Developing and Updating Guidelines - Quick Reference Guide

All policies,procedures and guidelines are required to be developed in accordance with the NHS Forth Valley Policy on Developing Guidance

Stage 1 - Development

Stage 2 - Equality Impact Assessment

  • Complete the screening template to help determine whether a standard equality impact assessment is required
  • If during your screening assessment any adverse impact has been found you will have to complete a Standard Impact Assessment which should be sent to Lynn Waddell (

Further information on equality impact screening can be accessed on the Equality and Diversity website

Stage 3 - Approval

  • Policies, procedures and guidelines are required to be approved prior to publication by a recognised group or committee that has been given the authority to approve See flowchart
  • The lead author should submit the document to the appropriate approval group

Stage 4 - Publication

  • Once approved, clinical documents should be published on the NHS Forth Valley QI Hub and emailed to to be loaded onto the Quality Improvement Website
  • Approved non-clinical documents should be published on the NHS Forth Valley Staff Intranet and emailed to for publication

Stage 5 - Review

  • The lead author is responsible for the document review and will be contacted prior to the expiry of the current review date Review Process
  • Where a document exceeds the review date, the relevant General Manager will be alerted in accordance with the Document Review Escalation Process