Policy Approval Process
Number: THCCGCG0020
Executive Summary
Date of approval
Document Author(s)
Version: 1
This procedure outlines which CCG Committees
(including the Governing Body) have delegated authority
for the approval of Strategies, Policies and Procedures.
It outlines which Management Leads and Executive leads
(CCG Governing Body Members have responsibility for
ensuring which particular documents are fit for purpose.
It also sets out the minimum requirements for NHS Tower
Hamlets CCG Strategies, Policies and Procedures must
meet; these are inclusive of content style, format, quality
and accessibility.
June 2013
Paul Balson – Governance and Risk Manager
been Archna Mathur – Deputy Director Quality and Performance
Collette McQueen – Business Manger
Senior Management Team – June 2013
Who
has
consulted?
Was
an
Equality No
Analysis required?
With what standards NHSLA Risk Management Standards - Standard 1: Governance does this document 1.2 Policy on Procedural Documents
demonstrate
compliance?
References
and NHS Tower Hamlets CCG Constitution
associated
CCG
documentation
List
of
obtained
approvals Audit Committee – 25 June 2013
Senior Management Team – June 2013
Recommended review
Every 2 years or when required.
period
Key words contained
in document
approval, audit and monitoring, baf, board assurance framework, committee,
communications, consultation, corporate governance, corporate template, delegated
authority, executive leads, finance, fit for purpose, governing body, human resources,
information governance, management leads, nhsla, policies, policy, policy approval
process, policy on procedural documents, prime financial policies, procedure, procedures,
protocol, quality improvement, ratification, reviewing , safeguarding, scheme of
delegation, standards of business conduct and managing conflicts of interest, storage,
strategies, strategy, style guide, sub-committees, whistleblowing policy, writing
Is this document fit for
the public domain? Y / Y
N
Date ratified: June 2013
If No, why?
THCCGCG0020 Policy Approval Procedure
N/a
1
1
2
Purpose and Scope ....................................................................................................... 3
1.1
Purpose .................................................................................................................. 3
1.2
Scope ..................................................................................................................... 3
Guidance ....................................................................................................................... 4
Summary ........................................................................................................................... 4
2.1
Note 1: Write the Strategy, Policy or Procedure using the CCG template ............... 5
2.2
Note 2: Assignment of a Management Lead, Executive Lead and Committee with
authority for final approval ................................................................................................. 6
2.3
Note 3: Consultation with the Senior Management Team, CCG staff and members
(where appropriate) ........................................................................................................... 7
2.4
Note 4: Committee Approval ................................................................................... 8
2.5
Note 5: Storage and application .............................................................................. 8
2.6
Note 6: Review, audit and monitoring...................................................................... 8
3
Responsibilities .............................................................................................................. 9
4
Review, audit and monitoring ....................................................................................... 10
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
2
1 Purpose and Scope
1.1
Purpose
The Policy Approval Procedure ensures that:
1. There is a clear signposting of which NHS Tower Hamlets CCG Committees
(including the Governing Body) have authority to approve strategies, policies and
procedures.
2. That all Strategies, Policies and Procedures meet a set of requirements inclusive of:
content style, format, quality and accessibility.
The development and on-going management of a Policy Approval Process is important
within any healthcare organisation. A standard approach to the development of documents
will support the management of risk at all levels of the organisation.
1.2
Scope
This procedure applies to all employees of NHS TH CCG who are writing, reviewing or being
consulted upon a Strategy, Policy or Procedure for application within NHS Tower Hamlets
CCG.
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
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2 Guidance
Summary
The Policy Approval Process is summarised in the diagram below. Additional guidance notes are available underneath. Additional guidance on
any aspect of the process is available from: Paul.Balson@towerhamletsccg.nhs.uk or Collette.McQueen@towerhamletsccg.nhs.uk
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
4
2.1
Note 1: Write the Strategy, Policy or Procedure using the CCG template
This is the main body of your document. There are mandatory titles that must be included. A smart use of the approved format will make your
document more accessible. The mandatory titles are below:
Minimum requirements ensure that your Strategy, Policy or Procedure is accessible and compliant with both best practice and NHSLA Risk
Management Standards. The template is available from the Governance Team and has built in styles and formats that should be adhered to.
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
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2.2
Note 2: Assignment of a Management Lead, Executive Lead and Committee
with authority for final approval
Every Strategy, Policy or Procedure created for use within the CCG will be allocated a
category. This category will indicate which Committee, Management Lead and Executive
Lead (Governing Body Member) have responsibility for approval.
„Approval‟ for the purposes of this procedure can be defined as: documentation which has
been ratified by the relevant body within the organisation as set out in this procedure.
The details of where categorised Strategies, Policies or Procedures go where are detailed
below:
2.2.1
Strategies, Policies and Procedures delegated to Committees of the
Governing Body
Management
Lead
Governing
Lead
Archna Mathur
Mariette Davis
Executive Team
Ellie Hobart
Catherine Boyle
Finance,
Performance and
Quality Committee
Henry Black
Mariette Davis
Finance
IG
Information
Governance
Executive Team
Henry Black
Dr
Isabel
Hodkinson
HR
Human Resources
Executive Team
Archna Mathur
Jane Milligan
Quality
Improvement
Finance,
Performance and
Quality Committee
Archna Mathur
QI
Dr
Everington
Archna Mathur
Dr Hannah Falvey
Code
Category
Committee
CG
Corporate
Governance
Governing Body
CO
Communications
FI
Body
Sam
(Children)
SG
Safeguarding
Safeguarding
Committee
Richard Fradgley
Dr Judith Littlejohn
(Adults)
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
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2.2.1
Strategies, Policies and Procedures reserved for the Governing Body
Document
Management Lead
Governing Body Lead
Scheme of Delegation
Henry Black
Jane Milligan
Prime Financial Policies
Henry Black
Mariette Davis
Standards of Business Conduct and
Managing Conflicts of Interest
Archna Mathur
Jane Milligan
Whistleblowing Policy
Archna Mathur
Jane Milligan
Board Assurance Framework
Archna Mathur
Jane Milligan
It must be noted that these tables are to be used a guide and are not
prescriptive as some Strategies, Policies or Procedures may fall outside of
these categories.
