Policy and Procedure Development Handbook

Transcription

1 Policy and Procedure Development Handbook

2 Preface This handbook is made available to you by the Regional Policy Advisory Council (RPAC). RPAC s mandate includes the constant review and clarification of the development process for policies and procedures. An integral aspect of the adopted approach is the desire for standardization and integration of policies and procedures. All staff must be supported and encouraged to actively use policies and procedures through accessible and up-to-date manuals or through the website. The Council s Terms of Reference are updated regularly and are available from the RPAC Administrative Assistant. ~ Regional Policy Advisory Council March 2009 Page 2 of 22

3 TABLE OF CONTENTS SECTION I OVERVIEW Introduction... 5 Definitions... 5 Numbering System... 6 Templates... 7 Header... 8 Policy Template Procedure Template SECTION II - POLICY AND PROCEDURE DEVELOPMENT PROCESS 1. Identify the Issue Think through the issue 1.2 Determine Policy Type 1.3 Obtain Authorization to Proceed 2. Research and Analyze Conduct Environmental Analysis 2.2 Conduct Initial Stakeholder Consultation 3. Draft the Policy Prepare first draft 3.2 Forward to Policy Consultant (for Regional Policy and Procedures only) 3.3 Meet with Policy Consultant (for Regional Policy and Procedures only) 4. Determine Extent of Influence Determine departments/individuals to be consulted 4.2 Determine consequential amendments Page 3 of 22

4 Table of Contents continued.. 5. Consultation Circulate draft 5.2 Compile feedback 5.3 Analyze # of responses, determine if another consultation required 5.4 Respond to each response 5.5 Revise 5.6 Ensure intent has not been altered 6. Approval & Distribution Review final draft with Policy Lead 6.2 Forward to Policy Consultant (for Regional Policy and Procedures only) 6.3 Submit to RPAC/Obtain Formal Approval 6.4 Distribution 7. Implementation, Monitoring and Review Implementation 7.2 Monitoring 7.3 Review SECTION III OTHER INFORMATION Deleting/Repealing Region-wide Policies and Procedures Region-wide Policy and Procedure Database Central Files Page 4 of 22

5 SECTION I - OVERVIEW INTRODUCTION This handbook applies to the creation and revision of Region-wide policies. It should also be used as a guide for policy and procedure development to achieve consistency across the organization. All SHR policies, procedures and protocols are intended to: Be accessible and user friendly Contain relevant and current material Be an accurate information source for day-to-day operations, as well as for orientation and training purposes. The Policy and Procedure Development Handbook provides managers and staff with some practical advice in writing policy and procedures. DEFINITIONS Policies are written directions that guide conduct and decision making. Policies reflect organization wide intentions, direction and position. Policies form the written basis of operation, secondary to legislation and an organization s bylaws. Policy prescribes limits, pinpoints roles and responsibilities and serves as guidelines for decision making within the organization. Procedures operationalize policy. Procedures are the natural outgrowth of policies, supplying the how to for the policy. Procedures communicate a series of steps, outline sequences of activities or detail progressions that describe how to carry out the policy. Like policies, procedures can apply to a whole organization, facility or to a department or unit within it. Protocols are another way to describe a procedure. A policy tells people what to do and a procedure tells them how to do it. Page 5 of 22

6 SHR POLICY AND PROCEDURE NUMBERING SYSTEM The policy numbering system for the Region-wide Policy and Procedure Manual consists of: a standard four digit # identifying it as a regional policy (7311); a two-digit subject categorization number a three digit individual item number (013) This number will be assigned to Region-wide policies by the Policy Consultant upon approval of the policy. Page 6 of 22

7 TEMPLATES Copies of the templates are located in the handbook. Electronic versions of the template are posted on the Region s internal website. The templates are used to write the actual policy. The templates describe the layout and format for policy documents. New Region-wide Policies and Procedures should be submitted to the Policy Consultant via . Revisions to Region-wide Policies should be submitted to the Policy Consultant via , with the changes marked in red. Page 7 of 22

