Using Evidence in Practice

 

Developing, Implementing, and Monitoring a System for the Management of Corporate Policies: A Partnership Between Risk and Evidence

 

Amanda Minns

Head of Evidence

NHS Lanarkshire

Bothwell, Scotland, United Kingdom

Email: amanda.minns@lanarkshire.scot.nhs.uk

 

Carol McGhee

Corporate Risk Manager

NHS Lanarkshire

Bothwell, Scotland, United Kingdom

Email: carol.mcghee@lanarkshire.scot.nhs.uk

 

Received: 2 Sept. 2019                                                                    Accepted: 18 Feb. 2020

 

 

cc-ca_logo_xl 2020 Minns and McGhee. This is an Open Access article distributed under the terms of the Creative Commons‐Attribution‐Noncommercial‐Share Alike License 4.0 International (http://creativecommons.org/licenses/by-nc-sa/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly attributed, not used for commercial purposes, and, if transformed, the resulting work is redistributed under the same or similar license to this one.

 

 

DOI: 10.18438/eblip29641



Setting

 

National Health Service Lanarkshire (NHSL) is the third largest health board in Scotland serving a population of approximately 655,000 across both rural and urban communities in Lanarkshire and employing approximately 12,000 staff.

 

The aim of the project was to develop and implement a system to manage and monitor the corporate policies for NHSL, providing assurance that policies were contemporary and extant. A working group, jointly led by

 

the departments of Corporate Risk and Evidence, was set up to manage and monitor corporate policies.  Corporate policies are core documents within the organization that provide a statement of principles and/or actions to ensure consistent decision-making and resource allocation. For example, much of the Human Resources Department’s actions are based on national guidelines which are then translated into local policies (e.g., maternity policy and retirement policy). Other departments also translate actions that all staff must adhere to (e.g., Copyright Policy and Password Policy). Ensuring we have a consistent way to communicate these core principles and required actions is the key function of a policy. At this early stage, the nature and depth of the requirements was not clear. However, it was known that policies were dissipated throughout the board without one governance system to allow them to be easily managed. Given the essential nature of the content in many of the policies, having a system that provided the necessary assurance to the board was essential.

 

Problem

 

From the earliest stage, it was identified that the landscape around policies within the board was complex and decentralized. The absence of control of policies over many years had already been recognized by the Corporate Risk Manager.

 

It was unclear at the start the project of the size, scale and complexity of the work that was required to be undertaken. The first step was therefore to set up a project group bringing in other interested parties to ensure the work would have buy-in across the board. This group was chaired by the Corporate Risk Manager and outlined the desired outcomes and scope the project work required. Representation from Corporate Risk, Evidence, Information Management Technology, Practice Development, Nursing Midwifery and Allied Health Professionals, Medical Education, staff side, Pharmacy, and Human Resources were all essential to the development of this early work.

 

At the initial stage in the project and in discussion with the Corporate Risk Manager, the Evidence team was able to demonstrate that they had the necessary skills to help manage this project. Initially the role for Evidence was to help with categorization and key terms for developing a search function of policies online. However, as the project progressed, the involvement from Evidence became more central and integral to the day-to-day running of the system.

 

Evidence

 

Evidence for this project spanned a number of areas, including the lived experience of the staff using policies every day, as it was recognized that this evidence would be as important as traditional printed evidence. 

 

The first evidence search was to ensure NHSL had the most up-to-date information on the existing landscape. An amnesty on the existing policies started in 2009. This allowed a developing picture of the scale of the issue that enabled discussion, consideration, and views from the collective expertise of those in the working group to outline the vision of where NHSL needed to be in one year, two years, and beyond.

 

The Evidence team was key to:

 

·         Searching the literature for definitions of policies, guidelines and protocols to help define the scope of the project; 

·         Seeking out who else might be doing similar work, what approach had they taken, and how far had they progressed;

·         Developing a policy for NHLS: Developing Organisation Policy.

 

A number of literature searches were completed at this early stage that helped form the NHSL Policy for Developing Organisation Policy, including definitions, and understand the approach others had taken, if any. Ensuring evidence was used – both from the printed literature and from talking to those designated authors and leads who develop policies in the health board – greatly influenced how the work developed and matured. The definitions of the different types of documents is the same now as it was at the start of the project and this has ensured that we have consistently applied the definitions as the project has changed and developed. These definitions have also helped shape other work in the management of guidelines for NHS Lanarkshire.

