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Updates to the manuals are done by Corporate Governance and Risk Management Branch as electronic amendments. A register of amendments accompanies the electronic version of each manual. Considering the complex nature of the structure of the healthcare industry, the scope of hospital policies and procedures is vast. This is, understandably, a huge headache for healthcare workers as it further adds to the complexity and workload of their already demanding roles. From patient discharge procedures, to maintaining hygiene of the staff workers, policies and procedures are comprehensive guidelines to ensure the organization is complying with the rules and regulations. The maintenance of policies also ensures reduced risk of accidents, improves efficiency, and helps maintain a sound working environment for patients, staff, and visitors. This is why having a great policy management system to organize and administer hospital policies and procedures is so critically important. You may find our software is the best option for this organization and administration, or you may find another vendors software is more suitable, however, the key is to find the best fit for your various types of hospital policies and procedures. Staff members are a vital component of a hospital, therefore, it is essential their well being, as well as, improving their skill sets is the primary focus of the department. In order to ensure that the department is taking care of its staff, as well as, ensuring its staff is following strict procedures, they need to create and maintain a comprehensive list of policies and procedures. Such policies may include, vacation days, personal hygiene maintenance, shift policies, as well as, assigning tasks to each individual. Therefore, it is no surprise that the most comprehensive set of policies and procedure manual is the one directed to this department.
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Such policies cover topics from, nutrition guides, patient and family education, abuse and neglect, admission and discharge, patient call back, patient rights and responsibilities, as well as, numerous other topics. The policies differ for each department as well, for instance, the paediatrics ward would have a separate set of policies as opposed to cardiological ward. It is essential that the department follows a strict set of guidelines to ensure there are no mistakes or accidents that may, otherwise, occur. From prescription, to handling drug samples, it is vital that the staff is following strict policies and procedures. Other policies include, handling of drug shipment, outpatient prescription availability, and the likes. This information can be related to a staff member, patient, or a visitor. It is very important for an organization to ensure everyone is following a strict code of privacy, and is not violating anyone’s right. Therefore, such policies include: confidentiality, security and integrity of information, medical records distribution, and the likes. In order to ensure that staff is complying with the policies and procedures, it is essential that the policies and procedure manuals are well organized and easily accessible. To that end, our policy management software may be able to help, or it may be that another vendors software is more suitable. Alternatively, if you would like to see our software in action, please ask for a free demonstration. She loves creating interesting and valuable content for PolicyMedical readers and lending a creative eye to the PM design team. Anna currently resides in Toronto and is actively trying to convince her boyfriend to adopt a dog. I have read and accept the Wiley Online Library Terms and Conditions of Use Shareable Link Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Copy URL.
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Moreover, well-written, up-to-date policies and procedures reduce practice variability that my result in substandard care and patient harm. Given increasing financial pressures and the top-priority status that must be given to direct patient care, managers may find it difficult to find time to review or update policies and procedures. Deferring policy and procedure development, however, may result in negative consequences. Policies and procedures may become outdated, and those who adhere to outdated policies may carry out actions that are no longer consistent with industry-recognized practices. Alternatively, they may simply elect to disregard the policy. Either choice may result in patient harm and a malpractice claim. Evidence that caregivers followed outdated policies may hinder defense of an otherwise defensible claim. The use of the word “policies” throughout this article shall refer to policies, procedures, and guidelines. The following definitions are based on the author’s experience. Policy statement: A concise statement outlining the context, goal, or purpose of a specific procedure. A statement that is the guide to any decision making in relation to processes or activities that regularly take place or might be expected to occur (Hollnagel et al., 2014). Procedure: The desired, intentional action steps to be taken by specified persons to achieve a certain objective in a defined set of circumstances. Protocol: Synonymous with procedure. Often used when describing clinical patient care-related interventions. For example, a chemotherapy protocol or The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. Guideline: Recommended actions for a specific situation or type of case. A clinical practice guideline could, for example, outline blood-testing practices for patients who are taking anticoagulants.
