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Clinical Effectiveness Coordinator NHS Fife
Clinical Effectiveness Coordinator NHS Fife
Chair General Policy Group; Chair Human Resources Policy Group; Chair Clinical Policy & Procedures Group
01 August 2013
09 March 2015
09 March 2021

1.0       FUNCTION


1.1       The procedure sets out the framework for the creation of policies, procedures and guidelines. This includes clinical documents, operational documents and corporate documents. The procedure provides the corporate requirements for development of documents, the procedure for approval and the requirements after approval relating to dissemination, implementation and review.


  1.     The procedure makes clear to staff what is required when policies,

          procedures and guidelines are created, and how they are approved.


1.3       This procedure will ensure that there is a process to ensure all documentation is consistent in format, compilation and dissemination.

2.0       LOCATION

2.1       The procedure applies to all staff in using and applying procedural 

            and policy documentation.


Senior Management Team

3.1       Members of the Executive Directors Group are responsible for approving general and clinical policies and for ensuring that all policies are implemented as appropriate by all relevant staff within their areas of responsibility.


3.1.1   Members of the Area Partnership Forum are responsible for approving Human Resources policies.


3.1.2   All Managers are responsible for ensuring that they and their staff are familiar with all policies, procedures and guidelines, ensuring they access the most up to date version for use on the intranet and they seek out every opportunity to keep up to date with their content.


3.1.3   The Equality and Participation Co-ordinator within Patient Relations is responsible for checking off Equality Impact Assessments carried out on all Policies and Procedures.


3.2       Policy / Procedures Groups

3.2.1   The Policy / Procedure Groups are responsible for the co-ordination of policies

procedures and, ensuring that all required documents have been delivered, and the intranet is kept up to date.

3.2.2   The Policy / Procedure Groups are responsible for reminding owners

when a policy or procedure becomes due for review, for supporting the owners through the process up to approval and for ensuring that new/revised policies/procedures are available on the Intranet. They are not, responsible for formatting the documents.

  1. The coordinators of the groups are responsible for checking documentation

prior to delivery to the approval group to ensure groups can operate effectively. The coordinator supporting the group will check the style and format to ensure there is an explanation of any terms used in the document, that review arrangements are identified, that associated documents are referenced, and the process for monitoring has been identified. Where gaps or omissions are identified these will be addressed by the document owner prior to going forward for approval.

3.2.4   The Policy / Procedure Groups are responsible for ensuring there has been a

consultation process and the approval process is appropriate. This is achieved by completion of the Pro-forma for Recording Changes made to Policies and Procedures form appendix 5. Where gaps or omissions are identified these will need to be addressed by the document owner prior to going forward for approval.

  1. The Policy / Procedure Groups are responsible for version control and will

            achieve this by amendment/creation of the footer.

  1. The Policy / Procedure Groups are responsible for ensuring that policies and procedures are made available on the NHS Fife Intranet; authorisation will be given when all relevant documentation is received to ensure that monitoring of documents can be achieved.


  1. The Policy / Procedure Groups will provide a brief for Dispatch to inform staff of any new policies or procedures.


3.3       Document Authors

3.3.1   Document authors should understand the rationale for the policy or procedure, and have confirmation that the policy or procedure is required.

3.3.2   Policy and procedure owners and staff setting out a procedure must be a senior member of staff and have a relevant level of expertise, and hold a

position with responsibility for that area.

3.3.3   The author is responsible for ensuring the document complies with this procedure. The document must be formatted correctly, with evidence of circulation and consultation with stakeholders, and all documentation completed prior to going forward for approval.


3.3.4   The author must ensure that consultation and communication with relevant

stakeholders occurs, including service users, to ensure all relevant information is considered.

3.3.5  The author is responsible for adding the document to the agenda for the

relevant approval group, and must ensure that all paperwork is provided.

  1. The document author is responsible for ensuring the list of individuals

/groups consulted in development/review is completed (Appendix 4) The purpose of this form is to provide assurance to the approval group that the process for compiling or reviewing the document is robust. The form provides a guide for document authors to check that they have delivered all requirements. For example the form asks: has the document been adequately circulated, have financial considerations been taken into account etc.

  1. The document author is responsible for completing an equality impact

assessment form and ensuring that any required actions following this are taken forward. Equality impact assessment is required for all policies and procedures

3.3.8 The document owner has responsibility for disseminating information about the

document as necessary (in addition to publication on the intranet and information posted on Dispatch which will be completed by the policy/procedures groups)


3.3.9 The document owner has responsibility for considering any training implications

            and to co-ordinate or liaise with staff as required.