8 HEADER The first page of the policy contains a header identifying the approval authority, number, title, source, cross index,, date approved, date revised, date effective, date reaffirmed and scope. Approval authority: Regional Policies may be approved by the President and CEO or VP Finance and Administration on behalf of SLT/the Authority; is indicated by an X in the appropriate box(s) in the header on the first page of a policy and procedure. The Regional Policy Advisory Council determines the appropriate approving authority. Number: Title: Source: Is the unique seven digit number assigned to each Region-wide policy. The number serves for policy identification in the Region-wide Policy and Procedure Manual. Numbers are assigned by the Policy Consultant following approval of a Region-wide policy. Clearly describes the content of the policy. The title should be carefully chosen keeping the reader in mind. It should be descriptive yet short in length. The title/position of the Policy Lead. Indicates the specific position that owns the policy and is responsible for communication, education, implementation, monitoring, audit, review and amendment of the policy. The source must be a Vice President, Director, Executive Director, Professional Leaders or Chairperson. Avoid listing committees as the sole source of a policy as committees change and are disbanded less frequently than positions. Cross Index: Indicates other region-wide policies that are mentioned within the policy or that may be affected by an amendment to the policy. Date Approved: Indicates the date the policy was signed by the approval authority. Date Revised: Indicates the date when a policy was last reviewed/updated/revised and approved. To be completed by Policy Consultant for Region-wide policies following approval. Date Effective: Indicates the first date the policy and procedure becomes operational. During subsequent revisions, the effective date for implementation remains the same. Date Re-affirmed: Scope: Indicates the date the policy was reviewed and reaffirmed without change. For Region-wide policies the scope is either SHR or SHR and Affiliates. In this context, SHR means all owned, leased, operated and integrated facilities. Page 8 of 22

9 Affiliates that are fully integrated with the Region follow the Region s policies and do not require that the policies receive separate approval by the affiliate s Authority. (ie. the operating agreement with St. Paul s Hospital (SPH); Affiliates that are not fully integrated, manage their own programs and directly employ their own staff, are not automatically subject to SHR policies unless the Operating Agreement includes this expectation (ie. Long Term Care Facilities). Page 9 of 22

10 POLICY TEMPLATE The preferred font for policy documents is Arial 12. Subheadings should be in bold using the following format. Text should be regular typeface except where emphasis is required. Use only Bold and Italics or a combination to emphasize key points. The main body of the policy and procedure is made up of the following sections. The sections are in an open format. The length of each will vary with the individual policy or procedure. The sections are numbered by a simple decimal system. Number: Title: Authorization [ ] President and CEO [X] Vice President, Finance and Administration Source: Director/Chair Cross Index: Date Approved: Date Revised: Date Effective: Date Reaffirmed: Scope: SHR or SHR & Affiliates? OVERVIEW/PREAMBLE Background information the reader needs to fully understand the policy. (Bold, Italic) DEFINITIONS (ie) Definition means an explanation of the basic elements. Defines terminology used in this particular policy, intended for reader clarity, not intended for organization wide use, only applies to this policy. 1. PURPOSE The purpose of this policy is to establish The objective of the policy, explains why the policy exists and what activities are to be regulated. 1.2 Positioned here to allow readers know SHR s reason (or purpose) for writing, policy users can read with that purpose in mind. Page 10 of 22

11 2. PRINCIPLES 2.1 An explanation of the fundamental reasons that can be used as a basis for reasoning or conduct; guiding sense of the requirements and obligations of right conduct. 3. POLICY 3.1 Policy statements must be clear and concise statements of expected behaviors, practices and standards. 3.2 Policy statements state the position of SHR regarding a particular issue or situation 3.3 All SHR staff shall.. 4. ROLES AND RESPONSIBILITIES 4.1 Outlines the roles & responsibilities to enable/operationalize the policy. (ie) Committees, Directors, Executive Directors, Managers, Supervisors, all staff etc. 5. POLICY MANAGEMENT The management of this policy including policy communication, education, implementation, monitoring, audit, review and amendment is the responsibility of the (same as source) 6. NON-COMPLIANCE/BREACH Non-compliance with SHR policy shall result in disciplinary action, up to and including termination of employment and/or privileges. 7. REFERENCES 7.1 List and link to other internal polices and/or external material quoted (ie. Conflict of Interest Policy, Code of Conduct, Acts, Regulations, CCHSA etc ) 7.2 Appendix(s): for more information, to further describe, used to list reference information that is not part of the text; the appendix can be used to keep information such as, lists, tables, maps, diagrams, technical specifications. Appendices may be added to the end of the document if it is necessary to attach additional material that supports the policy and procedures and/or information that may change over time. Appendixes can be updated as required and do not require approval. 7.3 Guidelines: communicates additional important information. Page 11 of 22

