policy for the production, consultation, approval ... · publication and dissemination of...

Policy for the Production, Consultation, Approval, Version: 3.0

Publication and Dissemination of Strategies, Policies And Other Key Documents

of 23 Paper copies of this document should be kept to a minimum and checks made with the

electronic version to ensure the version to hand is the most recent.

POLICY FOR THE PRODUCTION, CONSULTATION,

APPROVAL, PUBLICATION AND DISSEMINATION OF STRATEGIES, POLICIES, AND OTHER KEY DOCUMENTS

Document Author: Corporate Governance Manager

Executive Lead: Committee Secretary

Approved by: Corporate Directors Group

Issue Date: 1 September 2015

Review Date: 1 September 2018

Document No: 054





Document History

Revision History

Version

No.

Revision date Summary of Changes Updated

to version

no.:

1.0 31/10/12 Amended to reflect new Management

Group

1.1

2.0 31/05/13 Updated to reflect revised arrangements 2.1

2.1 17/08/15 Approved by Corporate Directors Group 3.0

Date of next revision

Consultation

Name Date of

Issue

Version Number

Management Team 12/12/11 0.2

Joint Committee 31/01/12 0.3

Management Group 08/11/12 1.1

Corporate Directors Group 17/08/15 2.1

Approvals

Name Date of

Issue

Version No.

Joint Committee 01/02/12 1.0

Management Group 08/11/12 2.0

Corporate Directors Group 17/08/15 3.0





CONTENTS

1. POLICY STATEMENT ............................................................. 5

2. SCOPE OF POLICY ................................................................ 5

3. AIMS AND OBJECTIVES ........................................................ 5

4. DEFINITIONS ...................................................................... 6

4.1 Strategy........................................................................... 6

4.2 Policy............................................................................... 6 4.3 Procedure......................................................................... 7

4.4 Protocol ........................................................................... 7 4.5 Guideline ......................................................................... 7

5. RESPONSIBILITIES .............................................................. 7

5.1 Joint Committee ................................................................ 7

5.2 Cwm Taf Audit Committee .................................................. 7 5.3 Quality and Patient Safety Committee .................................. 8

5.4 Integrated Governance Committee ...................................... 8 5.5 Management Group ........................................................... 8

5.6 Corporate Directors Group Board ........................................ 8

5.7 Managing Director of Specialised and Tertiary Services Commissioning ......................................................................... 8

5.8 Executive Directors ........................................................... 9 5.9 Executive Leads ................................................................ 9

5.10 Assistant/Deputy Directors .............................................. 9 5.11 Corporate Governance Manager and Business Support Officer

10 5.12 Authors of Key Documents .............................................. 10

5.13 Line Managers ............................................................... 11 5.14 All Staff ........................................................................ 11

6. KEY DOCUMENT DEVELOPMENT ............................................ 12

6.1 WHSSC Wide/Local Documents .......................................... 12

6.2 Document Development .................................................... 12 6.3 Equality Impact and Assessment ........................................ 13

6.4 Process ........................................................................... 13





6.5 Language ........................................................................ 13

6.7 Data Protection Act .......................................................... 13 6.8 Legislation, National and Professional Guidance ................... 14

6.9 Training .......................................................................... 14 6.10 Resource Implications .................................................... 14

6.11 Style and Format ........................................................... 14

7. CONSULTATION PROCESS ................................................... 15

8. APPROVAL PROCESS ........................................................... 16

8.2 Strategies and Policies ...................................................... 17

8.3 Other Key Documents ....................................................... 18 8.4 Department Specific Documents ........................................ 18

9. IMPLEMENTATION ............................................................... 18

10. REVIEW .......................................................................... 19

11. DOCUMENT CONTROL INCLUDING VERSION CONTROL ......... 20

12. PUBLICATION, DISSEMINATION AND DISTRIBUTION ........... 20

13. KEY DOCUMENT COMPLIANCE ........................................... 21

14. RESOURCES .................................................................... 21

15. TRAINING ....................................................................... 21

16. EQUALITY ....................................................................... 22

17. REFERENCES / FURTHER INFORMATION.............................. 22

Key Document, Specialised Services Policy and Specialised Services

Service Specification Templates can be found in..\..\..\..\..\Corporate Business 01\Corporate Identity & Templates\Policies etc

