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Policy Guide

Policy Development Office 2 of 40 July 27, 2012

Table of Contents

Sponsorship and Development Framework

Policy Sponsor Associations by Sponsor

Policy Sponsor Associations by Category

Definitions

Introduction

Purpose

Principles

Scope

Roles and Responsibilities

The Policy Cycle

Phase 1 – Initiating Policy Development

Phase 2 – Development and Consultation

Phase 3 – Approval

Phase 4 – Implementation

Phase 5 – Auditing

Phase 6 – Three Year Review

Aboriginal Engagement

Effective Policy Writing

Policies on InsideNet

Tools and Templates

Appendix A – Policy Request Form

Appendix B – Stakeholder Consultation Framework

Appendix B1 – Aboriginal Policy Development Protocol

Appendix C – Stakeholder feedback Form

Appendix D – Policy Approval Request

Appendix D1 – Implementation Plan

Appendix E – 3 Year Review Framework and Guidelines

Appendix F – Policy Template

Appendix G – Policy Formatting Guidelines

Appendix H – Policy and Procedures Web Page

Appendix I – Policy Cycle Checklist

Policy Guide


Sponsorship and Development Framework

ISSUE IDENTIFIED

(directional document may be required)

Policy or

CDST?

Clinical Decision Support Tool (CDST)Follow CDST

Development Guide

Policy

Development

approved?

Policy Request Form to Policy Sponsor/Designate(see following tables)

POLICY WORKING GROUP

· Consult with stakeholders

· Draft policy and Implementation Plan

Review with Quality Improvement

Patient Safety Committee (QIPS)

Health Authority Medical

Advisory Committee

QIPS

END

Patient

Safety?

NO

NO

YES

YES

YES

YES

Medical

Practice?

Patient

Safety?

Patient

Safety?

NOICCC

YES

SET

NO

POLICY v CDST

A policy describes the organization’s

operational goals and/or objectives around

an issue and will set out why, where, when

and who will be responsible for meeting the

goals and/or objectives. Policies generally

do not direct how individual patient care is

provided.

A CDST is a document that sets out a

procedure, guideline and/or standard to

follow (how to) once a decision has been

made to provide clinical care. A CDST may

be a stand alone document or may flow from

a policy.

NO

Professional

Practice issue?

Review with Professional

Practice Office (PPO)

Patient

Safety?

YES

NO

NO

YES

Policy Sponsor/Designate

Follow CDST Development Guide

http://inet.interiorhealth.ca/infoResources/clinresources/Documents/Clinical%20Decision%20Support%20Tools%20Development%20Guide.pdf

http://inet.interiorhealth.ca/infoResources/clinresources/Documents/Clinical%20Decision%20Support%20Tools%20Development%20Guide.pdf

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Policy Sponsor Associations by Sponsor POLICY SPONSOR (VP) POLICY CATEGORY

Acute and Tertiary Services Acute and Tertiary Care

Communications and Public Affairs Administration/Organization

Communications

Health Promotion

Community Integration Aboriginal

Home and Community Care

Mental Health and Addictions

Medicine and Quality Infection Control

Legal/Ethical

Medical Staff

Networks (Surgical, Perinatal, Critical, Emergency Department

Patient/Client Relations/Care

Quality

Risk Management

People and Clinical Services Human Resources

Information Privacy and Security

Information Systems

Laboratory Services

Pharmacy

Workplace Health and Safety

Planning and Strategic Services Health Protection

Policy

Residential Services and Chief Financial Officer Facilities Management

Finance

Purchasing Residential Care Support Services Policies in these classifications must have QIPS oversight

Policy Guide


Policy Sponsor Associations by Category

Policies in these classifications must have QIPS oversight

POLICY CATEGORY POLICY SPONSOR (VP)

Aboriginal Community Integration

Acute Care Acute and Tertiary Services

Administration/Organization Communications and Public Affairs

Communications Communications and Public Affairs

Facilities Management Residential Services and Chief Financial Officer

Finance Residential Services and Chief Financial Officer

Health Promotion Communications and Public Affairs

Health Protection Planning and Strategic Services Home and Community Care Community Integration

