CFP 4 Quality Impact Assessment (QIA) Policy

CFP 4 Quality Impact Assessment (QIA) Policy Policy number CFP 4 Version 1.0 Approved by Name of author/originator Owner (director) Commissioning, Finance and Performance Committee Helen Collins, Associate Director of Quality and Improvement Vicky Stobbart, Executive Director for Nursing, Quality and Safeguarding Date of approval January 2017 Date of last review January 2017 Review to be completed by January 2018 To be next approved by January 2019 Page 1 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Version control sheet Version Date Author Status Comment 1.0 December 2016 Helen Collins Draft 1.0 January 2017 Helen Collins Approved Approved by Commissioning, Finance and Performance Committee 1.0 March 2017 Helen Collins Approved Submitted to Quality and Clinical Governance Committee for information Page 2 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Equality statement NHS Guildford and Waverley aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. We take into account the Human Rights Act 1998 and promote equal opportunities for all. This document has been assessed to ensure that no employee receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Members of staff, volunteers or members of the public may request assistance with this policy if they have particular needs. If the member of staff has language difficulties and difficulty in understanding this policy, the use of an interpreter will be considered. We embrace the four staff pledges in the NHS Constitution. This policy is consistent with these pledges. See next page for an Equality Analysis of this policy. Page 3 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Equality Analysis Equality analysis is a way of considering the effect on different groups protected from discrimination by the Equality Act, such as people of different ages. There are two reasons for this: to consider if there are any unintended consequences for some groups to consider if the policy will be fully effective for all target groups Name of Policy: QUALITY IMPACT ASSESSMENT POLICY Policy Ref: TO BE CONFIRMED Assessment conducted by (name, role): Helen Collins, Associate Director of Quality and Improvement Is this New? [Y ] Or Existing? [ ] Date of Analysis: 16 th February 2017 Directorate: Quality and Safeguarding Director s signature: Who is intended to follow this policy? Explain the aim of the policy as applied to this group. Employees of the Guildford and Waverley Clinical Commissioning Group or those who are host commissioned by them Who is intended to benefit from this policy? Explain the aim of the policy as applied to this group. Everyone who uses or is involved in delivering health and social care. The policy is far reaching. 1. Evidence considered. What data or other information have you used to evaluate if this policy is likely to have a positive or an adverse impact upon protected groups when implemented? None as it is designed to ensure that equality and quality are maximised at all times. 2. Consultation. Have you consulted people from protected groups? What were their views? No, as the policy is designed to enhance the quality of care for protected groups in conjunction with equality processes. 3. Promoting equality. Does this policy have a positive impact on equality? What evidence is there to support this? Could it do more? Positive impact as the policy is designed to enhance equality for protected groups 4. Identifying the adverse impact of policies Page 4 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Identify any issues in the policy where equality characteristics require consideration for either those abiding by the policy or those the policy is aimed to benefit, based upon your research. a) People from different age groups: None b) Disabled people: None c) Women and men: None d) Religious people or those with strongly help philosophical beliefs: None e) Black and minority ethnic (BME) people: None f) Transgender people: None g) Lesbians, gay men and bisexual people: None h) Women who are pregnant or on maternity leave: None i) People who are married or in a civil partnership: None 5. Monitoring How will you monitor the impact of the policy on protected groups? Through quality alerts and complaints Page 5 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Contents 1. Introduction and Policy Objective... 7 2. Legislative Framework/Core Standards... 7 3. Scope... 7 4. Definitions... 7 5. Roles and Responsibilities... 9 6. Procedure for assessing impact... 9 7. Frequency of assessment... 10 8. Raising concerns... 10 9. Implementation... 11 10. Monitoring... 11 11. Review, ratification and archiving... 11 12. Dissemination and publication... 11 13. Associated documents... 12 14. Bibliography... 12 15. Appendix 1: Risk Assessment Matrix... 13 16. Appendix 2: Initial Impact Screening Tool... 16 17. Appendix 3: Full Quality Impact Assessment... 18 18. Appendix 4: Quality Assurance Group Terms of Reference... 22 19. Appendix 5: Procedural Document Checklist for Approval... 25 20. Appendix 6: Compliance & Audit Table... 27 Page 6 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