../../Corporate%20Identity%20&%20Templates/Policies%20etc

../../Corporate%20Identity%20&%20Templates/Policies%20etc





1. POLICY STATEMENT

1.1 This document outlines the process within Welsh Health Specialised Services Committee (WHSSC) for development,

consultation, approval, dissemination, and review of key organisational documents such as policies, strategies,

procedures and protocols.

1.2 High quality organisational documentation is an essential tool of governance, which will help us achieve our strategic objectives,

as well as facilitating the delivery of a consistently high standard of care to service users.

1.3 All documents must undergo a rigorous process of development

and be approved and monitored by the Joint Committee or the appropriate designated subcommittee.

2. SCOPE OF POLICY

2.1 This policy applies to all staff and any particular areas of

responsibility are listed in section setting out responsibilities.

2.2 For ease of reading, this document will refer to all strategies, policies, guidelines, procedures or protocols as ‘key documents’

unless specific terminology is more appropriate.

2.3 This policy is intended to relate to organisation wide documents, however, its principles equally apply to any local key documents

that are developed which are specific to a defined department /directorate. This is to ensure that they are appropriately

authenticated and regularly updated in order to form a reliable and valid source of good practice for staff.

3. AIMS AND OBJECTIVES

3.1 The purpose of this policy is to:

3.1.1 Ensure that all written key documents comply in terms of their format and content.

3.1.2 Ensure that there are systems in place for: • Maintenance of a comprehensive index of all key

documents;





• Consultation and approval of organisation wide

key documents; • Comprehensive arrangements for dissemination of

organisation wide policies, procedures, protocols, and guidelines across the organisation;

• Review of such documents within an appropriate timescale.

3.1.3 Provide a template for local key documents.

4. DEFINITIONS

4.1 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.

4.2 Policy

4.2.1 A policy is a set of guiding or governing principles, which meets all or most of the following criteria:

• It is a governing principle that mandates or constrains actions;

• It has application throughout WHSSC; • It will change infrequently and sets a course for

the foreseeable future; • It helps to ensure compliance with overarching

principles, legislation or professional guidance;

• It helps to reduce organisational risk.

4.2.2 Examples of policies within WHSSC include: Specialised Services Policies (Commissioning

Policies) Specialised Services Service Specifications

Policy Positions Operational (corporate) policies





4.3 Procedure

A standardised method of performing clinical or non-clinical tasks

by providing a series of actions to be conducted in an agreed and consistent way to achieve a safe, effective outcome. This will

ensure all concerned undertake the task in an agreed and consistent way. These are often the documents detailing how a

policy is to be achieved.

4.4 Protocol

Protocols are a set of measurable, objective standards which determine a course of action.

4.5 Guideline

A guideline is a set of systematically developed standards or

rules, which assist in the decision about how to apply an agreed policy, or may relate to the appropriate management of specific

conditions or situations. Guidelines are often used to underpin a policy, and represent good practice.

5. RESPONSIBILITIES

5.1 Joint Committee

The Joint Committee is responsible for setting the strategic context in which WHSSC key documents are developed, and for

ensuring the formal review and approval of documents takes place.

5.2 Cwm Taf Audit Committee

The Cwm Taf Audit Committee will review and assure the

systems and processes regarding document development, review and monitoring they have responsibility for.





5.3 Quality and Patient Safety Committee

The Quality and Patient Safety Committee provides clinical

leadership and support for service development and clinician engagement. New and strategic revised clinical documents

should be circulated to the Quality and Patient Safety Committee Members for consultation prior to submission to the Joint

Committee or the subcommittee for ratification.

