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A standardised approach to procedural documents across Norfolk and Waveney

10 October 2022


A standardised approach to procedural documents is being rolled out across Norfolk and Waveney’s acute hospitals

From today, Monday 10 October, all three acute hospitals covering Norfolk and Waveney will adopt the same approach and template for procedural documents, such as policies, guidelines, and standard operating procedures. The change will add to the safety, standardisation and robustness of all procedural document across the three hospitals, making it easier for staff who work across sites to follow procedures as they move between the James Paget University Hospital, the Norfolk and Norwich University and the Queen Elizabeth Hospital, King’s Lynn.

Gemma Lynch, Governance Compliance Manager at NNUH, who was a key member of the Joint Procedural Policy Development Group, said: “We worked together with representatives from all three Trusts to understand each others’ existing policy and collaborate on a unified approach and template for all procedural documents. 

It's allowed us to take the best elements from each Trust as part of a longer-term plan to aid cross-site working and patient safety.”

The first joint policy across the three acute Trusts was the consent policy launched in November 2021 with a joint approach to mandatory training in the pipeline.

From 10 October, any staff who are developing a new policy or revising an existing one will need to use the new guidelines and template. As procedural documents are reviewed up to every three years, there will be a changeover period, with the new template applied to all procedural documents across all three Trusts by September 2025.

NHS Norfolk and Waveney Acute Hospital Collaborative logo.