Policy and Standard Operating Procedure (SOP) Ownership and Review SOP

Overview

To ensure BrisDoc Policy and SOP documents are kept up to date and fit for purpose, each document has a review date and an “owner”. This SOP will outline the role of a Policy or Standard Operating Procedure owner and the process they must follow.

Roles and Responsibilities

Governance Team – will maintain an index of Policy and SOP documents, the team will track dates and highlight to Policy / SOP owners when a document needs reviewing. When the document has been reviewed and a final version is issued, the governance Team will update the index / shared drive and radar. The Governance Team are responsible for highlighting updated policies through the BrisDoc newsletter. Review compliance levels will be reported via the Quality Board.

Policy or Standard Operating Procedure Owner – Responsible for ensuring the Policy is reviewed and updated, including documenting all changes in the change register. The owner of the document is responsible for liaising with any other contributors and combining changes as necessary. For policies – the owner should get approval for the policy changes from the appropriate governance group meeting (eg: Quality group or LOB) The owner is responsible for sending a complete final version of the document to the Governance Team. If delays occur in reviewing the document, the owner is responsible for communicating this to the Governance Team

SOP details

When a policy or SOP has reached the review date, the following steps need to happen:

• The document will show as ‘red’ on the policy / sop index
• The Governance Team will highlight the document and the need for review to the document owner
• The document owner should review the document in conjunction with any relevant contributors and amend as needed.
• The document owner should maintain the change register
• The document owner should ensure all dates are updated (review date etc)
• For Policies, the owner should get approval from the most appropriate governance meeting.
• If there are delays in completing the review the document owner should flag this at the most appropriate governance meeting. And to the Governance Team to ensure the index is updated.
• When a final document has been agreed, the owner should send a word version to the Governance Team.
• The Governance Team will update the Policy / SOP index.
• The Governance Team will archive old versions and save the new version in the confidential policy folder on the shared drive.
• The Governance Team will replace the version on radar with a PDF version for general staff access.
• For SOPs – the owner should circulate a new version to the staff members who regularly use the document.
• For Policies – The Governance Team will highlight in the newsletter that the policy has been reviewed and updated and encourage staff to familiarise themselves with the new version.

Change Register