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Discrepancies in clinical policies may also result in allegations that leadership allowed “two levels of care” to be provided, thereby increasing the organization’s risk exposure in several ways. First, exposure may be triggered by inconsistency with The Joint Commission’s leadership accreditation standard, LD.04.03.07: Patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital (Schyve, 2009).That may invite a plaintiff lawyer to take a statement out of context and allege that it places an obligation on the defendant that was not intended. The following example illustrates problematic and preferred phrasing within a policy statement: They opine in retrospect about what a reasonable healthcare provider with similar training and experience would have done. They also passed this Act in order to prevent “patient dumping”—when a hospital refuses to treat or transfers a patient to another hospital, such as for financial reasons. It is ABC hospital’s policy to provide care to all patients and to refrain from patient dumping. This description is oversimplified, potentially misleading, and fails to conform tightly to the EMTALA regulations. Requests to accept patients (with an emergency medical condition) in transfer from another acute care hospital will be handled in accordance with the procedures noted below, with consideration of the hospital’s capabilities and capacity to provide the level and type of care required at the time of the request. Typical disclaimer statements include the following (which should be approved by legal counsel): Procedures do not specify all circumstances to which they apply. Safety is promoted by people being skilled at judging when and how (and when not) to adapt procedures to local circumstances.
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For example, when writing a policy that pertains to the delivery of patient care in an emergency department, reviewing guidelines issued by the American College of Emergency Physicians and the Emergency Nurses Association would be a logical first step. Such guidelines are thoroughly researched and vetted by the issuing association before release. These practice guidelines are often introduced as evidence of the standard of care in a malpractice case. It is important to remember, however, that if a hospital’s procedures differ from those outlined in a professional association-issued guideline on the same subject, without a bona fide reason, that disparity may be called into question. For instance, ABC hospital’s surgical count procedures did not require instrument counts, as specified in the Association of periOperative Registered Nurses (AORN) practice standards (2013, p. 311). If a surgical operation at ABC hospital results in a retained instrument and becomes a claim, the plaintiff counsel will likely allege that the perioperative counts procedure was substandard because it was less rigorous than those recommended by AORN. Failure to do so may cause a staff member to follow an outdated policy, possibly comprising patient care as well as potential allegations of corporate negligence. To protect the organization from corporate negligence claims, documentation that affirms all affected workers—including floating, part-time, and traveling employees—have reviewed the new or revised policy prior to its effective date should be collected and kept on file. Legal counsel should determine the length of time documentation of this type of training should be maintained, factoring in applicable statutes of limitations. If it becomes lengthy, create a table of contents so the user can easily locate specific sections. Any policy that outlines medical staff responsibilities warrants their input during development and subsequent reviews.
Medical staff members also need to know where to access those policies. Incorporate any related form(s) or computer screen images referred to in a policy The advantage is that readers are aware of a professional source for more information on that subject. Another advantage is that it demonstrates the policy was developed with awareness of recognized professional guidelines and evidence-based best practices. However, potential risks arise when: a) the organization’s policy differs from the cited professional guidelines or omits some key element noted in those guidelines; b) If the cited professional guideline is updated following issuance of the policy, and the organization has not updated the policy accordingly. For example, the American College of Radiology publishes an evidence-based, comprehensive “Use of Contrast Media Manual” with regular updates. Rather than develop its own policies on this subject (which would likely be shorter and oversimplified when compared to this manual), a hospital-based radiology department may wish to endorse the staff’s use of this manual, with the proviso noted to the right. Next, they must empower all staff to intercede in real time and “stop the line” if they witness a red rule violation, since non-adherence poses a significant risk of patient harm. Red rule violations are subject to discipline in many organizations, unless the party involved can provide legitimate reasons why that step was skipped. The Institute for Safe Medication Practices (2008) supports the use of red rules and emphasizes that they should be “few, well-understood, and memorable.” Practices worthy of classification as red rules may include: Disparate policies can expose organizations to risk because a plaintiff lawyer may allege that one entity’s policy was less comprehensive than the other’s and thereby represented a lower standard of care.
