Governance guidance on Guidelines, SOPs or other papers for submission to East Lancashire Medicines Management Board

  1. When preparing guidelines, prescribing procedures or other written medicines advice for use in East Lancashire, the follow points must be included in the document.

Checklist
1.1Ownership
The document must contain clear information on who the author(s) or compiler(s) of documents are, with contact details, and who has reviewed the document.
1.2Dates
Dates of preparation and review dates must be presented.
1.3Supercession
Documents previously pertinent to the subject such as earlier versions must be referenced. A system of version control and archiving is required.
1.4Area of relevance
The geographical/organisational and clinical area to which the document relates.
  1. The following points must be considered and be demonstrable to the East Lancashire Medicines Management Board (ELMMB) at time of submission.

Checklist
2.1 Organisational governance requirements
Most high level clinical policy documents would require ratification within individual organisations after ELMMB approval. Has this been considered? This has an impact on implementation planning.
2.2 Risk Assessment
Be aware of the need for risk assessment prior to introduction of new guidance or policy. This should be dealt with through organisational governance frameworks.
2.3 Implementation plan
A written schedule of actions to be taken and the timetable must be available to give an assurance of safe introduction.
2.4 Diversity and Equality impact
A demonstration of assessment in this area in terms of access to service.
2.5ELMMB document insert
For documents intended for use in multiple organisations, a cover sheet or insert page should be used to signify ELMMB approval across these organisations.This should be inserted into the document after approval, before any further approval processes occur within individual organisations. The document is available on request via ELMMB contact persons.
A sample document insert is presented on page 3 of this document.
2.6 Submission coversheet
The submission sheet proforma as presented on page 4 should be used to accompany the submitted paper help present some of this information.

ELMMB contacts:

<Document Title>

Approved by East Lancashire Medicines Management Board

This document has been reviewed and approved with respect to clinical safety, effectiveness and prescribing strategy within East Lancashire.

Approval date:

Review date:

East Lancashire Medicines Management Board contacts:

lisa.rogan@eastlancspct

East Lancashire Medicines Management Board chair:

Dr. Duncan Gavan

Associate Medical Director, Diagnostics and Treatments Division, East Lancashire Hospitals NHS Trust

SUBMISSION TO MEDICINES MANAGEMENT BOARD
MMB Meeting Date: / Submission Purpose:
For Decision □
Performance Monitoring □
For Information □ / Agenda Item:
Report Author: / Report Sponsor: / Report Title:
Previously Considered By:
Committee Date
NA / Declaration of Confidentiality Required:
Yes No
Implications For Partner organisations:
Related to key risks identified on Assurance Framework: / All patient care risks
Related to Corporate Commitments:
(Delete as appropriate) /
  • Improved patient experience by putting quality at the centre of everything we do.
  • Delivery of all national standards and targets.
  • Improved productivity.
  • Improved efficiency.
  • Invest in and develop our workforce

Legal Implications Identified:
Data Protection Implications Identified:
Diversity and Equality Implications Identified:
Related to NHS Constitution:
(Delete as appropriate) /
  • A comprehensive service available to all
  • Access based on clinical need
  • Aspiring to highest standards of excellence & professionalism
  • Reflecting needs and preferences of patients & families
  • Working in partnership across organisational boundaries
  • Providing best value & effective & fair sustainable use of finite resources
  • Accountable to public, patients & communities

Related to CQC Regulation & Outcomes:
(Delete as appropriate) /
  • Involvement & Information
  • Personalised care, treatment & support
  • Safeguarding & Safety
  • Suitability of staffing
  • Quality & management
  • Suitability of management

Executive Summary:
Recommendation/ What Is Required From The Committee:

Document prepared by Vincent Goodey, Pharmacy Department, RBH

Approval date 17.11.10

Review date 17.11.15