1. Introduction and Policy Objective Guildford and Waverley Clinical Commissioning Group is committed to ensuring that commissioning decisions, business cases and any other business plans are appropriately evaluated for any potential impact on quality. The document outlines the process to be undertaken in order to assess the impact of any major change or policy decision and then ensure that adequate mitigations are put in place if necessary. 2. Legislative Framework/Core Standards The purpose of this document is to set out the responsibilities, process and format to be following when undertaking a quality impact assessment or where necessary a combined assessment also considering equality. The following legislation is relevant to this procedure: Equality Act 2010 Health and Social Care (Safety and Quality) Act 2015 Health and Social Care Act 2012 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 3. Scope This procedure relates only to impact assessments that are undertaken during the course of decision making on any of the following aspects of CCG business: Commissioning decisions Service redesign and pathway development Business case refusal Quality and cost improvement plans Changes to the infrastructure of the organisation Workforce redesign The above list is not exclusive or exhaustive and therefore when making any changes to service or policy an impact assessment should be considered. The remainder of this document will refer to this list collectively as business decisions. 4. Definitions 4.1 Quality Page 7 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Quality can be defined as embracing the following three components: Patient Safety ensuring all appropriate measures are taken to avoid harm to patients Effectiveness of care providing the most appropriate treatments, interventions, support and services to patients at the right time Patient Experience ensuring that the patients experience is at the centre of the organisations approach to quality 4.2 Equality The Equality Act 2010 defines nine protected characteristics which the organisation must consider when making business decisions. The characteristics are as follows: Age - including specific ages and age groups Disability including cancer, HIV, multiple sclerosis and physical or mental impairment where the impairment has a substantial and long term adverse effect on the ability to carry out day-to-day activities Race including colour, nationality and ethnic or national origins Religion or belief including a lack of religion or belief, and where belief includes any religious or philosophical belief Sex Sexual orientation meaning a person s sexual orientation towards persons of the same sex, persons of the opposite sex and persons of either sex Gender re-assignment where people are proposing to undergo, are undergoing or have undergone a process for the purpose of reassigning the person s sex by changing physiological or other attributes of sex. Pregnancy and maternity Marriage and civil partnership If these are not considered and any risks mitigated, then quality is inevitably affected. This is why it is a key part of the Quality Impact Assessment. The organisation has an equality policy and impact assessment which should therefore be considered in its own right, and is referred to in the initial and full assessment including where to access the correct documentation and guidance. 4.3 Impact Assessment An impact assessment is a continuous process to ensure that possible or actual business decisions are assessed and the potential consequences on quality and equality are considered and any necessary mitigating actions are outlined in a uniformed way. Page 8 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

5. Roles and Responsibilities 5.1 Governing Body The Governing Body have overall responsibility for balancing necessary business decisions with quality and equality standards. They also have responsibility for providing assurance to external stakeholders. They will delegate the operational responsibility to the Executive Management Team (EMT). 5.2 Executive Management Team (EMT) The Executive Management Team is responsible for reviewing, at every meeting, the outcome of the Quality Assurance Group and the decisions they take on approvals for quality and equality impact assessments business decisions, where necessary, intervening if they feel the decision should be overturned. 5.3 Quality Assurance Group (QAG) The Quality Assurance Group will consist of the Executive Director of Nursing, Quality and Safeguarding, Associate Director of Quality, Quality and Safety Manager and two more members of the Senior Delivery Group (preferably Deputy Director of Governance and Compliance and Head of Partnership and Patient Engagement) to assigning approval of quality impact assessments of business decisions based on the levels of residual risk following mitigating action. They are responsible for keeping a log of assessments, and instructing a periodic audit of them to ensure no impact has actually occurred. 5.4 Senior Delivery Group (SDG) The members of the Senior Delivery Group are responsible for ensuring that business decisions are evaluated and locally approved for their impact on quality and/or equality. They are also responsible for ensuring they are submitted to the Quality Assurance Group for final approval. 5.5 Deputy Director of Governance and Compliance The Deputy Director of Governance and Compliance is responsible for the Trust s risk management processes and systems and ensuring a consistent approach to risk assessment. They are responsible for ensuring that any identified risks from the quality impact assessment are captured on the Trust s risk management system and escalated to the Corporate Risk Register as appropriate. 6. Procedure for assessing impact The flowchart below provides a step by step outline of the procedure for assessing impact. The scoring tool attached at Appendix 1 provides guidance on the criteria to consider when scoring each risk. Page 9 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

