POLICY FOR THE IMPLEMENTATION OF THE NATIONAL CONFIDENTIAL ENQUIRIES, AND RECOMMENDATIONS FROM OTHER HIGH LEVEL INQUIRIES AND REPORTS Version 7 Name of responsible (ratifying) committee Clinical Effectiveness Steering Date ratified 29 May 2018 Document Manager (job title) Clinical Audit and Assurance Manager Date issued 05 July 2018 Review date 31 December 2021 Electronic location Management Policies Related Procedural Documents Policy for the assurance and implementation of NICE guidance in Portsmouth Hospitals NHS Trust Key Words (to aid with searching) National Confidential Enquiries; NCEPOD; MPMN; NCISH; Official enquiries; Research implementation; Standards of care; Quality of patient care; Patient outcome; Avoidable death; Maternal mortality; Perinatal mortality; Suicide; Homicide Version Tracking Version Date Ratified Brief Summary of Changes Author 7 29/05/2018 Update to Quick Reference Guide. Review and revision of external agencies, internal committees, and job titles. Review and revision of references section. Review and revision of Gap Analysis template. D Williams J Burnett 6.1 19/02/2018 Extension to review date D Williams 6 21/01/2015 Review/revision updating external agencies such as CORPs formerly known as NCEPOD and removal of references to NHS Litigation Authority Standards D Williams CONTENTS
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS As a minimum the following elements will be monitored to ensure compliance. Element to be monitored Lead Tool Frequency of Report of Compliance Reporting arrangements Lead(s) for acting on recommendations Process for identifying relevant documents: 100% of all published reports are placed on Clinical website Clinical Audit and Assurance Manager Review of clinical audit website Annually Policy audit report to: Clinical Effectiveness Steering W&CGQC Q&PC Clinical Audit and Assurance Manager Process for disseminating relevant documents 95% of documents will be disseminated within 14 days of publication Clinical Audit and Assurance Manager Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering Group W&CGQC Q&PC Clinical Audit and Assurance Manager Process for conducting an organisational gap analysis: 100% of relevant documents will undergo a gap analysis Responsible Lead Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering Group W&CGQC Q&PC Responsible Lead Process for ensuring that recommendations are upon throughout the organisation 95% of recommendations will be implemented within the timescales Responsible Lead Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering Group W&CGQC Q&PC Medical Director Process for documenting any decision not to implement Confidential enquiries recommendations 100% of such recommendations will have an associated rationale and documented Trust Board agreement Responsible Lead Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering W&CGQC Q&PC Medical Director
EQUALITY IMPACT SCREENING TOOL To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments. Stage 1 - Screening Title of Procedural Document: National Confidential Enquiries Implementation Policy Date of Assessment 28 May 2018 Responsible Department Clinical Audit Name of person completing assessment Jen Burnett Job Title Clinical Audit Facilitator Does the policy/function affect one less or more favourably than another on the basis of : Yes/No Comments Age No Disability No Gender reassignment No Pregnancy and Maternity No Race No Sex No Religion or Belief No Sexual Orientation No Marriage and Civil Partnership No If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2 More Information can be found be following the link below Stage 2 – Full Impact Assessment What is the impact Level of Impact Mitigating Actions Responsible Officer