- Policies are reviewed at a minimum of every 36 months
- Notices are sent by email to the policies primary author four (4) to six (6) months in advance of the renewal date in order to allow needed time for routing to stakeholders and other approval committees. Instructions, date deadlines and a checklist are provided to assist with the steps involved in the review and revision process.
- Policies can be reviewed outside of their scheduled review date to accommodate changes in regulations, law and/or practice
- When changes need to be made to a policy outside of the normal review schedule, begin the process by contacting the Administrative Policy Manual Coordinator to obtain the most current version of the policy in a “Word” format for editing purposes
- The policy chairs and the Administrative Policy Manual Coordinator are available at any time during this process to answer questions and address concerns
Consider the following when revising an existing policy:
- If more than one policy author is listed in the Coordination section, the primary (first title listed) author is responsible for routing the policy to the other authors
- All revisions need to be done on a single copy of the most current version of the policy using the “track changes’” feature in Word
- All revisions need to be routed through the listed Sr. Management Sponsor. Revisions also need to pass through any listed reviewers and approval committees prior to being submitted to the policy review committees, Medical Board and CEO.
- Plan accordingly and adhere to date deadlines. Most committees, including the Medical Board, meet on a monthly basis. All revisions/reviews and approvals are to be accomplished prior to a policy renewal date in order to maintain regulatory compliance.
- How will the revisions being made to the policy affect other processes? Will education/training be required? Is there a plan for communicating the changes to affected personnel?
- Policies can be submitted with no changes if appropriate
- Be prepared to attend committee meetings to explain revisions and answer questions
- Policy authors are responsible for making all suggested edits to the policy for final submission
Should the policy not be approved by the CEO, any questions, comments or requested edits must be responded to by the policy author. You will be notified by email through the Administrative Policy Manual Coordinator if the CEO does not approve the policy or has questions.