HOSPITAL NAME

Department:

INSTITUTIONAL POLICY AND PROCEDURE (IPP)

Manual: Section:

TITLE/DESCRIPTION

POLICY NUMBER

Policy & Procedure Format, Template Structure, and Numbering System

EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES

APPROVED BY

APPLIES TO

PURPOSE To provide guidelines for format standardization, template structures, and numbering system for written policies and procedures (PP). See attachment # 1 and # 2 for examples. DEFINITION 1. Clinical protocol/Practice Standard: Course of action to be followed by the provider relative to assessment, reportable condition, specific care, safety issues, patient/family education, and documentation for patient population described. 2. Guidelines: Written outline that describes how forms, equipment, and documents are to be implemented. 3. Policy: Guideline statement for implementing action (procedure): 3.1 Internal Policies and Procedure (IPP): Policies affecting all or multiple departments; are considered administrative in content; may direct a different level of management; and reflects the philosophy and objectives of the hospital. They are included in the IPP manual. 3.2 Nursing Service Policy (NSP): Clinical policies affect nursing care directly and care provided by the interdisciplinary department; are considered strictly clinical in content; and reflects the philosophy and objective of the hospital. They are included in the NSP manual. 3.3 Medical Staff Policies (MSP): Relates to the function of licensed physicians in carrying out their clinical roles as defined by their license and credentials and privileges granted. 3.4 Department Policies: Specific to departments and included in department policy and procedure manual. 4. Procedure: Step-by-step, logical course of actions required to carry out a policy, including specific responsibilities; may be administrative or patient-related. Administrative procedures address the conduct of the institutions business and regulatory requirements; whereas, patient related procedure address the delivery of patient care or services. 5. IPP Cover Page: A uniformly formatted electronic template into which the policy or procedure is entered as a draft. 6. Purpose: Description of why the policy is in place. 7. Reference: Current literature or book titles used in formulating the content of the policy. 8. Responsibility: Statement of what each person involved in the procedure is responsible for. 9. Standard(s): Statement, regulation or condition determined by appropriate authority to be the accepted level of practice/performance, which may be based on: Care written plan of care developed for a group of patients with predictable outcomes based on common

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identified problems; Outcome defines results to be achieved (either by patient/family or care giver). Process defines actions and procedures of giving care; in patient care it may be called protocols, and Structure defines conditions needed to control and operate the institution system.

RESPONSIBILITY 1. Author, Area Manager/designee 1.1 Initiates and coordinates policy through organizational approval process. Attends meetings to approve policy. 1.2 1.3 Prepares a draft of the policy using the approved format. Initiates and coordinates adequate input from relevant parties/departments; makes revision to the draft based on input. Assures that risk, safety, and compliance issues are addressed. Submits the completed draft of all Intra-departmental policies (within a department) to the highest authority (e.g., Chairman or Department Head to the Executive Medical Director) for review. Receive approved department policies and procedures and distributes accordingly.

1.4 1.5

1.6

2. Executive Director, Medical Services

2.1

Review all medical staff policy drafts and revision of content and format, to ensure compliance with policy guidelines. Propose changes as appropriate. Approves medical staff policies following review where more than two (2) departments are involved. Forwards approved medical staff policies to the author for distribution.

2.2 2.3 2.4

3. Executive Director, Operations 3.1 Reviews all operations staff policy drafts and revisions for content and format, to ensure compliance with policy guidelines. Propose changes as appropriate. Approves operations staff policies following review where more than two (2) departments are involved as appropriate. Forwards approved operations staff policies to the author for distribution.

3.2 3.3

3.4

4. Associate Executive Director, Nursing Services 4.1 Reviews all nursing policies (administrative and clinical), drafts and revisions for content and format to ensure compliance with policy guidelines. 4.2 Proposes changes as appropriate and returns revised policies to the author/department for further review. 4.3 Approve NSPs that do not require changes from the author/department.

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4.4 Review all proposed department nursing policies and procedures and approves them. 4.5 Forwards approved NSPs (hard and soft) to the administrative area for archiving (policy and Procedure Office). CROSS REFERENCES POLICY PROCEDURE 1. Policy & Procedure Standardized Format Paper 1.1 1.2 1.3 1.4 The paper to be used is white plain paper A4 (210x297). The Paper Size Orientation is Portrait. Use Type Size 11 points and above, to enhance readability. Use standards Times New Roman font that is easy to read. Decorative or unusual fonts should be used sparingly and only when consistent with the message or the tone of the publication. Bold face and italics are intended for emphasis of selected words and phrases and are to be used sparingly. Screens or shaded areas behind text can limit readability and should be used sparingly. Use sufficient line spacing (leading), unjustified right paragraph formatting, and suitable paragraph widths (no more than 6-!/2 on a standard 8-!/2 x 11 page) to enhance readability.

1.5

1.6 1.7

Medical Illustrations 1.8 If medical illustrations are used, cite the source of the illustration.

Writing 1.9 1.10 Writing must be clear and suited to the reading skills of the audience and as free of jargon as possible. Minimize use of abbreviations. On the first reference, always write the full name, with the abbreviation in parenthesis. The abbreviation alone may be used in later references. Writing in the present tense is preferred.

1.11

Page Layout 1.12 Electronic Policy & Procedure Template is provided by the Quality Management Department to all Secretaries for usage.

Policy Identification and Revision Data 1.13 The First Page: header includes

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1.13.1 1.13.2 1.13.3 1.13.4 1.13.5 1.13.6 1.13.7

Title/Description Effective Date Review Due Replaces Version Applies to Index Number (including Version No.) Approved By

2. Template for Writing Internal Policies & Procedures 2.1 The top of the page has the following titles, and the rest of the IPP is free text.