As part of the impact assessment, the assessor is required to consider any risks which should be added to the risk register. Any risks graded as 15 or above or with a consequence of five would automatically form part of the Trust s Corporate Risk Register and will be considered by the Audit Committee and the Quality and Clinical Governance Committee. Flowchart for Assessing / Reviewing / Monitoring Impact Initial screening of potential for impact to be undertaken by the manager or project lead (APPENDIX 2) Identification of impact in one or more areas? YES - Business decision put on hold and full impact assessment required and submitted for approval by QAG NO - Submit and gain approval from QAG and continue with business decision unless otherwise informed by QAG Full assessment of impact and identification of mitigating actions (APPENDIX 3) Escalation to appropriate member of SDG of any impact assessed as 'significant' to 'major' QAG to review and take approval on full impact assessment including a full review of the impact assessment, mitigating action plan and monitoring arrangements Notification from QAG to EMT of approval status of business decision and to business decision lead of outcome of review If all agreed by the EMT, the manager can fully proceed with the proposal and should commence implementation of the business decision 7. Frequency of assessment Impact assessment is a continuous process to help decision makers think through and understand the consequence of business decisions. Impact assessments must be undertaken as part of the development and proposal stage of developing plans and should also be reviewed on a regular (e.g. monthly) basis by the project leads, as part of reviewing the actual impact throughout the implementation stage and during the final review after the business decision has been implemented. 8. Raising concerns Where quality concerns which have potential to impact on patients are identified, the monitoring of quality outcomes should occur by the relevant lead. If there are further Page 10 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

concerns with the impact, the individual should follow the organisation s raising concerns policies which are accessible from the Human Resource Department. 9. Implementation This procedure is new for the organisation and will be implemented with immediate effect. All managers will be notified of the new requirements and a series of briefings will be arranged to support managers with this. The Quality Assurance Group will be formed and will begin meeting immediately following ratification of this document. Terms of Reference for the Quality Assurance Group will be submitted to the Executive Management Team for approval. 10. Monitoring Refer to appendix 6. 11. Review, ratification and archiving The procedure will be reviewed every 3 years or earlier if legislation, national policy or guidance changes are required to be considered. The review will then be subject to approval and re ratification. The author or Central Policy Officer is responsible for ensuring that archive copies of superseded working documents are retained in accordance with the organisation s record management policies. Persons requiring access to an archived policy must contact the central policy officer or the company secretary and provide them with the document title, name of author, ratification date and the version required. In addition, an electronic version of this is available on the organisation s intranet. 12. Dissemination and publication A copy of this policy will be uploaded to the organisation s intranet. The Head of Communications is responsible for organisational wide notification of the new procedure. The Associate Director of Quality is responsible for ensuring a communication is issued to all managers regarding the new procedure and is followed up with a series of presentations / drop in sessions. Page 11 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

13. Associated documents This procedure should be read in conjunction with the following organisational documents: Equality Impact Assessment Policy Risk Management Strategy and Policy Raising Concerns Policy 14. Bibliography Page 12 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

