Self-Review Gap Analysis and Assessor RAG Report
This document is intended for you to complete with details of how you meet the Principles and Requirements of The Information Standard and where your evidence is to prove that you meet each of the Requirements.
The 6 Principles are the high level assessment areas of The Standard and the Requirements are the details which underpin the Principles, and it is the Requirements against which the applicants will be assessed.
Once you have completed your Self-Review Gap Analysis, it should be returned to The Information Standard team. They will forward it to your designated Assessor, who will review it, and provided they believe you are at a suitable level of readiness, will book your External Assessment visit. This document will then be used by the Assessor as the basis for their RAG (Red, Amber, Green) Report which they complete after your External Assessment and which details whether or not you have met the Requirements of The Standard and which areas, if any, need improvement.
You will complete the third column of the RAG report and the assessor will complete the fourth and fifth columns when they will identify your RAG measure for each requirement.
In addition to any comments or evidence you can also attach any supporting documents or information to demonstrate compliance. Any documents submitted or referred to during the assessment can be provided in either electronic or paper version at the discretion of the applicant.
The Self-Review Gap Analysis is intended to be completed with reference to the detailed guidelines within The Principles and Requirements of The Information Standard and reference can also be made to The Information Standard Assessor Guidelines if further clarification is required. These are available on our website, www.theinformationstandard.org together with best practice guides.
The Information Standard team can also offer you further advice if you email them at or telephone them on 01256 383 890. Alternatively they can put you in touch with other, similar organisations that have already been through the process themselves and would be willing to offer you some guidance.
Organisation Name:
Organisation Detail: (summary of organisation including what you do, how many employees and what kind of information products are produced e.g. leaflets, online, video etc)
Completed By (individual in Organisation): Date Completed:
Completed By (Assessor) Date Completed:
Assessing Body:
Scope of Certification: (e.g The provision of information relating to x y z disease that is aimed at people with x y z disease and/or their carers.)
The Principles and Requirements of The Information Standard / This column is to be completed by the Information Producera) Where is the documented evidence you are using to prove you meet the Requirements (ie links to the electronic document, location of hard copy, page and name of document etc)?
b) How does this prove you meet (or plan to meet) the Requirements? / This column is to be used by the Assessor – either during their initial review of the applicant Gap Analysis and/or for the Assessor RAG Report.
Red – Requirements have not been met and must be resolved prior to certification; Amber – Requirements have not been met and there must be a plan in place to resolve within 12 months or less; Green – Requirements have been met. / This column is to be used by the Assessor to show if the Requirements have been met
R / A / G
1. / Information Production - you have a defined and documented process for producing high quality information.
1a. / You have a documented process for producing information. / Attach a copy of your process, which could be illustrated in a variety of ways from a flow chart with the process steps described, to a detailed production process manual.
1b. / All of your public-facing health and care information within scope follows that documented process. / You could prove it by attaching your checklist which shows that each time a step is passed, that element is signed/checked – either manually or electronically. Demonstrate which of the information products you produce are in scope of TIS and those which are out of scope and why.
1c. / All those involved in the information production process understand and are trained to follow your process. / Show the assessor the list of the team and 3rd parties who produce information. Prove how those individuals are aware of their input in the process and their training (e.g. email, training records or talking to the assessor directly, either on the assessment day or on the phone).
2. / Evidence Sources - you only use current, relevant, balanced and trustworthy evidence sources.
2a. / You have checked the most current and relevant evidence sources. / Show your assessor the evidence reviews that you undertook as part of your process and the justification for including the evidence that you have referenced.
2b. / You have referenced your evidence and signposted people to those references. / Show how you record the list of evidence sources used for every information piece – that could be on the production checklist, your recorded search strategy or as a page on the website for example. Ensure that your final products signpost your evidence sources either on the information piece itself or by giving contact details to request them.
2c. / Your organisation has an approved list or guidelines for evidence sources to support your information production and these are reviewed and updated regularly. / Show your assessor the guidelines or evidence sources that have been approved by your organisation and give a brief overview of who is qualified or has the experience to approve them.
2d. / You have provided a balanced account, reflecting the weight of the available evidence and clearly identified any uncertainties or unknowns. / Explain how you deal with differing views, uncertainties and unknowns in the evidence references and detail how you ensure that they are presented in a balanced manner.
2e. / The content, context and quality of the evidence within your information product have been checked by a suitable peer reviewer. / Show your assessor the documentary evidence/email trail to show that expert peer review has been carried out by the assigned suitable reviewer(s) and explain why you consider them to be suitable. Explain how the reviewers’ comments have been documented and implemented or if not implemented, record the justification for why not.
2f. / If re-using another Information Standard organisation’s approved information you must cross-reference that organisation’s name and state the production or last review date as well as the date of next review of the source material. / This may not be relevant, in which case write n/a in the green colum. If you do reuse another organisation’s information, explain how you check the evidence sourced from other IS organisations. Check that the evidence references the name of the organisation and the production or last review date as well as the date of next review of the source material. / / / /
2g. / If required, you have selected your sample products for external product quality check. / Please select 5 sample products that have gone through your production system that contain health and or care information, then provide either links to web pages or copies of leaflets and complete a Product Sample Cover Sheet for each which can be found on our website. (You may not submit re-used information (as in 2f) as one of your sample products).
