NORTH CAROLINA BAPTIST HOSPITAL POLICY AND PROCEDURE BULLETIN. NCBH Policy and Procedure Committee

Transcription

1 Page 1 of 11 NORTH CAROLINA BAPTIST HOSPITAL POLICY AND PROCEDURE BULLETIN PREPARED BY: NCBH Policy and Procedure Committee CONTACT PERSON: Vice President, Legal Affairs SUBJECT: Policies & Procedures I. POLICY: It is the policy of North Carolina Baptist Hospital to maintain up-to-date policies and procedures, consistent with institutional and regulatory standards, governing all aspects of Hospital operations. All department directors and administrative staff are responsible for ensuring the use of the format outlined herein to develop, implement, review, revise, and distribute appropriate policies and procedures for their area(s) of responsibility. II. PURPOSE: To establish minimum criteria for the development, standardization, review, and distribution of policies and procedures throughout the Hospital. III. PROCEDURES: A. ELEMENTS: All policy and procedure bulletins should contain the following essential elements: 1. Heading: (See above, Prepared By, Contact Person, and Subject.) The heading identifies the division of the Hospital that has primary responsibility for the policy and procedure. It identifies the division or department that prepared and approved the policy and the subject of the policy. All divisional and departmental policies should be numbered in the upper right hand corner. (See Section C.) The next line should show Last Revision Date (or Review Date), or if new policy, the Effective Date. The third line should show Page x of y. On the last page list dates of all prior reviews and/or revisions. 2. Policy statement: Clearly and accurately state the policy. The wording should be positive and leave no doubt as to the Hospital/Department policy on the subject. If the policy supersedes another policy, state this fact and refer to the former policy in this statement. 3. Purpose: States the reason for the policy. 4. Procedures: Outlines the procedures to be followed to implement the policy.

2 Page 2 of 11 B. STRUCTURE: Procedures should be delineated using Microsoft Word outline format, using Roman and Arabic numbers, as well as capital and lower case alphabetical letters. This makes ready reference very easy when a particular section of a policy and procedure is being discussed. The hierarchy to be followed by all departments and divisions (with the exception of Human Resources) is shown in a template that is supplied in Appendix V. C. NUMBERS/ABBREVIATIONS: 1. Each policy and procedure bulletin is to be assigned a number, identifiable as Hospital (NCBH) and by division and department, where applicable, as shown in the following examples: PPB-NCBH-01 Hospital, Policy #1 PPB-NCBH-NSG-01 Hospital, Nursing, Policy #1 PPB-NCBH/WFUHS-IS-01 Information Services, Policy #1 2. The Office of Legal Affairs will assign numbers of Hospital, NCBH Board, and NCBH/WFUHS policies and procedures before routing for signature. A log of assigned numbers is maintained in the Office of Legal Affairs. 3. Divisional/departmental numbers should be assigned by a designated person within the division/department and a log of assigned numbers maintained. Refinement of the numerical system may be incorporated as necessary for departments with multiple sections and subsections, but the departmental director should preserve established divisional and departmental abbreviations used to identify the policy and procedure bulletin. The master index of divisional and departmental abbreviations is in Appendix I. To avoid duplication within the division/department, the divisional vice president or departmental director should establish abbreviations for departmental sections and subsections and maintain a master index of all departmental abbreviations within each division. D. CLASSIFICATIONS AND APPROVALS: 1. Policy and procedure authorization (i.e., who approves a policy) is determined by policy classification. Five policy classifications have been developed for North Carolina Baptist Hospital for the minimum approval required for each. A Routing Sheet showing the required approvals must accompany each policy that is circulated (Appendix III.) Approvals should be obtained beginning with the least title seniority and ending with the highest title seniority. a) Departmental policies and procedures are used exclusively by one department and must be approved by the Hospital Vice-President for that department s division. b) Divisional policies and procedures affect the operations of more than one department, but do not cross divisional lines and must be approved by the Hospital Vice-President for the division.

