MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS As a minimum the following elements will be monitored to ensure compliance. Element to be monitored Lead Tool Frequency Reporting Lead(s) for acting of Report of arrangements on Compliance recommendations Process for identifying relevant Clinical Audit and Review of clinical Policy audit report to: Clinical Audit and documents: Assurance audit website Assurance Manager Clinical Effectiveness Manager 100% of all published reports are placed Steering Annually on Clinical website W&CGQC Q&PC Process for disseminating relevant Clinical Audit and Review of Policy audit report to: Clinical Audit and documents Assurance confidential Assurance Manager Clinical Effectiveness Manager enquiries database 95% of documents will be disseminated Annually Steering Group within 14 days of publication W&CGQC Q&PC Responsible Lead Process for conducting an organisational Responsible Review of Policy audit report to: gap analysis: 100% of relevant Lead confidential Clinical Effectiveness documents will undergo a gap analysis enquiries database Annually Steering Group W&CGQC Q&PC Process for ensuring that Responsible Review of Policy audit report to: Medical Director recommendations are upon Lead confidential Clinical Effectiveness throughout the organisation enquiries database Annually Steering Group 95% of recommendations will be W&CGQC implemented within the timescales Q&PC Process for documenting any decision Responsible Review of Policy audit report to: Medical Director not to implement Confidential enquiries Lead confidential Clinical Effectiveness recommendations enquiries database Steering Annually 100% of such recommendations will W&CGQC have an associated rationale and Q&PC documented Trust Board agreement
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS As a minimum the following elements will be monitored to ensure compliance. Element to be monitored Lead Tool Frequency of Report of Compliance Reporting arrangements Lead(s) for acting on recommendations Process for identifying relevant documents: 100% of all published reports are placed on Clinical website Clinical Audit and Assurance Manager Review of clinical audit website Annually Policy audit report to: Clinical Effectiveness Steering W&CGQC Q&PC Clinical Audit and Assurance Manager Process for disseminating relevant documents 95% of documents will be disseminated within 14 days of publication Clinical Audit and Assurance Manager Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering Group W&CGQC Q&PC Clinical Audit and Assurance Manager Process for conducting an organisational gap analysis: 100% of relevant documents will undergo a gap analysis Responsible Lead Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering Group W&CGQC Q&PC Responsible Lead Process for ensuring that recommendations are upon throughout the organisation 95% of recommendations will be implemented within the timescales Responsible Lead Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering Group W&CGQC Q&PC Medical Director Process for documenting any decision not to implement Confidential enquiries recommendations 100% of such recommendations will have an associated rationale and documented Trust Board agreement Responsible Lead Review of confidential enquiries database Annually Policy audit report to: Clinical Effectiveness Steering W&CGQC Q&PC Medical Director
National%20Confidential%20Enquiries%20Implementation%20Policy.docx