12 PROCEDURE TEMPLATE PROCEDURE Number: Title: Authorization [ ] President and CEO [X] Vice President, Finance and Administration Source: Director/Chair Cross Index: Date Approved: Date Revised: Date Effective: Date Reaffirmed: Cross Index: Scope: SHR or SHR & Affiliates? 1. PURPOSE 2. PRINCIPLES (optional) 3. PROCEDURE 4. PROCEDURE MANAGEMENT The management of this procedure including procedures education, monitoring, implementation and amendment is the responsibility of the (same as source) 5. NON-COMPLIANCE/BREACH Non-compliance with this procedure may result in. 6. REFERENCES SHR Policy.. SHR Forms Page 12 of 22

13 SECTION II POLICY AND PROCEDURE DEVELOPMENT PROCESS 1. Identify the Issue 1.1 Think through situations and their consequences before writing a policy or procedure. At this early stage, pause and ask: What is SHR s position as an organization? What is the nature of the problem? Who and what are affected? How frequently does the problem occur? What are the consequences when the problem occurs? How severe are the consequences? Low? Medium? High? What combination of factors or circumstances contributes to the problem? Can the factors or circumstances be eliminated, controlled or managed? What approaches can be used to deal with the contributing factors? Are there other areas that experience the same or similar problem? How do the other areas deal with the problem? 1.2 Determine Policy Type - determine if issue is a region-wide policy, service department policy or discipline specific policy, or a department/unit/sector/ program protocol. It is impractical and inefficient to have a policy for every situation. Use the Regional Policy Criteria to determine when a regional policy would be appropriate If it is an SHR Region-wide Policy and/or procedure, determine who has operational responsibility for this issue? This can be done in consultation with the Policy Consultant. Is this issue adequately addressed elsewhere in existing policies? If a policy on a similar issue or topic already exists, is there any need for a separate policy to cover your situation? Perhaps a simple revision to an existing policy is all that is necessary to cover a gap or need. Are other parts of the organization working on a similar policy? Can you combine your work under one regional policy If it is a Service Department/Discipline Specific policy or procedure, or a department/unit/sector/program procedure or protocol consider the following: Is your protocol consistent with provisions in any higher-level (overarching) policy and or procedure that deals with this issue? Does it conflict with practices in other operational areas? Page 13 of 22

14 Will differences between operational areas cause problems or confusion for the people using the policy/procedure/protocol? In these cases, the overarching policy and or procedure should be revised to provide a consistent direction for all departments and staff. 1.3 Obtain authorization to proceed A=Approves R=Recommends Policy or Procedure Level Authority Policies SHR Region-wide Policies and Procedures Authority A VPs Executive Director, Director, Professional Leader A 1, R R R Manager, Supervisor, staff Discipline Specific A A, R R Service Department Specific Department/Unit/Sector/ Program Protocols A A,R R 2. Research and Analyze 2.1 Conduct an environmental analysis for best practice. Research relevant policies and procedures from other healthcare organizations. Exploration of options is an essential component of policy analysis and strategy development. It is important that policy development is supported by sound evidence. For Regional Policies and Procedures the Policy Consultant will assist in gathering sample policies from other healthcare institutions. 2.2 Conduct Initial Stakeholder Consultation Consult with people, groups and organizations (stakeholders) who have a stake in resolving the problem and to help you focus on the issue that needs to be addressed. The initial stakeholders are determined by the Policy Lead. A,R R 1 Includes President and CEO and Vice President, Finance and Administration only Page 14 of 22