 

Evidence searching was and continues to be the backbone of the development and updating of policies. For example, all policies must reference their evidence base, whether this is from other policies, national standards, legislation, Scottish Government circulars, or Partnership Information Guidelines produced by NHS Scotland, etc.

 

In continuing to improve the effective management of NHSL policies, seeking evidence on accessibility of policies was also important in ensuring NHSL adopted best practices and complied with NHS Lanarkshire Communications Strategy 2013-2018.

 

Implementation

 

The working group met quarterly from 2009 and was responsible for the development, implementation, monitoring, and continuous improvement of the organizational systems that will enable access to up-to-date and endorsed polices, in support of the Board of NHS Lanarkshire.

 

There were a number of complexities when it came to implementation, in particular: how to develop a system that has the right levels of controls, but allows a degree of flexibility to work well; and how to engage with the managers/staff/teams to bring them on board?

From the literature review, a policy template was developed. All new policies had to use the template and over a period of three years (maximum review period) all policies due for an update were re-written in the new template policy. This was closely monitored by the Evidence team, who returned policies to authors and leads if they were not in the approved format.

 

Information Management and Technology was key in the development of the control systems. Given the size and complexity of the board, it quickly became obvious that change was required: the repository for the polices moved from a paper policy system to an online one, which allowed for the monitoring of policy review dates, and enabled watermarking on policies with “out of date” when printed on each document for version control.  

 

While there was no additional funding made available, the key to success was the use of the available subject expertise recognizing that the approach would be incremental and would be at a pace that both suited the project group and the change management for the policy authors and leads. Listening to users was invaluable in the development and implementation, especially as the system of notification of review dates was implemented.  Feedback from users influenced a change in notification times, triggered by the Evidence team, to allow for the endorsing process through the governance groups to be extended to a more reasonable period. The Evidence team implemented a revised trigger process, which has proven to be much more effective. 

 

Outcome

 

Information Management and Technology built a bespoke page on the intranet as the central repository for policies and the Evidence team built the behind the scenes online management system that tracked and monitored the policies. In conjunction with these two systems – a key performance indicator was agreed upon by the group – it is monitored on a monthly basis. It has enabled a reporting function that provides a level of assurance to the board on the management of corporate policies across the system (Figure 1). The partnership between Corporate Risk and Evidence and their relevant expertise in continuous monitoring and improvement has led to having a system that ensures high levels of compliance.

 

There has been a further change within the last 12 months to move the policies from the intranet site to the NHSL public site, which involved a quality review of policies ensuring they met agreed standards for posting on the public website. A further exercise was taken to check all polices for stating compliance with General Data Protection Regulations. The Head of Evidence is also the NHS Lanarkshire representative for working towards the One for Scotland national policies project with the Scottish Government which has led to further changes within policies governance.

 

The overall systematic approach to the effective management of the corporate policies has also been used as an exemplar for other projects within the board, demonstrating a consistently good way to approach complex management of official documentation.

 

Figure 1

Corporate policy key performance indicators. All corporate policies are reviewed within the review date, and no later than 10 working days of the scheduled review date. The tolerance threshold has been set at 95%.

 

Reflection

 

Collaborative working and effective leadership from the Risk and Evidence heads of service has been the key to the success of this project. Both teams recognized their expertise and were able to bring together others in a working group to ensure the project delivered impact and value. Through the corporate risk management function, the corporate management team for NHSL were fully sighted on, and supported the improvements for the change and the expectations, helping unblock barriers as they arose.

Making sure there was strong evidence for change was vital. While there was some resistance at the start, there has been great benefit to having a controlled, systematic, consistent, and focused approach to a complex area of system control.

 

Conclusion

 

Continuous development was and continues to be a core principle of the working group.  While the membership of the working group has reduced and changed over nine years, the desire to continually improve the systems for staff continues. 

 

From an Evidence team point of view, be brave and put your head above the parapet. There are many skills within the evidence department that can strengthen, and bring added value to operational and governance arrangement across an organization. Initially, there was a suggestion to outsource this work. Had that happened, the current system would not have been developed with the control and flexibility required and with the same passion to continue to improve.

 

References

 

Brown, C. (2013) NHS Lanarkshire Communications Strategy:  2013-18. NHS Lanarkshire, Scotland.

 

NHS Lanarkshire (2020) Policies, Procedures, Strategies and Plans. Available at  https://www.nhslanarkshire.scot.nhs.uk/about-us/policy-procedure-plan/ [Accessed 25 November 2019].