Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
DOCUMENT DEVELOPMENT AND
REVIEW FRAMEWORK
POLICY AND PROCEDURE
©
DOCUMENT SUMMARY/KEY POINTS
Refer to the SCHN Document Development & Review Process flowchart.
•
The Director of Clinical Governance and Medical Administration has governance over
SCHN policy processes.
•
SCHN document shall come under one Directorate. Directors are responsible for
document development from within their area.
•
SCHN document development/review shall be underpinned by National and State policy
(where available) and the respective Health Practitioner Code of Conduct and where
applicable, Code of Ethics.
•
Line manager/s must approve/signoff new policy document development.
•
Document development and review teams should be multidisciplinary and consist of
representatives of key stakeholders from the different SCHN facilities.
•
All key stakeholders must be given the opportunity to comment and approve the final
draft of a document.
•
All SCHN documents must:
o
Be processed via ePolicy
o
Follow the endorsed approval process described in this policy.
o
Reflect considerations for family, cultural and ATSI health issues.
o
Be formatted using SCHN document templates.
o
Be reviewed within the defined review period.
o
Support best clinical or corporate practice (providing evidence where appropriate).
o
Be written in plain English
•
Documents are to be used ‘on-line’, wherever possible (hardcopies are discouraged).
•
Only one authorised version shall be available electronically at any one time.
Approved by:
Date Effective:
Team Leader:
SCHN Policy, Procedure & Guideline Committee
1st July 2014
Network Manager Policy & Procedures
Review Period: 3 years
Area/Dept: SCHN Clinical Governance Unit
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
CHANGE SUMMARY
•
Minor review to amend:
o
Review periods for documents with IV medications from annual to 3 yearly.
o
The approval process where SCHN PP&G are the peak approval body for SCHN
documents and HCQC are notified of new documents.
o
Role titles of Clinical Governance Unit staff
o
At SCH, change in the location of where the hard copies are located. In the event
where the intranet is down, SCH staff should go to the After Hours Nurse Manager
office (i.e. no longer located in the Systems Integration Managers office).
READ ACKNOWLEDGEMENT
•
All managers and any staff who are developing or reviewing a SCHN policy document
should read this document.
Approved by:
Date Effective:
Team Leader:
SCHN Policy, Procedure & Guideline Committee
1st July 2014
Network Manager Policy & Procedures
Review Period: 3 years
Area/Dept: SCHN Clinical Governance Unit
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
SCHN Document Development and Review Process Flowchart
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
TABLE OF CONTENTS
SCHN Document Development and Review Process Flowchart ....................................... 3
1
Introduction.................................................................................................................. 6
1.1
Purpose .........................................................................................................................6
1.2
Scope ............................................................................................................................6
1.3
Outcomes ......................................................................................................................6
1.4
Legislative Context ........................................................................................................ 6
1.5
Definitions ......................................................................................................................7
1.6
Abbreviations ................................................................................................................. 8
2
Policy and Principles .................................................................................................. 9
2.1
Principles .......................................................................................................................9
2.2
Policy .............................................................................................................................9
Governance .........................................................................................................................9
Document Review................................................................................................................ 9
Major amendments ............................................................................................................ 10
Minor amendments and no amendments .......................................................................... 10
Records Management ....................................................................................................... 10
3
Procedures ................................................................................................................. 11
3.1
Developing a Document .............................................................................................. 11
1.
Needs Analysis ........................................................................................................ 11
2.
Obtain approval to proceed...................................................................................... 11
3.
Submit a request in ePolicy to DEVELOP a document ............................................ 11
4.
Form a Document Development Team (DDT) ......................................................... 11
5.
Perform a Literature Search ..................................................................................... 12
6.
Drafting the Document ............................................................................................. 13
7.
Establish a Risk Rating for the document ................................................................ 14
8.
Consultation ............................................................................................................. 14
9.
Submit draft document into ePolicy ......................................................................... 14
3.2
Reviewing a document ................................................................................................ 15
1.
Mandatory Review Period ........................................................................................ 15
2.
Submit a request in ePolicy to REVIEW a document .............................................. 15
3.
Form a Document Review Team (DRT) .................................................................. 15
4.
Review the document .............................................................................................. 15
5.
Consultation ............................................................................................................. 16
6.
Submit REVIEWED document into ePolicy ............................................................. 16