15 3. Draft the Policy and/or Procedure 3.1 Prepare the first draft If is a new policy or procedure, draft the policy using the appropriate template. If it is a revised regional policy or procedure, the Policy Consultant will provide you with a editable, draft of the most recent policy in effect. Policy development requires thinking through the implementation processes as a coherent package 3.2 Forward to Policy Consultant (if Region-wide Policy and/or Procedure) Complete Policy Development and Approval Form A copy of this form is located in Appendix A of the handbook. Electronic versions of the template are posted on the Region s internal website. Completion of this form is required for all new and revised Regionwide policies. This form includes contact information for the policy development lead. It also documents the stakeholders consulted during policy development, the nature of the policy content, significant changes made during policy revisions, and implementation strategies. Forward draft forward the draft policy and the completed Policy Development and Approval form to the Policy Consultant for initial review 3.3 Meet with Policy Consultant for initial policy review (content, editing and to determine next steps). 4. Determine Extent of Influence 4.1 Determine departments/individuals to be included in the consultations. If it is a regional policy or procedure, do this in consultation with the Policy Consultant. Considerations will include: Primary Stakeholders - consider anyone specifically mentioned in the policy and anyone specifically affected by the policy. Regional policies and procedures usually undergo a broad consultation which would include key stakeholders. Many or all members of OLT and/or SLT will be consulted. It is important for stakeholders to identify flaws, gaps and inconsistencies in the draft policy when it is circulated for comments and feedback. Page 15 of 22

16 Additional consultations could include: Secondary stakeholders - current users of a system to ensure they are informed and that services are kept relevant and appropriate to their needs; Current health service providers to ensure proper coordination and resource utilization; Other departments and agencies to ensure consistency of key policy directions and coordination where cross-departmental/ cross agency policies are being developed; Employees, physicians, contracted staff, knowledge experts and representatives of organizations where considering changes that may affect working conditions or their responsibility for effective implementation of the policy; Standing committees and councils with experience and knowledge in specific areas (e.g. ethics, forms development, service standards, medical issues) 4.2 Determine Consequential Amendments 5. Consultation Determine in consultation with Policy Consultant if there will be any consequential amendments as a result of this draft new/revised policy. (ie) Other approved policies that will require revision as a result of the content in the new/revised policy. Policy Consultant will advise respective policy leads of consequential amendments upon formal approval. 5.1 Circulate policy to stakeholders and obtain feedback Aims and objectives of consultation should be clearly identified and communicated with stakeholders prior to proceeding with the consultation process so they are aware of: why they are being consulted, how the consultation process will work how much influence they can realistically hope to have in decisionmaking Note: Allow stakeholders a minimum of two weeks to provide feedback to you; LTC requires four weeks. 5.2 Compile Feedback Page 16 of 22

17 5.3 Analyze number of responses and determine if another consultation is required. Determine if number of responses are appropriate (send the draft out again if you received only a few responses). 5.4 Evaluate the feedback determine where to include or not to include the feedback in your policy or procedure. 5.5 Respond to each response as to whether you will be including their feedback in to the policy or not. If not, explain why. 5.6 Revise the policy based on feedback. 5.7 Ensure the policy intent and related procedures have not been altered. Page 17 of 22

18 6. Formal Approval and Distribution TABLE 2 A=Approves R=Recommends Policy or Procedure Level Authority VPs Executive Director/Director/ Professional Leader Manager/ Supervisor/ Staff Authority Policies Region-wide Policies and Procedures A A 2, R R R Discipline Specific A A, R R Service Department Specific A A,R R Department/Unit/Sector/ Program Protocol A,R R 6.1 If you are not the stated Policy Lead, review the final draft of the policy and or procedure with the Director or Professional Lead. For professional discipline policies and Service Department specific policies and procedures contact your Manager, Director, Professional Leader or Supervisor to find out what process is used to review, approve, distribute and maintain policies in your area. 6.2 For regional policies and procedures, forward the final draft to the Policy Consultant for submission to the Regional Policy Advisory Council (RPAC). 6.3 Obtain Formal Approval For Region-wide Policies and Procedure the approval process is conducted as follows: The Policy Consultant will: Contact the Policy Lead to arrange for attendance at the next RPAC meeting to present the policy, if necessary. Circulate all the information to RPAC committee members prior to the presentation. 2 Includes President and CEO and Vice President Finance and Administration only Page 18 of 22

