APP
ADMINISTRATIVE POLICY AND/OR PROCEDURE
POLICY NUMBER HOSPITAL -03-0002 (1) TITLE
REPLACES NUMBER
Policy & Procedures Format, Template Structures and Numbering System
EFFECTIVE DATE
NO. OF PAGES
REVISION DUE
APPROVAL DATE
APPLIES TO
APPROVED BY
SIGNATURE
1.0
PURPOSE To provide guidelines for standardized format, template, and numbering system for writing policies and procedures.
See attachment # TQM-002 & # TQM -003 2.0 DEFINITIONS 2.1.1 Index Numbering System: a systematic method for organizing the policies and procedures in a standardized way. 3.0 RESPONSIBILITY The process owner and the P&P Coordinator 4.0 POLICY 4.1
All Departmental Policies and Procedures shall comply with the standard format included in this policy.
4.2
The top of the page has the following Boxes, and the rest of the IPP is free text. 4.2.1 For the Administrative policy (APP):
APP
ADMINISTRATIVE POLICY AND/OR PROCEDURE
POLICY NUMBER
Number of policy in the system
REPLACES NUMBER
TITLE
What is this process/procedure about?
EFFECTIVE DATE
NO. OF PAGES
No of pages X of Y
REVISION DUE
APPROVAL DATE
Date of approval
APPLIES TO
APPROVED BY
Date of making the policy into action. Date OF THE BI ANNUAL REVISION OF or as needed To whom this policy is applied (e.g. department & sections).
SIGNATURE
4.2.2 For the Institutional Policy: Departmental (DPP) and Interdepartmental (IPP):
INSTITUATIONAL POLICY AND PROCEDURE (IPP) Department:
Manual:
Section:
TITLE/DESCRIPTION EFFECTIVE DATE
POLICY NUMBER REVISION DUE
APPROVED BY
4.3
REPLACES NUMBER
NO. OF PAGES
APPLIES TO
Follow the guidelines to develop & complete the contents of the Policy & Procedure: Heading
Definition
Purpose
A description of why the policy is in place (e.g. The purpose of this policy is to reduce error, identify process, assure appropriate input and obtain correct and necessary agreement by the responsible administration person prior to implementing any administrative or practice change.
Definitions
Explain new or unusual terms.
Responsibilities
A statement of what exactly each person involved in the procedure will be responsible for.
Policy
A statement about what standard is being set (e.g., It is the policy of the International Medical Center-Jeddah that all policies will be in a prescribed format).
Cross Reference
Identify any other related policy if applicable
Procedure
A step-by-step description of how the policy will be carried out.
Forms
Any forms will be used to implement this policy, should be attached to the policy.
Equipment
Any equipment will be used in this process, if it’s applicable.
References
Include any and all references to support the policy including but not limited to Joint Commission International JCI.
Standard(s)
Statement, regulation or condition determined by appropriate authority to be the accepted level of practice/ performance. Such as JCI Standards and governmental laws.
Approval
1. Departmental (DPP) – approval within a department is obtained from the highest authority (e.g., Chairperson or Department Head). 2. Inter-departmental (IPP) – approval is obtained from the highest authority in both departments (directors/chairpersons) and/or divisions (chiefs). 3. Administrative (APP) that applied to ALL HOSPITAL - will be REVISIONed by the Hospital P&P Committee and approved by the Chief Executive officer.
4.4
Policy & Procedure Layout 4.4.1
Paper 4.4.1.1
The paper to be used is white plain paper A4 (210x297). The Paper Size Orientation is Portrait.
4.4.1.2
Use Type Size 11 points and above, to enhance readability.
4.4.1.3
Use standard Times New Roman font that is easy to read.
4.4.2
4.4.3
4.4.1.4
Decorative or unusual fonts should be used sparingly and only when consistent with the message or the tone of the publication.
4.4.1.5
Bold face and italics are intended for emphasis of selected words and phrases and are to be used sparingly.
4.4.1.6
Screens or shaded areas behind text can limit readability and should be used sparingly.
4.4.1.7
Use sufficient line spacing (leading), ragged right paragraph formatting, and suitable paragraph widths (no more than 6-1/2" on a standard 8-1/2 x 11 page) to enhance readability.
Writing 4.4.2.1
Writing must be clear and suited to the reading skills of the audience and as free of jargon as possible.
4.4.2.2
Minimize use of abbreviations. On the first reference, always write the full name, with the abbreviation in parenthesis. The abbreviation alone may be used in later references.
4.4.2.3
Writing in the present tense is preferred.
Page Layout 4.4.3.1
4.5
Electronic Policy & Procedure Template is provided by the Quality Management Department to all Secretaries for usage.