5.4 Integrated Governance Committee

The Integrated Governance Committee will ensure that WHSSC has documents in place to support delivery of key functions and

that the document production and development process is in place to do this.

5.5 Management Group

The Management Group will ensure that WHSSC has documents

in place to support delivery of key functions.

5.6 Corporate Directors Group Board

The Corporate Directors Group will review the process used to develop documents and approve them for implementation, or

recommend them to the appropriate individual or committee for final approval in accordance with the designated approval level.

5.7 Managing Director of Specialised and Tertiary Services

Commissioning

The Managing Director of Specialised and Tertiary Services Commissioning has overall responsibility for the strategic and

operational management of WHSSC which includes ensuring that documents comply with all legal, statutory and good practice

guidance requirements.





5.8 Executive Directors

5.8.1 All Executive Directors are responsible for identifying

and developing documents relevant to their area of responsibility.

5.8.2 The responsibility for ensuring the documents are

implemented and becomes an active document within WHSSC lies with the Executive Directors.

5.8.3 The Executive Directors are accountable to the

Managing Director of Specialised and Tertiary Services

Commissioning for ensuring documents are implemented and become active documents within

WHSSC.

5.9 Executive Leads

5.9.1 The Executive Lead is responsible for ensuring that the final version of the key document is fit for purpose and

that it has followed a robust consultation process prior to it being presented for final approval (see Section 6

and 7 for information on the consultation and approval process).

5.9.2 The Executive Lead is responsible for ensuring that all

key documents within their remit are maintained and updated through effective delegation to the appropriate

author(s). They are responsible for ensuring that the appropriate advice and assistance is provided to authors

and that consideration is given to any equality, training, audit and resource implications prior to approval.

5.10 Assistant/Deputy Directors

Assistant/Deputy Directors will support the implementation of

documents and monitor their effectiveness.





5.11 Corporate Governance Manager and Business Support

Officer

The Corporate Governance Manager will act as the ‘Policy Process Manager’, acting as the WHSSC key document gate-

keeper with the responsibility for providing guidance, training and support for the process. The Corporate Governance

Manager, with the assistance of the Business Support Officer, will:

Maintain the WHSSC key document database, (including a record of equality impact

assessments);

Ensure the appropriate management of the approval process in line with this policy;

Issue reminder notices to ensure the timely review of any key documents;

Cascade approved/amended key documents in accordance with Section 12 of this Policy;

Maintain an archive of the previous versions of centrally held revised or reviewed policy and

written control documents; Provide advice and assistance as required.

5.12 Authors of Key Documents

5.12.1 Authors of key documents are responsible for ensuring

that the guidance provided in this policy is followed. This will include:

Ensuring that appropriate consultation has taken place with the relevant individuals and groups;

Ensuring that training needs and resources required for implementation are clearly identified;

Ensuring that the necessary equality impact

assessment has been carried out and consideration given to the findings prior to the

document entering the approval process (see Section 8);

Liaising with the Executive Lead to ensure that key documents are implemented appropriately

and, where necessary, compliance with those documents is formally audited;





Ensuring that there is an appropriate review of

key documents, either in line with the review timescale set at the time of approval or as a

result of changes to practice, organisational structure or legislation.

5.12.2 Authors are responsible for the review of their policy

documents. If an author leaves WHSSC, the responsibility for their policy document is taken on by

their role replacement. Where no direct role replacement is appointed, responsibility reverts to the

post holder's line manager.

5.13 Line Managers

Line Managers at all levels are responsible for ensuring that the staff for whom they are responsible are aware of and adhere to

this policy. This includes ensuring that: Copies of the WHSSC, and its host Cwm Taf LHB,

key documents are readily available and accessible to all staff. This should preferably be

via SharePoint. However where staff do not have

access to the SharePoint paper copies should be made available;

Information is disseminated on a regular basis, to ensure staff have read and understood the

relevant documents and are aware of any new guidance or revisions;

Specific staff training needs are identified on the implementation of new or updated documents;

Ensure that documents developed which are only applicable to their area are managed and

maintained in accordance with the provisions laid down in this Policy).

