Policy AD-750 Policy Management Development_ Format and Approval Guidelines 2018-01-22

Policy Title:  Policy Management: Development, Format, and Approval Guidelines

Policy Number: AD-750

Effective Date: January 22, 2018

Pages: 4

Reviewed Without Revision Date: N/A

Attachment(s): None

Reviewed With Revision Date: N/A

Policy Owner: Director, Quality Improvement and Risk Management

Original Date: 01/2018

Policy Executive:

Chief Medical Officer

Policy Executive Signature:

Policy Executive Approval Date:

Board Representative:

N/A

Board Representative Signature:

N/A

Board Representative Approval Date: N/A

Purpose:

To establish and adhere to a structure which supports the effective and efficient management of policies, including their addition, modification and deletion.

Policy:

In order to maintain an effective Compliance Program and to guide the provision of high-quality, consistent healthcare, WFH will develop and implement policies and procedures that that will serve as guiding principle or courses of actions for individuals affiliated with WFH.  These policies and procedures will be consistent with the requirements and standards established our Board of Directors, federal and state law and regulations, relevant reviewing and accrediting organizations (such as the Bureau of Primary Health Care or the Joint Commission) and, as applicable, managed care and other third party payors.”

Scope:

All Staff

Definitions:

Policy Title: The name of the policy as defined by the Policy Owner.

Policy Number: Indicates the number assigned to the policy by the Clinical Administrative Assistant. The person(s) responsible for developing the initial policy will contact the Clinical Administrative Assistant during development and prior to distribution to obtain the policy number. The category is based on the following:

Administrative (AD) - Policies that address administrative functions and do not qualify for any other policy category.

Emergency Management (EM) – Policies that address an unexpected or sudden event that significantly disrupts the organization's ability to provide care, treatment, or services or the environment of care itself or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both. They exist on a continuum of severity.

Environment of Care (EC) – Policies that address the environment in which health services are provided to individuals during the time services are rendered at WFH.

Human Resources (HR) – Policies that address the human resources within the organization.

Infection Prevention and Control (IC) – Policies that address the prevention and/control of the transmission of a pathogenic microorganism to a host, with subsequent invasion and multiplication, with or without resulting symptoms of disease.

Medication Management (MM) – Policies that address the processes taken to provide medication therapy to individuals. The components of the medication management process include: procurement, storage, security, prescribing or ordering, transcribing, preparing, dispensing, and  administering.

Provision of Care, Treatment, and Services (PC) – Policies that address the services rendered by members of the health profession and non-professionals for the benefit of the patient.

Record of Care, Treatment and Services (RC) – Policies that address complete and accurate clinical records ensuring quality and coordinated patient care, treatment, and services.

Effective Date: The date of the final written authorization of the current version of the policy.

Pages: The number of pages for the entire policy.

Reviewed Without Revision Date: The date the policy was reviewed and no changes were applied.

Attachment(s): The names of all attachments. If there are no attachments note “None”.

Reviewed With Revision Date: The date the policy was reviewed and changes were applied.

Policy Owner: The title, not name, of the person who is primarily responsible for the development, implementation, and maintenance of the policy.

Original Date: The date of original adoption of the policy.

Policy Executive: The title of the Chief Executive who has the overall responsibility of the policy.

Policy Executive Signature: The signature of the Policy Executive. An electronic signature is acceptable.

Policy Executive Approval Date: The date the Policy Executive approved the current version of the policy.

Board Representative: The name of the Board Representative reviewing and approving the current version of the policy.

Board Representative Signature: The signature of the Board Representative. An electronic signature is acceptable.

Board Representative Approval Date: The date the Board Representative approved the current version of the policy.

Purpose: The reason for the need for the policy. The policy purpose answers the question “WHY?”

Policy: A brief summary of the policy. The policy statement answers the question “WHAT?”

Scope: Listing of all departments affected by the policy.

Definitions: Includes definitions for terms used in the policy which might not be obvious without explicitly defining.

Procedure: The procedure (i.e. series of activities) that clearly defines what is required to achieve the stated purpose. The procedure answers the question How.

References: Listing of all references used in the development/revision of the policy.

Procedure:

1. Established policies must be reviewed, and revised as appropriate, at least every 36 months. Note that in some cases reviews are required on an annual basis.
2. The Policy Owner is responsible for the development, implementation, and maintenance of the policy and is so authorized to work with any and all staff members to meet this objective.
3. Only the Westside Family Healthcare template is to be used when developing or revising any policy.
4. All fields of the policy template are to be populated by the Policy Owner. In the event a field is not applicable to the specific policy the Policy Owner is to document “N/A”.
5. It is the responsibility of the Policy Owner to obtain the policy number, reviews from key stakeholders, approval signatures, and to facilitate staff education of the new or revised policy.
6. Once the policy has been approved by all necessary signatories, the final/completed version will be provided to the Clinical Administrative Assistant as a card copy or an electronic copy with signatures.  An editable copy in Microsoft Word format (without signatures) will also be provided.
7. The Clinical Administrative Assistant will post a PDF version of the policy to the intranet under Policies and update the “Policy Tracking” Smartsheet including attaching the PDF and MS Word formats of the current policy version to the appropriate row.

References:

NACHC Compliance Toolkit