7.
Overdue Documents for review ............................................................................... 16
3.3
Approval Process ........................................................................................................ 17
1.
Stakeholder approval ............................................................................................... 17
2.
Governing Committee approval (if necessary) ......................................................... 17
3.
SCHN Policy, Procedure and Guideline Committee approval ................................. 17
4.
Minor Amendment approval ..................................................................................... 17
5.
Urgent Approval (performed in exceptional circumstances only) ............................. 18
4
Ad-hoc Feedback from staff ..................................................................................... 18
5
Document Implementation ....................................................................................... 19
6
Notification and Communication ............................................................................. 20
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
7
Applying Risk ratings to SCHN documents ............................................................ 20
7.1
How assign a risk rating to a document ....................................................................... 21
8
Document Evaluation and Monitoring Compliance ............................................... 22
8.1
Additional compliance monitoring processes .............................................................. 23
Regular Auditing Program – SCHN documents................................................................. 23
Departmental Notification records – Auditing Program...................................................... 23
9
Availability of documents in the event of a Disaster ............................................. 23
9.1
Hard copies ................................................................................................................. 23
9.2
Electronic (soft) copies) ............................................................................................... 23
10
Processing NSW Ministry of Health Policy Documents ........................................ 24
11
Accountability Framework ........................................................................................ 24
11.1 Retention and Disposal of SCHN documents .............................................................. 24
11.2 Document Numbering System ..................................................................................... 24
11.3 When a document becomes active? ........................................................................... 25
12
Processing of Other Documents .............................................................................. 25
12.1 Standing Orders, Nurse Initiated Medication & Drug Protocols ................................... 25
12.2 Local Disaster Response Plans (at CHW) ................................................................... 25
12.3 Local Emergency Plans (at SCH) ................................................................................ 26
13
Bibliography............................................................................................................... 26
Appendix 1: Escalation process for policies overdue for review .................................... 27
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
1
Introduction
The Sydney Children’s Hospitals Network (SCHN) has a document development and
management framework that will permit documents to be identified, developed, evaluated
and reviewed in accordance with NSW Health and the Australian Council on Healthcare
Standards (ACHS) Accreditation requirements and the National Safety and Quality Health
Service Standards (published by the Australian Commission on Safety and Quality in Health
Care).
The CHW framework is based on NSW Health Policy Directive PD2009_029 and the AGREE
Collaboration (Appraisal of Guidelines, Research and Evaluation), an internationally
recognised document evaluation system.
1.1
Purpose
This document describes the policy and related processes for document development,
dissemination, implementation, evaluation and review, and outlines associated
responsibilities of those processes.
1.2
Scope
This policy and procedure applies to all staff working at SCHN who are or intend upon
developing or reviewing a policy document that pertains to SCHN.
1.3
Outcomes
Compliance with this policy and procedure ensures sound governance and document control
of all SCHN policy documents. This will provide confidence to staff that their work practices
are underpinned by evidence based and/or current best practices.
1.4
Legislative Context
•
Australian Standards (AS3806 Compliance Monitoring, 8000 – 8004 Corporate
Governance)
•
Australian Standard/New Zealand Standard (AS/NZS4360 Risk Management)
•
Australian Standard/New Zealand Standard ISO 9001Quality Management Systems –
requirements.
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
1.5
Definitions
Term
Definition
Departmental
document
Document containing information pertaining to the operations in a single
department at Randwick or Westmead facility.
Document
'Document’ is synonymous with policy, procedure, practice guideline or homecare
guideline.
Facility specific
document
Document containing information pertaining to the values, core principles and
operations of a SCHN facility (e.g. Randwick or Westmead).
Titles are to be suffixed by “SCH” or “CHW” or “NETS” or “CCC” or “PSN”
Homecare
Guideline
Homecare Guidelines provide information based on one or more SCHN Practice
Guidelines, but is expressed in a ‘parent/carer friendly’ lay version. When
Homecare Guidelines are reviewed, they are to be submitted to the PP&G
Committee simultaneously with the relevant SCHN Practice Guideline or
Procedure.
Key Search
Words
Nominated intuitive words which are representative of the content found within the
document that staff may use to generate a search for the document on the
Intranet.
Major
Amendment
A change to a current document that is of a substantial nature, affecting or
altering the effect, responsibility, stakeholders, meaning or intent of any part of the
document.
Minor
Amendment
A change to a current document that is of an insubstantial nature, not affecting or
altering the effect, responsibility, meaning or intent of any part of the document.
Network
document
Document containing information pertaining to the values, core principles and
operations of SCHN (Randwick, Westmead, NETS, PSN or CCC facilities).
Policy
A directive or decision that requires mandatory compliance and is expected to be
understood by relevant staff.
Practice
Guideline
A set of directions or principles to assist the health care practitioner with patient
care decisions about appropriate diagnostic, therapeutic or clinical procedures for