Human Resources People and Clinical Services

Infection Control Medicine and Quality

Information Privacy and Security People and Clinical Services Information Systems People and Clinical Services Laboratory Services People and Clinical Services Legal/Ethical Medicine and Quality

Medical Staff Medicine and Quality

Mental Health and Addictions Community Integration

Networks (Surgical, Perinatal, Critical, Emergency Department

Medicine and Quality

Patient/Client Relations/Care Medicine and Quality

Pharmacy People and Clinical Services Policy Planning and Strategic Services Purchasing Residential Services and Chief Financial Officer

Quality Medicine and Quality

Residential Care Residential Services and Chief Financial Officer

Risk Management Medicine and Quality

Support Services Residential Services and Chief Financial Officer

Tertiary Care Acute and Tertiary Services

Workplace Health and Safety People and Clinical Services

Policy Guide


Definitions Policy

A clear, concise, non-negotiable, formal statement directing staff decision-making. It enables and guides informed action, prescribes limits, assigns responsibilities and accountabilities and is secondary to legislation and by-laws. It must align with the mission and vision of the organization. All staff are required to comply with policy.

Administrative Policy

Policy which addresses operational issues (finance, risk, human resources etc.). Does not directly touch client care however may deal with client management issues. Examples of Administrative Policies are: Abuse Free Environment of Clients, Appeal of Care/Service Decisions, Standards of Conduct, Record Retention, Expense etc.

Clinical Policy

Policy which directly addresses client care. Generally direct client care will be addressed with a Clinical Decision Support Tool. Examples of Clinical Policies are: Consent, CPR Directives etc.

Board/Governance Policy

Policy which focuses on strategic directions, roles, responsibilities and relationships involving board, management and stakeholders. They are approved by the Board and issued by the Board Chair. Examples of Board/Governance Policies are: Decision making Authority, Safe Reporting, etc.

Note: For Interior Health purposes the word Policy is used exclusively to identify Regional directional documents. Local or site specific directional documents will be identified as Guidelines, Procedures or Protocols.

Policy Sponsor (or Designate)

The Senior Executive Team (Vice President) member with the overall responsibility for approving development of policy under his/her jurisdiction as set out in the Policy Sponsorship and Development Framework.

Policy Lead/Steward

The individual, as designated by the Policy Sponsor, as the person most responsible for the day to day management and operation of a particular policy, including the ongoing and periodical review of the policy.

Clinical Decision Support Tools Clinical Decision Support Tools: Development Guide

An umbrella term used to describe a variety of resources which guide health care providers in assessing, planning, implementing and evaluating care. Developed with rigor these tools reflect the use of evidence, best practice and standards. (Osheroff et al., 2006) CDSTs foster professional judgment in the interest of optimal patient/resident/client-centered care. These tools provide various levels of direction, from broad to specific. Although they may be stand alone, CDSTs frequently accompany or intersect other companion tools. Developed by a team, they are generally

http://insidenet.interiorhealth.ca/Clinical/Documents/Clinical%20Decision%20Support%20Tools%20Development%20Guide.pdf

Policy Guide


inter-professional but may also support a single profession depending upon the nature of the knowledge and skill required for safe, competent & ethical care. CDSTs may include Care Pathways, Guidelines, Order Sets, Procedures and Protocols.

Care Pathway

A defined method of care specific to an identified condition or population. It is presented sequentially and reflects interventions and outcomes and may refer to order sets. Also known as a pathway, care path, care map®, care plan or critical pathway.

Guideline

A systematically developed strategy statement to assist in making appropriate decisions in specific circumstances. Guidelines allow for flexibility and encourage professional judgment.

