strategies, policies and procedures.

Standard Operating Procedures

A set of instructions, usually in a clinical setting, for undertaking a particular task.

Strategy A long term plan designed to achieve particular goals or

objectives. A strategy is often a broad statement of an approach to accomplishing these desired goals or objectives and can be supported by policies and procedures.

(5)

SECTION A – POLICY

1. Policy Statement, Aims & Objectives

1.1. Procedural documents offer advice, guidance and instruction to staff within organisations, whether they are in the form of a strategy, policy or procedure.

Establishing a clear system for the management of procedural documents is a critical component of a transparent risk management programme and

integrated governance.

1.2. The purpose of this document is to provide guidance to staff leading on the development of procedural documents. The aim is to ensure that there are documented, up-to-date, authorised organisation-wide procedural documents in place which enable the organisation to achieve its objectives.

1.3. The aims of this procedural document policy are:

 To ensure that the development and review of strategies, policies and procedures is commissioned, coordinated and progressed through appropriate channels.

 To ensure that all procedural documents are produced in a standard format using a consistent corporate approach.

 To ensure that the dissemination of procedural documents is coordinated and monitored.

 To ensure that the effectiveness of all procedural documents is audited, monitored, reviewed and updated routinely.

1.4. To ensure continuous improvement in risk management, the organisation has a range of key performance indicators (KPIs) which it uses for monitoring purposes:

No. Key Performance Indicator Method of Assessment 1. Progress on procedural

document development and review is reported within the organisation.

Quarterly Governance Reporting.

2. Approved procedural

documents are published on the website.

Website review.

2. Legislation and Guidance

 The Race Relations Act 1976 as amended by the Race Relations (Amendment) Act 2000

 The Gender Recognition Act 2004

(6)

 The Civil Partnership Act 2004

 Sex Discrimination (Gender Reassignment) Regulations 1999

 The Human Rights Act 1998

 Equality Act 2010 (Statutory Duties) Regulations 2011

 Health and Social Care Act 2012

 Records Management Code of Practice for Health and Social Care 2016.

3. Scope

3.1. This policy applies to those members of staff that are directly employed by NHS Doncaster CCG and for whom NHS Doncaster CCG has legal responsibility. For those staff covered by a letter of authority / honorary contract or work experience this policy is also applicable whilst undertaking duties on behalf of NHS Doncaster CCG or working on NHS Doncaster CCG premises and forms part of their arrangements with NHS Doncaster CCG. As part of good employment practice, agency workers are also required to abide by NHS Doncaster CCG policies and procedures, as appropriate, to ensure their health, safety and welfare whilst undertaking work for NHS Doncaster CCG.

4. Accountabilities and Responsibilities

4.1. Overall accountability for ensuring that there are systems and processes to effectively manage procedural documents lies with the Chief Officer.

Responsibility is also delegated to the following individuals:

Associate Director of HR and Corporate Services (or

equivalent)

Has delegated responsibility for:

 Developing the Policy on Procedural Documents and

maintaining an overview of the corporate procedural document ratification and governance process.

 Leading the development, review and approval of governance and risk management procedural documents.

 In the role of Senior Information Risk Owner (SIRO), is also responsible for managing the development and implementation of Information Management & Governance procedural

documents.

Chief Nurse (or equivalent)

 Leading the development, review and approval of clinical procedural documents including those relating to Individual Placements.

 Leading the development, review and approval of safeguarding procedural documents.

(7)

Chief Finance Officer (or equivalent)

 Leading the development, review and approval of financial procedural documents including those related to Counter Fraud.

Director of Strategy &

Delivery (or equivalent)

 Leading the development, review and approval of

commissioning procedural documents including those related to Individual Funding Requests.

Corporate Governance

Manager (or equivalent)

 Overseeing and coordinating corporate procedural document processes, issuing procedural documents to all Procedural Document Manual Holders, maintaining appropriate records regarding procedural documents, and monitoring developments in policy management.

Document Authors

 Are responsible for ensuring procedural documents remain up to date and in line with relevant legislation and guidance.

 Document Authors are also responsible for ensuring new / reviewed procedural documents are sent through the appropriate approval process.

 Follow the CCG’s checklist for the development, approval and implementation of policies or procedures.

 Ensure that any new or revised policies or procedures are prepared in accordance with the CCG’s Policy on the

Development and Management of Policies and Procedures.

