FCCC Administrative Policy and Procedure; (Administrative Policy Management)

Page 1 of 16

FOX CHASE CANCER CENTER

ADMINISTRATIVE POLICIES AND PROCEDURES

NUMBER:FCCC-ADMIN-Gen A-1.0 CAMPUS POLICY: NO TUH POLICY:YES

TITLE:ADMINISTRATIVEPOLICY MANAGEMENT

EFFECTIVE DATE:8/2013

LAST REVIEWED:8/2013

LAST REVISED: 8/2013

REFERENCES:TUH-ADMIN-950.1000

ATTACHMENTS:1. Review/Revise/Create a Policy Checklist

2. Template for Administrative Policy Development

3. Template for Hospital Policy Development

SCOPE:

This policy shall apply to Fox Chase Cancer Center (FCCC) policies for both the Center and the Hospital. Processes and procedures are defined to ensure that all FCCC Administrative policies are created, approved, updated, and maintained in a consistent manner. This policy replaces all prior FCCC policies regarding the subject matter in both the Administrative policy and procedure manual and the Hospital policy and procedure manual. References to other types of policies (i.e. Departmental, Corporate, TUH, etc) are included only to differentiate them from an FCCC Administrative policy.

PURPOSE:

To define the overall process and standards that govern creation, review and revision, documentation, document formatting, posting, dissemination, and archiving of FCCC Administrative Policies, Procedures, and related documentsfor both Center and Hospital policies and procedures.

POLICY:

All administrative policies must be reviewed on an annual basis and revised as appropriate.

Formulation of an administrative policy is accomplished at the appropriate level of the organization and with the appropriate approvals. In its formulation and implementation, standardization of the policy and associated procedures with FCCC/Jeanes Hospital campus practices is to be considered when appropriate, to better manage a single standard of care across the campus.

Implementation of administrative policies and associated procedures is reflected in the issuance and maintenance of these policies and any related documents at the organizational levels appropriate to their content (e.g. Entity and Department). These policies are posted to the on-line Administrative Policy manual that contains Center and Hospital policies. The on-line policy manual is available for employee viewing. Policies are also maintained in alternate media to ensure accessibility during FCCC Network downtime.

The development, publication, and maintenance of administrative policies and any related documents are managed consistently throughout FCCC as defined by this policy and any associated supportive policies and procedures maintained by the Temple University Health Systems (TUHS).

DEFINITIONS: (May be N/A)

Policy

A policy is a statement of intent in the form of a directive that provides direction and guidance so that members of the work force may take action that is consistent with legal, ethical, and organizational requirements with regard to a specific area of performance, process or operation. The directions and guidance are linked to the mission of the institution and to requirements of regulatory and accrediting bodies.

A policy statement usually includes one or more of the following elements: a description of what, when, or where actions are to occur in a particular situation.

Procedure

A procedure is defined as a statement of instruction that provides direction in the form of specific steps for the implementation of a process or operation and identifies specific areas of responsibility.

A procedure is a particular way of accomplishing an activity. It can be a series of steps or a detailed description of how a policy or other related actions are to be carried out. The procedural steps may reference specific tools and techniques relevant to carrying out the procedure in the most effective and efficient manner. Procedures show the events that are to be taken in order to complete the task and provide for no action that is in violation of any law or requirements of regulatory and accrediting agencies.

Policy Owner

The policy owner is the designated owner of the development, review, revision, and maintenance of a policy, approvals, and all policy-related documents. The policy owner responsibility may be shared by more than one individual or be assigned to a committee and therefore delegated by the committee chairperson. The policy owner is designated under the heading “Written by” above the approval signature page.

Policy Portfolio

This is the organizational folder in the on-line policy database in which a policy and or/policy-related documents are placed for corporate policies and policies for all TUH institutions. The Portfolio may be accessed by Fox Chase Cancer Center employees via the FCCC intranet.

