Policy & Procedure Development Worksheet STEP 1: APPLICATION FOR POLICY/PROCEDURE DEVELOPMENT / REVIEW Instructions: To be filled out by p/p initiator; complete Step 1 of this form if possible, attach a draft of the proposed p/p use p/p template (available on P&P website) email documents to the P&P Coordinator @ Donna.Osipow@covenanthealth.ca Title of Policy/Procedure: Is this a new Comment: policy/procedure? Yes No Initiator / Representative / Committee Name and Position Date: This policy/procedure will (check all that apply) Explain why you feel this policy/procedure needs to be developed Purpose Briefly describe the purpose of the policy/ procedure Finance Will implementation of this p/p have a financial impact? If so, what? Practice Change Will there be an organizational change management required to implement this p/p (professional practice change)? Staff Education Who will require Communicate an organizational goal or objective Parallel and/or support AHS P/P or initiatives Meet Legislative/Mandated Requirements Meet standard(s) [specify]: Meet Risk Management / Legal Requirements Best Practice initiative which will lead to professional practice changes Act as a resource for staff Other (provide detail below)
education? all sectors; or identified sectors (eg. nursing, medical staff, etc.) What will the requirements be? one-time education; ongoing certification? other STEP 2: POLICY/PROCEDURE COMMITTEE RECOMMENDATIONS Instructions: To be filled out by Covenant Health P&P Committee (chaired by Jon Popowich) review documents provided by p/p initiator make recommendation (based on information provided by initiator in Step 1 of this form) communicate decision with initiator as appropriate, forward documents to SLT/SLT Ops. Covenant Health Policy & Procedures Committee Meeting Date: Recommends development of p/p for: Corporate applicable to all sites Corporate applicable to Acute Care sites only Corporate applicable to Continuing Care sites only Site Specific only (location: ) Portfolio Specific only (specify: ) Recommends p/p to be sent to the Medication Management Committee (NOTE: All medication-related p/p shall be sent to the Medication Management committee.) Recommends P/P development NOT APPROPRIATE. Reason/Alternate Suggestion/Comment: STEP 3: ENDORSEMENT OF SENIOR LEADERSHIP TEAM / OPS Instructions: VP of Quality - document SLT / Covenant Health Ops recommendations Appointed Executive Lead/Sponsor identifies P&P Project Lead Recommendations and documents provided to appointed P&P Project Lead SLT/OPS Committee Recommends development of p/p for: Meeting Date: Corporate applicable to all sites Corporate applicable to Acute Care sites only Corporate applicable to Continuing Care sites only Site Specific only (location: ) Portfolio Specific only (specify: ) Recommends p/p to be sent to the Medication Management Committee (NOTE: All medication-related p/p shall be sent to the Medication Management committee.) Recommends P/P development NOT APPROPRIATE.
Reason/Alternate Suggestion/Comment: Appointed Executive Lead / Sponsor: (Name & Title) P&P Project Lead: (Name & Title) P&P Signing Authority: (Name & Title) President & CEO Vice President & Chief Medical Officer Vice President & Chief Operating Officer Vice President & Chief Financial Officer Vice President & Chief Human Resources Officer Vice President of Mission, Ethics & Spirituality Vice President of Innovation & Business Development Other: (Appointed by P/P Executive Lead) (If other than the Appointed Executive Lead ) TARGET COMPLETION DATE: STEP 4: START THE DEVELOPMENT / REVIEW PROCESS Instructions: Steps 4 10 to be completed by appointed Policy Lead take action to ensure that the policy/procedure is developed in a timely manner ensure all stakeholders are identified and included in the development/review process ensure appropriate education/communication plans are identified and rolled-out to staff as appropriate This policy/procedure will apply to (check all that apply): All staff & volunteers Medical Staff Administration/Management (Out of Scope) Volunteers In-scope staff Board of Directors Patient care staff Other: Support staff This policy/procedure will impact the following areas (check all that apply): All Areas and/or Services Legal / Risk Management Acute Care Services Materials Management Seniors Health Medical Staff / Medical Affairs Administration Mental Health Admitting/Discharge OH&S Communications Patient Care Unit(s) *see below Diagnostic Imaging Pharmacy Environmental Services Rehab Medicine Facilities Management Respiratory Therapy Finance Security Services Food & Nutrition Services Social Work Health Records Spiritual Care Human Resources Volunteer Services Infection Prevention & Control Other (please specify):
Laboratory This policy/procedure applies to the following patient care unit(s): *Complete this section ONLY if you selected Patient Care Units as being impacted by the policy/procedure* All patient care units and/or areas Sub acute Seniors Health specialty Seniors Health conventional Ambulatory Clinics Child Health Centre Emergency Geriatric Assessment Unit ICN ICU/CCU Labor & Delivery Maternal-Infant Obstetrics Medicine Mental Health Operating Room Orthopedics Outpatient Clinics Palliative Pediatrics Pre-Admission Clinic Recovery Room Stroke Surgery Other (please specify): STEP 5: KEY STAKEHOLDER CONSULTATION AND P&P DEVELOPMENT PROCESS Review is required by the following persons/groups (check all that apply). Senior Leadership Team Board of Directors Medical Staff VP Medicine / CMO Patient Care areas (see above for list) CNEs, NPs, Clinical Nurse Specialist Support Services: Risk Management/Legal Direct Reports (Directors, Managers) Frontline staff Unions: Ethics Other Human Resources Finance Infection Control Medication Management Committee (all medicationrelated p&p) AHS representatives (if yes, please specify below): STEP 6: IDENTIFY SITE POLICIES / PROCEDURES This policy/procedure will replace (supersede) the following policies and procedures: Contact the Policy and Procedures Coordinator for help with this. 1. 2. 3. 4. STEP 7: CHRONOLOGICAL RECORD OF DEVELOPMENT / REVIEW PROCESS Use this section to keep of record of who reviewed drafts of the p/p, significant comments, etc. The Policy and Procedure Review Committee members, and the Executive Lead will review this category prior to sign-off. NB: For clinical policies, include details of medical staff and/or others with specialized clinical competency (content experts) who provided input at the initiation stage of the policy. Date Sent to: Record of Comment/Feedback