15. Appendix 1: Risk Assessment Matrix Step 1 Calculate the potential consequence: CONSEQU- ENCE 1 2 3 4 5 DOMAIN NEGLIGIBLE MINOR MODERATE MAJOR CATASTROPH IC Minimal injury requiring no / minor interventi on Minor injury or illness, requiring first aid / minor medical treatment. Moderate injury requiring medical intervention Major injuries, or long term incapacity / disability Death Patient / Staff Safety No time off work required >3 days off work 4-14 days off work >14 days off work An event that impacts on a large number of patients RIDDOR reportable injury Multiple permanent injuries or irreversible health effects in a staff member Patient Experience Unsatisfactory patient experience not directly related to patient care Unsatisfactory patient experience readily resolvable Mismanageme nt of patient care Serious mismanageme nt of patient care Totally unsatisfactory patient outcome or experience Complaints Informal complaint resolved at local level Formal complaint where resolution achieved Formal complaint with potential to go to independent review Potential for more than one complaint / independent review Multiple complaints / inquest / ombudsman inquiry Page 13 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Workforce Short-term low staffing (<1 day) which does not impact on quality Short-term low staffing (<1 day) which temporarily impacts on quality Unsafe staffing level or competence >1 day Unsafe staffing level or competence >5 days Ongoing unsafe staffing levels or competence Service / Business Interruption Loss / interruption more than 1 hour Loss / interruption more than 8 hours Loss / interruption more than 1 day Loss / interruption more than 1 week Permanent loss of service or facility Financial Small loss < 5000 Loss more than 0.1% of budget 5000 - < 25K Loss more than 0.25% of budget 25K - < 100K Loss more than 0.5% of budget 100K - < 500K Loss more than 1% of budget > 500K S External Bodies / Inspections / Statutory Duties No or minimal recommendatio ns No or minimal noncompliance with standards / statutory duties Minor recommendatio ns given. Minor noncompliance with standards / statutory duties Reduced rating. Challenging recommendatio ns. Noncompliance with core standards / single moderate breach of standards / statutory duties Enforcement Action. Low rating. Critical report. Major / multiple noncompliance with core standards / statutory duties Prosecution. Zero Rating. Severely critical report Gross failure to meet national standards / statutory duties Adverse Publicity / Reputation Rumours Local media Short term. Minor effect on staff morale Local media Long term. Significant effect on staff morale National Media less than 3 days National media more than 3 days. MP Concern (Questions in House) Objectives / Projects Insignificant cost increase / schedule slippage. Barely noticeable reduction in scope or quality Less than 5% over budget / schedule slippage. Minor reduction in quality / scope 5-10% over budget / schedule slippage. Reduction in scope or quality 10-25% over budget / schedule slippage. Doesn t meet secondary objectives More than 25% over budget / schedule slippage. Doesn t meet primary objectives Page 14 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Step 2 Calculate the potential likelihood: LIKELIHOOD Likeliho od Descript or Likelihood Examples CONSEQUENCE 1 2 3 4 5 1 Rare Difficult to believe that this will ever happen/ recur 1 2 3 4 5 2 Unlikely Do not expect it to happen/recur, but it may 2 4 6 8 10 3 Possible It is possible that it may occur/recur 3 6 9 12 15 4 Likely Is likely to occur/recur but is not a persistent issue 4 8 12 16 20 5 Almost Certain Will almost certainly occur/recur and could be a persistent issue 5 10 15 20 25 Step 3 Calculate overall risk score (consequence x likelihood): Low Risk Moderate Significant Major Risk 1-3 Risk Risk 15-25 Page 15 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

16. Appendix 2: Initial Impact Screening Tool Please submit this initial screening assessment with the full details of the business decision to the Associate Director of Quality and Improvement. Full contact details of this person are available from the Administration team. Does the business decision directly affect patients or their families/carers? No Area of Quality Positive Impact Negative Impact No Impact Duty of Quality Compliance with NHS Constitution Impact on partner organisations and any aspect of shared risk Impact on organisations duty to safeguard children and vulnerable adults Impact on other services within the organisation List any other risk indicators relevant to the Duty of Quality Patient Safety Impact on patient safety Impact on preventable harm Impact on reliability of safety systems and processes Impact on systems and process for ensuring that the risk of healthcare acquired infections to patients is reduced Impact on clinical workforce capability and skills List any other risk indicators relevant to the Patient Safety Patient Experience Impact on self- reported experience of patients and service users in national / local surveys Impact on self- reported experience of patients and services users through the complaints process Impact on the self- reported experience of patients and service users through PALS contacts Impact on patient choice Impact on patient access Impact on the commitment to provide individualised care List any other risk indicators relevant to Patient Experience Page 16 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