19 The Regional Policy Advisory Council will: Review the policy for clarity, conciseness, comprehensiveness and coherency. If needed, make suggestions for revisions, ask for clarifications and/or request that additional stakeholder consultations occur prior to accepting the policy and recommending its approval by Administration. The Policy Lead will: Address questions, concerns or suggestions raised by RPAC. Revise the policy as needed and re-submit the final version, including tracked changes in red to the Policy Consultant The Policy Consultant will: Verify all RPAC requested revisions have been made; Forward the policy to the appropriate approval authority (President and CEO or Vice President, Finance and Administration.). New policy must be vetted through the Authority and/or SLT prior to formal approval. Inform the Policy Lead once approval has been received Assign a policy number, enter the effective date, and complete the authorization section. Update the Table of Contents and the Region-wide Policy and Procedure Manual on the intranet For discipline specific and service department policies contact your Director Professional Leader to find out what process is used to review, approve, distribute and maintain policies in your area. 6.4 Distribution For Region-wide policies and procedure the distribution process must be coordinated by the Policy Consultant to ensure that: The Policy Consultant will ensure: the proper approvals have been obtained, only the final version of a policy is circulated and placed on the Intranet, all Region-wide polices and procedures are properly numbered and dated all staff & physicians are included in the distribution Page 19 of 22

20 the most current version of the policy is posted on the website. The RPAC Administrative Assistant will Distribute approved policy to all SHR users, physicians and others as identified, electronically. Maintain electronic copies and a Master Binder in hardcopy form of all Region-wide Policies and Procedures For care group, support department, program, service or professional discipline policies contact your Director, Professional Leader or Manager to find out what process is used to review, approve, distribute and maintain policies in your area. 7. Implementation, Monitoring and Review For Region-wide Policies and Procedures the Policy Lead is responsible for implementation, communication, education, monitoring, audit, review and amendment. 7.1 Implementation The Policy Lead is responsible for the implementation plan which identifies timelines, tasks, people, materials, costs, education and training necessary to implement new or revised policies and or procedures The Policy Lead is responsible for communication and education plans to inform all stakeholders of the introduction of the policy, its purpose, how it will be rolled out and any actions required by the stakeholder. The Policy Lead is responsible for answering specific inquiries relating to the policy and or procedure. 7.2 Monitoring The Policy Lead or delegate is responsible for monitoring and auditing the policy. 7.3 Review Revising Region-wide policies: The Policy Lead will: Review and revise policies they are responsible for on an ongoing basis, and formally at a minimum or every three years. Page 20 of 22

21 Complete the Policy Development and Approval Form (see policy and procedures website and submit to the Policy Consultant for review. Forward revised policy in standard format (with changes tracked in red for ease of reviewing), to the Policy Consultant. The Policy Consultant will: Consult with RPAC members to determine if revisions can be approved at the RPAC level (minor policy changes), or if the policy must be approved by Administration (significant/major policy changes). May ask the Policy Lead to attend a RPAC meeting to present the policy in case of significant and/or major changes. Ensure appropriate approval is received and distribute the policy and or procedure Re-affirming Region-wide Policies Existing Region-wide policies will be reaffirmed at least every three years. Page 21 of 22

22 SECTION III - Other Information Deleting/Repealing Region-wide Policies and Procedures The Policy Lead may decide that a policy is no longer needed. The Policy Lead will inform the Policy Consultant. The Policy Consultant bring the policy to RPAC for review, RPAC will make a recommendation to repeal the policy, the Policy Consultant will prepare a memo about the deletion, update the Table of Contents for the Region-wide Policies and Procedures Manual, and update the InfoNet and all master records. A notice will be sent electronically to all staff. The deleted policy will be removed from the internet site. Deleted policies will be archived. Region-wide Policy and Procedure Database A Policy Database will be maintained centrally. The database is a comprehensive list of all the Region-wide policies and procedures in effect. All policies and procedures are maintained in Microsoft Word and PDF. Policies are also posted on the SHR website. Central Files The Master Binder contains the current approved originals for each Region-wide Policy and Procedure. The originals are used for reproduction. Saskatoon Health Region Policy and Procedure Development Handbook March 2009 (revised) December 2006 (revised September 2005 (revised) November 1998 (revised) September 1998 (revised) September 1997 (revised) September 1995 (revised) March 1995 Page 22 of 22