Implementing Policies and ProceduresFadwa Bawazir, CPHQ

Director, TQM Dept.

Hera General Hospital

The basic purpose of establishing systems, processes and guiding them in policies and procedures is to implement them well.

Failing to implement, is wasting time, money, effort and other resources.

It is encouraged to have a minimum of two (2) weeks between the date of issue and the date of effect for orientation and in-service training

Policy Implementation

Implementation process involves a period of three (3) months to give time for distribution, familiarization, actual practice and monitoring

Policy Implementation

All the hospital staff shall sign in the Acknowledgement Sheet to signify that they have read and understood the Policies and Procedures (Hospital Wide, Departmental, Safety, Infection Control, etc.).

Original Copy filed as page 3 in the Manual kept in every department

Policy Implementation

Acknowledgement SheetKINGDOM OF SAUDI ARABIAMinistry of HealthDirectorate of Health AffairsHoly Makkah

السعودية العربية المملكةالصحة وزارة

بالعاصمة الصحية الشئون مديريةالمقدسة

العام اء حر مستشفى

HOSPITALWIDE POLICIES AND PROCEDURESTAFF ACKNOWLEDGEMENT SHEET

I, the undersigned, have read and understood the contents of this Hospital-wide Policy and Procedure Manual.

NAME ID NO. SIGNATURE DATE

Note: Original Copy in the Hospital Wide Policies and Procedure Manual.Duplicate Copy to be forwarded to the Total Quality Management

(TQM) Department.

Accrediting bodies require that policies are:DocumentedApprovedCommunicated/educated Implemented

Implementing the Various Types of Policies

Philosophical

Code of Ethics Mission Vision Organizational values Code of Conduct Dress Code Communication culture

Methods

Distribution of the policy Departmental meetings

announcements Posting Quiz and questions for the staff Staff attitude Provision of uniforms Staff adherence

Resources Deployment

Allocation of resources:Manpower: staff distribution Equipment Space Financial

Methods

Staffing plan per unit Pull out process Leave plan Actual distribution of spaces

amongst services Distribution of equipment according

to priority criteria Budget and reimbursement process

Working /Departmental/ Multidisciplinary policies

ProcessesGuidelines Daily work/ services

Methods

Departmental meetings announcements

In-service training Workshops Presentations and discussions Posting of process flowchart Quizzes Competence checks (periodically)

Administrative

General Rules and regulations Leaves, personnel processes Smoking policySecurity policies Staff developmentTQM policies

Methods

Departmental meetings announcements

Posters and signs Process flowchart Handouts Facility Rounds

Memo policies

Management notification, General distribution, Delegation of authority

Methods

Bulletin board Departmental meeting

announcement

Verbal and Telephone Order Policy

Staff need to know when they are acceptable

How to document them What is the patient safety goal

related to this policy Communication with the doctors Nurses related responsibilities in

implementing the policy

Occurrence Variance Report/ Incident Report

Posting of the flowchart Knowing the process flow Ability to identify reportable events Practice of using the form Actual use of the form Corrective actions-short and long term Trends review and recommendations Receipt of concerned departments and units Enhancement of long term measures.

It costs organizations a lot of time, money and effort to work on policies and procedures and

establish systems and processes.

Not living those policies may lead to unsafe patient care as well as jeopardize the wellbeing of the

staff.