Unit 1 Establish policies and procedures

Unit Code - R/600/9606
Level - 7
Credit Value - 8

Learning Outcome - The learner will:	Assessment Criteria - The learner can:
1. Understand the legal and regulatory requirements that impact upon own area of responsibility.	1.1 Examine the legal and regulatory requirements that impact upon own area of responsibility. 1.2 Analyse potential risks associated with relevant legal and regulatory requirements.
2. Understand the ethical and social requirements that impact upon own area of responsibility.	2.1 Examine the ethical and social requirements that impact upon own area of responsibility to others. 2.2 Analyse potential risks associated with relevant ethical and social requirements.
3. Be able to develop policies to meet legal, regulatory, ethical and social requirements for own area of responsibility.	3.1 Develop policies that meet legal, regulatory, ethical and social requirements. 3.2 Ensure procedures are aligned to developed policies.
4. Be able to communicate policies to stakeholders.	4.1 Communicate policies to stakeholders.

Learning outcome 1

1. Understand the legal and regulatory requirements that impact upon own area of responsibility
1.1 Examine the legal and regulatory requirements that impact upon own area of responsibility
The candidate should be able to research and describe the legal and regulatory requirements related to areas of work for which they have direct responsibility.

Evidence: Descriptions, explanation and referenced research in their portfolio

Further information and guidance:
Legal and regulatory requirements vary in different places and for different aspects of healthcare. The candidate is expected to demonstrate a good understanding gained through the examination of relevant documents associated with their area or areas of responsibility. Where areas of responsibility overlap with others they should consider the impact of this overlap and be sufficiently aware of overlapping areas of responsibility to function effectively in their own. They should focus especially on the relevance of legal requirements to their impact on quality.

1.2 Analyse potential risks associated with relevant legal and regulatory requirements.
The candidate must show clear competence in identifying risks, analysing them in terms of their importance to quality and their relationship to statutory and regulatory requirements.

Evidence: Descriptions, explanation and referenced analysis in their portfolio

Further information and guidance
Analysis is the key to this criterion. There must be evidence of breaking down the legal and statutory requirements in the area of responsibility into specific issues that have associated risk. Examples of the type of risk that should be covered are professional risk to themselves eg from claims against them for negligence or failing to meet legal requirements; risks to clients, eg bureaucratic procedures making access difficult for those with poor education; organisational risks such as cost-benefit of services and budget constraints. The candidate's portfolio should show substantial documented analysis relevant to their area of work or interests and they should be able to discuss these with their assessor.

Learning outcome 2

2. Understand the ethical and social requirements that impact upon own area of responsibility
2.1 Examine the ethical and social requirements that impact upon own area of responsibility to others
The candidate should be able to identify and explain the ethical and social values in the community that will affect the processes and responsibilities they undertake inside the organisation and any implications for quality management.

Evidence: Descriptions, explanation and referenced analysis in their portfolio

Further information and guidance
The candidate might show the importance of having an ethical and value-based approach to governance and how they can put this into practice within their own organisation. The candidate should be able to make a SWOT analysis of the ethical and social requirements of stakeholders. They should relate ethical and social requirements to external environmental factors and, for example, collect empirical data to measure their effects on the area of responsibility within the organisation. They should demonstrate awareness of current and emerging ethical and social concerns and expectations within the area of responsibility.

2.2 Analyse potential risks associated with relevant ethical and social requirements
The candidate be able to create risk analysis tools for ethical and social requirements to identify the potential risks such as sex, religion, habit and appropriate actions to reduce them.

Evidence: Descriptions, explanation and referenced analysis in their portfolio

Further information and guidance
The candidate should conduct Failure Modes and Effects analysis (FMEA) and calculate the Risk Priority Number RPN and recalculate it after actions are taken.

Learning outcome 3

3. Be able to develop policies to meet legal, regulatory, ethical and social requirements for own area of responsibility
3.1 Be able to develop policies to meet legal, regulatory, ethical and social requirements for own area of responsibility
The candidate should be able to develop policies to meet (legal, regulatory, ethical and social requirements) in the affected area under his/her responsibility and align this policy with strategic planning of the organisation to support quality.

Evidence: Descriptions, explanation and referenced analysis in their portfolio

Further information and guidance
The candidate might take the policies and procedures that already exist within their organisation and provide a critical evaluation of them saying how they might be improved. Candidates should cover the basic elements needed for developing a policy and provide confidence that they have the ability to develop it. These policies should be consistent with (legal, regulatory, ethical and social requirements) as well as the organisation's values. The candidate may develop a policy for solving any conflicts between existing policies and legal, regulatory, ethical and social requirements. They might draft a new policy for a specific area of work or in response to a change of circumstance or other event. Whichever route or routes are taken, the key is to provide confidence in the ability to develop policy relevant to their particular area of responsibility with particular references to quality management.

3.2 Ensure procedures are aligned to developed policies
The candidate should be able to develop procedures for developing policy in general in the affected area under his/her responsibility and align it with strategic planning of the organisation.

Evidence: Descriptions, explanation and referenced analysis in their portfolio

Further information and guidance
The candidate should know how to translate a policy into a step by step procedure or procedures which direct activity in a way that is likely to support the policy. A useful exercise is the analysis of existing policies and the provision of procedures as a result of the analysis. Can existing procedures be improved to reduce cost and maintain quality? When developing procedures, candidates should include consideration of the stakeholders, how they will receive the procedures and any consequences resulting from people not complying with the procedures and how this should be dealt with, for example, through contingency planning.

Learning outcome 4

4. Be able to communicate policies to stakeholders
4.1 Communicate policies to stakeholders.
The candidate should be able to demonstrate clear competence in communicating policies to stakeholders taking into account the impact that the communication is likely to have.

Evidence: Descriptions, explanation and referenced analysis in their portfolio

Further information and guidance
The candidate may use organisation structure and business processes to identify the needs and expectations of colleagues and other key stakeholders'. The candidate should show sensitivity to individuals and make clear judgements about the likely effect of not only the message but the way the message is delivered. These judgements should include the communication medium, for example, email, intranet, internet, publications, face to face, delegated etc. The candidate should be able to build a comprehensive communication plan to support quality and consistency in the way communication is carried out within their organisation.