Corporate Policy

These policies and procedures are created and maintained in Temple University Health System Corporate Offices. Corporate policies are written to cover the actions of all entities. TUHS policies apply to all TUHS employees.

Administrative Center Policy

All policies, procedures and other informational material that substantially affect more than one department in an institution will be deemed an Administrative Center policy. At FCCC, Administrative Center policies are applicable to both the Hospital at Fox Chase Cancer Center and the Research facility at Fox Chase Cancer Center. The policy number will have the prefix ‘ADMIN’ to indicate it is an Administrative Center policy.

TUH Administrative policies are applicable to only TUH entities; therefore, they do not apply to the FCCC workforce unless they have been specifically adopted by the FCCC leadership and are cross-referenced in the Administrative Policy and Procedure manual of the Fox Chase Cancer Center.

Administrative Hospital Policy

The policies, procedures and other informational material that substantially affect more than one Hospital department at Fox Chase Cancer Center are Administrative Hospital policies. At FCCC, the Hospital Policies and Proceduresapply only to processes and procedures conducted at the Hospital of Fox Chase Cancer Center. The policy number will have the prefix ‘HOSP’ to indicate it is an Administrative Hospital policy.

Campus Policy

These policies and procedures are developed by staff representatives from both Jeanes Hospital and Fox Chase Cancer Center. The policies were developed to standardize policies, procedures and related documents across the campus. The policies are approved by the leadership of each organization and are maintained as part of the policy and procedure manual of each organization. The designation of Campus Policy “yes” indicates that the policy owner should consult with associates of the other institution when reviewing and/or revising the policy to maintain the standardization. The Review and Revision process must be conducted and approved at each institution.

Department Policy

Departmental policies and procedures are those that affect the internal operations of a department and are created and maintained by the affected department. The Department Director / Manager is responsible for departmental policy coordination, filing, posting, notification of reviews and follow-up on necessary revisions. Departmental policies should be accessible to all employees of that department. Departmental policies and procedures are applicable to only the staff of that organization’s department. Departmental policies and procedures may be Campus Departmental policies, however they must follow the guidelines for Campus Policies and be approved and maintained by each individual organization.

Policy Coordinator

A policy coordinator is the Administrative Policy Coordinator for Center and Hospital Policies and as such, has responsibility for managing the administrative policy portfolio of the organization including maintaining a tickler system for review, notification, communication, approval, filing and archiving to maintain a current and complete portfolio. The coordinator will maintain the on-line posted manual and index. The Policy Coordinator is not responsible for Departmental Policies.

Major Revisions

Include, but not limited to: additions, deletions, or revisions which alter the processes or procedures included within a policy; wording that reflects changes in internal practices and /or changes in regulatory rules or regulations; associated documents or changes to documentation.

Minor Revisions

Include correction of grammatical, punctuation or spelling errors and/or any change in the name of one or more policy approvers or owners.

Effective Date

The month and year policy was first implemented at FCCC. The effective date NEVER changes.

Last Reviewed

All FCCC Administrative and Hospital Policies are read and reviewed by the policy owner on an annual basis. Departmental policies are read and reviewed by the Department designee every year. Whether the policy requires major revisions or not, the last reviewed date indicates that the policy has been read and reviewed and:

  1. Is declared valid “as is”
  2. Is determined to need minor revisions. Revisions of this type do not require a change in “Last Revised” date
  3. Is determined to need major revisions. Revisions of this type require a change in the “Last Revised” date as well as the “Last Reviewed” date.

Last Revised

The month and year is changed when the last major revisions were made to the policy. Each time major changes are made, this date is changed.

Downtime Procedures

Contingency plans that identify alternative processes and recovery methods employed during and following a system outage in order to ensure continuity of services and availabilityof documents and information.

RESPONSIBILITIES:

The Policy Coordinator(s) ensures the coordination, publication, and distribution of all new and revised administrative policies and procedures according to the dictates of this policy. The Policy Coordinator will facilitate the signature process for all new and revised policies.

