Governance Documentation SOP

Documentation

The function of corporate governance is holistically supported by a suite of documents which enable quick reference and assurance to stakeholders. There are three key types of documents used by BrisDoc to inform practice and procedure. Each document is monitored and reviewed regularly to ensure accuracy and compliance with organisational corporate governance principles.

The definition of each type of governance document recognised by BrisDoc is provided below.

Policy

Policies guide processes and ensure a clear plan of what to do in particular situations. These documents have been agreed to by the relevant corporate governance groups and provide the basis against which compliance is measured.

Standard Operating Procedure

Standard operating procedures (SOPs) set out step-by-step instructions to ensure routine operations achieve efficiency, quality output and uniformity of performance, while reducing miscommunication and failure to comply with regulations.

Handbooks

A Handbook is a convenient, reference tool which makes available facts and information on role or team’s specific functions which links to SOPs and Policies as required.

Framework

A basic structure underlying a system, concept, or intent, these may accompany a strategy and are used to provide guidance on the approach to a specific intent.

Strategy

A strategy is used to clearly articulate a plan of action designed to achieve a long-term or overall aim in relation to a specific area.

Terms of Reference (TOR)

Terms of reference (TOR) define the purpose and structures of a meeting, or any similar collection of people who have agreed to work together to accomplish a shared goal. Terms of reference show how the object in question will be defined, developed, and verified. Each TOR covers purpose, membership, quoracy and engagement as well as a standard agenda template.

Steps for Approval of Documentation

The steps for authorising and publishing a Policy, SOP, Handbook, Terms of Reference (TOR), Framework or Strategy are as follows:

1. The Document is written by the author using the relevant BrisDoc Template (available from the Corporate Administrator)
2. The DRAFT should be saved on a local drive (e.g. Y:\Policies & Procedures\SOPs\ sops for Draft) identifying:
   1. Initials of author
   2. That it is in Draft (Versions would be 0.1, 0.2, 0.3, or 1.1 DRAFT etc)
   3. The Full Title
3. Once the Document is ready to be agreed, it should be shared with relevant local team/s (e.g. Practice Lead Team) for review
   1. Move on a local drive to indicate its change in status (e.g.: Y\Policies & Procedures\SOPs\sops for PLT)
4. Once agreed by the relevant team/s the Document should be sent to the Corporate Administrator to be added for approval to a suitable Board/Committee Agenda with an approving Director identified.
5. The Corporate Administrator will index and store the new document as DRAFT
   1. Move on a local drive to indicate its change in status (e.g.: Y:\Policies & Procedures\SOPs\ sops for QB)
6. The relevant board/Committee (e.g. Clinical Quality Performance Committee/Leadership Oversight Board) will approve the Document
7. The Corporate administrator will update the version number (e.g. 1.0, 2.0, 2.1), the index, front page dates and upload to radar.
8. Once added to radar all local copies of drafts MUST be sent to the Corporate Administrator for filing.
9. All local copies should be archived to ensure they are not available to staff.

Version Control