Key documents: Do you know what support is available?

Authored by the clinical effectiveness team

There are lots of key documents available at SWB to support our people, but do you know there are different types of key documents (policies, guidelines and SOPs), with different publication requirements and support channels?

The clinical effectiveness team have put together some simple guidance to aid understanding of the different types of Key documents and the support available:

Policy A policy will specify must do rules, steps, and regulations that have to be followed.

A policy is a set of principles of action in a particular field, which should be based on evidence, legislation, best practice and statute and incorporate any standards laid down by recognised professional bodies or other national or NHS institutions where available. A policy, once implemented, is mandatory for all staff and failure to comply may result in disciplinary action.

Corporate And General News

Associate Director of Corporate Governance swbh.policy-admin@nhs.net

1. Local approval (Team & Directorate)

2. Group Governance Approval

3. Policy Assurance Group

4. Publication

Clinical Guideline

A guideline provides general guidance on how to undertake a particular practice.

Clinical guidelines are systematically developed statements, based on a thorough evaluation of the evidence, to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances, across the entire clinical spectrum. As the name implies, guidelines are suggested principles, which are set down to help determine a course of action.

Clinical guidelines are available to support but professional judgement and discretion can still be used. Guidelines may also contain clinical treatment pathways and process flowcharts.

Clinical effectiveness team and library knowledge services swbh.guidelines@nhs.net

Or direct contact with the Clinical effectiveness Coordinator for your Group: https://connect2.swbh.nhs. uk/governance/clinicaleffectiveness/clinical-auditteam/

1. Local approval (Team & Directorate / Relevant specialist forum)

2. Group Governance Approval

3. Medicines & Prescribing Effectiveness Group (MPEG) if guideline contains medicines and prescribing

4. Publication

Standard operating Procedure (SOP)

A SOP is a set of step-by-step instructions for a team to undertake routine process.

SOPs are detailed written instructions used to document and achieve uniformity on the performance of a specific function or process. These should only contain minimal clinical information, such as how to book transfers for patients, where to store equipment etc. If more clinical information is included, consider whether this should be a clinical guideline.

SOPs may also capture how a team standardly functions.

In response to feedback from our colleagues we also wanted to use this opportunity to improve understanding about the governance requirements for key documents and share some top tips for a quick turnaround:

The need to have a good governance process for document approval can be explained by the need for key documents in general. We want to be able to confidently say: “This document contains correct information about best practice…This document does not contain incorrect information…This document enables us to do the best thing for our patients, people and population at SWB.”

Sign off can go through the following groups:

• Local sign off (team/directorate/ specialist forum): this allows the people most impacted by the guideline to voice their approval or raise queries about the content or how to apply the document in practice.

Your local team and admin support

1. Local approval

2. Group Governance for awareness

3. Local team upload to local intranet site

• Group governance sign off: groups are responsibility for monitoring governance processes and outcomes across all specialties within the group to then inform executive quality group (EQG). The attendance at group meetings provides an opportunity to consider the document from multiple viewpoints so discussion in this forum can advise about wider impact of the document, including things like risk management.

• Medicines and prescribing effectiveness group: this forum has attendance from pharmacists and non-medical prescribers as well as representation from the groups. This sign off is designed to provide assurance specifically around the medication and prescribing content of documents in view national best practice, regional procurement arrangements and local service provision.

Top tips:

• Complete the relevant checklist: these documents were designed based on frequently seen issues – completing the checklist will reduce the number of queries you have to rectify before publication therefore speeding up the process!

• Present your document: It is really useful to have the author or appropriate representative available in the meeting to say ‘this is my document and this is what has changed’. It also reduces avoidable delays by having an expert present to clarify any content queries.

• Final changes: It is common for “conditional approval” of documents to be granted at the various sign off stages.

As far as years go, 2023 is a momentous year for SWB. It is the year when it’s full steam ahead as teams are busy making all the changes we need, to ensure our move to Midland Met becomes a reality. The start of 2023 has seen us achieve significant milestones, including ramping up community engagement with our near neighbours, transforming services in cardiology and frailty, and opening our Sandwell same day emergency care unit. On site, there has been positive progress with the completion of level eight, and perhaps one of the most crucial achievements is appointing a move partner to help us safely and efficiently move into Midland Met.

Health Care Relocations (HCR) is an international company with an outstanding reputation and 30 years of experience. They have safely relocated 500 hospitals, with thousands of patients transferred securely from one healthcare facility to another.

HCR will be helping us refine our relocation planning. They have unparalleled expertise