Compliance is responsible for the oversight of the Hospital Administrative Policy Manual which contains approximately 320 active policies. New policy development and existing policy reviews are done using established guidelines and timeframes to ensure accuracy within the policies and to assure that we are in compliance with current law and meeting expectations of regulatory bodies.
Two committees, made up of multi-disciplinary leadership, are assigned the responsibility of reviewing new and revised policies and making recommendations to the CEO.
- Administrative Policy and Procedure Committee… chaired by the Director of Compliance
- Patient Care policy and Procedure Committee… chaired by a physician
Existing policies are reviewed at a minimum of every 36 months.
New and revised policies are published on a monthly basis. An explanation regarding the updates is sent to management who is then responsible for communicating changes to their staff as appropriate.
Policy 1.10 (Development and Revision of the Administrative Policy and Procedure Manual) discusses the criteria used to determine if a policy belongs in the Hospital Administrative Manual along with the process for adding new policies and for reviewing existing ones.