Clinical Effectiveness Impact on the implementation of evidence based practice Impact on clinical outcomes Impact on clinical leadership Impact on the full adoption of Best Care Impact on variations in care Impact on ensuring care is delivered in the most clinically and cost effective setting Impact on clinical engagement List any other risk indicators relevant to the Clinical Effectiveness Equality A full equality assessment must also be conducted. Guidance and appropriate forms are available via the CCG s intranet: http://nww.guildfordandwaverleyccg.nhs.uk/corporate /FormsTemp/Pages/default.aspx Please now submit this initial screening assessment with the full details of the business decision to the Associate Director of Quality and Improvement. Full contact details of this person are available from the Administration team. Page 17 of 27 CFP 4 Quality Impact Assessment (QIA) Policy

17. Appendix 3: Full Quality Impact Assessment Please submit this initial screening assessment with the full details of the business decision to the Associate Director of Quality and Improvement. Full contact details of this person are available from the Administration team. QUALITY IMPACT ASSESSMENT SUBJECT OF ASSESSMENT: TEAM: DIRECTORATE: REASON FOR PROPOSED CHANGE: DOES THE SUBJECT OF THE ASSESSMENT DIRECTLY IMPACT ON PATIENTS OR THEIR CARERS? PLEASE LIST ANY RELEVANT STANDARDS / REGULATORY / STATUTORY REQUIREMENTS AND CONFIRM THIS PROPOSAL COMPLIES WITH THESE NAME OF ASSESSOR: DATE: RISK INDICATORS POSITIV E IMPACT NEGATIV E LOCAL / TRUST IMPACT DESCRIPTIO N MITIGATED RAW RISK RISK MITIGATION STRATEGY C L Total C L Total MONITORING LEAD Duty of Quality Compliance with NHS Constitution Impact on partner organisations Page 18 of 27

and any aspect of shared risk Impact on organisations duty to safeguard children and vulnerable adults Impact on other services within the organisation List any other risk indicators relevant to the Duty of Quality TOTAL 0 Patient Safety Impact on patient safety Impact on preventable harm Impact on reliability of safety systems and processes Impact on systems and process for ensuring that the risk of healthcare acquired infections to patients is reduced Impact on clinical workforce capability and skills List any other risk indicators relevant to the Patient Safety TOTAL 0 Patient Experience Impact on self- reported experience of patients and service users in Page 19 of 27

national / local surveys Impact on self- reported experience of patients and services users through the complaints process Impact on the self- reported experience of patients and service users through PALS contacts Impact on patient choice Impact on patient access Impact on the commitment to provide individualised care List any other risk indicators relevant to Patient Experience TOTAL 0 Clinical Effectiveness Impact on the implementation of evidence based practice Impact on clinical outcomes Impact on clinical leadership Impact on the full adoption of Best Care Impact on variations in care Impact on ensuring care is delivered in the most clinically / cost effective way Page 20 of 27

List any other risk indicators relevant to the Clinical Effectiveness TOTAL 0 SUMMARY OUTCOME OF IMPACT ASSESSMENT (to be completed by the Quality Assurance Group) AREA OF QUALITY OVERALL RISK RATING Key Risks (based on mitigated score) Duty of Quality 0 Patient Safety 0 Patient Experience 0 Clinical Effectiveness 0 TOTAL 0 RECOMMENDATIONS: Please now submit this initial screening assessment with the full details of the project to the Associate Director of Quality and Improvement. Full contact details are available from the Administration team Page 21 of 27

18. Appendix 4: Quality Assurance Group Terms of Reference 1. Constitution/ purpose The Group is to be known as the Quality Assurance Group (the Group). The Group has the powers either specifically delegated in these terms of reference or the organisation s scheme of delegation. The Group s role is to oversee the Quality Impact Assessment (QIA) process and review all business decisions to ensure there have been appropriate identification, assessment and mitigation of any significant major impacts The Group is constituted as a sub group of the Governing Body with delegated authority to make recommendations to the Executive Management Team regarding the potential impact on quality and equality of business decisions being proposed. 2. Membership, Chairmanship and Quorum (a) Membership Executive Director of Nursing, Quality and Safeguarding (Chair) Associate Director of Quality and Improvement Quality and Safety Manager Two members of the Senior Delivery Group preferably those involved in equality assessments and risk management NB Members must send an appropriate deputy if they are unable to attend a meeting. (b) Chairmanship The Executive Director of Nursing, Quality and Safeguarding shall be the Chair of the Group. (c) Quorum A quorum shall be either the Executive Director of Nursing, Quality and Safeguarding plus two other members 3. Frequency of meetings Meetings shall be held fortnightly and members must attend at least 50 % of all meetings but should aim to attend all scheduled meetings. Page 22 of 27