Order Set

Precise instructions detailing action(s) for prevention, care and/or treatment of a clinical condition. An Order Set must be client specific and signed in order to be enacted. (e.g. Pre-Printed Orders, Prescriber Orders, Patient Orders or Computerized Provider Order Entry)

Procedure

A description of a series of steps required to complete a specific task or activity.

Protocol

A set of required actions to manage a clinical condition, operational issue or population occurrence. Any deviation requires documented rationale.

(Ilot, Rick, Patterson, Turgoose & Lacey, 2006)

Standard

A desired and achievable level of performance against which actual practice can be compared. It provides a benchmark below which performance is unacceptable. Standards are developed by expert and/or authoritative bodies.

Stakeholder

A Stakeholder is an individual, group and/or organization who will be directly or indirectly affected by or have a vested interest in the decision to implement a policy document. Stakeholders must be involved in the development and implementation of Policies.

Introduction

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Interior Health (IH) is an amalgamation of a number of regional health services entities that were previously more autonomous. Each of these had its own leadership, history, culture, policy and patterns of practice. Since amalgamation, IH staff and their leaders have been working toward the goal of a more fully integrated organization. To further assist in this integration, the IH Board and the Senior Executive Team (SET) have recognized the need for a consistent, authority-wide policy framework.

An administrative policy framework has been developed to standardize governance, administrative and health services decision making at all levels in the organization. Although it has been developed with the current organization in mind it is adaptable to future organizational structures.

Policies and procedures clarify rules of conduct and steps to be taken in given situations. They serve to resolve differences of opinion, define expectations, and assist in managing risk to patients, the community and the organization. Carefully developed and implemented, they will support greater integration and more consistency in service delivery.

The IH Policy Sponsorship and Development Framework is a result of interviews with senior staff and adopting/adapting appropriate content from a variety of sources. Although policy frameworks can get fairly detailed, a deliberate attempt has been made to keep this simple and straightforward. It will be noted that a great deal of responsibility is placed on the role of the Policy Sponsor.

Policy is an integral component of Interior Health’s quality service toolkit. Policies ensure:

clients receive quality healthcare in a safe compassionate environment,

services are aligned with the goals of the organization, and

the operational needs of the organization are met.

This document is explains the framework within which policies are developed, published and implemented and reviewed.

Purpose The purpose of this Policy Guide (the Guide) is to define a structure for the development and implementation of policies and procedures within Interior Health. The Guide provides staff with a single source reference tool which will assist in understanding the policy development process and requirements and to provide tools to assist those responsible for or involved in developing, writing, implementing and reviewing policy.

The Guide will ensure staff:

know the what, when, why, who and how of policy development,

follow a consistent policy approval and endorsement process,

understand the roles and responsibilities of the various committees and individuals in the policy development, approval, and implementation process, and

understand and use the tools that guide practice and support organizational policy.

Principles

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Policy Development is grounded on the following principles:

staff are expected to carry out their assigned functions according to the organization’s policies and evidenced based practice tools.

policies and the tools that support them are based on the best evidence available.

policies and the tools that support them are reviewed on a regular basis to ensure that they are consistent with current evidence, community standards and legal requirements.

policies and the tools that support them will be developed using a broad consultative process to ensure there will be no duplications and/or conflicts between policies in the organization.

only those policies and the tools that support them and are necessary to support the achievement of IH’s goals and objectives will be developed, i.e. less is more.

the Guide will be made available to all staff to support clinical, professional and administrative practices related to policy development.

Scope The Guide applies to all new and policies being revised (3 year review) Regional (Interior Health wide) Administrative, Clinical and Board Governance policies. Regional The framework, procedures, templates and forms contained in this Guide must be followed/used for the development of all Regional policies. (see IH AA0100 Policy and Clinical Decision Support Tools Policy. Local/Site Specific The framework and procedures contained in this Guide may not have a direct transferability to specific site structures; however the underlying principles and processes of sponsorship, accountability, consultation, approval, implementation and review should be followed. Directional documents developed using these principles/processes will ensure well developed documents which meet the needs of clients, stakeholders and the organization. Local/site specific directional documents must be written and formatted using the Interior Health templates and guidelines contained in this Guide. Minor revisions may be made to the templates to meet local criteria. Development of Clinical Practice Documents must follow the procedures as set out in the Clinical Decision Support Tools: Development Guide published by the IH Professional Practice Office.