5.14 All Staff

All staff are responsible for ensuring that:





Their practice is in line with key documents in use

throughout WHSSC and specific to their area of work;

Information regarding failure to comply with the policy, for example, lack of training, inadequate

equipment, is reported to their Line Manager and that the incident reporting system is used where

appropriate; Information regarding any changes in practice,

organisational structure or legislation that would require an urgent review of documents is

immediately reported to their Line Manager; They comply with the provision of this policy and

where requested to demonstrate such compliance. Failure to comply will be dealt with under the All

Wales Disciplinary Policy as appropriate.

6. KEY DOCUMENT DEVELOPMENT

6.1 WHSSC Wide/Local Documents

The diverse nature of health care means there will be a large

number of policies, procedures, guidelines and protocols in place. Some will apply throughout WHSSC and be relevant to all

staff, and others will be specific to certain areas or activities.

6.2 Document Development

6.2.1 Key documents must be developed using the agreed templates. This will ensure that WHSSC key documents

are presented in a professional and consistent manner and address all necessary requirements.

6.2.2 Documents that apply to WHSSC ultimately need to be

sponsored by an Executive Lead and therefore the author proposing the development of a policy document

will need to discuss any proposal to create a new policy document with the relevant sponsor before proceeding.





6.2.3 Rather than drafting a completely new key document in

some instances there may be an existing version that that simply needs updating or an existing version in

another NHS organisation that can be adapted for WHSSC purposes. In such instances this will need to be

flagged by email to the Corporate Governance Manager.

6.3 Equality Impact and Assessment

In accordance with the Equality Act 2010, all key documents will be subject to an Equality Impact Assessment. The document

author must carry this out. A “Word” version of the Equality Impact and Assessment tool is available on request by

contacting the Corporate Governance Manager or Business Support Officer.

6.4 Process

The process for formulation and production and approval must

follow the steps outlined in this document under sections 6-8.

6.5 Language

The language used within a key document should be plain English avoiding technical terms wherever possible. If technical

terms are necessary, or abbreviations desirable, they must be explained using a glossary / footnotes.

6.7 Data Protection Act

In accordance with the requirements of the Data Protection Act

1998, names of individual staff must not be contained within key documents. Individuals with particular responsibilities can be

identified by their job title only.





6.8 Legislation, National and Professional Guidance

6.8.1 All key documents must comply with current legislation,

national and professional guidance. Policies must be based on sound evidence and be appropriately

referenced. 6.8.2 Where a key document requires that records are to be

kept, the requirements of such documentation should be clearly set out in the document. Staff are responsible

for the records they use and create.

6.9 Training

Where training is required to be able to implement a key document, this must be clearly defined.

6.10 Resource Implications

Any resource/cost implications arising from a key document

must be defined in the covering report circulated at the time of consultation and approval.

6.11 Style and Format

6.11.1 All key documents should be written in a style which is

concise and clear using unambiguous terms and language

• The main document header must be in Verdana 14;

All text, within the main body of the document

must be in Verdana 12 and left justified; • All documents must have a ‘footer’ in Verdana 9,

detailing the title of the document, version number and page number.

6.11.2 Document templates have been developed to provide

guidance on what information must be contained (as a minimum) in key documents along with some standard

clauses that can be used as appropriate (see





appendices). It indicates the fields that are mandatory

and contains the standard front cover which is to be applied to WHSSC wide key documents, together with

some specific points regarding formatting.

6.11.3 A “Word” version is available on request by contacting the Corporate Governance Manager or Business Support

Officer.

6.11.4 If WHSSC is adopting an externally approved document or document approved by its host, Cwm Taf LHB, it will

not need reformatting providing it meets the standards set above.

7. CONSULTATION PROCESS

7.1 All new or significantly revised key documents must be

developed in consultation with the relevant target audience including:

Executive Directors Assistant and Deputy Directors

Relevant professional groups and/or individuals Staff representatives affected by the key

document Stakeholder representatives, organisations or

groups (see 7.4) Service user representatives or groups (if

appropriate – see 7.3) Clinical representatives.