 Ensure that records are kept of the stages of development including discussion, consultation, negotiation and the outcome of the Equality Impact Assessment.

Staff

Responsibilities of Staff (including all employees, whether full/part time, agency, bank or volunteers) are:

 Complying with all procedural document of the organisation.

 Identifying any gaps in procedural documents and identifying these to procedural document authors / responsible officers.

4.2 Committees and Sub Committees of the Governing Body have been delegated responsibility to approve new procedural documents and significantly updated procedural documents according to the scheme of delegation detailed below. These Committees and Sub Committees should

(8)

ensure that relevant consultation on planned changes has been undertaken with relevant groups prior to reaching the approval stage. The full mapping of each organisational policy to an approving body is held by the Governance Team.

Procedural documents to which only minor updates have been made may receive Lead Officer approval from a lead officer in the relevant area as listed under 3.1 above and will not be required to be reviewed by an Approving Body.

Approving

Body Type of procedural document

Governing Body

Overarching corporate and planning strategies such as the Strategic Plan and Organisational Development Strategy.

Procedural documents where there is a legislative or national requirement for Governing Body approval.

Procedural documents which relate to a significant risk on the Assurance Framework.

Audit Committee

Financial procedural documents.

Governance procedural documents.

Overarching procedural documents which fall within the terms of reference of the Committee. The approval of underpinning procedural documents

may be delegated to sub groups where considered appropriate.

Remuneration Committee

Human Resources procedural documents.

Quality &

Safety Committee

Clinical procedural documents.

Safeguarding procedural documents.

Engagement &

Experience Committee

Procedural documents relating to engagement, communication, public &

patient experience and equality.

Executive Committee

Commissioning procedural documents and strategies.

(9)

Approving

Body Type of procedural document

Primary Care Commissioning

Committee

Overarching primary care related procedural documents which fall within the terms of reference of the Committee.

5. Equality Impact Assessments 5.1. The Equality Act 2010

The Equality Act 2010 includes a general duty to:

 Eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited by the Act

 Advance equality of opportunity between people who share a protected characteristic and people who do not share it

 Foster good relations between people who share a protected characteristic and people who do not share it

5.2. The Protected Characteristics

 Age

 Disability

 Gender reassignment

 Marriage or civil partnership (only in respect of eliminating discrimination

 Pregnancy and maternity

 Race

 Religion or belief

 Sex

 Sexual orientation 5.3. Due Regard

5.3.1 Public bodies have to demonstrate due regard to the general duty. This means active consideration of equality must influence decisions reached that will impact on patients, carers, communities and staff. The CCG’s Equality Impact Assessment (EIA) tool is a way of systematically analysing a new or changing policy, strategy, process etc. to identify what effect, or likely effect, it could have on protected groups.

5.3.2 There is no specific legal requirement to carry out an Equality Impact Assessment on all policies, procedures, practices and plans but the CCG does need to be able to demonstrate that it had paid due regard to the general duty. An EIA should be carried out on a policy that is likely to have an impact on patients, carers, communities or staff. (The EIA form is available at

Appendix D).

(10)

5.3.3 It is not necessary to carry out an EIA linked to the review or revision of a policy where an EIA has already taken place and there has been no

significant change to the policy or its impact on protected groups or to a policy that does not have an impact on patients, carers, staff or the wider community e.g. financial regulations.

5.3.4 Potential adverse impact on any protected group identified through the EIA will be monitored as part of the routine work to monitor compliance with the policy.

5.3.5 Guidance on the completion of EIAs can be found: Equality-and-diversity - EIA.

6. Dissemination, Training & Review 6.1. Dissemination

6.1.1. The effective implementation of this procedural document will support openness and transparency. NHS Doncaster CCG will:

 Ensure all staff and stakeholders have access to a copy of this procedural document via the organisation’s website.

 Provide advice to Procedural Document Authors on format and authorisation flows from the Corporate Governance Manager.

6.1.2. This procedural document is located in the General Policy Manual. A set of hardcopy Procedural Document Manuals are held by the Governance Team for business continuity purposes and all procedural documents are available via the organisation’s website. Staff are notified by email of new or updated procedural documents.

6.2. Training

6.2.1 All staff will be offered relevant training commensurate with their duties and responsibilities. Staff requiring support should speak to their line manager in the first instance. Support may also be obtained through their or HR Department. Managers should contact the Governance Team if there are specific training needs.