specific clinical circumstances and are based on a thorough review of the
literature.
Procedure
A set of documented instructions detailing the approved and recommended steps
for a particular process, and be evidence based and be consistently applied (no
deviations).
Stakeholder
Any person or group of people who affects or is affected by the document.
Transdepartmental
document
Documents containing information pertaining to the operations of 2 departments
within a single facility (i.e. SCH or CHW) or between 2 facilities.
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
1.6
Abbreviations
Abbreviation
Term
ACHS
Australian Council on Healthcare Standards
AGREE
Appraisal of Guidelines, Research and Evaluation [in Europe]
ATSI
Aboriginal or Torres Strait Islander
CALD
Culturally And Linguistically Diverse
CCC
Children’s Court Clinic
CHW
The Children’s Hospital at Westmead
DDT
Document Development Team
DRT
Document Review Team
HCQC
Health Care Quality Committee
IIMS
Incident Information Monitoring System
MoH
NSW Ministry of Health
NETS
Neonatal & paediatric Emergency Transport Service
RCA
Root Cause Analysis
PD
Policy Directive (from NSW Ministry of Health)
PP&G Committee
Policy, Procedure and Guideline Committee
PSN
NSW Pregnancy and newborn Services Network
SCH
Sydney Children’s Hospital
SCHN
Sydney Children’s Hospitals Network
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
2
Policy and Principles
2.1
•
Principles
SCHN document development/review shall be underpinned by:
o
National and State policy (where available) and
o
The respective Health Practitioner Code of Conduct and where applicable, Code of
Ethics. Refer to the Australian Health Practitioner Regulation Agency (AHPRA) for
more information.
2.2
Policy
Governance
•
All SCHN documents shall fall under one of the SCHN Directorates with each Director
being responsible for document development/review, implementation and compliance
within their area.
Note: Where possible, all facility specific policy documents are to be transitioned to
become SCHN policy documents.
•
All documents shall be tabled at the SCHN Policy, Procedure and Guideline (PP&G)
Committee for approval.
•
All new Network and Facility specific documents shall be tabled at the SCHN Health
Care Quality Committee (HCQC) for noting by the Executive.
•
Documents produced (or reviewed) at SCHN must:
o
Support best clinical or corporate practice (providing evidence where appropriate).
o
Reflect (and reference) legislated practice or NSW Ministry of Health policy.
o
Adhere to the SCHN approval process.
o
Be developed by a multidisciplinary team.
o
Be written in plain English
•
All SCHN documents must be submitted to ePolicy for document control purposes.
•
Document templates (available in Word) shall be used to ensure consistency in
branding and ‘look and feel’ of the document.
•
Documents are to be used ‘on-line’, wherever possible (hardcopies are discouraged).
•
Only one authorised version shall be available electronically at any one time on the
SCHN intranet or the SCHN internet.
•
Policy documents must not be uploaded onto the intranet or internet outside of the
document control processes of ePolicy.
Document Review
•
All SCHN documents will be reviewed every 3 years by the document owners unless
otherwise stated in the Processing other Documents section of this policy.
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
•
SCHN documents may be reviewed prior to the above mentioned review period if
legislation, clinical evidence and/or best practice (or any other reason to prompt a
review) is changed.
•
The review procedures should be followed as outlined in Section 3.2 below.
Major amendments
•
Major amendments will follow the procedures set out in Section 3.2 and will be tabled
and reviewed for approval at the SCHN PP&G Committee.
Minor amendments and no amendments
•
•
Minor amendments made to a document may occur outside the document approval
process however the amended document must be:
o
Approved by the document owner and
o
submitted to ePolicy for document control purposes
Documents with minor amendments or no amendments are tabled at the SCHN PP&G
Committee for noting.
Records Management
•
The latest approved Word version will be stored in ePolicy; a centrally controlled
database, electronically accessible to staff developing/reviewing a document.
•
All documents stored in ePolicy shall have SCHN approved identifiers attached. All
identifiers are built into the SCHN templates.
•
The approved Word version is converted to PDF version and it is this version that is
published onto a central ‘SCHN Policy’ intranet site accessible to all SCHN staff (CHW,
SCH, NETS, PSN and CCC).
•
Policy documents published on the SCHN Policy intranet site shall be considered the
authoritative source. Individual facility specific intranet sites shall link to this source.
•
Only the current PDF version is accessible to staff.
o
Previous Word version in ePolicy is not accessible to staff other than the owner and
identified staff in the Clinical Governance Unit. ePolicy manages version control.
o
Previous PDF versions are archived to the ‘Expired Policies’ intranet site and is not
accessible to staff other than identified staff in the Clinical Governance Unit.
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
3
Procedures
3.1
Developing a Document
Education is available – Contact the Clinical Governance Unit for details.
1. Needs Analysis
•
•
A need may be identified by way of:
Responsibility: Team Leader
or other identified person
o
New evidence
o
Legislative changes or requirements.
o
Recommendations from Root Cause Analysis (RCA).
o
Incident Information Monitoring System (IIMS) data.
o
Actions from complaints management, accreditation or audit.
o
Risk Management outcomes.
o
Documenting commonly used ‘best practice’ processes used at SCHN
If a need is identified:
o
Check if there is an existing SCHN document (Network, Facility specific or
departmental or trans-departmental) already covering the issue.
2. Obtain approval to proceed
Approval is required before development begins.
Approval should be confirmed from the following:
i.
Responsibility: Team Leader
Line Manager, Clinical Director and/or Director as appropriate.
ii. ePolicy: Approval to proceed may be attained from ePolicy when the proposed
document is registered in ePolicy (see point 3 directly below).
3. Submit a request in ePolicy to DEVELOP a document
o
Responsibility: Team Leader
Register the document development in ePolicy.
NOTE: SCH managers will have access to ePolicy in the first instance.
(Refer to ePolicy Quick start for instructions on how to use ePolicy)
o
The Policy team in the Clinical Governance Unit ensure another team are not
developing a similar document before approving the request.
4. Form a Document Development Team (DDT)
o
Responsibility: Team Leader
A Document Development Team is a group of representative stakeholders.