Department and Service Line Directors and Managers are responsible for dissemination of information to staff about new policies and changes to existing policies. They are responsible for assuring staff adhere to administrative policy during day to day practices and reinforce understanding of the policies and procedures as required.

All staff members are responsible for reading and practicing within the guidelines of administrative policies.

The Policy Coordinator(s) will be actively involved in the follow-up process necessary to ensure that the annual policy review and any necessary revisions to existing administrative policies are completed in a timely manner.

The Director of Quality is responsible for presentation of new policy to ECOS and the members of the governing board as appropriate and communicating with the policy owner.

Senior Executives are responsible for assigning the creation of new Administrative Policies and Procedures to the appropriate FCCC staff member(s), committee or workgroup as Policy Owner.

PROCEDURE:

New policies or changes to existing policies

  1. Based on a need determined by a new or changed practice, process, equipment, form, etc. the policy owner (see above) will draft a new or revised policy and procedure.
  2. The policy owner will use the Review/Revise/Create a Policy Checklist (attachment 1) and the Policy and Procedure Template to ensure procedures have been followed consistently during the creation / revision process.
  3. The policy owner will consult with representatives of the appropriate departments, committees, and others who may be impacted, to ensure that:
  4. There is justification for the new policy.
  5. The policy owner will search the on-line policy database for any related existing policy to preclude conflicting content. Other policies in the TUHS organization should be researched for comparable information that may serve as a resource for policy development.
  6. The contents of the new policy are being addressed by the correct unit or at the correct organizational level.
  7. There is appropriate representation in its development (including Jeanes Hospital and other TUHS campuses as appropriate).
  8. Opportunities for standardization and system-ness are fully considered.
  9. The draft policy is prepared using the most current template, according to the format described in this policy.
  10. All appropriate committee review and approval has been completed including legal review if necessary.
  11. The policy owner has evaluated and incorporated, as appropriate, comments received through the review process.
  12. Once a working draft of the new Center or Hospital Policy has been created, it should be reviewed with all affected department leaders, committee chairpersons, and other content expert until the policy is in final form.
  13. New policies that are related to processes that affect the quality, safety, service or performance of patient care will be sent to the Executive Committee of Staff (ECOS) and the Professional Affairs Committee of the Board for review and approval as required. Policies will be presented to both committees by the Director of Quality.
  14. The policy owner will send the final form of the policy in WORD format with all attachments to the Policy Coordinator. The completed Review/Revise/Create a Policy Checklist should be scanned and emailed to the Policy Coordinator with the policy.
  15. New and revised policies will be sent in hard copy to the Cancer Center Director, the Chief Medical Officer, Chief Academic Officer, and Chief Operating Officer for review and approval. Additionally, the Chief Nursing Officer will review and approve all Hospital policies. The Policy Coordinator will deliver and track the documents ready for signature.
  16. If necessary, at any point in the approval process, the policy will go back to the policy owner for additional revisions, until such time that it has met the approval of all parties.
  17. When all reviews and approvals have been granted, the Policy Coordinator will:
  18. Assign a policy number to a new policy
  19. Upload the new policy to the on-line policy and procedure manual.
  20. Update the index for the appropriate policy and procedure manual
  21. Send electronic notification to the policy owner that the new policy has been approved.
  22. Send a PDF formatted version of the new or revised policy to the editor of Connect(a campus news publication for the staff of Jeanes Hospital and Fox Chase Cancer Center) every 2 weeks to be posted for staff review.
  23. Send a monthly update to Center Managers and Directors with a list of new and revised policies.
  24. The original signed version of the approved document is filed in the Executive Suite.
  25. An electronic portfolio containing a folder for each active policy is maintained.

