Scope

All Hospital leadership personnel

Policy

This document provides guidelines for initiating, preparing and updating policies and procedures at the Hospital; to outline the mechanism for approval, authorization and distribution; and to ensure that policies are developed in collaboration with associated departments.

Procedure

  1. Hospital-wide policies/procedures are developed for significant organizational issues that are interdepartmental or mandated to be hospital wide by accreditation agencies or state/federal legislation.
  2. All hospital policies and procedures are housed on a policy management system.
  3. All hospital staff can easily access all active policies via their PolicyStat website.
  4. Staff can use the search feature to access active policies by:
  5. Text
  6. Title
  7. Policy Area
  8. Author
  9. References
  10. Hospital personnel without a user identification and password are limited to viewing only approved/active policies and procedures.
  11. Staff identified as policy authors, editors or policy area owners are assigned a user identification number, password and permission levels.
  12. Each Policy Approval Workflow contains the steps that a policy must follow in order to be made active in PolicyStat.
  13. Each policy is assigned a Policy Approval Workflow at its inception and each Policy Approval Workflow has an individual assigned as its approver.
  14. As a policy is submitted for approval, the approver is notified via email that a policy is awaiting their authorization. In addition, the approver can view all of their pending policies on theHome Screen on the PolicyStat system.
  15. Approval Workflows have been created to insure that a policy is reviewed by at least one member of the Policy Committee prior to submission for approval.
  16. The Approval Workflow can be changed for any new or existing policy at any time.
  17. Examples of Approval Workflowsare:
  18. Administration
  19. Chief Executive Officer (CEO)
  20. Policy Committee
  21. Medical Executive Committee (MEC)
  22. Board of Managers (BOM)
  23. Administration/Infection Control
  24. CEO
  25. Infection Control Committee
  26. Policy Committee
  27. MEC
  28. BOM
  29. Clinical Services
  30. Vice President of Clinical Services
  31. Policy Committee
  32. MEC
  33. BOM
  34. Clinical Services/Infection Control
  35. Vice President of Clinical Services
  36. Infection Control Committee
  37. Policy Committee
  38. MEC
  39. BOM
  40. Finance and HIM
  41. Chief Financial Officer (CFO)
  42. Policy Committee
  43. MEC
  44. BOM
  45. Human Resources
  46. Director of Human Resources
  47. Policy Committee
  48. MEC
  49. BOM
  50. Human Resources/Infection Control
  51. Director of Human Resources
  52. Infection Control Committee
  53. Policy Committee
  54. MEC
  55. BOM
  56. Infection Control
  57. Infection Control Committee
  58. Policy Committee
  59. MEC
  60. BOM
  61. Pharmacy
  62. Pharmacy and Therapeutics Committee
  63. Policy Committee
  64. MEC
  65. BOM
  66. P&T/IC
  67. Pharmacy and Therapeutics Committee
  68. Infection Control Committee
  69. Policy Committee
  70. MEC
  71. BOM
  72. Safety and Quality
  73. Clinical Safety Manager
  74. Vice President of Clinical Services
  75. Policy Committee
  76. MEC
  77. BOM
  78. Safety and Quality/Infection Control
  79. Clinical Safety Manager
  80. Vice President of Clinical Services
  81. Infection Control Committee
  82. Policy Committee
  83. MEC
  84. BOM
  85. Surgical Services
  86. Director of Surgical Services
  87. Policy Committee
  88. MEC
  89. BOM
  90. Surgical Services/Infection Control
  91. Director of Surgical Services
  92. Infection Control Committee
  93. Policy Committee
  94. MEC
  95. BOM
  96. Bylaws
  97. MEC
  98. Medical Staff
  99. BOM
  100. Rules & Regulations
  101. MEC
  102. BOM
  103. Historical documentation of the approval process for new, revised and retired policies shall be maintained in PolicyStat. In addition, a historical file for legal and reference purposes is maintained in Hospital Administration for policies approved prior to March, 2011.
  104. All new/revised policies shall be:
  105. Reviewed by the appropriate committee, obtaining committee input as needed.
  106. Submitted to individuals/departments for additional comments and revisions as needed. The chairperson shall review and compile comments/revisions.
  107. Submitted to the Policy Committee for final comments, revisions and approval.
  108. Submitted to the MEC and BOM for final approval.
  109. Requests for new policies, revisions or deletions may be made by Medical Staff committees, Hospital committees, hospital departments or individuals on the Hospital Policy Committee.
  110. The Hospital Policy Committee shall be:
  111. Composed of representatives (additional members may be added as needed):
  112. CEO
  113. Vice President of Clinical Services
  114. Human Resources Director
  115. CFO
  116. Clinical Safety Manager
  117. Infection Control Preventionist.
  118. Chaired by a member of the Hospital Administration Staff.
  119. The Chair shall maintain a current list of all policies, schedule Policy Committee Meetings and provide copies of new and revised policies for inclusion in the MEC and BOM packets.
  120. This individual is also identified as the Site Administrator onPolicyStat.
  121. The Policy Committee will:
  122. Meet prior to each MEC and BOM meeting to review and approve pending policies.
  123. Identify the appropriate manager for policy development.
  124. Insure that input is solicited and incorporated into a final policy statement.
  125. Review User permission levels on PolicyStat.
  126. Once completed, the committee shall submit the policy to theMECandBOM for final approval.
  127. All existing Hospital policies will be reviewed at least every three years and/or as needed.
  128. When an entire section of policies is reviewed, a coversheet will be completed stating a section wasreviewed prior to being submitted to the BOM for their approval.
  129. The date the section was reviewed by the BOM will be placed on the Tracking Sheet.
  130. The coversheet will be signed by:
  131. Medical Director/Advisor (as appropriate)
  132. The department manager that reviewed the section
  133. Vice President of Clinical Services
  134. Infection Control Preventionist
  135. Hospital's CEO
  136. Once signed, the coversheet will be stored in a binder.
  137. Within 7 business days of the date of the BOM meeting, the chairperson shall:
  138. Approve policiesin PolicyStat to make them active.
  139. Send an emailto all hospital staff notifying them of all recently new/revised policies and instructions on how they can be accessed on the PolicyStat system.
  140. Electronic copies of all policies will be maintained on the hospital Shared Drive and on two portable drives. One drive will be retained by the Policy Administrator and the other will be retained in the hospital Security Office.