Team Leader should be identified if not already done so.
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
o

Network (SCHN) documents: multidisciplinary team from 2 or more SCHN
facilities as appropriate.

Facility specific documents: interdepartmental multidisciplinary team.

Departmental or Trans-departmental documents: key departmental staff
should be on the team.
The DDT are responsible to:

Determine if a policy, procedure or practice guideline is required.

Determine if the document should be Network, facility, departmental or transdepartmental.

Define the scope of the document and prioritise what needs to be in the
document.

Where appropriate, appraise/grade the evidence and make recommendations
for practice. This is particularly important for clinical documents.

Draft the document ensuring the purpose and any measures are clearly
identifiable. The document should be concise and easy to read so the target
group may understand it.

Identify key performance indicators relating to the document.

Consult with all stakeholders – multidisciplinary input is required.

Implement and disseminate the document.

Evaluate and review the document.
5. Perform a Literature Search
Responsibility: Team Leader –
delegation to other team members
o
Where appropriate, a literature search must be
performed to ensure the information in the document is supported by latest evidence
or best practice.
o
NHMRC Levels of Evidence Resource:
http://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/evidence_statement_form.pdf
o
Record key search words in ePolicy to assist literature searches at the next review.
Referencing – Vancouver Style
o
The Vancouver referencing system should be used.
o
EndNote may be used to manage references.
(Note: to import references into the document, ensure the template is NOT protected.)
Contact Librarians for assistance with EndNote. EndNote and literature search education
sessions are available.
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
6. Drafting the Document
Resource: How to write a policy document:
Responsibility: Document
Development Team
http://chw.schn.health.nsw.gov.au/o/groups/ppc/resources/guidelines_-_how_to_write_a_policy_.pdf
o
Use the approved templates found in Word>File>New>My Templates>select
required template. There are instructions provided within the template. Save the
working document.
o
Structure it so that is easy to read and follows a logical sequence of events.
o
Provide headings and subheadings that assist the reader in finding information
quickly and easily. Examples are provided in the above linked document.
o
Consider the audience who will be using the document. Set the language so they
can understand it (i.e. use Plain English) and avoid using jargon. Use ‘active’ not
‘passive’ language (i.e. use phrases like “give panadol” rather than “panadol should be given”).
o
All SCHN documents, particularly Practice Guidelines, should be outcome focused.
Wherever possible, KPIs should be identified to help measure the impact/success of
the document. KPI statements are recorded in ePolicy. At the next review, KPI data
is collected, analysed and documented in ePolicy. Refer to “Document Evaluation
and Monitoring Compliance” Section for processes.
o
All SCHN documents must have a risk rating applied (MoH coversheets,
departmental & trans-departmental documents are exempt).
o
Complete the following sections:

Document Summary/Key Points: to provide the essential information at a
glance.

Change Summary: to highlight any changes from the previous version so
staff don’t have to waste time looking for the changes. If the document is new,
add ‘N/A – new document’

Read Acknowledgement: to assist managers identify relevant staff who may
require training, who need to be very familiar with the document (these staff
should read and acknowledge they understand the contents [e.g. sign off]), or
staff who may only need to know about the document (i.e. read only).
This provides evidence of understanding and is associated with the risk rating of the
document. Generally for extreme and high risk documents, staff should read and sign
a Policy Notification Record whilst for medium and low risk documents records of
notification need only be minutes of meetings, emails, and memos.
o
Additional considerations:

Family Considerations
Any document developed needs to ensure that consumers are appropriately
consulted and involved in the document development as appropriate. If families will be
using the document it must be written in simple Plain English. Where appropriate,
consumers/families should be given an opportunity to review the document as they
are stakeholders too.
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Policy: Document Development and Review Framework

Aboriginal Health
All SCHN policies should consider the impact on the health of Aboriginal and Torres
Strait Islander (ATSI) peoples. If a document is going to impact on the health (which
includes the social, emotional and cultural well-being) of ATSI peoples, a statement
identifying the issue/s should be included. NSW HealthPD2007_082

Culturally and Linguistically Diverse (CALD) Considerations
Sensitivity to the cultural needs of families should be considered. Interpreters may be
required or particular information may need to be translated for families. Sometimes
presenting the information in picture form is appropriate.
The Government Information (Public Access) [GIPA] Act NSW, 2009 states that
Government agencies (such as SCHN) must have their policy documents freely
available to the public (via the internet). There are only a few exceptions permitted
under the constraints of the GIPA Act. All SCHN policy documents must reflect best
practice and must be evidence based.
Education is available: Contact the Clinical Governance Unit for ad-hoc education and advice.
7. Establish a Risk Rating for the document
o
Responsibility: Document
Development Team
Risk ratings may assist the team to develop
outcomes and is also used in the document evaluation process. Refer to “Applying
levels of risk to SCHN documents” Section.
8. Consultation
Responsibility: Team Leader /
Document Development Team
o
When a document is published it should never be
a surprise to a stakeholder.
o
Consultation with stakeholders is essential.
o
Governing Committee/s should be included into this process.
o
Record responses from each representative and outcomes and/or actions for each
response.
9. Submit draft document into ePolicy
Responsibility: Team Leader
o
After stakeholder approval, the document is submitted into ePolicy.
o
Complete all of the ePolicy questions before submitting.
o
The document will be tabled at the SCHN PP&G Committee for approval.
o
All new SCHN & Facility specific documents approved at the SCHN PP&G
Committee are then tabled at SCHN HCQC for noting.
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Policy: Document Development and Review Framework
3.2
Reviewing a document
1. Mandatory Review Period
Responsibility: CGU Policy team
o
All SCHN documents have a mandatory review period of three years.
o
Exception: Other documents outlined under ‘Processing of Other Documents’.
o
Document owners will be notified via email when a document is due for review (6
months before expiry).
o
Documents may be reviewed any time prior to mandatory review period expiry if
required.
2. Submit a request in ePolicy to REVIEW a document
Responsibility: Team Leader
o
Document custodian may download the draft document
from under the “My Policies” tab in ePolicy. Use this version throughout the review.
o
Then register the document review in ePolicy.
(Refer to ePolicy Quick start for instructions on how to use ePolicy)
o
The Policy Team in the Clinical Governance Unit ensure another team are not
reviewing the document before approving the request.
3. Form a Document Review Team (DRT)
o
Team Leader should be identified if not already done
so.
o
Representative stakeholder group:
Responsibility: Team Leader