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Policies and procedures of the following types lend themselves to being “system” policies: To optimize the usefulness of electronic libraries: Without such a search function, staff may have difficulty locating the policy they are seeking. There may be legitimate reasons why persons in other departments may need to refer to those documents. This will facilitate access in response to legal discovery requests. Check with your corporate compliance office regarding organizational document retention policies. The following strategies represent best practices observed by the author: The Corporate Compliance Office and the Legal Department are well-suited for this responsibility since many policies pertain to regulations. Consider forming domain-specific subcommittees for each department: nursing, pharmacy, biomedical engineering, etc. In such circumstances, the staff member must understand the need to document the rationale for that decision—and the manner in which the procedure was modified—in the patient’s medical record. Incorporate review of this responsibility into the annual performance appraisal process. Situations that prompt staff to use a workaround indicate possibly unreliable processes or practices. By reporting them to management, with the expectation that they will be investigated and addressed, the potential for patient harm may be reduced. Identify policy disparities and develop a plan for standardization, unless there are legitimate reasons why the system’s current policy needs to be modified in whole or in part, because of different jurisdictional statutes or different services offered by a particular organization. For instance, in the Commonwealth of Virginia, discovery of such documents is generally allowed, with the proviso that they may be deemed inadmissible later in the legal process for a given suit (Creager, 2008).
Healthcare risk managers, particularly those shifting to an Enterprise Risk Management approach, may wish to draw upon the ideas in this article as they: a) collaborate with system leaders in developing “system-wide” policies and procedures (modified to meet a unique characteristic of a specific entity); b) meet with department or service line managers to identify optimal policy formats and content; and c) offer input to corporate leaders regarding policy review and updating practices. Litigation News, Virginia State Bar, XIII(9). Midwest Legal Advisor. Lamson, Dugan and Murray, LLP. Surrey, England: Ashgate. Medication Safety Alert. Retrieved from Retrieved August 19, 2014, from We will continue to provide daily patient safety and quality news and analysis on our website, as well as provide insight via various innovative formats such as podcasts, webinars, and virtual events. Thank you for your continued interest. Please enable it to take advantage of the complete set of features!Get the latest public health information from CDC. Get the latest research from NIH. Find NCBI SARS-CoV-2 literature, sequence, and clinical content:.It also shares the discoveries made during this process which might benefit other hospitals attempting either to rewrite or create manuals of their own. Much of the available literature either deals with the need for policies and procedures, differentiates between policy and procedure, or gives sample policies or procedures for different hospital areas. These topics have been pointedly avoided here in favor of the practical aspects of policy and procedures manual development. MCN’s Policy Library includes more than 18,000 customizable policies and procedures authored by MCN clinical staff. Every MCN Policy Library document is up-to-date and instantly downloadable. The documents are in Microsoft Word format, and can be edited and customized by your organization.
The Job Description Library has over 500 job descriptions and associated competencies! Click on Policies and Procedures: Are Yours What They Need to Be? Free Trial. Manuals are cross referenced to Joint Commision, AAAHC, Urgent Care Association standards and CMS regulations as applicable. All manuals are cross-referenced to Joint Commission standards and CMS regulations. Any PRINTED version of these documents are only accurate up to the date of printing. Saskatoon Health Region cannot guarantee the currency or accuracy of any printed policy and accepts no responsibility for use of this material by any person or organization not associated with the Health Region. No part of these documents may be reproduced in any form for publication without permission of Saskatoon Health Region. These include procedures, protocols, guidelines, work standards, standard work, medical directives, etc. This is by no means an exhaustive list as it covers only documents that were found in the center at the time of preparing the list. It is intended as to guide information seekers and health professionals to some of the resources available in the Ministry. Most of the documents listed are produced by the Ministry of Health. The entries in blue are documents used by the Health Ministry, but are not published works of this Ministry. Infants and children under 5 years old are more likely to catch it. But, older children and adults can also get it. What are the common symptoms of HFMD. They draft mission statements to clarify their goals and empower directors to enforce those goals. Without a dedicated staff, hospitals cannot carry out their goals and provide optimum services. Like corporations, hospitals can inspire employee loyalty through policies and procedures that apply to all. Assembling these policies in one manual makes them easily accessible and promotes compliance. Write a table of contents as the next page. It should coincide with the policies and procedures written in Step 2.
