implementing policies and procedures fadwa bawazir, cphq director, tqm dept. hera general hospital
TRANSCRIPT
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Implementing Policies and ProceduresFadwa Bawazir, CPHQ
Director, TQM Dept.
Hera General Hospital
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The basic purpose of establishing systems, processes and guiding them in policies and procedures is to implement them well.
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Failing to implement, is wasting time, money, effort and other resources.
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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
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Implementation process involves a period of three (3) months to give time for distribution, familiarization, actual practice and monitoring
Policy Implementation
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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
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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.
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Accrediting bodies require that policies are:DocumentedApprovedCommunicated/educated Implemented
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Implementing the Various Types of Policies
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Philosophical
Code of Ethics Mission Vision Organizational values Code of Conduct Dress Code Communication culture
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Methods
Distribution of the policy Departmental meetings
announcements Posting Quiz and questions for the staff Staff attitude Provision of uniforms Staff adherence
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Resources Deployment
Allocation of resources:Manpower: staff distribution Equipment Space Financial
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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
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Working /Departmental/ Multidisciplinary policies
ProcessesGuidelines Daily work/ services
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Methods
Departmental meetings announcements
In-service training Workshops Presentations and discussions Posting of process flowchart Quizzes Competence checks (periodically)
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Administrative
General Rules and regulations Leaves, personnel processes Smoking policySecurity policies Staff developmentTQM policies
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Methods
Departmental meetings announcements
Posters and signs Process flowchart Handouts Facility Rounds
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Memo policies
Management notification, General distribution, Delegation of authority
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Methods
Bulletin board Departmental meeting
announcement
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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
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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.
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It costs organizations a lot of time, money and effort to work on policies and procedures and
establish systems and processes.
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Not living those policies may lead to unsafe patient care as well as jeopardize the wellbeing of the
staff.
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