3.3.10 The document owner has responsibility for considering how policies,

procedures will be monitored. This can be through an audit process, through monitoring incidents, concerns and complaints, or delivery of good practice. The policy owner must describe this in the policy/procedure.


3.3.11 There is no requirement to monitor procedures however it is best practice to

consider auditing compliance with procedures, or audit outcomes, in order to

provide assurance that practice is followed and patients and staff are safe. For

example, infection control procedures are regularly audited for compliance to

procedure to assure the organisation that good practice is consistent.

3.3.12 The document owner is responsible for ensuring the policy and procedure is

            kept up to date.

3.4       Group Chairs

3.4.1   The Chairs of the groups have responsibility for approving minor amendments to an existing policy/ procedures if required. Changes considered to be of a minor nature are updating job titles or job functions, telephone numbers etc. All occasions of chairman’s action must be reported to the next meeting of the Group and recorded formally in the minutes.


3.4.2   The Chairs of Groups have a responsibility to direct group members

to an indication of whether the policy/ procedure is approved, or whether additional amendments or information is required. Chairs should advise members that content is not necessarily required to be reviewed in detail however group members should assure themselves that the policy or procedure has been compiled or reviewed by the relevant staff and due process has been followed.

3.5       Secretaries to the Groups

  1. The secretary to the group is responsible for ensuring the policy or procedure

is accompanied by the relevant documentation. In particular the Proforma form must be provided to group members to enable them to understand what the policy /procedure is for, and to assure themselves that the document has been compiled appropriately with the relevant expertise. The Proforma form enables members with no expertise in the document content to effectively contribute to the approval process.


  1. The secretary to the group is required to inform the owner of the outcome of a

            document being presented for approval.

  1.  Directors, General / Service Managers Clinical Directors and Professional Leads

Directors, Clinical Directors and all line managers are responsible for ensuring staff are made aware of policies/procedures, and receive specific training or instruction if appropriate.

  1. Operational Procedure




A policy is a statement of corporate intent. A policy is adopted and followed across the Board. (It would therefore be very unusual for individual Departments to have their own ‘Policies’). Policies direct Board practice in fulfilling statutory and organisational responsibilities and are contractually and legally binding on all employees.


A procedure is a clinical or operational process or step by step description, which details the manner in which a specified issue is to be handled. This can be described as ‘how we do it ‘.A procedure should be followed as described. There is no decision making process and no judgment required.


A guideline is a recommendation of practice. It should be based on best practice and must be supported by evidence of expertise. Guidelines are a supportive tool for staff to be able to understand and implement best practice. They are not binding and should be utilized within the current operational framework i.e. taking account of other polices and professional codes.


A protocol is a set of guidelines. The term protocol is likely to be used when a set of guidelines is established from multiple agencies and is a recommendation of process or care to be implemented across boundaries.

.           Document

The term document is taken to mean policies, guidelines and procedures(including SOP’s).


Equality Impact Assessment: (EQIA’s Standard and Full)

Is a legal requirement under the:

  • Equality Act (UK) 2010
  • Public Sector Duty (UK) 2011
  • Specific Duties (Scotland) Regulation 2012 requires the organisation  tocarryout EQIA’s routinelyand topublish and monitor  them
  • Fairer Scotland Duty 2018


The EQIA process is split into two stages: Standard EQIA and should negative impact be found a Full EQIA will be required.


  1. Appendix 1is a flow chart which demonstrates the process for creation or

review of a document, the approval process and what is required after approval to ensure the document is available on the intranet for staff.



4.2       Information for writing Policies, Procedures and Guidelines must

• be related to a single topic, clearly identified by the title

• be clearly written, and unambiguous

• be based on the most recent information available and should reflect best practice

• clearly indicate relevant legislation or directives

• be cross-referenced as appropriate

• be formulated by key staff involved in the relevant work practices or requirements

• be circulated widely to interested parties for comment

• show the date of Approval, the ratifying body, the review frequency and a contact for comments

• note who has carried out the impact assessment

• record who the target audience is

4.3       Review arrangements: a full review must be undertaken as a minimum every three years. Where new guidance or regulation is issued the policy/procedure should be amended to reflect this.

  1. Templates

Appendix 2 and 2aare the templates to use when creating a policy / procedure document. The front sheet should be completed in draft and finalised after approval of the document. Review dates can be up to 3 years from the approval date. Reference should be made to other documents that link to the policy.


4.5       Style and Format

4.5.1   The corporate font is Arial and font size is 12.

4.5.2   Main headings should be in bold.


4.6       Equality Impact Assessment

Appendix 3is the Equality Impact Assessment Form

  1. All public bodies have a statutory duty to carry out Equality Impact

Assessments .Equality Impact Assessments are a systematic way of ensuring that legal obligations are met in relation to both service provision and employment and should facilitate the identification of any potential inequalities or discriminatory elements resulting from policy, strategy or practice.