7.2 For further detail regarding consultation for Specialised Services

Policies and Service Specifications please refer to the

Consultation Guide for Commissioning Policies and Service Specifications (054b).

7.3 The period of consultation for new policy documents must be

adequate to allow robust consultation i.e. not less than 4 weeks but possibly as long as 8 weeks. The consultation must be led by

the author and completed prior to the document beginning the approval process.





7.4 To assist with this process a consultation site has been included

on the intranet (SharePoint) site. Authors must ensure their policy, procedure or control document is available for

consultation across the organisation for a minimum of 4 weeks. Consideration should also be given to alerting key groups to the

availability of the draft policy, procedure or control document for comment.

7.5 If the key document is relevant to patient care it must also be

sent for consultation to relevant patient representatives. The Executive Lead will provide advice with regards to identifying the

appropriate groups/individuals for consultation.

7.6 Stakeholder/partner organisations/groups will also be consulted regarding key documents as appropriate. The Executive Lead will

provide advice with regards to identifying the appropriate

groups/individuals for consultation.

7.7 WHSSC will develop and identify mechanisms to involve patients and members of the public where appropriate. This will

strengthen the stakeholder involvement with WHSSC and demonstrate our commitment to working with the community.

All consultation will be led by the author and must be completed before the policy or written control document begins the

approval process.

7.8 The author, in association with the Lead Director, must identify and document the consultation arrangements and provide

assurance to the approving Committee that this has been conducted thoroughly and that comments have been

incorporated into the policy. The author is responsible for

ensuring that the consultation process is documented in the relevant section of the key document which will provide

assurance that consultation has been robust. Details of any significant differences of opinion raised or risks identified and

how these were managed should be included in the covering paper for the approving committee.

8. APPROVAL PROCESS

8.1 It is necessary to ensure that all key documents undergo the appropriate scrutiny and consultation prior to their approval.





8.2 Strategies and Policies

8.2.1 The Joint Committee is responsible for the ratification of

all strategy and policy documents which support the Governance and Accountability Framework e.g.

Standards of Behaviour Policy.

8.2.2 The Management Group is responsible for the

ratification of Specialised Services Policies, Specialised Services Service Specifications and other relevant

policies. Where a policy has a financial impact which is outside of the annual planning arrangements the policy

can be supported and approved by Management Group but must be taken to Joint Committee for ratification.

8.2.3 Where policies are written on an All-Wales/National

basis, or where policies of the host, Cwm Taf LHB, are for formal adoption by WHSSC, Joint Committee will

delegate this function to the relevant Sub Committee, Management Group or Corporate Directors Group . The

formal adoption of such documents must be recorded in

the minutes of the meeting where it was agreed.

8.2.4 The ratification of key documents, excluding strategies and policies, will be delegated to Sub Committee or

Corporate Directors Group in line with their individual remits and responsibilities.

8.2.5 Changes required to a WHSSC Strategy or Policy after it has been ratified and approved must be formally

approved by the ratifying committee. Where changes are minor Chair’s action maybe considered. Significant

changes will require consultation and presentation to the ratifying committee.

8.2.6 The Corporate Governance Manager will ensure that all

approved policies are recorded in the WHSSC Key

Documents Register and published on intranet and/or internet site as appropriate.





8.2.7 The Sub Committee, Management Group or Corporate

Directors Group will advise the Joint Committee of policies that have been approved. The Joint Committee

maintains the right to call in and scrutinise these policies.

8.3 Other Key Documents

The Joint Committee may delegate the approval of WHSSC wide

key documents (excluding Strategies) to Management Group, a relevant Sub Committee or the Corporate Directors Group . This

power must be recorded in the Terms of Reference of the sub committee(s).