Network Documents: inter-facility and interdepartmental multidisciplinary
team.

Facility Specific documents: interdepartmental multidisciplinary team,

Departmental or Trans-departmental Documents: key departmental staff.
4. Review the document
Responsibility: Team Leader /
Document Review Team
o
Critically review the document to ensure it is still
relevant. If deemed no longer relevant initiate
withdrawal of the document, by contacting (in writing) the Network Manager Policy
and Procedures.
o
Perform a literature search to ensure latest evidence/best practice is captured.
o
Make amendments to the ‘authorised’ Word version (including updating references)
with ‘track changes’ turned on. If no amendments are required, the document must
still travel through ePolicy in order to reset the review period.
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Policy: Document Development and Review Framework
o
Collect KPI data and other qualitative and quantitative data to evaluate the
document. Refer to Document Evaluation and Monitoring Compliance section.
o
Refer to Approval Process if:

Only minor amendments are required or

Urgent review is required and the document needs to be ‘fast-tracked’.
5. Consultation
Responsibility: Team Leader /
Document Review Team
o
When reviewing a document consultation with
stakeholders is essential.
o
Governing Committee/s should be included into this process.
o
Record responses from each representative and outcomes and/or actions for each
response.
6. Submit REVIEWED document into ePolicy
Responsibility: Team Leader
o
After stakeholder approval, the document is submitted into ePolicy.
o
Complete all ePolicy questions before submitting.
7. Overdue Documents for review
Responsibility: CGU Policy Team
o
Document owner/team leader will be contacted prior to the expiry date (approx. 6
months prior) and guided through the required process.
o
An escalation process will be activated if documents remain overdue for review 6
months post expiry date. (refer to Appendix 1) The SCHN PP&G Committee shall
action the process and will consult the appropriate senior managers.
o
Directors shall be notified of documents that are >12 months overdue for review and
a report is entered into ERMS (risk register) for action.
o
Documents that remain overdue for review for an extended period of time (>12
months) without a clear rationale may risk ownership or being withdrawn from the
intranet/internet.
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Policy: Document Development and Review Framework
3.3
Approval Process
1. Stakeholder approval
Responsibility: Team Leader
o
All representatives in the DDT or DRT should approve the final draft.
o
If for some reason a stakeholder is not represented, the document must be
forwarded to the identified stakeholder for approval.
o
If a stakeholder does not approve, a consultation process should occur to facilitate
approval. Record the discussion outcomes.
o
Outstanding issues may need to be escalated through line managers to resolve.
2. Governing Committee approval (if necessary)
Responsibility: Team Leader
o
A governing committee may be a ‘reporting to’ Committee or a Committee such as
the Drug Committee.
o
Governing committee should approve the document before for being tabled at the
SCHN Policy and Procedure Committee.
o
The Policy Team in the Clinical Governance Unit can help facilitate this process.
Contact the Clinical Governance Unit.
3. SCHN Policy, Procedure and Guideline Committee approval
o
All documents must be submitted into ePolicy for
approval by the SCHN PP&G Committee.
o
Complete all information in ePolicy before submitting.
4. Minor Amendment approval
Responsibility: Team Leader
Responsibility: Team Leader
o
Document custodian/Team Leader must approve minor amendments.
o
Minor amendments must meet the criteria as defined in the “Definitions” section of
this policy otherwise a full review will be required.
o
Submit a request into ePolicy and state in the ‘Additional Comments’ section of
ePolicy ‘minor amendments required’.
o
In the ‘Change Summary’ section of the document, state the minor amendments.
o
Submit the amended document into ePolicy and complete all questions in ePolicy.
o
The document will be tabled at the SCHN PP&G Committee for noting.
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Policy: Document Development and Review Framework
5. Urgent Approval (performed in exceptional circumstances only)
o
A document may need to be ‘fast-tracked’ through
the approval process for patient safety, legal or
other purposes.
o
The approval process may be fast-tracked at the discretion of the Director of Clinical
Governance and Medical Administration (DCGMA) or delegate.
o
In these exceptional circumstances.
o
4
Responsibility: Team Leader in
consultation with NMPP/DCGMA

Contact (in writing) the Network Manager Policy & Procedures (NMPP)
identifying reasons for urgent approval.

The NMPP will coordinate the approval process.

