- Based on a review schedule maintained by the committees, policy authors will be notified by email four to six months prior to a policies renewal date that it is time for a review. Instructional information will be provided at that time including dates for when the revisions need to be returned. It is important to adhere to all noted return dates as policies need to go through the entire review/revision and approval process including final approval by the CEO (and potentially the Medical Board) prior to the policy renewal date.
- Notifications for reviews are sent to the primary author. If there is more than one author listed in the coordination section of a policy, it is the responsibility of the primary author to make sure that the policy is routed accordingly.
- The policy will be sent in “word” format so that the “Track Changes” feature in word can be used. All policy edits, by all contributors, are to be made using this tool.
- If there are related documents or forms that go with a policy, it is the author’s responsibility to review and update them accordingly
- All reviews and revisions must be routed through the Sr. Management sponsor listed on the policy prior to sending to other reviewing and/or approval committees
- If a policy has more than one reviewing body listed in the coordination section, it must be routed to all other committees before it is brought to the Patient Care or Administrative Policy Committees. This will require that the policy author plan accordingly so that all reviews are accomplished by the stated deadlines in the initial notification.
- The primary author is responsible for preparing a brief written explanation of the revisions for the benefit of the committees who will be reviewing them
- The author should be prepared to attend the Patient Care or Administrative Policy committee meeting to explain revisions and to address questions or concerns. Depending on the nature of the revisions and the clarity of the written explanation, the committee chairperson may make the determination that the author does not need to appear at the committee meeting.
- If there are edits that are needed as a result of a committee meeting, it is the responsibility of the author to make the additional edits to the policy
- Once a policy has received final approval, it is prepared for the UConnect intranet site. A memo is sent to Directors/Managers/Supervisors letting them know what policies have been published. A brief explanation regarding any changes is provided.
- Directors/Managers and Supervisors are responsible for training and updating their staff with regard to policy changes.
- Begin the review/revision process as soon as you receive notification
- On initial notification check the instructional letter/checklist for important information and dates that will assist you with your review
- Review the “Coordination” section at the end of the policy to determine if it has more than one author and review/approval body. If so, plan accordingly as the entire process needs to be completed prior to the policies renewal date.
- If a policy has no changes, the policy still goes through the committee review process
- Make sure the Sr. Management Sponsor has reviewed the proposed revisions before submitting to committee
- Submit your changes as soon as they are completed. Policies can be reviewed ahead of schedule.
- Policies that require changes between regular (36 month) reviews can be submitted at any time.
- Occasionally there are extenuating circumstances that prevent a policy from being renewed before the renewal date. These situations should be the exception not the rule and would need to be discussed with the appropriate policy chairperson.
For further information, or if you have any questions please contact one of the following:
Daniel J. Weissburg, JD, CHC
Director of Compliance & Privacy Officer
Chairman, Administrative Policy and Procedure Committee
Scott McMurray, MD
Associate Professor (CHS)
Chairman, Patient Care Committee
Katherine ‘Kate’ Parent
Administrative Policy Manual Coordinator