The Management Group, Sub Committee or Corporate Directors Group will advise the Joint Committee of documents that have

been approved. This will be carried out through the Chair’s Report to Joint Committee. The Joint Committee maintain the

right to call in and scrutinise key documents.

8.4 Department Specific Documents

Where key documents relate to a single department/function and where there is no wider impact on WHSSC they may be

approved by the Executive Lead. Examples of such documents include Standard Operating Procedures explaining an internal

process.

Such documents will still need to be recorded on the Key

Documents Register, issued with a unique reference number and meet the standards set within this policy. There must also be a

clear documented audit trail to indicate where and by whom the document has been considered.

9. IMPLEMENTATION

9.1 It is the responsibility of the author to identify how a policy or key document will be implemented. This may include

consideration of staff training requirements.





9.2 Executive Directors and Divisional Directors have key

implementation roles in this policy and should ensure that information is cascaded appropriately to the staff within their

divisions.

10. REVIEW

10.1 WHSSC key documents will usually be current for a maximum of

three years prior to review unless agreed otherwise when the document is approved. There are exceptions to this where some

documents must be reviewed on an annual basis, for example, Standing Orders, Standing Financial Instructions and their

related documents.

10.2 When documents are approaching their agreed review date: • The Corporate Governance Manager or Business

Support Officer will contact the document author

and responsible Director to initiate the review approximately six months prior to the scheduled

review date; • The author, with the Lead Director, will determine

if the document is still required and whether the necessary revisions to update the document are

minor or major; • Where a document is no longer required due to

changing practices etc. then a paper outlining those reasons should be submitted to the

Management Group, appropriate Sub Committee or Corporate Directors Group for approval by the

responsible director; • Where minor revisions are necessary these will be

completed by the author and the document

together with a covering paper that clearly summarises the minor changes can be submitted

to Joint Committee, Management Group, the relevant Sub Committee or Corporate Directors

Group for approval; • Where major (significant) changes are required,

the document may be treated as a new document and subject to some or all of the processes

outlined above.





10.3 On occasion it may be necessary for a document to be reviewed

earlier than the agreed review date, e.g. in the light of changing legislation or national guidelines. Document authors are

responsible for ensuring that documents are reviewed following any changes to relevant legal and statutory requirements, NHS

guidance and policy. Where the need for early review is identified the appropriate Committee should be informed and the

process managed as outlined in 10.2 above.

11. DOCUMENT CONTROL INCLUDING VERSION CONTROL

11.1 To ensure all staff has access to current documents all current

versions will be available on SharePoint with superseded versions removed. Key documents relevant to WHSSC staff only

will be available on the WHSSC SharePoint.

11.2 All documents must be clearly marked with the up-to-date

version to aid accurate tracking and retrieval, including date of approval and date for review on the front page.

As changes are made to the document, each new “Draft” will be

given a higher sequential number using the convention 0.1, 0.2 or 1.1, 1.2 etc.

Once the “Draft” document is ratified by the appropriate

committee, it will then be given the “Final” version number e.g. 1.0 or 2.0 etc

It is important the version control number of the document is

detailed in the footer section of the document.

12. PUBLICATION, DISSEMINATION AND DISTRIBUTION

12.1 All key documents that have been ratified appropriately must be forwarded to the Corporate Governance Manager by the

document author within seven working days.

12.2 The Corporate Governance Manager will then ensure that the key document together with the corresponding Equality Impact

Assessment (where applicable) is uploaded onto SharePoint and/or the internet as appropriate.





12.3 Once issued, individual line managers will be responsible for

ensuring that all staff are aware of the revisions and that any out of date versions are taken out of local circulation.

12.4 Where the document is to be circulated outside of WHSSC,

including distribution to professional groups, the document author will be notified of the URL address once uploaded onto

the intranet/internet. The document author will then be responsible for circulation of the document outside of WHSSC.

13. KEY DOCUMENT COMPLIANCE

13.1 Any advice required on implementation of this policy should be obtained from the Corporate Governance Manager or Business

Support Officer.