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Make an index that arranges policies and procedures in alphabetical order by subject. Write each policy and procedure in a separately titled subsection. Provide rows of lines beneath column headings for recording policy changes. Write an introduction that explains the purpose of the policies and procedures. Add a flowchart or graphic that demonstrates the policy development process. Discuss roles that top-level supervisors and department managers play in initiating, developing, interpreting and enforcing the guidelines. Provide a contact page. Identify hospital administrators who can answer questions about the policies. For example, the planning and analysis staff might be contacted about hospital-wide policies, while human resources might be asked for information about personnel procedures. Conclude the policies and procedures manual with a statement explaining how they are to be used. Specify that employees should interpret the policies on the basis of consultations with the appropriate department heads. References University of Alabama: Policy Reference Manual Pioneer Memorial Hospital: Credit and Collection Policy Writer Bio Michele Vrouvas has been writing professionally since 2007. In addition to articles for online publications, she is a litigation paralegal and has been a reporter for several local newspapers. A former teacher, Vrouvas also worked as a professional cook for five years. She holds a Bachelor of Arts in history from Caldwell College. CDHB policies are controlled documents maintained by authorised CDHB staff only. For more information contact: Corporate Corporate document control Email: Corporate Document Control ?Clinical Manual Policy Name Associated Resources Cell phones in clinical areas. Chaperones? ?? Child Abuse and Neglect: Management of ? ? Child Protection Alerts Management. Clinical Audit ? ? ? Clinical Governance Policy. Clinical Record Management ? ? Clinical Records Retention and Disposal of Clinical Information ? ?
Clinical research policy ?. CDHB research manual Complementary and alternative medicines Coordinated Care Planning and Clinical Pathways for Patients Consumers. Correct patient - correct side - correct site - correct policy Correct Patient Correct Site Correct Side and Procedure. Direction and delegation. DNACPR Decisions guideline Early Warning Score (EWS) Procedure Elder abuse policy ?? Electricity dependency in the home. Medically Dependent Consumer Status Form ??Enablers Safe and Appropriate Use incl. Bedrails ? Enteral Feeding Policy ? ? ? Food Allergy Management Adverse Reactions Identification And Documentation. Health Practitioner Radiology Referral Policy 2017 ? ? Health Practitioner Radiology Referral Procedure 2017 ? ?Hospital Falls Prevention Procedure. Human tissue disposal. Informed Consent ?? Internal referrals for consultation ? ? ? Intimate Partner Violence policy. Acute Post-Strangulation form Family Violence Assessment Intervention Suppression-of-Patient-Details ISBAR handover ? ? Latex Sensitisation And Allergy in Patient Prevention And Management. ? Malnutrition: Identification and Management Adult and Pediatric ? ? Management of Negative Pressure Wound Therapy Policy Management of Negative Pressure Wound Therapy Guideline. Nursing and midwifery scholarships ? ? Patient identification ? ? Patient's money and valuables ? ? Patient status communication boards ? ? Patients Who Are Prisoners. Point of care testing ? ? Pressure Injury Prevention? ? Restraint Minimisation and Safe Practice? ? Return body tissue parts ? ? ? Safe sleep for infants from birth to 6 months policy ? ? Single use medical devices reprocessing ? ? Smokefree Policy Stop Smoking Referral Form Te Ha Waitaha Stop-For-Your-Op: Smokefree-Fact-Sheet Standing orders? ? Support care funding. Support care nominated clinicians. Temperature monitoring of medication and vaccine fridges ? ? Transfer of Patients between Hospitals ? ? ?
Treating Adults who Decline Blood Products (including Jehovah's Witnesses) - links to the Red Book ? ? Use Of Mixed Gender Clinical Space For Patient Care. This policy review process is conducted to ensure appropriate maintenance of our AAHRPP accreditation as part of UH Cleveland Medical Center’s commitment to the highest Human Research Protection standards. The FDA regulations pertinent to IRBs include 21 CFR 50, Part 56, Part 312, and Part 812. Much of the training and education provided by the Clinical Research Center reference these policies to ensure that compliance standards set by University Hospitals are met. Search now:With this mobile app, you can find a doctor and find a location. In addition, you can log into your UH Personal Health Record and schedule an appointment. UH Now also allows you to explore health topics that are important to you. Take charge of your health by downloading UH Now today, and get health information delivered right to your fingertips. Please see HR Policies and update your bookmark accordingly. These manuals are available to staff only—JHED ID login is required. Policy Updates On July 1, 2020, the following HR policies were harmonized across the Johns Hopkins Health System (JHHS). It also summarizes your rights and responsibilities and the general conditions of employment. Please read this handbook and use it as a reference guide. If you need further information, contact your supervisor or the Department of Human Resources. Choose the handbook that reflects your employment status: Employee handbook for represented (union) employees Employee handbook for non-represented (non-union) employees The following addendum has been made since the handbooks were published: JHHS Corporate Compliance - Please see this important information on corporate compliance and quality reporting. Visit the Corporate Compliance Office's website for more information. Show me more. View Policies and Handbooks Contact Us Patient Safety Reporting I want to.