4. Terms of authority The Group is authorised to investigate any activity within its Terms of Reference and to seek any information it requires from any employee and all employees are directed to cooperate with any requests made by the Group. The Group is authorised to reject any QIAs that do not meet the required standard of completion The Group is authorised by the Governing Body to obtain legal or other independent advice and to secure attendance of outsiders with relevant experience and expertise if it considers this necessary. The Group is authorised to provide advice and make recommendations to managers and staff regarding the QIA process The Group is authorised to amend the QIAs as they see fit and to complete the summary information for onward presentation and consideration by the Executive Management Team 5. Objectives The Group shall: Ensure all required information is available to them to enable a full and thorough assessment of quality and equality impacts can take place Ensure a consistent approach is applied to the assessment of quality and equality impacts Keep the QIA process under review and recommend changes where necessary Produce the summary information sheets for each proposal to highlight the key risks and mitigations for each and present the overall impact findings to the Executive Management Team Provide a regular report to the Executive Management Team and the Quality and Clinical Governance Committee on the QIA process and an overview of the outcomes. Provide recommendations to the decision making committee with regard to whether the proposal can be implemented whilst maintaining required quality and equality standards Ensure members of the Group are provided with appropriate risk management training to enable them to fulfil their functions effectively. Page 23 of 27

6. Accountability The Group s meetings will be formally recorded and submitted to Executive Management Team 7. Review of effectiveness On a quarterly basis the Group shall monitor its effectiveness as follows: Ensuring its objectives, accountability and reporting arrangements are effective and meet the Group s requirements. The programming and implementation of any action plans Membership and attendance record Quorum requirements Agreed by the Quality Assurance Group.. (Chair Person) Date Page 24 of 27

19. Appendix 5: Procedural Document Checklist for Approval Procedural document checklist for approval To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: Policy framework for the development and management of procedural documents A Is there a sponsoring director? 1. Title Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? 2. Rationale Are reasons for development of the document stated? 3. Development Process Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target group clear and unambiguous? Are the intended outcomes described? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? /No/ Unsure 6. Approval Does the document identify which committee/group will approve it? 7. Dissemination and Implementation Is there an outline/plan to identify how the document will be disseminated and implemented amongst the target group? Comments/Details Page 25 of 27

Procedural document checklist for approval To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: Policy framework for the development and management of procedural documents Please provide details. 8. Process for Monitoring Compliance Have specific, measurable, achievable, realistic and time-specific standards been detailed to monitor compliance with the document? 9. Review Date Is the review date identified? 10. Overall Responsibility for the Document Is it clear who will be responsible for implementing and reviewing the documentation i.e. role of author/originator? Director Approval /No/ Unsure Comments/Details On approval, please sign and date it and forward to the chair of the committee/group where it will receive final approval. Name Karen McDowell Date Signature Committee Approval On approval, Chair to sign and date. Name Dominic Wright Date 17/02/2017 Signature Page 26 of 27

20. Appendix 6: Compliance & Audit Table Standard Source of Assurance / Timescale Frequency Reporting To: Responsibility Where a potential quality / equality impact of a business decision is identified, a full impact assessment should be conducted and a summary outcome submitted to the Executive Management Team to support the request for a decision Scrutiny of papers for meetings and any business cases / policies submitted without the required supporting documents should be returned for completion before being progressed. Annually Commissioning, Performance and Finance Committee Chief Executive and Senior Management.. Risk registers contain appropriate risks in relation to the potential impact of business decisions Risk registers reviewed on a quarterly basis and presented to Quality and Clinical Governance Committee Annually Commissioning, Performance and Finance Committee Associate Director of Quality and Improvement All assessments judged as having significant to major impact must be referred to the Quality Assurance Group Minutes of the Quality Assurance Group Annually Commissioning, Performance and Finance Committee Associate Director of Quality and improvement Page 27 of 27