3 Page 3 of 11 c) Hospital policies and procedures that affect or pertain to the entirety of NCBH (Appendix II may not be originated by a single department and must be approved by the Policy and Procedure Committee. If the policy involves patient care, the Chief of Professional Services, must approve. d) Board policies are made by the governing body and require the signature of the Hospital president and chairman of the Board of Trustees. e) NCBH/WFUHS policies and procedures, by their very nature, are broad in scope and affect, or have the potential to affect, every department, management group and division in the Medical Center. They must be approved by the Chief Operating Officer (COO) or Chief Executive Officer (CEO) of WFUHS and COO or CEO of NCBH. f) Human Resources Division policies and procedures will continue to use the format, authorization and distribution standards for all Human Resource Management Policies, as established and approved by the Human Resources divisional vice president and president/ceo. g) Review of a policy and procedure occurs when either a department, division head, or senior manager may request review by consulting departments (for example, Risk Management, Legal Affairs.) If review by Legal Affairs is required, a request form (Appendix IV) must be completed and attached to the policy to be reviewed. Request form can also be found under Forms on Infinet. E. DEPARTMENTAL/DIVISIONAL POLICIES: 1. Must follow the formatting requirements of this policy. 2. Must ensure that their policies do not conflict with any other policy. 3. If the policy involves legal issues, please send for legal review utilizing appropriate form. (Appendix IV.) 4. Should send the policy to their assigned webmaster. F. REVIEWS & REVISIONS: 1. Departmental directors and administrative staff or designee of the Hospital will cause the review and/or revision and approval of each policy and procedure at least every three years to ensure compliance with current Hospital and regulatory standards. a) Any policy and procedure must be circulated for approval under the terms of Section D when there is a material change of content or a change of appointment for who approved the policy. b) Departmental directors and administrative staff should utilize an effective control

4 Page 4 of 11 mechanism to identify policies and procedures for review. Reviews should begin 120 days prior to the anniversary of the effective date or last review and/or revision date to allow ample time to process and obtain necessary approvals for the policy and procedure. G. DISTRIBUTION & TRACKING: 1. A cover letter shall be attached stating no changes were necessary, or in the event of changes, state that there are changes and attach a copy of the old policy with the changes highlighted or redlined. 2. The originating department or committee preparing the policy shall distribute copies of the policy and procedure in accordance with the guidelines in Appendix II. 3. A Routing Sheet must accompany the policy needing approval. The Routing Sheet shall indicate the required approvals for each policy. (Appendix III.) 4. An executed copy of the new, reviewed, or revised NCBH Policy and Procedure Bulletin will be sent to Legal Affairs in hard copy with signed routing slip and the Word document via disk or . Legal Affairs will forward to the Webmaster for posting on the Infinet. The executed original will reside in the Office of Legal Affairs unless it is a departmental only policy, in which case it resides in the originating department. 5. If the approved policy is made available on Infinet, a hard copy does not have to be distributed. A notice will be posted on Infinet and a memo or will be distributed, giving notification of new or revised policy. H. RETENTION: 1. The Office of Legal Affairs shall maintain the original policy and procedure bulletins for NCBH/WFUHS and NCBH. The President s office has the original NCBH Board policy and procedure bulletins. The originating department should maintain all departmental or divisional policies. NCBH/WFUHS, NCBH Board and NCBH policies and procedures will be kept in an accessible, safe area in a distinct notebook(s), appropriately labeled and indexed to aid in retrieval. Retention of superceded policies (refer to PPB-NCBH-FM-82) should be kept for the life of the manual plus six (6) years. I. REFERENCES: All policies shall list authoritative references, including federal and state law, JCAHO, or clinical references, as applicable. J. CROSS REFERENCES: When a policy incorporates materials or procedures (including guidelines) from departments or divisions, that department or division will have to approve the policy and be cross referenced and listed at the end of the policy. K. ATTACHMENTS: Attachments include information that clarifies or is related to the procedure or the policy. All shall be listed on the last page of the Policy and Procedure as

5 Page 5 of 11 demonstrated on page 5 and attached at the end of the written policy itself. L. HISTORY: (not included in the header): On the last page, after the list of attachments, the original effective date and the previous revision and/or review dates shall be referenced by descending numerical order, if the policy is not new. Attachments: Appendix I Appendix II Appendix III Appendix IV Appendix V (template) Effective Date: Revision or Review Dates: /01/99 1/02/02 4/29/02 5/28/02 8/26/02 12/02 3/03 5/2/03

6 Page 6 of 11 APPENDIX I INDEX OF ABBREVIATIONS North Carolina Baptist Hospital and Wake Forest University Health Sciences NCBH/WFUHS Hospital Policies NCBH Divisional Abbreviations Development/Alumni Affairs Facilities Planning/Construction Financial Services Human Resources Information Services Legal Affairs Nursing Patient Financial Services Strategic Planning DAA FPC FS HR IS LA NSG PFS MCSP Departmental/Subsidiaries Abbreviations Activity Therapy Baptist Hospital Home Care Cardiology Diagnostic Services Cardiac Catherization Lab Heart Station Electrophysiology Lab Ultrasound/Treadmill Ultrasound Cardiovascular Information system Center on Aging Center for Congregational Health Chaplaincy and Pastoral Education Child Life Church & Community Relations Clinical Labs CompRehab Downtown Health Plaza Financial Management Food and Nutrition Services Hearing & Speech Internal Audit AT BHHC CDS CCL HS EP US-TM US CVIS COA CCH CPE CL CCR LAB CRO DHP FM FNS HS IA