Assigning Index numbers for Administrative Policies & Procedures (APP): HOSPITAL - Dept - No -(V.) 4.5.1
HOSPITAL = the administrative policy is the one applies to all HOSPITAL staff.
4.5.2
Dept= Originating Department acronym (e.g. LAB= Laboratory, QMD = Quality Management Department).
4.5.3
No.= the serial number of the policy
4.5.4
(V.)= the version number of the current policy.
Example: HOSPITAL -TQM-0001 (01) 4.6
Assigning Index numbers for Departmental Policies & Procedures (DPP): 4.6.1
Index Numbering System: AAA- BB- CC- XXX-(V.) 4.6.1.1 AAA = Originating Department acronym (e.g. LAB= Laboratory, QMD = Quality Management Department). 4.6.1.2 BB = Refers to the Departmental section - for large departments only- where the department is subdivided into sections (e.g. Dermatology is a section of Medicine). 4.6.1.3 CC= Refers to the category of the IPP manual to which the IPP subject matter relates (see the following Matrix). For example IPP’s belonging to a particular function of the department according to the following approved Data Base (e.g. Quality Management (03), Departmental Orientation (01), Leadership (01) , clinical (06))
01 02
08 09
03
010
04
011
05
012
06
013
07
014 4.6.1.4 XXX = Refers to the sequential numbering of the IPP’s, after the chapter to which the IPP subject matter relates. 4.6.1.5 VERSION NUMBER (V.) = Refers to the status the IPP is currently at with regard to the number of times the IPP has been revised. This is a useful tracking tool to
ensure that all areas are working to the same Version of the implemented IPP. The Version Number should be updated each time a revised IPP is re-approved and distributed for implementation, i.e. If Version (1) is revised, it will be changed to Version (2). However, each approving signatory may make several changes to the IPP so there could be several drafts of Version (2). Once all revisions to Version (2) are complete and IPP has been approved and signed by all signatories, Version (2) will then be implemented, replacing Version (1) in the IPP Manual. This process is repeated for each version. N.B Only approved IPPs should be in the IPP Manual and should not include any Draft IPPs. 4.6.2
For departments that do have sections: AAA- BB- CC- XXX-(V.)
4.6.2.1 AAA = Department Acronym + BB = Refers to the Departmental section + CC =
departmental functions/category to which the IPP relates + XXX = the sequential numbers of the grouping related to the departmental function + (V.) = Version Number of the current IPP. Example: MED-DR-06-013(1) = Medicine + Dermatology Section + Clinical policies + title of policy (e.g. Controlled Access to the Laser Room) + Version Number. 4.6.3
For departments that do not have sections: AAA- CC- XXX-(V.) 4.6.3.1 AAA = Department Acronym + CC = refers to the category to which the IPP relates
+ XXX = the sequential numbers of the grouping related to the departmental function + (V.) = Version Number of the current IPP. Example: QMD-01-001(1) = Quality Management Department + Administrative policies + 001 title of policy (e.g. Scheduling of Quality Management Staff) + Version Number. 4.6.4
For Multidisciplinary policies: AAA -XXX -(V.) 4.6.4.1 AAA = the Acronym of originating department + XXX = the sequential numbering of the policy + (V.) = Version Number of the current IPP.
Example: Phr-001(1) = Pharmacy (the originating department) + title of policy (e.g. Medication Administration) + Version Number.
4.6.5
For Patient Care Chapters: HOSPITAL - BB- XXX-(V.) 4.6.5.1 HOSPITAL = Applied to All HOSPITAL + BB = the chapter / section of JCI standards + XXX = the sequential numbering of the policy + (V.) = Version Number of
the current IPP. Example: HOSPITAL -PFR-001(3) = Administrative policy applies to All HOSPITAL + Patient and Family Rights (PFR) Chapter + title of policy (e.g. Death Certification) + (third version) AAA- BB- CC –XX-(V.) AAA = Dept APP
Dept P&P Multidisciplinary
Process
Chapter Policy (Applies to All HOSPITAL )
Exampl
CC = Category
XX = Sequential Numbers
(V.) = Version Number
HOSPITAL
HR
-----
001
(1)
APP
Human Resources DR Dermatology ---N/A
N/A
Title of policy
First version
06 Clinical (COP) ---N/A
013 Title of policy 001 Title of policy
(2) Second version (1) First version
---N/A
---N/A
003 Title of policy
(1) First version
HOSPITAL
PFR
----
001
(3)
APP
Patient Family Chapter
N/A
Title of Policy
Third version
MED Medicine PCI Infection Control ADM Admission process
Definition
5.0 FORMAT:
o o
BB = Section
APP format IPP foramt
6.0 REFERENCES
King Abdul Aziz Medical City
and Right
APPROVALS:
Name Prepared By
Reviewed By
Latest Revision Approved By
Signature
Date 15-12-2005
