/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/facilities--engineering-services/,

/policies/administrative/uwhc/department-specific/facilities--engineering-services/fe010101.policy

201509251

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UWHC,

Policies,Administrative,UWHC,Department Specific,Facilities & Engineering Services

Development and Revision of Facilities and Engineering Services Policies (F&E.01.01.01)

Development and Revision of Facilities and Engineering Services Policies (F&E.01.01.01) - Policies, Administrative, UWHC, Department Specific, Facilities & Engineering Services

F&E.01.01.01

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
X Computer Room Manual

PE.01.01.01


X Original
Revision
Page 1
of 1
Title: Development & Revision of
Facilities & Engineering Services
Policies


PE.01.01.01 Development & Revision of PE Policies

I. Purpose:

To establish a Facilities & Engineering Services policy for developing new department
policies and to establish guidelines for periodic review and approval of existing
department policies.

II. Policy:

The Facilities & Engineering Services Department reviews and updates department
policies triennially. The Continual Readiness Committee is responsible for coordinating
the development, revision, approval, and distribution of all policies. The Director of
Facilities & Engineering Services remains responsible for the final approval of all
policies.

Criteria for inclusion in the Facilities & Engineering Services Policy Manual include, but
are not limited to:
a. The action or decision directly affects patient and staff safety.
b. The action or decision directly affects patient care.
c. The action or decision directly affects the operation of any associated
facilities.
d. The action or decision corresponds to The Joint Commission’s Life
Safety or Environment of Care Standards.
e. The action or decision directly affects the functioning of the Facilities &
Engineering Services Department.
Facilities & Engineering Services employees are expected to have access to and
observe all applicable department policies.

III. Forms Used: Policy Review Checklist

IV. Procedure:

a. Development of New Policy
a. Any Facilities & Engineering Services staff member may submit topics
for consideration to the Continual Readiness Committee.
b. Policies proposed for inclusion in the Facilities & Engineering Services
Policy Manual are submitted in draft form to the committee and include
the following information: title, proposed effective date, purpose, policy
statement, forms used (if any), procedure to be followed, required
management and/or committee coordination.
c. Upon final approval from the Director of Facilities & Engineering
Services, new policies are made available to all F&E employees on the

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
X Computer Room Manual

PE.01.01.01


X Original
Revision
Page 1
of 1
Title: Development & Revision of
Facilities & Engineering Services
Policies


PE.01.01.01 Development & Revision of PE Policies

Department’s page of the hospital’s intranet site, U-Connect. Managers
and supervisors in the Continual Readiness Committee are responsible
for notifying affected staff.
d. Department managers and supervisors are responsible for training staff
regarding applicable new policies.

b. Review of Existing Policy
a. Each policy is reviewed at least once in a three year period by the
Continual Readiness Committee. The Facilities & Engineering Services
Coordinator distributes electronic copies of the policies under review and
the Policy Review Checklist via email following a Continual Readiness
Meeting. In addition, policies are reviewed when warranted based on
changes in the state of UWHC, current knowledge, current technology,
changes in laws or regulations, or other factors.
b. The Committee members review each policy and bring revisions and
their rationales to the F&E Services Coordinator during or before the next
Facilities & Engineering Services Staff Meeting. Upon approval from the
Director of Facilities & Engineering Services, the F&E Services
Coordinator revises each policy appropriately and brings revised copies
to the next Continual Readiness Meeting. If there are no changes to a
policy, this is noted by the F&E Services Coordinator.
c. Electronic copies of updated policies are made available to all F&E
employees on the Department’s page of the hospital’s intranet site, U-
Connect. Managers and supervisors in the Continual Readiness
Committee are responsible for notifying affected staff.
d. Department managers and supervisors are responsible for training staff
regarding applicable revised policies.
e. Old versions of policies will be archived for 10 years.

V. Coordination:
Continual Readiness Committee


Wayne Abbott
Director, Facilities & Engineering Services