The Senior Management Team will advise on any other groups, Sub-Committees or
Committees that may be useful to consult.
Responsibility for „Approval‟ will be allocated to one Body in the majority of cases. A notable
exception would be where a Strategy, Policy or Procedure being developed for more than
one organisation.
2.3
Note 3: Consultation with the Senior Management Team, CCG staff and
members (where appropriate)
A penultimate draft of each document should be sent to individuals or groups who will be
responsible implementing aspects of the Strategy, Policy or Procedure, or who will be
significantly affected by it. Details of who has been consulted should be recorded on the
front sheet. For example:
HR policies reviewed by the CSU HR team 11 June 2013
As a minimum the Senior Management Team will be consulted. The Senior Management
Team will advise on any other groups, Sub-Committees or Committees that may be useful to
consult.
.
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
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2.4
Note 4: Committee Approval
Once the individuals or groups who will have responsibility for implementing aspects of the
document or who will be affected by it have been consulted; it is ready for approval. At this
point the Management Lead and Executive Lead will present it to the Committee with
delegated authority for final approval.
Approval is essentially a test of fitness for purpose. Typical prompts to ask include:
When an individual or group is asked to approve a Strategy, Policy or Procedure this needs
to be made clear to them:
Marked for “Approval” on the agenda of the meeting
Marked for “Approval” on the coversheet (where required)
The outcome clearly recorded in the minutes
2.5
Note 5: Storage and application
Following approval, the governance team will arrange for documents to be uploaded onto
the intranet and shared drive. Approved documents will be stored on the shared drive here:
I:\NHSTHCCG\NEW I DRIVE STRUCTURE\Strategy and Planning\Governance
and Risk\4 Document Management\Tower Hamlets CCG Policies\Ratified
Whilst it is acknowledged that some staff will need to print hard copies from the intranet, the
CCG will discourage the routine use of this access route, and staff are alerted to the fact that
documents viewed outside the intranet may have been updated since printed. Staff will
therefore need processes in place to ensure they are accessing up to date documents.
The documents that are superseded as a result of reviews, change in policy or become out
of date will be stored in a folder on the shared drive.
There will be other documents, for example those relating to emergency or business
continuity, which will need to be accessed in situations where the intranet is not accessible.
2.6
2.6.1
Note 6: Review, audit and monitoring
Review
Each Strategy, Policy or Procedure will be given a review date. When the date of review
approaches the the author or author‟s department will be asked to begin the review process
by the Governance team.
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
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The review and approval process should follow the same process as if writing a new
document.
2.6.2
Audit and monitoring
To ensure that the Strategy, Policy or Procedure is delivering on its purpose every Strategy,
Policy and Procedure will have a section on Audit and Monitoring.
This section must make it clear how the efficacy of the Strategy, Policy and Procedure will
be measured.
A few examples are included below:
What standards / key Method
of Monitoring
performance
indicators monitoring
information
will you use to confirm this
prepared by
document is working /
being implemented
Minimum
Monitoring
frequency of reported to
monitoring
All staff will attend record Monitoring
Governance
keeping training.
of
training Team
uptake
Quarterly
Senior
Management
Team
3 Responsibilities
The following members of CCG staff have the following responsibilities under this procedure.
Role
Responsibilities
Management Lead
The lead for Strategy, Policy or Procedure creation. Champions
the Strategy, Policy or Procedure at Committees or the
Governing Body.
Informs the Senior Management Team of Strategy, Policy or
Procedure creation and ensures that:
It is dovetailed with objectives
is not duplicated in other teams
is completed
is removed when no longer required.
Governing Body Lead
To provide support and review of the Strategy, Policy or
Procedure.
Committee with delegated Provide approval as allocated by the Governing Body
authority for approval
Monitor the development and review process for each
document.
Date ratified: June 2013
THCCGCG0020 Policy Approval Procedure
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Document author
The lead for creation of Strategy, Policy or Procedure. Ensures
that:
It is compliant with the requirements laid out in this
procedure.
It reflects current practice.
It has received the appropriate level of scrutiny.
Is completed within declared timescales.
Governance Team
Provide oversight of the policy approval process
Operational management of the systems for controlling and
delivering the Trust Policies and Procedures Manual.
4 Review, audit and monitoring
This document will be reviewed every 2 years.
What standards / key Method
of Monitoring
performance
monitoring
information
indicators will you
prepared by
use to confirm this
document is working
/ being implemented
Minimum
Monitoring
frequency of reported to
monitoring
All
Strategies,
Policies
and
Procedures in use by
the CCG will be
compliant with the
style and format
requirements of this
document
Every
Strategy,
Policy and
Procedure
Date ratified: June 2013
Review of all
Strategies,
Policies and
Procedures
Governance Team
will
review
the
document prior to
storage
in
the
shared drive and
uploading to the
Intranet
and
internet.
THCCGCG0020 Policy Approval Procedure
Senior
Management
Team on a
monthly basis
10