HOSPITAL POLICY AND INFORMATION MANUAL

DOCUMENT CONTROL Page 1 of 4 Date Issued: Date Last Revised: Next Review Date: Approved By: 3/10 08/13 8/15 Poli y !o""ittee

Key Words Do u"e#t o#trol$ poli y$ pro ess$ %uideli#e Po!"#y a$$!"es %o All &er y 'ospital sta(( E&'IP Cr"%er"o( )*1*+ Do u"e#ted orporate a#d li#i al poli ies assist t)e or%a#isatio# to provide *uality are+ Ra%"o(a!e ,ervi e provisio# at &er y 'ospital is %uided -y poli ies a#d pro edures t)at e#a-le t)e or%a#isatio# to deliver sa(e e((e tive are to our patie#ts$ a#d e#%a%e i# appropriate e"ploy"e#t$ le%islative a#d o#tra tual pra ti es+ .)ese poli ies set out &er y 'ospital/s o-0e tives$ pri# iples$ %uideli#es a#d pro esses to -e applied o#siste#tly a ross t)e or%a#isatio#+ Def"("%"o( Document Control re(ers to t)e pro ess w)ere-y all &er y 'ospital poli ies$ pro esses a#d %uideli#es are syste"ati ally writte#$ reviewed$ updated a#d stored to "ai#tai# do u"e#t i#te%rity+ A policy is a set o( pri# iples t)at is used as a %uide (or a tio#1 t)e pri# iples "ost o(te# relate to le%islatio# a sta#dard or -est pra ti e+ Poli y re%ulates$ dire ts a#d o#trols a tio#s a#d o#du t+ A poli y provides )i%) level dire tio# a#d %uida# e$ esta-lis)es 2ey pri# iples a#d respo#si-ilities$ a#d sets (u#da"e#tal re*uire"e#ts+ Poli ies a# ra#%e (ro" -road p)ilosop)ies to spe i(i rules a#d i# lude "et)od a#d ti"e(ra"e (or evaluatio#+ Process/procedure is a series o( a tio#s #e essary (or a o"plis)i#% a parti ular %oal1 ourse o( a tio#+ I#(or"s users )ow to$ a#d w)o will$ i"ple"e#t a poli y+ Pro edures are spe i(i $ (a tual, su i# t a#d to t)e poi#t+ Pro edures are a parti ular way o( a o"plis)i#% a# o-0e tive1 %e#erally re(erri#% to t)e pro ess rat)er t)a# t)e result+ Pro edures des ri-e t)e "et)ods a#d respo#si-ility (or i"ple"e#tatio# o( a poli y$ statute or re%ulatio#+ A guideline is t)e detailed steps (or arryi#% out tas2s wit)i# a pro edure$ or to de(i#e a rule t)at is spe i(i to a lo al or%a#isatio#al area+

HOSPITAL POLICY AND INFORMATION MANUAL

O-.e#%"/es .)at t)e or%a#isatio#/s poli ies$ pro esses a#d asso iated do u"e#ts: Are urre#t a#d re(le t -est pra ti e a#d "eet le%islative a#d or o"plia# e sta#dards a#d re%ulatio#s+ Are releva#t$ lear$ easy to use a#d appropriate to t)e or%a#isatio#+ Are developed wit) i#put (ro" releva#t sta(( a#d exter#al sta2e)olders+ Are aut)orised a#d updated t)rou%) a ro-ust poli y develop"e#t (ra"ewor2+ Are easily a essed -y sta(( Are reviewed a ordi#% to t)e ris2 rati#% poli y wit) su((i ie#t re%ularity to e#sure urre# y+ At a "i#i"u" )owever$ all poli ies s)ould -e reviewed t)ree yearly+ I0$!e0e(%a%"o( Resour es are availa-le to e#sure urre# y o( do u"e#ts e+%+ !)ap"a# .ripp le%islative o"plia# e$ 3oa##a Bri%%s I#stitute A poli y te"plate is i# pla e a#d is ad)ered to+ A poli y /pro ess/%uideli#e (ra"ewor2 is i# pla e w)i ) ide#ti(ies pro esses -y w)i )1 All poli y do u"e#ts$ asso iated do u"e#ts a#d %uideli#es are reviewed at a "i#i"u" every t)ree years+ .)e i"ple"e#tatio# o( #ew poli y or )a#%es to existi#% poli y re*uires si%# o(( (ro" t)e poli y %roup$ wit) desi%#ated a ou#ta-ilities (or t)e appropriate edu atio# a#d or update o( sta((+

.)ere are two desi%#ated do u"e#t o#trollers w)o are a-le to "a2e )a#%es to do u"e#ts+ 4ollowi#% Poli y !o""ittee rati(i atio# all poli ies will -e disse"i#ated to sta(( .)e updati#% o( area spe i(i wor2-oo2s is t)e respo#si-ility o( t)e sta(( w)o wor2 i# a# area+ .)is pro ess will -e (a ilitated -y t)e '5D/&a#a%er/!li#i al !oordi#ator/5'I! Nurse A##ess a(d Re$os"%ory Poli ies wit) asso iated pro ess a#d (or"s are o#6li#e o# t)e 748 Drive a#d are also availa-le t)rou%) 9/&5RRI,:+ All do u"e#ts are i# read o#ly (or"at+ All #ew a#d updated poli ies are pla ed o# t)e &5RRI, (ro#t pa%e (or 30 days (ollowi#% rati(i atio# -y t)e Poli y !o""ittee