6.3. Review

6.3.1. As part of its development, this procedural document and its impact on staff, patients and the public has been reviewed in line with NHS Doncaster CCG’s Equality Duties. The purpose of the assessment is to identify and if possible remove any disproportionate adverse impact on employees, patients and the public on the grounds of the protected characteristics under the Equality Act.

(11)

An Equality Impact Assessment (Appendix E) has been undertaken and does not demonstrate any disproportionate adverse impacts on employees.

6.3.2. The procedural document will be reviewed every three years, and in accordance with the following on an as and when required basis:

 Legislatives changes

 Good practice guidelines

 Case Law

 Significant incidents reported

 New vulnerabilities identified

 Changes to organisational infrastructure

 Changes in practice

6.3.3. Procedural document management will be performance monitored to ensure that procedural documents are in-date and relevant to the core business of the CCG. The results will be published in the regular Governance Reports.

(12)

SECTION B – PROCEDURE

1. Types of Procedural Document

1.1. There are three types of procedural documents to which this procedural document refers:

 Strategies

 Policies

 Procedures

1.2. Templates for these documents are appended to this document. Templates show the minimum required for content headings. Authors may not remove sections listed within the template.

1.3. Procedures are the instructions that support the plan outlined in policies and it is therefore usual that a policy will have a procedure included as part of the procedural document.

2. Style and Format of Procedural Documents

2.1. All procedural documents should be written in a style which is concise and clear using unambiguous terms and language. Consideration should be given to producing appropriate documents in languages other than English,

dependent on the population groups represented in the Doncaster area.

2.2. All procedural documents should be prepared in Microsoft Word using Arial font, point size 12 with headings of point size 14 and sub headings of point 12. Left-alignment should be used.

2.3. The correct organisational logo should be used on all procedural documents.

2.4. Paragraphs should be numbered as demonstrated in this guidance.

2.5. Page numbering should be used in the format “1 of 23” and placed in the bottom right hand corner.

2.6. Version control should be observed. When a procedural document is first being written and is in the draft stage, its version number will be 0.1. If that procedural document is later amended and a second draft completed, its version number should be changed to 0.2. As soon as the procedural

document has been ratified by a Lead Officer as identified in paragraph 4.1 or an Authorising Body as identified in paragraph 4.2, its version number will change to 1.0.

2.7. A review period for the procedural document must be entered. The set review period is three years, or earlier if legislation/guidance indicates otherwise.

(13)

3. Development and Approval Process for new Procedural Documents 3.1. STEP 1: The need is identified for a new procedural document or a revision to

an existing procedural document. A lead author for the procedural document is identified.

3.2. STEP 2: The Document Author informs the Governance Team, who will advise on the authorising body and provide any guidance on procedural document development.

3.3. STEP 3: The Document Author develops and consults on the procedural document. It is the responsibility of the Document Author to ensure that the relevant people have been consulted with regard to the procedural document.

The Document Author should ensure that the procedural document is assessed for equality impact and, where relevant, consulted upon with the NHS Local Counter Fraud Specialist.

3.4. STEP 4: The Document Author sends the finished and approved procedural document (see section 3.1 and 3.2 for approving bodies / lead officers) to the Governance Team, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ.

3.5. STEP 5: The Governance Team publishes the document on the organisation’s website and ensures it is advertised to staff.

4. Review of Procedural Documents

4.1. Review of procedural documents will be three yearly unless legislation / guidance states otherwise.

4.2. Document Authors are responsible for reviewing procedural documents within their area of responsibility to ensure that they are up to date with current legislation and within their review date.

4.3. When a procedural document requires updating or is due to expire, the Document Author should undertake the review in consultation with relevant individuals / approving bodies.

 If a procedural document is reviewed and there are no changes, the procedural document coversheet and review sheet should be updated to reflect that a review has taken place and the procedural document should be forwarded to the Governance Team as in Step 4 above.

 If there are only minor changes to a procedural document (e.g. contact addressses, logos, names/titles, a paragraph inserted, deleted or

amended to bring procedural documents in line with new guidance which do not affect the intended purpose of the procedural document) the procedural document coversheet and review sheet should be updated to

(14)

reflect that a review has taken place. The Lead Officer with lead

responsibility should then confirm acceptance of the amendments and the procedural document should be forwarded to the Governance Team as in Step 4 above.