The DCGMA (or delegate) may provide ‘approval’ for the document to be
published on behalf of the SCHN PP&G Committee out of session.
The document must be submitted into ePolicy with all questions being completed.
Ad-hoc Feedback from staff
Every document has an ‘ad-hoc’ feedback form electronically attached to it. Staff may access
the form at any time via the ‘arrowed’ symbol
on the SCHN Policy intranet page.
Information may be forwarded anonymously or staff may choose to participate in discussions
with the document authors.
Submitted comments are forwarded to the document authors for follow-up/comment and
depending upon the urgency of the submitted feedback, a review may be activated
immediately or the feedback will be considered at the next mandatory review.
All feedback is also discussed at the SCHN Policy, Procedure & Guideline Committee.
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Policy: Document Development and Review Framework
5
Document Implementation
Responsibility: Team Leader /
DDT / DRT
1. A successful document will always have an implementation plan which incorporates an
appropriate evaluation of the document at review.
2. Implementation is not simply limited to notifying staff of the new document. The
document risk rating and scope shall determine the level of implementation required
(e.g. careful and detailed implementation is required for high risk documents that effect
many areas of SCHN or a facility).
3. The implementation and evaluation of the document should be discussed at the initial
stages of the document development. Discussion should include:
o
Equipment needs analysis (for staff and parents) and associated communication
strategies.
Rationale: By providing the right equipment there are greater compliance outcomes.
o
Identifying the risk rating of the document and the expected frequency of staff
accessing the document (e.g. extreme risk, high number of hits),
Rationale: The higher the risk, more extensive education and implementation may be
required.
o
Compliance points
Rationale: What points of compliance are not negotiable and therefore further resources and
education may need to focus on these points. This will guide the risk rating of the document.
o
Incident management and use of IIMS
Rationale: IIMS is a resource to capture incidents. Educating staff to use IIMs to capture
information relating to a document process can provide collated information on how to
manage or prevent the incident re-occurring (i.e. the document can be amended to help staff
avoid the incident re-occurring or processes /equipment can be improved or further
education can be identified).
o
Identify a key performance indicator/s (Note: only use existing collection data-sets – do
not create a new data-set unless essential)
Rationale: A measure (KPI) can assist to identify if the associated processes or the
document needs to change to match the expected KPI outcome.
o
Staff appraisals
Rationale: If the document is extremely important for staff to perform their core business then
compliance is necessary. Use the document in staff appraisals.
o
Staff and/or consumer feedback
Rationale: End-user feedback should be captured as these persons often identify small but
important issues that require action.
4.
Implementation Action Plan tool:
http://chw.schn.health.nsw.gov.au/o/groups/ppc/resources/action_plan_template_for_document_implementation.pdf
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Policy: Document Development and Review Framework
6
Notification and Communication
The following 3 processes should occur:
1. Team leaders are notified of the approved document
via ePolicy.
o
A list of approved documents is subsequently advertised in the following locations
for notification to all staff:

Electronic staff newsletter: “Chief Executive Update”

‘New Policies’ intranet page

Monthly email to managers listing the recent NSW MoH policy documents.
This email also provides a link to the ‘New Policies’ page.
2. Managers should notify their staff by reviewing the list
of new and reviewed documents that are important to
their area of work.
o
Responsibility: CGU Policy team
Responsibility: Manager
Notification records should be maintained.
Refer to:

Information about notification records:
http://chw.schn.health.nsw.gov.au/o/groups/ppc/resources/staff_notification_records__information_sheet.pdf