Roles & Responsibilities

http://inet.interiorhealth.ca/infoResources/policies/Documents/Policy%20and%20Clinical%20Decision%20Support%20Tools.pdf



Policy Guide


Senior Executive Team

Approve all Regional Policies.

Exception: Policies which are limited to one department or service delivery area (e.g. Mental Health, HR, Finance) may be approved by the Policy Sponsor and/or other designated authority at her/his discretion. The Policy Sponsor advises SET of any policies approved under this exception.

Policy Sponsor (or Designate)

Initiating Phase

Responsibilities during the identification and initiation phase include:

Review the Policy Request Form from a broader context and determine if:

a. a new policy requires drafting or an existing policy requires significant modifications, or

b. the issue can be resolved in some other manner (directive, guideline etc.).

If a new policy is required or an existing policy requires modifications:

a. determine development stream as per Sponsorship and Development Framework,

b. determine approval stream as per Sponsorship and Development Framework,

c. appoint a Policy Lead,

d. allocate adequate resources for development and implementation of the policy , and

e. submit signed copy of Policy Request Form to the Policy Development Office.

Development Phase

Responsibilities during the development and approval phase include:

a. assign timelines for development and implementation,

b. confirm membership of policy working group,

c. confirm stakeholder consultation lists,

d. present Policy Request to Quality Improvement & Patient Safety Committee (if required)

e. approve final draft and implementation plan and advise SET, or

f. approve final draft and implementation plan and take to SET to request approval, and

g. provide Policy Development Office with approved policy and implementation plan.

Integrated care Coordinating Committee

a. endorse Policy and Implementation Plan

Quality Improvement and Patient Safety Committee

b. confirm decision for IH wide policy,

c. advise/recommend on membership of policy working group,

d. advise/recommend on stakeholder consultation lists, and

e. confirm development process before policy and implementation plan goes back to Policy Sponsor to take forward for approval.

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Policy Lead/Steward

a. is the primary policy content expert,

b. present Policy Document Request Form and Stakeholder Group List to Quality Improvement & Patient Safety Committee,

c. create the policy working group from advice/recommendation of Policy Sponsor and Quality Improvement & Patient Safety Committee

d. schedule and Chair meetings of the Policy Working Group,

e. liaise with the Policy Sponsor and/or the Quality Improvement & Patient Safety Committee,

f. manage the policy document and implementation plan development process within the timeline and guidelines set out by the Policy Sponsor and/or Quality Improvement & Patient Safety Committee,

g. sign-off final draft of policy document and implementation plan,

h. submit final drafts to Policy Sponsor, Quality Improvement & Patient Safety Committee, and/or Integrated Care Coordinating Committee, and

i. present to SET at request of Policy Sponsor.

Policy Working Group Members

a) represent and consult with stakeholder group during drafting phase,

b) provide content advice on policy and implementation plan, and

c) contribute to the drafting of the policy and implementation plan.

Policy Development Office

a. monitor regional policies under development to ensure compliance with Policy Sponsorship and Development Framework,

b. provide general support on policy development, implementation and review,

c. provide support to working groups as required,

d. participate in working groups as required, and

e. maintain Policy and Procedures Documents on InsideNet.

The Policy Cycle

Policy Guide


Phase 1 - Initiating Policy Development

Any individual, committee or group can initiate a request for development of a Health Authority wide policy. The request is formal process which must be submitted to the appropriate Policy Sponsor prior to work being done on the policy. The request is made by completing a Policy Request Form (Appendix A). The Policy Development Office should be consulted prior to completing a Policy Development Request Form.