Title/Description the title of policy is placed here

Index Number (incl Version No): QMD-01-01 Version 1 Must be in accordance with the ________ IPP Numbering System

Effective Date: The date the policy is typed

Review Date: The date the policy is due for review (2 years after date of IPP)

Replaces Version: If a prior policy is being replaced

Applies To: Approved By: Refers to the department(s) to which the IPP applies, it may be Division, Department or Section

Highest authority necessary for implementation

2.2

PURPOSE: a description of why the policy is in place, e.g. the purpose of this policy is to ensure that a standardized format is used when developing policies and to obtain the necessary input and agreement by the responsible Department Heads prior to implementation. DEFINITION(S): OPTIONAL Provide explanations of any new or unfamiliar terms or abbreviations. EQUIPMENT/MATERIAL: OPTIONAL For clinical procedures, this section is used to identify the equipment and/or supplies needed to perform the procedure. For administrative policies, this section is used for cross-referencing other policies. COMMENTS: 2.5.1 Comments: Statements for clarification or background information if needed.

2.3 2.4

2.5

2.6

POLICY: A statement about what standard is being set, e.g., it is the policy of the ________________ that all policies follow a prescribed format.

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Administrative policies do not normally require a step-by-step explanation but clinical policies normally do. For all policies not requiring a step-by-step explanation, the policy statements should be typed with numbered paragraphs under Policy. For all policies requiring step-by-step instructions, under Policy enter the following statement: For stepby-step instructions, refer to Procedure/Explanation, using the guidelines stated in Paragraph 4-7. 2.7 PROCEDURE/EXPLANATION: 2.7.1 Procedure: A step-by-step of how the policy will be carried out and includes who is responsible/accountable. Explanation: OPTIONAL a statement generally used in clinical procedures which provides the rationale for the step. This should be indented and typed in Italic font.

2.7.2

2.8 2.9

REFERENCE(S): OPTIONAL generally provided for clinical policies to reflect current knowledge. APPROVAL(S): PREPARED BY: ___________________________ (person(s) or committee that developed the IPP) APPROVED BY: __________________________ APPROVED BY: __________________________ DATE: ________________

DATE: ________________ DATE: ________________

1 - Intra-departmental approval within a department is obtained from the highest authority (e.g., Chairman or Department Head). 2 - Inter-departmental (2 departments) approval is obtained from the highest authority in both departments. 3 - The Executive Director, Medical services or the Executive Director, Operations approves the IPP where more than (2) departments are involved as appropriate. 3. Assigning Index numbers for Internal Policies & Procedures (IPP) 3.1 Index Numbering System a systematic method for organizing IPPs in a standardized way. 3.1.1 3.1.2 CCC = Department acronym (e,g, LAB = Laboratory, QMD = Quality management Department). XX = Refers to the Departmental section for large departments only where the department is subdivided into sections (e.g. Dermatology is a section of Medicine). YY = Refers to the chapter of the IPP manual to which the IPP subject matter relates. For example IPPs belonging to a particular function of the department (e.g. Quality Management, departmental orientation, Administrative, clinical, etc.). ZZ = Refers to the sequential numbering of the IPPs, after the chapter to which the IPP subject matter relates. VERSION NUMBER = Refers to the status the IPP is currently at with regard to the number of times the IPP has been revised. This is a useful tracking toll to ensure that all areas are working on the same Version of the implemented IPP.

3.1.3

3.1.4

3.1.5

The Version Number should be affixed to the first IPP and subsequent revisions in sequential order. That is, if Version 1 (the original IPP) is revised, the revised IPP becomes Version 2. However, each approving signatory may make several changes to the IPP so there could be several drafts of Version 2.

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Once all revisions to Version 2 are complete and IPP has been approved and signed by all signatories, Version 2 will then be implemented, replacing Version 1 in the IPP Manual. This process is repeated for each version. N.B. Only approved and signed IPPs should be in the IPP Manual and should not include any Draft IPPs. 3.2 For departments that do not have sections: 3.2.1 CCC = Department acronym + YY = departmental functions to which the IPP relates + ZZ = the sequential numbers of the grouping related to the departmental function. Example: QMD-01-01 = QMD (Quality Management Department) 01 (Administrative policies) 01 (Scheduling of Quality Management Staff title of policy). 3.3 For departments that do not have sections: 3.3.1 CCC = Department Acronym + XX = Refers to the Departmental sections + YY = departmental functions to which the IPP relates + ZZ = the sequential numbers of the grouping related to the departmental function. Example: MED-01-01-01= MED (Medicine, Dermatology Section) 01 (Administrative policies) 01 (Lectures: Pheripheral Clinics title of policy). 4. Review of Documents: 4.1 Policy will be reviewed every two (2) years.

5. Approvals PREPARED BY: ____________________________ APPROVED BY: ____________________________ APPROVED BY: ____________________________ 6. IPP HISTORY Initial IPP: Replaced by: Deleted: Replaced by New IPP: Version 1 dated (enter effective date) Version (enter new Version Number) dated (enter new effective date) If an IPP is deleted and removed from circulation, this should be documented here. If a new IPP with a new Index Number is replacing the removed IPP, this should be documented here. DATE: ______________________ DATE: ______________________ DATE: ______________________

FORMS EQUIPMENT REFERENCES

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APPROVAL: Name
Prepared by Reviewed by Approved By Approved By Latest Revision Approved By

Signature

Date

IPP HISTORY Initial IPP: Replaced by:

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