Date of Last Review 2/16/09
Date of Last Review 11/10/10
SME: Policy
and Procedure Committee
Purpose
To provide procedures that guide and support patient care, treatment, and services. To provide guidelines for initiating, preparing, and updating policies and procedures To outline the mechanism for approval, authorization and distribution. To ensure that policies are developed in collaboration with associated departments.| 1 | Hospital-wide policies and procedures are developed for significant organizational functions that are interdepartmental or mandated to be hospital wide by accreditation agencies or state/federal legislation. |
| 2 | The Hospital Policy and Procedure Committee shall be: |
| A. Composed of representatives from all Departments within the hospital | |
| B. Chaired by a designated member selected by the Executive Director in consultation with the Hospital Administrator. The Chair shall maintain a current distribution list for all policies, distribute policies for review, and insure timely completion of the process. | |
| 3 | Committee members shall be selected annually by the Executive Director in consultation with the Hospital Administrator. |
| 4 | Documentation of the review process and revised policies shall be maintained in the Policy and Procedure Binders for reference purposes. |
| 5 | The Policy and Procedure Committee shall meet six times a year unless otherwise directed. |
| 6 | Policies shall be: |
| A. reviewed by the Policy and Procedure committee via scheduled meeting or virtually. | |
| B. submitted to individuals/departments for additional comments and revisions as needed. The chairperson shall review and compile comments/revisions; final policy will be determined by committee majority. | |
| C. routed to individuals designated on the Signature Sheet for Policy and Procedure Approval Form. | |
| D. placed on the UTHCPC web-site by the Web Interface person within ten days of submission of the Policy and Procedure Form/Checklist and Signature Sheet for Policy and Procedure Approval. Persons unable to access the web-site may obtain a copy of the policy by contacting their departmental manager/director. | |
| 7 | Requests for new policies, revisions, or deletions, may be made by the Executive Director, Administrator, Medical Director, Medical Staff committees, Hospital committees, Hospital Departments, or individuals on the Hospital Policy and Procedure Committee. |
| 8 | All Hospital policies will be reviewed at least every three years and/or as needed. |
| 9 | Department Specific Policies |
| Department specific policies and procedures shall be reviewed and revised at least every three years and as needed, to ensure compliance with institutional practice, federal state, and regulatory body requirements. Department policies and procedures only require the approval of the Department Manager and his/her supervisor. Multidisciplinary policies require approval from affected Departmental Directors. |
Links: Signature Sheet for Policy and Procedure Approval
Policy and Procedure/Form Checklist
The Joint Commission: Leadership
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