Review of existing policies

  1. All existing policies and procedures are to be reviewed on an annual basis.
  2. Notification of required annual policy review will be sent to each policy owner by the Policy Coordinator along with the target date for completion of the review. If a policy has more than one owner, each will receive notification.
  3. The Policy Coordinator is responsible for creating and maintaining a tickler system that will be utilized for annual review/revision notification.
  4. Vice Presidents, AVP’s, and Directors will be actively involved in the follow-up process necessary to ensure staff compliance to complete the annual policy review and necessary revisions.
  5. On a quarterly basis, notification via email will be sent to policy owners regarding the required annual review and the target date for completion.
  6. For policies that require no or minor revisions, the policy owner will have 30 days for completion.

For policies that require major revisions, policy owners may request an extended target date for completion up to 90 days.

  1. Policy owners are to review the Administrative Center or Hospital policy to ensure compliance with current regulatory and accreditation standards. Comparison of the policy to current internal practices must be verified. If a change in practice from the policy is discovered, the policy owner must discuss with the department leaders to determine if the policy should be updated or if the staff practices should be coached to regain compliance to the existing document. The policy owner is responsible for ensuring that all relevant personnel are included in the review.
  2. Policies that require no or minor revisions(see definitions) following the review by policy owner, will have the “Last Reviewed” date changed on the electronic version of the document maintained by the Policy Coordinator. The policy owner will complete the Review/Revise/Create a Policy Checklist to indicate no /minor revision. If minor revisions are required, a paper copy of the policy with handwritten edits will be attached to the checklist and returned to the Policy Coordinator. The Policy Coordinator will make the minor changes to the electronic document and update the “Last Reviewed” date. Copies of the annual checklists are kept in the active policy file. The revised policy will be uploaded to the on-line manual and the previous version removed.
  3. Policies that require major revisions(see definitions) following initial review by the policy owner, will require changes to the “Last Reviewed” and “Last Revised” dates. The policy owner may request an extension of up to 90 days maximum (including the first 30 days for review) to complete the update process. The current policy owner is responsible for initiating the policy revision.
  4. The policy owner will consult with representatives of the appropriate departments, committees, and others who may be impacted, to ensure that:
  1. There is justification for the revision to the policy.
  2. The policy owner will search the on-line policy database for any related existing policy to preclude conflicting content. Other policies in the TUHS organization should be researched for comparable information that may serve as a resource for policy development.
  3. The contents of the revised policy are being addressed by the correct unit or at the correct organizational level.
  4. There is appropriate representation in its development (including Jeanes Hospital and other TUHS campuses as appropriate).
  5. Opportunities for standardization and system-ness are fully considered.
  6. The draft policy is prepared using the most current template, according to the format described in this policy.
  7. All appropriate committee review and approval has been completed including legal review if necessary.
  8. The policy owner has evaluated and incorporated, as appropriate, comments received through the review process.
  9. When all changes are complete, the policy owner will be responsible for obtaining all approvals from the appropriate committees.
  10. The policy owner will attach a copy of the “Review/Revise/Create a Policy Checklist” to the revised policy and email both to the Policy Coordinator.
  11. Revised policies will be sent to the Cancer Center Director, the Chief Medical Officer, Chief Academic Officer, and Chief Operating Officer and Chief Nursing Officer as applicable by the Policy Coordinator for review and approval.
  12. If necessary, at any point in the approval process, the policy will go back to the policy owner for additional revisions, until such time that it has met the approval of all parties.
  1. Once approvals have been granted, the Policy Coordinator will:
  2. Upload the revised policy to the on-line policy manual (Verify updated “last revised” date has been changed)
  3. Archive the previous electronic and paper version of the policy
  4. File the updated signed copy of the policy in the active file folder
  5. Send electronic notification to the policy owner that the revised policy has been approved
  6. Send a PDF formatted version of the revised policy to the editor of Connect(a campus news publication for the staff of Jeanes Hospital and Fox Chase Cancer Center) every 2 weeks to be posted for staff review.

Approval Process