HOSPITAL POLICY AND INFORMATION MANUAL

A pri#ted set o( poli ies is updated as #ew or a"e#ded poli ies are developed a#d t)ese are 2ept at Re eptio# 7see -elow8 i# ase o( a o"puter or power (ailure+ .)is is t)e respo#si-ility o( t)e Do u"e#t !o#trollers+ &ost poli ies are a-le to -e a essed o# t)e &er y we-site+ .)e pro ess o( putti#% poli ies o# li#e is "a#a%ed -y t)e desi%#ated do u"e#t o#trollers+
Co!o'r Po!"#"es ;e#eral I#(or"atio# 'ospital Poli ies I#(e tio# !o#trol Nursi#% ,ervi es 'ospital 'R Poli ies Do#'0e(% Co(%ro!!er <xe utive Assista#t 5'/I! Nurse Ad"i#istratio# ,e retary Dire tor o( Nursi#% <xe utive Assista#t 'u"a# Resour es Ad"i#istratio# &a#a%er ,e retary O/era!! Res$o(s"-"!"%y Poli y !o""ittee

Ma('a!

'ospital Poli y a#d Blue I#(or"atio# &a#ual I#(e tio# !o#trol Red Nursi#% ,ervi es 'u"a# &a#ual ;ree#

Resour e =)ite

E/a!'a%"o( a(d Re/"e1 ,ta(( are a-le to a ess poli ies appropriately+ All poli ies$ pro edures a#d %uideli#es are up to date+ All poli es are i# t)e a%reed (or"at+ Poli ies$ pro esses a#d %uideli#es )ave -ee# re#ewed or developed usi#% t)e a%reed (ra"ewor2+ All )a#%es to poli y are su-"itted via t)e Do u"e#t !o#trollers Asso#"a%ed Do#'0e(%s R"s2 Ra%"(g Po!"#y 'ospital a#d I#(or"atio# Poli y &a#ual Po!"#y Te0$!a%e 4:>&er y ,)ared>Poli y &a#uals>'ospital Poli y a#d I#(or"atio# &a#ual>Poli y Develop"e#t a#d Review i#(or"atio# Po!"#y De/e!o$0e(% Pro#ess F!o1 4:>&er y ,)ared>Poli y &a#uals>'ospital Poli y a#d I#(or"atio# &a#ual>Poli y Develop"e#t a#d Review i#(or"atio# Po!"#y Re/"e1 Pro#ess F!o1 4:>&er y ,)ared>Poli y &a#uals>'ospital Poli y a#d I#(or"atio# &a#ual>Poli y Develop"e#t a#d Review i#(or"atio# Po!"#y De/e!o$0e(% fro(% s3ee% 4:>&er y ,)ared>Poli y &a#uals>'ospital Poli y a#d I#(or"atio# &a#ual>Poli y Develop"e#t a#d Review i#(or"atio# Po!"#y U$da%es 4:>&er y ,)ared>Poli y &a#uals>'ospital Poli y a#d I#(or"atio# &a#ual>Poli y ?pdates I(43o'se R'!es5 H'0a( Reso'r#es Po!"#y Ma('a!

HOSPITAL POLICY AND INFORMATION MANUAL

Reso'r#es !)ap"a# .ripp Le%islative !o"plia# e (ra"ewor2 <@uIP sta#dards a#d riterio# Pro#ess of Do#'0e(% Co(%ro! 1+ Poli y ow#er ide#ti(ied -y t)e poli y %roup i( it is a #ew poli y or as t)e AReviewed -y: positio# i( t)e poli y is a# update+ B+ Re"i#der se#t to t)e do u"e#t ow#er (ro" t)e 7<xe PA or Ad"i# PA8 do u"e#t o#troller w)o )olds a -ri#% up list (or poli ies re*uiri#% re#ewal+ 3+ Added to o# li#e list o( poli ies out (or re#ewal+ .)is will i# lude t)e do u"e#t a#d ti"e(ra"e allo ated+ .)is list to -e 2ept -y t)e do u"e#t o#troller wit) i#put (ro" t)e !)air o( t)e poli y %roup+ C+ Under review added to o# li#e existi#% poli y/paper "a#ual -y PA+ 5+ Do u"e#t ow#er reviews do u"e#t as per Poli y (ra"ewor2 D+ Poli y/pro ess or %uideli#e developed as per (ra"ewor2 E+ ;uideli#es (iled i#to appropriate wor2-oo2 via do u"e#t o#troller/or '5D 8+ Poli y$ pro ess a#d a#y related (or"s sit to%et)er i# t)e appropriate (older a#d o# A4: Drive F+ A#y do u"e#ts t)at are re*uired to -e o# t)e &er y 'ospital we-site will -e (orwarded to t)e I. !o6ordi#ator+ C3e#2!"s% for Do#'0e(% O1(er As per pro ess outli#ed o# t)e A4: drive G re(er F:\Mercy Shared\Policy Committee\Policy Document Owner Checklist.doc C3e#2!"s% for Do#'0e(% Co(%ro!!er As per pro ess outli#ed o# t)e A4: drive G re(er 4:>&er y ,)ared>Poli y !o""ittee>Poli y Do u"e#t !o#troller !)e 2list+do