Implementing Policies and Procedures - PowerPoint PPT Presentation

1 / 24
About This Presentation
Title:

Implementing Policies and Procedures

Description:

Acknowledgement Sheet. ??????? ??????? ... STAFF ACKNOWLEDGEMENT SHEET ... Not living those policies may lead to unsafe patient care as well as jeopardize ... – PowerPoint PPT presentation

Number of Views:148
Avg rating:3.0/5.0
Slides: 25
Provided by: Fuj5
Category:

less

Transcript and Presenter's Notes

Title: Implementing Policies and Procedures


1
Implementing Policies and Procedures
  • Fadwa Bawazir, CPHQ
  • Director, TQM Dept.
  • Hera General Hospital

2
  • The basic purpose of establishing systems,
    processes and guiding them in policies and
    procedures is to implement them well.

3
  • Failing to implement, is wasting time, money,
    effort and other resources.

4
Policy Implementation
  • It is encouraged to have a minimum of two (2)
    weeks between the date of issue and the date of
    effect for orientation and in-service training

5
Policy Implementation
  • Implementation process involves a period of three
    (3) months to give time for
  • distribution,
  • familiarization,
  • actual practice and
  • monitoring

6
Policy Implementation
  • All the hospital staff shall sign in the
    Acknowledgement Sheet to signify that they have
    read and understood the Policies and Procedures
    (Hospital Wide, Departmental, Safety, Infection
    Control, etc.).
  • Original Copy filed as page 3 in the Manual kept
    in every department

7
Acknowledgement Sheet
HOSPITALWIDE POLICIES AND PROCEDURE STAFF
ACKNOWLEDGEMENT SHEET I, the undersigned, have
read and understood the contents of this
Hospital-wide Policy and Procedure Manual.
Note Original Copy in the Hospital Wide
Policies and Procedure Manual. Duplicate Copy to
be forwarded to the Total Quality Management
(TQM) Department.
8
  • Accrediting bodies require that policies are
  • Documented
  • Approved
  • Communicated/educated
  • Implemented

9
Implementing the Various Types of Policies
10
Philosophical
  • Code of Ethics
  • Mission
  • Vision
  • Organizational values
  • Code of Conduct
  • Dress Code
  • Communication culture

11
Methods
  • Distribution of the policy
  • Departmental meetings announcements
  • Posting
  • Quiz and questions for the staff
  • Staff attitude
  • Provision of uniforms
  • Staff adherence

12
Resources Deployment
  • Allocation of resources
  • Manpower staff distribution
  • Equipment
  • Space
  • Financial

13
Methods
  • Staffing plan per unit
  • Pull out process
  • Leave plan
  • Actual distribution of spaces amongst services
  • Distribution of equipment according to priority
    criteria
  • Budget and reimbursement process

14
Working /Departmental/ Multidisciplinary policies
  • Processes
  • Guidelines
  • Daily work/ services

15
Methods
  • Departmental meetings announcements
  • In-service training
  • Workshops
  • Presentations and discussions
  • Posting of process flowchart
  • Quizzes
  • Competence checks (periodically)

16
Administrative
  • General Rules and regulations
  • Leaves, personnel processes
  • Smoking policy
  • Security policies
  • Staff development
  • TQM policies

17
Methods
  • Departmental meetings announcements
  • Posters and signs
  • Process flowchart
  • Handouts
  • Facility Rounds

18
Memo policies
  • Management notification,
  • General distribution,
  • Delegation of authority

19
Methods
  • Bulletin board
  • Departmental meeting announcement

20
Verbal and Telephone Order Policy
  • Staff need to know when they are acceptable
  • How to document them
  • What is the patient safety goal related to this
    policy
  • Communication with the doctors
  • Nurses related responsibilities in implementing
    the policy

21
Occurrence Variance Report/ Incident Report
  • Posting of the flowchart
  • Knowing the process flow
  • Ability to identify reportable events
  • Practice of using the form
  • Actual use of the form
  • Corrective actions-short and long term
  • Trends review and recommendations
  • Receipt of concerned departments and units
  • Enhancement of long term measures.

22
  • It costs organizations a lot of time, money and
    effort to work on policies and procedures and
    establish systems and processes.

23
  • Not living those policies may lead to unsafe
    patient care as well as jeopardize the wellbeing
    of the staff.

24
THANK YOU
Write a Comment
User Comments (0)
About PowerShow.com