7 Page 7 of 11 Legal Affairs Medical Center Treasurer Medical Records Nursing Center at Oak Summit Pastoral Counseling Patient Relations Pharmacy Physical/Occupational Therapy - Administration Physical/Occupational Therapy - Therapy Radiology (Radiological Sciences) Recreation Therapy Respiratory Care Respiratory Care - Clinical Respiratory Care - Administrative Pulmonary Laboratory Pulmonary Rehabilitation Respiratory Care - Oak Summit Extra Corporeal Membranous Oxygenation Risk Management LA TR MR OAK PC PR PHARM PT/OT Adm PT/OT - TX RS RT RC RCAD RCPL PULR RCOS ECMO RM Other Divisional Abbreviations (Determined by vice president) Other Departmental Abbreviations (Determined by department director)

8 Page 8 of 11 APPENDIX II REQUIREMENTS FOR POLICY & PROCEDURES BULLETINS Policy Classification Departmental Divisional Hospital Board Required Review Medical Director Division Vice President Other Administrative/Medical Staff (if applicable) Departmental Directors (if applicable) Medical Directors Divisional Vice President Divisional Vice President (if applicable) Medical Director (if applicable) Senior Vice President for Operations/COO Chief of Professional Services (if applicable) President/CEO President/CEO Chairman of the Board NCBH/WFUHS Chief of Professional Services COO of WFUHS Sr. V.P. Operations/COO President/CEO of NCBH President/CEO of WFU Health Sciences Distribution List Departmental Staff Departmental Director Medical Director/Admin. Director Divisional Vice President Departmental Staff Departmental Directors Medical Directors Divisional Vice President Hospital Management (Call Charlene Teague, 63338, to get labels for all Hospital Management) Chief of Professional Services Associate Chiefs of Professional Services Director of Medical Staff Services All Divisional Vice Presidents Senior Vice President for Operations/COO President/CEO All Divisional Vice Presidents COO of WFUHS Sr. V.P. Operations/COO President/CEO President/CEO of WFU Health Sciences If patient care may be affected, the policy requires approval by the Chief of Professional Services. At the discretion of the management team, policies that involve legal, compliance or human resources issues may require review by these departments.

9 Page 9 of 11 APPENDIX III ROUTING SHEET POLICY SIGNATURE SHEET (The original shall be maintained by Legal Affairs and a copy by the Department.) Company/Facility(s) Department Policy Action NCBH or NCBH/WFUHS POLICY APPROVALS: Title Approved by Signature Date Other Admin/Medical Staff Departmental Director Medical Director Compliance Legal Division Vice President Chief Professional Services Sr. VP/COO/Hospital Sr. VP/COO/WFUHS President/CEO/NCBH President/CEO/WFUHS Chairman of the Board GROUP APPROVALS: Committee/Taskforce, etc. Chairperson Date DATES OF APPROVAL: Initial Effective Date Date Reviewed/Revised Date of next Review POSTING PROCESS: Date sent to Legal Affairs: Date sent to Webmaster: Date notice posted on Infinet: Was notification by or hard copy?

10 Page 10 of 11 [Hyperlink to Forms] APPENDIX IV *REQUEST FOR POLICY LEGAL REVIEW TO: VICE PRESIDENT, LEGAL AFFAIRS DEPARTMENT OF LEGAL AFFAIRS SUBMITTED BY: NAME OF POLICY: DATE: We request legal review of the attached policy. 1. The original policy was written on (date). (Please attach a copy of original policy.) 2. The policy was last reviewed/revised on (date). 3. The current policy was approved by (department or group name). 4. It is recommended that the policy should/should not (please circle) be placed online. If there are any questions, please contact telephone #. A review of this policy must occur no less frequently than every three years. The review will be conducted by. Department(s) that will be affected by this policy include: Plan for dissemination and education: *Please send an electronic copy of Policy and Procedure Bulletin to rleftwic@wfubmc.edu as well. Thank you.

11 Page 11 of 11 APPENDIX V NORTH CAROLINA BAPTIST HOSPITAL POLICY AND PROCEDURE BULLETIN PREPARED BY: [Insert Department Name] CONTACT PERSON: [Insert Contact Name and Title] SUBJECT: I. POLICY: It is the policy of North Carolina Baptist Hospital (NCBH) to [e.g., comply with law, standard, expectation.] II. PURPOSE: The purpose of this policy is to [e.g., implement A, B, C.] III. PROCEDURES: A. B. C a) b) (1) (2) (a) (b) IV. [or appropriate letter (C, D, etc.] REFERENCES: CROSS REFERENCES: [Please list any other policies that may apply.] ATTACHMENTS: Effective Date: Revision Dates: Save to file and as an attachment to rleftwic@wfubmc.edu Legal Affairs.