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Lean Events Archive

Bureaucracy: Policies and Guidelines

You'll be pleased to hear that this project has now delivered!

The Policy for the Development of Policies and Guidelines was approved by James Scott on 27 September 2012 and the new process is now live.

Key changes to the process following the lean event are:

What’s out? 

What’s in?  

Up to 2 years to get a policy approved.

Separate approach for policies, procedures & guidelines

An impossible template that is difficult to update

Policy Group Control

Ratification committees

Details are now live on the intranet:

Writing and updating policies & Guidelines

On this page:


  1. To reduce the amount of time it takes to publish a policy

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Lean Event Focus and Participants

A Lean event mapping the current state process, identifying waste in the process and design the future state process was held on the 19th July.  Key stakeholders that attended the event include:

  • Dr Carol Peden (Consultant Anaethetist)
  • Sharon Mahni (Head of Quality Improvement)
  • Yvonne Pritchard (Infection Control Lead)
  • Helen Maria (Transfusion Specialist)
  • Mary Chapman (Health and Safety lead)
  • Simon Edwards (IG Manager)
  • Louette Eagles (Web Developer)
  • Eric Sanders (Trust Secretary)
  • Lisa Lewis, Tricia Mills (Facilitators)

Lean Event Discussions

Current State Mapping

The group process mapped the process from decision to create a new policy to publication on the intranet.  They identified 30 steps from start of the policy being written to the final approval and publication on the website.

A minimum and maximum time was then allocated for each step. From this they calculated that it could take between 4 months and 2 years and 8 months to get a policy approved! From the group's experience this was representative of the process. 

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What Does Good Looks Like?

The group then spent the afternoon designing their future state process by focusing on the the customer (the policy writer) and what adds value to them. 

They agreed that the policy group, approval group and ratification group added little value to the process and the consultation part was the most important.

Once the consultation was finished, the appropriate Director/Divisional Lead/Manager could approve the policy, putting the responsibility back into the hands of the subject matter experts and the individual approving the policy.

The value added processes came to 16 steps - a removal of 14 (time consuming) steps. The group decided that if the process for consultation was clear and comprehensive then there’s no reason why a policy could not be approved and published in 6 weeks.

There was no identified reason why Guidelines could not follow the same process. Amended policies and guidelines could join the process at the appropriate stage and complete the approval process if there are major amendments.

The future state process therefore looks like this;

Revised Policy Creation and Approval Process

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Action Plans

To take these changes forward the below action plan was agreed and put into place with a target implementation date for the new policy process being the 28th Sept 2012.

Policy Approval Action Plan

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