 If a procedural document has significant changes then a summary of the changes should be listed and sent, alongside the procedural document, to the relevant Authorising Body. Once approved, the procedural document should be forwarded to the Governance Team as in Step 4 above.

5. Dissemination of Procedural Documents

5.1. The Governance Team at Sovereign House disseminate all procedural documents as follows:

 STEP 1: Place the procedural document in Adobe format on the organisation’s website.

 STEP 2: Print a single hard copy of the procedural document for business continuity purposes.

 STEP 3: Maintain a database of procedural documents in Adobe format and Word format.

6. Control of Procedural Documents

6.1. The Governance Team have overarching responsibility for the control of procedural documents which will be contained alphabetically within Procedural Document Manuals:

 Manual 1 – General

 Manual 2 – Employment

 Manual 3 – Clinical

 Manual 4 – Commissioning

 Manual 5 – Multi-Agency Policies

6.2. The Governance Team will electronically archive all old procedural documents upon receipt of reviewed documents, maintaining access to the past library of procedural documents.

(15)

SECTION C - APPENDICES

TEMPLATE FOR PROCEDURAL DOCUMENTS

TITLE OF PROCEDURAL DOCUMENT [ARIAL POINT SIZE 22, CENTRED]

Last Review Date Approving Body Date of Approval Date of Implementation

Next Review Date Review Responsibility

Version

(16)

REVISIONS/AMENDMENTS SINCE LAST VERSION

Date of Review Amendment Details

(17)

Section A - Policy

1. Policy Statement. Aims and Objectives

1.1 Describe the topic of the procedural document, giving a summary of the background to what the document aims to achieve.

1.2 The aims of this procedural document are:



1.3 To ensure continuous improvement, the organisation has a range of key performance indicators (KPIs) which it uses for monitoring purposes:

No. Key Performance Indicator Method of Assessment 1.

2.

2. Legislation & Guidance

2.1 The following legislation and guidance has been taken into consideration in the development of this procedural document:

 List legislation and guidance.

3. Scope

3.1 This policy applies to those members of staff that are directly employed by NHS Doncaster CCG and for whom NHS Doncaster CCG has legal responsibility. For those staff covered by a letter of authority / honorary contract or work experience this policy is also applicable whilst undertaking duties on behalf of NHS Doncaster CCG or working on NHS Doncaster CCG premises and forms part of their arrangements with NHS Doncaster CCG. As part of good employment practice, agency workers are also required to abide by NHS Doncaster CCG policies and procedures, as appropriate, to ensure their health, safety and welfare whilst undertaking work for NHS Doncaster CCG.

4. Accountabilities & Responsibilities

4.1 Overall accountability for ensuring that there are systems and processes to effectively [what the procedural document aims to do] lies with the [job title e.g. Chief Officer]. Responsibility is also delegated to the following individuals:

(19)

[Job title]

or equivalent]

 Xxxxxxx

Staff

Responsibilities of Staff (including all employees, whether full/part time, agency, bank or volunteers) are:

 Xxxxxx

5. Equality Impact Assessment

5.1 An Equality Impact Assessment has been undertaken and can be reviewed in the appendices section.

5.2 [Add any other relevant information]

6. Dissemination, Training & Review 6.1 Dissemination

6.1.1 The effective implementation of this procedural document will support openness and transparency. NHS Doncaster CCG will:

 Ensure all staff and stakeholders have access to a copy of this procedural document via the organisation’s website.

 Communicate to staff any relevant action to be taken in respect of complaints issues.

 Ensure that relevant training programmes raise and sustain awareness of the importance of effective complaints management.

6.2 Training

6.2.1 All staff will be offered relevant training commensurate with their duties and responsibilities. Staff requiring support should speak to their line manager in the first instance. Support may also be obtained through their HR

Department.