STEP 8: EDUCATION & COMMUNICATION PLAN Provide education plan/resources: STEP 9: RISK ASSESSMENT Answer the following questions: 1. When does this policy/procedure need to be implemented by? 2. Is this policy/procedure a priority? If so, why (eg. new legislation). 3. What is the risk to staff, patients/residents or the organization if not implemented? 4. What, if any barriers, may be encountered when implementing the policy/procedure? 5. Are there any outstanding or unresolved issues? STEP 10: RETURN COMPLETED DOCUMENTS TO THE P&P COORDINATOR Send this worksheet, your draft p/p and all related information (eg. learning packages and/or education roll-out plans and resources) to the P&P Coordinator. STEP 11: FINAL REVIEW / SIGN-OFF / DISTRIBUTION Instructions: P&P Committee Final Review/Recommendations P&P Coordinator sends signing authority for sign-off once sign-off is obtained, P&P ensures communication process complete (below). The P&P Review Committee recommends: Date: Sign-off by P&P Signing Authority (refer to Step 3) Return to the developer for additional information Other (please specify): Distribution: Compass (Covenant Health Communications) Memo/email from: Covenant Health policy/procedure intranet site Other P&P Effective Date: VERSION: April 2014
DEFINITIONS: POLICY A policy sets out the organization s position on a specific subject, providing a common frame of reference and direction by establishing minimum requirements and expectations, benefitting those we serve and those within the organization. Requirements in a policy may be further expended upon through the procedure or other practice support documents. PROCEDURE Provides detailed information necessary to fulfill requirements for a specific process. DIRECTIVE Provides temporary governance in exceptional circumstances and offers instruction and guidance for decision-making and actions to support dayto-day operations. PRACTICE SUPPORT DOCUMENTS Practice documents accommodate the unique nature of a department and are aimed at fostering decisions or streamlining a particular process within a department s routine boundaries. They allow the opportunity to expand on the requirements set out in a higher level of governance document (eg. corporate policy, legislation, etc.) to meet the operational needs and provide direction. In order of authority, the practice support documents include: Standard or Code of Practice sets out the desired and achievable level of performance that establishes best practice as may be established by national, provincial, or professional associations, and against which actual performance can be compared. Protocol prescribes interventions for undertaking specific investigations, therapies and/or activities in an identified situation. Guideline established a recommended course of action that aligns with best practice, but individuals are afforded a reasonable amount of professional judgement in complying with the provisions. Clinical practice guidelines are systematically developed statements to assist practitioner and patient
decisions about appropriate health care for specific clinical circumstances 1. Their purpose is to make explicit recommendations with a definite intent to influence what clinicians do 2. APPENDICES An appendix is a useful tool to provide supplementary reference information related to the requirements set out in the principal document. ACCOUNTABILITIES / RESPONSIBILITIES Accountabilities and responsibilities mean different things. One is accountable to another individual or body, but is responsible for a particular task or event. Each of us is accountable to the people of Alberta and to one another to ensure we comply with the requirements of the governance documents (eg. policy) and support Covenant Health s mission, vision, and core values. All Covenant Health staff, physicians, volunteers, students and any other persons acting on behalf of Covenant Health play a role in ensuring our policies/procedures are accurate and reflect best practice. Policies/procedures do not replace, but are in addition to, professional selfregulation and individual accountability. EXECUTIVE LEAD / SPONSOR The executive lead/sponsor is the member of the Senior Leadership Team who has accountability for the subject matter addressed in the policy/procedure. The executive lead/sponsor commits to ensuring that the infrastructure and resources necessary to support the requirements of the policy/procedure, including ensuring educational and practice change resources, will be in place as necessary. The executive lead/sponsor acts as a decision-maker in the event of an impasse or dispute during the development process. POLICY LEAD The policy lead is accountable to the executive lead/sponsor. The policy lead is usually the individual who is the primary content expert during the document s development. The policy lead may delegate roles/responsibilities to others (eg. working group) but is ultimately responsible for preparing drafts for review and consultation, coordinating consultation feedback, developing communication and education strategies/resources, and planning the implementation and evaluation strategies. KEY STAKEHOLDERS Key stakeholders play a crucial role in the development and review of policies and procedures. As a normal practice, representative groups referred to as key stakeholders are required to act as the spokespersons
for the employees, medical and other professional staff, and others. They represent those who are most affected by the contents of a policy/procedure in terms of compliance with the requirements. It is critical that the key stakeholders engage with the constituencies that they are representing, including frontline staff, to obtain as broad a range of viewpoints as possible. Prior to approval of a policy/procedure, key stakeholders are asked to provide feedback on the contents as a measure of good governance to ensure the document adequately addresses the issue and establishes sound, practical, and achievable requirements. POLICY & PROCEDURE REVIEW COMMITTEE ROLE Act as the hub for corporate policy and procedure development and review. In the final review process, identifies: any potential gaps or issues that must be addressed before implementation; and ensures that each document has a plan for communication, education, and practice change strategies.