13.2 The Corporate Support Department will undertake periodic

sampling to verify compliance with the requirements of this policy and results will be reported to the Corporate Directors

Group annually.

13.3 Where policy documents are received for publication and it is not felt that the content meet the necessary requirements of this

policy then they will be rejected by Corporate Governance Manager who will return them to the Executive Lead for action.

14. RESOURCES

14.1 A Key Documents Register has been established and will be further developed in support of this policy. Resources required to

maintain the register and uploading of documents onto the Intranet and Internet will managed within current resources.

14.2 Resources in terms of time will be required to educate staff on

both the requirements of this policy and the development of documents throughout WHSSC.

15. TRAINING

15.1 Line Managers must ensure that new starters are aware of this policy, induction arrangements and of their individual

departmental processes.





15.2 It is the responsibility of individual Line Managers to inform the

Corporate Governance Manager of the requirement where specific staff training needs are identified, particularly in relation

to the implementation of new or updated documents.

15.3 Executive Directors will ensure that responsibilities for policy

development are clearly outlined in each individual Job Description, in accordance with their role.

16. EQUALITY

16.1 The Equality Impact Assessment (EQIA) process has been developed to help promote fair and equal treatment in the

delivery of health services. It aims to enable WHSSC to identify and eliminate detrimental treatment caused by the adverse

impact of health service policies upon groups and individuals for reasons of race, gender re-assignment, disability, sex, sexual

orientation, age, religion and belief, marriage and civil

partnership, pregnancy and maternity and language (Welsh).

16.2 Developing policies and practices that ensure individuals are treated equally is the first step towards delivering health services

that are patient focussed and effective. This requires WHSSC to take action to identify and eliminate inequality. Undertaking an

Equality Impact Assessment in relation to all key documents provides a means of doing this. Authors are responsible for

undertaking an EQIA and must begin conducting an appropriate assessment at the initial stage of development. All final

documents must include reference to the Equality Impact Assessment that has been undertaken. This will also be

presented to the approving committee.

16.3 Advice regarding undertaking of an Equality Impact Assessment,

including up to date documentation, can be found on SharePoint.

16.4 This policy has been subjected to an EQIA. The Assessment has shown that there will be no adverse effect or discrimination

made on any individual or particular group.

17. REFERENCES / FURTHER INFORMATION





Welsh Health Specialised Services Committee (2011) Patient and

Public Engagement Strategy and Delivery Plan for 2011-2014

NHS Centre for Equality and Human Rights (date not stated) A Toolkit for Carrying Out Equality Impact Assessment

http://www.wales.nhs.uk/sites3/page.cfm?orgid=256&pid=4315

The Equality Act 2010 http://www.legislation.gov.uk/ukpga/2010/15/contents

Data Protection Act 1998

http://www.legislation.gov.uk/ukpga/1998/29/contents

Abertawe Bro Morgannwg University Local Health Board (2011) Policy for the Production, Consultation, Approval, Publication and

Dissemination of Strategies, Policies, Protocols, Procedures and

Guidelines

Aneurin Bevan Local Health Board (2012) Policy and Procedure for the Management of Policy Documents

Betsi Cadwaladr University Local Health Board (2012) Policy for the

Management of Policies, Procedures and other Written Control Documents

Cardiff and Vale University Local Health Board (2011) Management of

Policies, Procedures and other Written Control Documents Policy

Croydon Primary Care Trust (2009) Policy for Procedural Documents

Cwm Taf Local Health Board (2011) Policy for the Management,

Identification and Authorisation of Policies and Procedures

Hywel Dda Local Health Board (2011) Policy for Written Control Systems

NHS England (2013) Development & Approval of Policy & Procedure

Documents: Policy & Corporate Procedures http://www.england.nhs.uk/wp-content/uploads/2013/05/pol-

1001.pdf

http://www.wales.nhs.uk/sites3/page.cfm?orgid=256&pid=4315



http://www.england.nhs.uk/wp-content/uploads/2013/05/pol-1001.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/05/pol-1001.pdf