  1. The equality impact assessment process has been developed to help promote fair and equal treatment in the delivery of health services. It is intended to enable the board to identify and eliminate detrimental treatment caused by the adverse impact of health service policies and procedures upon groups of individuals regardless of gender, martial status, age, disability, race, colour, nationality, ethnicity, gender reassignment, sexual orientation, religion, employment status or language.
  1. All policies and procedures need to have an equality impact assessment, which should identify whether a more detailed impact assessment or any action is required. This document must be published along with the policy /procedure as an appendix on the intranet
  1. Consultation Process

Appendix 4List of Individuals /Groups consulted in development/review

  1. It is important that the document is circulated to a wide audience for comments prior to approval. This enables staff who will be implementing the document, or be affected by the document to feed into the process. The audience should include a representative group of those staff that will be expected to use the policy and the holder of any named roles relevant to the policy.

A reasonable period should be allowed taking into account the prioritisation of the document, availability of key people, and responses received.

4.7.2   When a document is being reviewed staff you will need to understand what changes are being made. See appendix 4

  1. Approval

Appendix 5Pro-forma for Recording Changes made to Policies and Procedures

4.8.1   The Pro-forma for Recording Changes made to Policies and Procedures

provides the approval group with the necessary information to enable members to approve the document. It must be fully completed and sent to the group secretary as part of the paperwork.


4.8.2   Where minor amendments are required e.g. change of names, job titles, these can be made and approved and ratified by the relevant Chair of the Group through Chairman’s action. The review form must be used to clearly document the changes. The amendments must be recorded in brief on the front sheet of the document for policies, guidelines and procedures.


4.8.3   A pharmacist must be consulted in respect of any policy comprising an aspect of drug prescribing/administration/management. The policy/procedure must also be presented at the Area Drugs & Therapeutics Group. This group can either ratify the document, if it relates solely to drugs, or approve the content prior to presentation at a more senior group for approval.


4.8.4   The policy/procedure owner will nominate a group member to present the document if it requires detailed or expert explanation. In most cases the Proforma form and the review communication form should provide the relevant information for the Group.



4.8.5   Groups responsible for ratifying documents:

Document Type

Ratifying Group

FifeWide Clinical Policies

Clinical Policy and Procedures Authorisationand Coordination Group

FifeWide Clinical Procedure

Acute Services Division Clinical Procedures

Community Health & Social Care Partnership Clinical Procedures

Clinical Policy and Procedures Authorisationand Coordination Group

Fife Wide Corporate and governance related policies

General Policy Group

FifeWide Human Resources

Area Partnership Forum

FifeWide Health & Safety

General Policy Group

Financial Policies

General Policy Group

Policies relating to drugs

Area Drugs and Therapeutics Group

Nursing and Midwifery policies

Senior Nursing Team

4.9       Following Approval of a document

4.9.1  The secretary of the group will inform the document owner when the document

has been approved and if any amendments or actions have been requested.

4.9.2 The front sheet must be completed prior to authorisation. Policies will need

to be reviewed when statutory requirements/best practice guidelines dictate, or no longer than 3 years after the previous review/initial approval.


  1. Dissemination and Implementation of Policies and Procedures

4.10.1All policies and procedures will be disseminated through NHS Fife Dispatch and the intranet

  1. Monitoring
  1. The policy and procedure groups, on receipt of every policy/procedure,  ensure that it meets the requirements as set out in this procedure. This will be achieved by the checking documentation for completeness. Where gaps are identified the document owner will be required to address this. Any risk identified will be highlighted as appropriate and considered for the risk register by the chairperson of each group.


  1. Risk Management
  1. The key risks involved in the implementation of this procedure are:
  1. The Policy and Procedure groups will incorporate any risks identified

through the implementation of this procedure, and will escalate any outstanding policies and procedures through the Quality Report to the NHS Fife Clinical Governance Committee or equivalent committee.


  1. Failure to adopt and implement a policy which might have adverse statutory or legal implications for NHS Fife
  1. Related Documents

Appendix 1 Flow chart for process for Policies, Procedures and Guidelines

Appendix 2 & 2a Policy & Procedure Template

Appendix 3 Equality Impact Assessment Form

Appendix 4
List of Individuals /Groups consulted in development/review

Appendix 5 Pro-forma for Recording Changes made to Policies and Procedures


7.1 NHS Scotland PIN Guidelines 2011