(20)

6.3 Review

6.3.1 As part of its development, this procedural document and its impact on staff, patients and the public has been reviewed in line with NHS

Doncaster CCG’s Equality Duties. The purpose of the assessment is to identify and if possible remove any disproportionate adverse impact on employees, patients and the public on the grounds of the protected characteristics under the Equality Act

6.3.2 The procedural document will be reviewed every three years, and in accordance with the following on an as and when required basis:

 Legislatives changes

 Good practice guidelines

 Case Law

 Significant incidents reported

 New vulnerabilities identified

 Changes to organisational infrastructure

 Changes in practice

Section B – Procedure

THIS SECTION CAN FOLLOW ANY LAYOUT SUITED TO THE SUBJECT MATTER, PROVIDING THE CONVENTIONS IN THE “POLICY ON PROCEDURAL

DOCUMENTS” ARE FOLLOWED 1. [A TITLE RELEVANT TO THE SUBJECT]

1.1

2. [A TITLE RELEVANT TO THE SUBJECT]

2.1

3.1

4.1

5.1

(21)

Appendices

[EQUALITY IMPACT ASSESSMENT TEMPLATE]

THIS SECTION CAN FOLLOW ANY LAYOUT SUITED TO THE SUBJECT MATTER, PROVIDING THE CONVENTIONS IN THE “POLICY ON PROCEDURAL

DOCUMENTS” ARE FOLLOWED

1. Equality Impact Assessment

Subject of equality analysis

Type

Tick Policy

Strategy

Business case

Commissioning service redesign

Contract / Procurement Event / consultation Owner

Name:

Job Title:

Date

Assessment

Summary Give a brief summary of the area you are assessing

Stakeholders

Tick Staff

General public Service users Partners Providers Other Data collection and

consultation

What data is available to you to support your analysis?

Has there been any consultation to inform your analysis?

Protected

characteristic Positive Neutral Negative

Negative: What are the risks?

Positive: What are the benefits / opportunities?

Age

(22)

Disability

Gender

Race

Religion & Belief

Sexual Orientation Gender

reassignment Pregnancy &

Maternity

Marriage & Civil Partnership Social Inclusion / Community Cohesion Conclusion &

Recommendations including any

resulting action plan Review date

(23)

Appendix E – Equality Impact Assessment for Policy on Procedural Documents

Equality Analysis Form

Subject of equality analysis

Policy on Procedural Documents

Type Tick

Policy √

Strategy

Business case

Commissioning service redesign Contract / Procurement

Event / consultation

Owner Name: Helen Harris

Job Title: Head of Corporate Governance Date 11 November 2019

Assessment

Summary To set out the CCG’s policy on procedural documents. The purpose of this policy is to provide guidance to staff leading on the development of

procedural documents. The aim is to ensure that there are documented, up-to-date, authorised organisation-wide procedural documents in place which enable the organisation to achieve its objectives.

Stakeholders Tick

Staff √

General public Service users Partners Providers Other Data

collection and consultation

Due to the small number of staff employed by the CCG, data with returns small enough to identity individuals cannot be published. However, the data should still be analysed as part of the EIA process, and where it is possible to identify trends or issues, these should be recorded in the EIA.

The Associate Director of HR and Corporate Services has reviewed the amendments to the policy. The policy has been strengthened to include EIAs as part of the strategy, policy and procedure development.

Protected

characteristic Positive Neutral Negative

Negative: What are the risks?

Positive: What are the benefits / opportunities?

Age x This strategy applies regardless of

Gender

(24)

Disability x

This Policy is not currently available in other formats. The assumption is

that all staff will have the correct physical equipment on their desktops to ensure that they will be

able to view this document. The CCG website does provide the facility to view documents in larger

fonts.

Gender x This strategy applies regardless of

Gender.

Race x

This policy applies to all staff regardless of race/ethnicity.

Analysis of employee data indicates that the percentage of white employees is reflective of the local population. However, the proportion of BME staff is lower than that of the

local population it serves All staff require competencies which

include the ability to read and understand English or to request the

information in another format available to them.

Religion & Belief x This policy applies to all regardless of religion or belief

Sexual

Orientation x This policy applies to all, regardless of sexual orientation

Gender

reassignment x This policy applies to all regardless

of transgender/gender reassignment Pregnancy &

Maternity x This policy applies to all regardless

of pregnancy or maternity Marriage & Civil

Partnership x This policy applies to all regardless

of marriage or civil partnership Social Inclusion /

Community Cohesion

x This policy applies to all.

Conclusion &

Recommendation s including any resulting action plan

This Policy is not currently available in other formats. The assumption is that all staff will have the correct physical equipment on their

desktops to ensure that they will be able to view this document. The CCG website does provide the facility to view documents in larger fonts.

CCG Communications to ensure website is fit for purpose for those who have a disability.

Review date July 2022

POLICY ON PROCEDURAL DOCUMENTS