A staff notification ‘sign-off’ sheet:
http://chw.schn.health.nsw.gov.au/o/groups/ppc/resources/policy_notification__staff_record_.pdf
3. The DDT/DRT should activate their implementation
strategies which includes communication processes.
7
Responsibility: DDT / DRT
Applying Risk ratings to SCHN documents
•
All SCHN and Facility specific documents should be risk
rated. (Exempt: MoH coversheets & Department documents)
•
The level of risk is determined by the relationship between
the consequences or outcome through non-compliance and the likelihood or probability
of the outcome occurring (NSW MoH PD2009_039 Risk Management Policy Directive).
•
When evaluating a document for risk, consideration should be given to the impact a
‘non-compliance’ outcome or consequence has on patients, visitors, staff or the
organisation.
•
Once a level of risk has been assigned, the document can be evaluated and monitored
for compliance via ePolicy.
Responsibility: Document
Development Team
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Policy: Document Development and Review Framework
7.1
How assign a risk rating to a document
STEP 1 – Determine the most severe consequence or outcome that may occur if there is
non-compliance to the document. Refer to the MoH Risk Matrix and consequence examples
table at: http://internal.health.nsw.gov.au/cgrm/rmra/risk_management/1_risk_matrix.pdf
STEP 2 – Determine the likelihood of the consequence or outcome occurring. Likelihood is
the chance of something happening and is measured in terms of probability or frequency.
Probability (%)
Frequency
Likelihood
> 95 – 100
Several times a week
Almost certain
> 70 – 95
Monthly or several times a year
Likely
Once every 1 – 2 years
Possible
> 5 – 30
Once every 2 – 5 years
Unlikely
<5
Greater than once every 5 years
Rare
> 30 – 70
OR
or
STEP 3 – Determine the risk rating
Combine the selection of consequences and likelihood to determine the risk rating. The
position on the MoH risk matrix is represented alphabetically from A – Y. Use the MoH Risk
Matrix or the below table to determine the risk rating.
STEP 4 – Interpret the results to determine the level of risk for the document and record it in
ePolicy.
•
Extreme risk
= red
= [A – E]
•
High risk
= orange
= [F – K]
•
Medium risk
= yellow
= [L – T]
•
Low risk
= green
= [U – Y]
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8
Document Evaluation and Monitoring Compliance
Monitoring compliance is performed according to the level of risk
Responsibility: Document
applied to a SCHN or Facility specific document and is performed
Review Team
at each review. Therefore the following should be performed in
order to evaluate if the document is performing the function or
purpose it is supposed to be doing. All of the data collected is recorded in ePolicy.
1. Collect qualitative and quantitative data about the document. Collect the following:
o
How frequently the document is used (i.e. number of hits)?
o
Are there any reported non-compliance issues?
o
Are there any IIMS incidents related to the document?
o
Has there been any audits performed relating to the document?
o
Has there been any staff or consumer feedback relating to the document?
o
After collecting the KPI data, do the results match the expected outcome?
o
Is the document discussed at staff appraisals?
o
Does the DRT consider the document to be best practice and/or evidence based?
2. The DRT should reflect upon the data gathered and draw one or more of the following
conclusions:
i.
Apart from updating information, there are no process changes required within
the document or related work practice processes.
That is, the document is performing its purpose and staff are complying.
ii. Processes within the document needed to be changed to match the expected
outcomes (e.g. KPI).
That is, the expected outcomes are not occurring. The processes captured in
the document need to change to try and align with the expected outcome.
iii. Related work practices needed to change to match the document.
That is, the document is performing its purpose but staff are not complying with
the documented practices.
iv. The document implementation strategy needs to be revised.
That is, the document is performing its purpose, but staff cannot fully comply
because they don’t know about the document and/or they need additional
education or training.
3. The DRT should comment in ePolicy about the conclusions drawn.
4. The SCHN PP&G Committee will review and confirm the data collected along with the
conclusions and may advise the DRT if further action is required.
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Policy: Document Development and Review Framework
8.1
Additional compliance monitoring processes
Regular Auditing Program – SCHN documents
Responsibility: Clinical
Governance Unit
•
Regular auditing of documents shall follow the requirements
of the National Safety and Quality Health Service Standards.
•
The audits will be incorporated into projects/improvement activities wherever possible
and use standardised audit tools.
Departmental Notification records – Auditing Program
•
Auditing of departmental notification records shall occur periodically (e.g. six monthly).
•
Departments shall be selected at random and contacted prior to performing the audit.
9
Availability of documents in the event of a Disaster
9.1
Hard copies
•
A single set of hardcopy Network and facility specific documents are located in the After
Hours Nurse Managers (AHNM) office.
•
These are to be used in emergency situations only. If accessed, it is the
responsibility of the person accessing it to ensure the copy is returned as soon as
practicable.
•
Managers are to maintain within their area a current hardcopy of:
o
Emergency Response Plan [CHW or SCH] HealthPlan and
o
Local Disaster Response Plan for their area.
Hard copies of all other documents are discouraged.
9.2
Electronic (soft) copies)
•
A program has been developed to regularly update identified soft copies on the C:drives
of SCHN computers. It is awaiting roll-out.
•
The most frequently accessed SCHN and facility specific documents will be available on
the C:drive (i.e. not all policies will be found here). These documents should only be
accessed if the SCHN/CHW and/or SCH intranet is non-operational.
•
Departmental documents from acute care areas may also be available via the C:drive in
the same folder.
•
Managers outside acute areas are responsible to have a system in place for staff to
access their local departmental documents.
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10
Processing NSW Ministry of Health Policy Documents
•
SCHN receives notification of state and national legislation
via NSW Health Policy Directives.
•
SCHN person/s responsible to implement a MoH policy documents at SCHN is notified.
Notifications are sent out weekly and notification records are maintained.
•
