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Policy and Procedure/Form Creation or Revision


Date of Last Review 2/16/09

Date of Last Review 11/10/10
Policy and Procedure Committee

This topic explains how to request a new procedure/form or revise existing hospital procedures/forms.


The following are the policies in place for developing and revising hospital-wide procedures:

All policies, procedures, rules, and regulations of UTHCPC are subordinate to those established by:


UT System Board of Regents

Local, state, and federal law

The P&P Owner drafts hospital-wide procedures using approved format

Procedures are approved by the administrative group as follows:

Department Manager


Policy and Procedure Committee


Medical Director

Executive Director

Process Owner then forwards to the Web Interface Person for entry to the web site. Revisions to procedures must be submitted to the Web Interface Person in red as to distinguish changes from the original procedure.

Emergency approvals

Emergency approvals are for policies/forms that need to be in place immediately for compliance, accreditation or certification issues.

An appointed committee chair or task force team leader may request emergency approval using the process below:


Performs Action

Committee or task force requesting emergency approval

Produces procedure/form or revisions using approved format

Seeks authorized signature from either the Administrator or Assistant Administrator on the hard copy

Sends to the Web Interface Person:

The signed hard copy of the procedure/form

An email with the electronic copy attached

Web Interface Person

Sends an email notification to managers hospital-wide with the approved procedure/form attached

Sends a hard copy to place in front of the appropriate back-up manual

Flags outdated website procedures with a notice of "Section currently under revision. See your department manager/supervisor for current version."

Department Managers and Supervisors

Are responsible for reviewing changes and training staff

Process Owner

Submits the new procedure/form to the Policy and Procedure Committee to begin the review process, see Decision Tree for P&P Approvals

Committee or task force requesting emergency approval

Sends any new or revised Medical Record forms to the Medical Records Committee for approval

Creation/alteration process

This table describes the process for creating a new policy/procedure/form or changing an existing policy/procedure/form:




Employees may request new procedures/forms or changes by routing them through their department managers.


Administration, Department Managers, Committee Chairs may request procedure/form changes as needs are identified.


The requestor completes the Policy and Procedure/Form Checklist and includes the following with the request:

Supporting documentation for use as reference material

Recommended subject-matter experts


Use this table to determine where to send the documentation in Item 3:



The procedure/form is new

Send it to the Chairman of the Policy and Procedures Committee for review

Does the committee approve?
If yes, forward to the Process Owner for drafting.
If no, the process stops.

The procedure/form is a revision

Submit documentation in Item 3 to the Process Owner.


The Process Owner creates a draft of the procedure/form and recommends changes to other procedures/forms that may also be affected by the proposed change.


The Process Owner returns the draft(s) to the requestor for their review and follow-up with other departments and/or committees.


When a final draft is approved by the appropriate individuals the Process Owner submits a final draft and a signature sheet to the requestor for signatures.

Sign-off and distribution

Timely review and signature is needed to complete the sign-off process. The following table describes
the process of approving and distributing the new/revised policy/procedure/form:




The department manager/requestor signs the Signature Sheet and forwards to the next person/entity on the signature sheet.


The last person to sign the signature sheet returns the signature sheet and the approved draft to the Process Owner. The Process owner forwards to the Web Interface Person.


The Web Interface Person processes the changes for uploading to the website at the end of each month and sends notice of the procedure change(s).


It is each Department Manager's responsibility to ensure that his/her staff understands and implements the policy/procedure/form change within his/her department.

Decision Tree for P&P Approvals

Writing a new P&P or making changes to an existing P&P?

Process Owner involves key departments/managers in the design/draft of the Document. Process Owner then checks to see which committees need to review for approval. These may include:

Name of Committee



Date Submitted

Date Approved

IM Steering


Medical Records











Clinical Practice



Discharge Planning



Human Resources



Infection Control









Patient & Family Education






Medical Staff









Process Owner forwards edited document to P&P Committee for Review

Changes will be reviewed by committees in the following order:


Form references

Policy and Procedure Signature Sheet and Checklist

Related standards

The Joint Commission: Leadership

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Harris County Psychiatric Center University of Texas Health Science Center