3.
/User Understanding and Involvement - you understand your users and you user-test your information.
3a. / You know who you are producing information for and why. / The target audience description could be outlined on a production checklist sheet or on a project brief.You may already have a process in place for ensuring that you capture and record that information.
The reason that information piece is needed and how you understood that need could also be recorded in the same place.
3b. / You understand their specific needs and your information products are produced appropriately for that audience and their needs. / You could show your assessor for example, survey sheets, returned questionnaires or individual feedback.
3c. / You have user-tested your information with the intended audience and you have taken account of user feedback in the final product. / The target audience feedback could be gathered via user groups, forums, questionnaires, patient groups, surveys or from individuals or friends who fall within your target audience.
4. / End Product - you double-check your end products
4a. / You have complied with the required elements of the Principle 4 checklists / Show your assessor that you have complied with the Principle 4 checklists.
4b. / Any conflicts of interest/funding/ advertisement are clearly identified and explained. / Explain to your assessor how you deal with any conflicts of interest/funding/advertisement. This would be demonstrated on the final product where are any conflicts of interest/funding/advertisement exist.
4c. / You follow the guidelines for use of The Information Standard Member Logo and display of the disclaimer (see Member Logo Guidelines). / The Member Logo Guidelines are available on the Member area of www.theinformationstandard.org and the disclaimer is detailed within that document.
Not applicable to applicant members who are yet to be certified to use The Information Standard logo.
5.
/Feedback - you manage comments/complaints/incidents appropriately.
5a. / You record comments/complaints/ incidents and have a standard process for dealing with them. / This could be done via a simple comments/complaints/incidents document which details the date, comments/complaints/incidents, contact details, communication and resolution of the comment/complaint/incident. You may already have one which would serve this purpose.5b. / You have a process for ensuring that information products are updated where the comments/complaints/incidents deem it necessary. / Show your assessor your complaint/feedback process and an example of where changes have been made based on feedback, if relevant.
5c. / You communicate with the complainant to inform them how their point has been addressed. / Show your assessor your complaint/feedback process and an example of communication between yourselves and the complainant, if relevant.
5d. / You have a documented moderation policy to manage all forms of user generated content. / Show your assessor a copy of your moderation policy/statement outlining what is/isn’t acceptable and how you control the user generated content as well as indicating where user generated content is available.
6. / Review - you review your products and process on a planned and regular basis.
6a. / You have an information product review process as part of your information production system. / Demonstrate there is a process for reviewing and updating information products (including back-catalogue
products) to the same standard as for new products.
6b. / You have a planned review schedule for your information products as per their review dates. / The planned review dates for each product could be entered onto a review calendar or schedule (maximum review period of 3 years).
6c. / You have a version control and archiving process in place. / Confirm, with documentary evidence, that a version control process is being used for electronic and/or hard copies of documents.
Confirm the process for archiving information products (after year 1, for a minimum of 4 years from the initial production date) and how the archived information will be managed. For example, when will archived documents be destroyed/deleted and how will electronic documents be backed up.
6d. / You regularly review your information production process and update it, if required. / Explain how you regularly review the production process or will be conducting this in the future.
Appendix A – Principle 4 Checklists
These checklists are designed to ensure that you comply with your production processes when you produce individual products.
The System ChecklistThis checklist is designed to help you and the assessor double-check that the key elements of The Information Standard have been implemented on each product. / Evidence
You must be able to demonstrate to the Assessor that each of these points has been implemented for each information product – you could cross-reference other documents, you may choose to incorporate these elements into your own production checklist/product or you could use this checklist. It is not mandatory to complete this as a separate checklist for every product, but you must be able to provide the evidence if asked, to prove that each point has been addressed for every product.
1. The needs and diversity of the target audience have been identified and met, with consideration given to the health literacy levels of the audience.
2. The evidence is up-to-date and has been derived from appropriate sources. The evidence is presented in a clear manner, reflecting the weight and quality of the evidence and it is clear where there is little or no evidence.
3. User feedback has been sought, assessed and included as appropriate.
4. Product has been peer reviewed by a suitable person.
5. Product has been proofread for grammar, spelling and punctuation.6. Product is designed according to the organisation’s style guide, where appropriate.
7. Product is designed to be accessible by the target audience (as far as budgets allow).
8. Product has been approved for publication by final authorised approvers.
Appendix A – Principle 4 Checklists continued
The Final Product ChecklistThis checklist outlines the elements that are required on a final product. / Evidence
Each of these should be evident on every information product. This checklist does not need to be completed for every information product but it must be evident from the product itself that these elements have been complied with.
1. Product features the production or last review date as well as the date of next review.
2. Product is in plain language, is free from spelling or grammatical errors and free from medical or social care jargon; medical terms are explained where necessary.
3. Sources of evidence are clearly signposted where appropriate.
4. The Information Standard logo is displayed correctly for certified organisations.