In addition, all SCHN managers are notified of all recent NSW MoH policy documents
via a monthly “Recent NSW MoH policy document” email.
•
All NSW Health Policy Directives should be reflected in SCHN documents. The
following should occur:
Responsibility: NMPP
o
If SCHN does not have a corresponding document, a policy statement (coversheet)
should be developed.
o
If SCHN does (or plans to) have a corresponding document, that document must be
reviewed against the Policy Directive as soon as possible.
o
Both types of documents are to be submitted to ePolicy and undergo the appropriate
approval processes.
•
Review period for MoH Policy Directive coversheets: 5 years.
•
MoH Policy Directive coversheets are exempt from the SCHN risk rating and document
evaluation processes.
•
NSW MoH Guidelines and Information Bulletins may have associated SCHN
documents. The development or review of such documents is at the discretion of the
respective SCHN contact person.
11
Accountability Framework
•
Clinical Governance Unit is responsible to ensure there is a SCHN policy document
framework and that it undergoes periodic review as required for all SCHN policies.
•
The SCHN DCGMA maintains governance over the SCHN Document Development and
Review Framework policy and is responsible for the processes implemented at SCHN
relating to policy document development and review.
11.1 Retention and Disposal of SCHN documents
•
All documents are currently kept indefinitely via ePolicy.
•
ePolicy is ‘backed-up daily.
11.2 Document Numbering System
•
Each SCHN document is issued a unique document number.
•
Refer to: http://chw.schn.health.nsw.gov.au/o/apps/ppc/epolicy/help/numbering_system.pdf
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Policy: Document Development and Review Framework
11.3 When a document becomes active?
•
All documents have 3 dates on the front page:
o
Date of Publishing
o
Date of Printing
o
Date Effective
•
A document becomes active or comes into effect at the ‘Date Effective’.
•
The review period starts from the date effective.
12
Processing of Other Documents
12.1 Standing Orders, Nurse Initiated Medication & Drug Protocols
Approved by the Drug Committee
1. Obtain approval from appropriate senior nursing staff and/or senior medical staff to
develop the document.
2. Complete the appropriate template. (Word>File>New>My Templates)
3. Register the document in ePolicy.
4. Obtain final draft sign-off by appropriate senior medical and/or nursing staff from
relevant teams.
5. Submit the final version in ePolicy.
6. The NMPP submits the document to the Drug Committee for approval.
7. The document is published when Drug Committee approval is received.
Review Period of Standing Orders, Nurse Initiated Medication and Drug Protocols
o
Standing Orders MUST be reviewed annually (NSW MoH PD2013_077).
o
Drug protocols and Nurse Initiated Medications are reviewed every 3 years.
12.2 Local Disaster Response Plans (at CHW)
Approved by the CHW Emergency Plan Committee
1. Department Manager submits the Local Disaster Response Plan to the Emergency
Response Committee for approval.
2. The approved CHW Local Disaster Plan is submitted to ePolicy and the document is
published.
Review Period for Local Disaster Plans
o
Local Disaster Plans are reviewed every 2 years.
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12.3 Local Emergency Plans (at SCH)
Approved by the Randwick Campus Emergency Plan Committee (Shared Service)
1. SCH Emergency Planning Committee submits the local (SCH) emergency management
plan to the Randwick Campus Emergency Plan Committee for approval.
2. The approved Randwick Campus Emergency Management plan is submitted to
SESLHD processes in addition to being submitted to ePolicy as a SCH facility specific
document. The document is then published.
13
Bibliography
1.
Australian Commission on Safety and Quality in Health Care “National Safety and Quality Health Service
Standards”, September 2011 publication: http://www.safetyandquality.gov.au/wpcontent/uploads/2011/01/NSQHS-Standards-Sept2011.pdf (accessed Mar 2014)
2. Australian Health Practitioner Regulation Agency (AHPRA) website: http://www.ahpra.gov.au/
(accessed Mar 2014)
3. National Health & Medical Research Council (NHMRC) “A guide to the development, implementation
and evaluation of clinical practice guidelines”.
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp30.pdf (Accessed Mar 2014)
4. “Government Information (Public Access) Act, 2009 (NSW):
http://www.austlii.edu.au/au/legis/nsw/consol_act/giaa2009368/ (Accessed Mar 2014)
5. NSW MoH Policy Directive (PD2009_029) “Policy Distribution System (PDS) for NSW Health”:
http://www0.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_029.pdf (accessed Mar 2014)
6. NSW MoH Policy Directive (PD2013_042) “Medication Handling in NSW Public Health Facilities”:
http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_043.pdf (accessed Mar 2014)
7. NSW MoH Policy Directive (PD2007_082) “Aboriginal Health Impact Statement and Guidelines”:
http://www0.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_082.pdf (accessed Mar 2014)
8. NSW MoH Policy Directive (PD2009_039) “Risk Management – Enterprise-wide Policy and Framework”.
http://www0.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_039.pdf (accessed Mar 2014)
9. Appraisal of Guidelines, Research and Evaluation (AGREE) Collaboration: http://www.agreetrust.org/
(accessed Mar 2014)
10. Grimshaw J.M, Thomas R.E, MacLennan G et al. Effectiveness and efficiency of guideline dissemination
and implementation strategies. Health Technology Assessment 2004.
http://www.hta.ac.uk/execsumm/summ806.htm (accessed Mar 2014)
11. Fretheim A, Schunemann H. J, Oxman A. D. Improving the use of research evidence in guideline
development: 15. Disseminating and implementing guidelines. Health Research Policy and Systems
2006, 4:27
12. Moulding N. T, Silagy C. A, and Weller D. P. A framework for effective management of change in clinical
practice: dissemination and implementation of clinical practice guidelines. Qual. Health Care 1999; 8;
177 – 183.
Copyright notice and disclaimer:
The use of this document outside Sydney Children's Hospitals Network (SCHN), or its reproduction in
whole or in part, is subject to acknowledgement that it is the property of SCHN. SCHN has done
everything practicable to make this document accurate, up-to-date and in accordance with accepted
legislation and standards at the date of publication. SCHN is not responsible for consequences arising
from the use of this document outside SCHN. A current version of this document is only available
electronically from the Hospitals. If printed, this document is only valid on the date of printing.
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Policy No: 1/A/12:9037-01:02
Policy: Document Development and Review Framework
Appendix 1: Escalation process for policies overdue for review
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