Download Forms Log in to Employee Self-Service Find a Job Follow Johns Hopkins Medicine Facebook Twitter LinkedIn Instagram YouTube Weibo Contact Information Contact us or find a patient care location. Failure to comply could result in non-renewal or termination of a Medicare Provider Agreement. Here are suggestions to start the process: If they conflict with the patient’s wishes, the hospital should make a statement which at a minimum:If the patient chooses to stay under the hospital or physician’s care, the hospital must agree upon a written plan of action and enter it into the medical record; This manual includes sample forms for all three types of directives. They are to assist each hospital, in consultation with its attorney, in developing its own suggested forms for its patients’ use, if it will be the hospital’s policy to provide patients with forms in addition to the obligation to inform its patients of their rights to formulate advance directives. Another good source for an advance directive document is the “5 Wishes” program (see: ). The educational materials must inform members of the public of their rights under state law to make decisions about their medical care, the right to formulate an advance directive, and the hospital’s implementation policies concerning an individual’s advance directive. The statute allows facilities to join with others to fulfill the education requirements. A provider must be able to document its community education efforts. Documentation may include simply maintaining copies of any materials used, such as a brochure. A sample brochure on advance directives is included in this section. ( See Section Two for a sample brochure on mental health advance directives.) Here are some ways this might be done:A hospital may hold them as frequently or infrequently as needed in the community.
They can be as simple as one knowledgeable person explaining the law or more complicated, such as convening a panel to present information and answer questions. Another idea is to seek out community organizations and ask if they are receptive to a presentation during a meeting.Keep records of contacts. Review the list periodically to decide which groups have been missed and what opportunities are available for reaching new groups. Here are some ways to incorporate them:This could result in a routine news story, feature story, television or radio interview, or an appearance on a talk show. The media will find real stories about the ethical dilemmas and struggles of medical providers compelling, but remember the duty to guard the privacy of individual patients. Submit opinion pieces stating views on the need for advance directives. The most important part of doing this correctly is knowing the community and assessing how best to reach it. Think about the community and the people who might be interested in advance directives. They may be ready to make orderly life plans. An obstetrics unit may provide a link to these younger individuals. Chances are that there is someone in the community with an interest in this issue. If no one on the hospital staff is available, there might be an attorney, clergy member, or physician with particular expertise. Finding a person or persons truly interested in this topic, who have the sensitivity and enthusiasm to talk about it, can make or break a project. Reporting entities are assigned a three-digit ID number by the State Cancer Registry. There are two separate Policy and Procedure Manuals, each directed to a particular audience.Reporting facilities that may have information about these cases are requested to assist in this task. Facilities that use the ISCR FTP Program can use this program to respond these requests. The following document gives instructions for using the ISCR FTP Program for death clearance follow-back.
See summary of updates. Your surveyor will request to look at a hard copy of the policy and procedure manual when they conduct an on-site office visit. The manual will meet all Federal and State requirements.Select a topic below: 1. Administrative 2. Clinical Guidelines 3. HIPAA Medical Records 4. Human Resources 5. Laboratory 6. Physical Plant and Safety 7. Program Evaluation 8. Additional Clinical Policies We are familiar with the needed civil rights policies and provide civil rights policy review assistance. Click here for Civil Rights Clearance for Medicare Providers Request a policy and procedure manual quote. All Rights Reserved Download the PDF to view the article, as well as its associated figures and tables. It is well organized and well indexed, and the procedures are grouped according to a functional classification which makes reference to a particular procedure relatively easy. Twenty-one drawings give considerable assistance to the text in explaining such procedures as the disinfection of a stool or the setting up of a Wangensteen suction apparatus. Though the descriptions of the nursing procedures are brief, they appear to be adequate. General nursing procedures are covered under the headings of administrative routines, the central supply department, general nursing care, procedures for diagnostic tests and the administration of medicines. Special nursing procedures are included under the titles of medical procedures, procedures for the care of children, surgical procedures, procedures of the specialty services (including otology, ophthalmology, rhinolaryngology. Download the report The following are some thoughts on policies and procedures developed during my four decades of working in and for healthcare organizations. The two terms are sometimes used interchangeably, and while they do go hand in hand, they are not the same. They are organizations’ fundamental positions on issues.