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P-61 ‘Have we got a policy for that?’ Monitoring of clinical policies and procedures using data management software
  1. Sarah Hay
  1. St Helena Hospice, Colchester, UK


An effective monitoring system for the management of clinical policies and procedures ensures that documents remain up to date with best practice, that Care Quality Commission (CQC) regulations are adhered to, and that a systematic archive is in place.

The creation of a bespoke system for robust monitoring would ensure improved oversight by both the clinical governance sub-group responsible for clinical policies and procedures, and for service leads. Prior to this there was little ownership and oversight; administrative management was led by one member of staff using a non-centralised database. The database often lacked key information, such as review dates, making effective monitoring difficult.

A bespoke system was designed and created for effective monitoring and robust version control. Individual records were created for each policy/procedure, and populated with relevant information such as ownership, review dates, and previous versions, to create a full history of each document. Reports were created to enable service leads to monitor policies/procedures for their own service, and for the Clinical Policies and Procedures Review Group to maintain oversight at monthly meetings.

Using the new system has resulted in improved governance in this area, with managers having clear oversight of any reviews due or overdue. The Clinical Policies and Procedures Review Group are able to monitor and chase overdue reviews, which did not happen before. Using the system to create an archive of previous versions of documents ensures a high standard of record keeping and records management is maintained.

An improved policy management system has meant that leaders and trustees can be assured of effective governance processes and that the organisation remains up to date with best practice guidance. Using a bespoke system means that every aspect of policy and procedure management can be captured under one roof, providing assurance that governance processes are in place, in turn assuring CQC of the same.

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