The initiator of the Request will need to determine if a policy necessary to resolve the issue?” The majority of issues can be resolved without a policy being written. Guidelines, Directives or informal protocols may be more appropriate than a policy. Remember that compliance with policy is mandatory. There must be resources available to ensure compliance. If we are unable to comply with the policy the organization is placed at risk. Another question to ask: “Is this a Regional policy or a local directional document?” Regional policies apply to all of Interior Health programs and/or operations. The identified issue may at first appear to be a local matter (e.g. how to manage client’s valuables and personal effects while the client is in our care) however it may have a much broader application. Local directional documents can be developed in the absence of a Regional policy. In the aforementioned example it would be reasonable to suggest this is much broader than just a local issue. As such it would be reasonable to complete a Policy Development Request Form and submit to the appropriate Policy Sponsor for consideration as a Regional policy. When in doubt initiate the process as an IH wide policy. The Policy development request form is designed to capture critical information required by the Policy Sponsor to aid in the decision making process. It also provides an opportunity for the initiator to provide input on the policy stakeholders and working group membership.

The Policy Sponsor is responsible for reviewing the Policy development request form and making the decision whether a Regional policy is required. If approval is given to develop the proposed policy the Policy Sponsor will appoint a Policy Steward/Lead to chair the Working Group. The Working Group will develop the policy and implementation plan. The Policy Sponsor will also determine if the policy requires approval by SET as a whole or will be approved by the Policy Sponsor.

For certain policies (see Policy Sponsorship and Development Framework) the approval for development of the policy will require confirmation from the Quality Improvement & Patient Safety Committee. The Quality Improvement Patient Safety Committee will also review the membership of the Working Group and will recommend revisions/additions if necessary.

Phase 2 - Development and Consultation

The Policy Working Group undertakes the task of writing the policy and implementation plan and ensuring a rigorous and comprehensive review by the stakeholders is conducted before a final draft is submitted for approval.

Development

The Working Group members are selected for their expertise in the subject area of the proposed policy. Additionally the Working Group members will each be representing a particular IH wide committee or interest group (e.g. ethics, emergency departments, professional practice, health records, admitting etc.). During the development phase the Working Group members will consult with their respective committee/ interest group on the content of the “working paper” (name of draft policy during development phase) and bring this feedback back to the Working Group.

Policy Guide


The Working Group will also conduct research as required to ensure the working paper reflects current best practice and law. External experts will also be consulted if appropriate. During the development phase distribution of the working paper will be restricted as much as practicable to the members of the Working Group.

The end of this phase occurs when the Working Group is satisfied the working paper adequately addresses the issue (purpose of the policy) and reflects current best practice, law and other appropriate standards.

Stakeholder Consultation

Upon completion of the foregoing development phase the working paper will be renamed as a “consultation draft”. The individuals, groups, committees etc. identified in the Policy Request Form will now be engaged in the consultation process as set out in the Stakeholder Consultation Framework (Appendix B).

Stakeholders are provided with a Stakeholder Feedback Form (Appendix C), which provides direction on providing feedback to the Working Group. A copy of the consultation draft and other appropriate background material are also provided. Stakeholders are given several options for responding (email, fax, and regular mail) and a time frame for responding.

The Working Group maintains a record of all feedback and the action taken in response to the feedback. This information is provided, along with further revisions of the consultation draft, to any stakeholder requests continued participation in the consultation process.

The consultation process will be repeated as necessary until the Working Group is satisfied the policy and implementation plan are ready to submit for approval. There is no specific time period prescribed for the development and consultation phase. The Policy Sponsor may prescribe one.

The end of this phase occurs when the Working Group is satisfied all issues arising out of the consultation process have been adequately addressed.

Phase 3 - Approval

Upon completion of the foregoing consultation phase the consultation paper will be renamed as an “approval draft”. The approval draft of the policy and implementation plan will be presented to the Quality Improvement & Patient Safety Committee, the Integrated Care Coordinating Committee and/or HAMAC (if required) for endorsement prior to sending back to the Policy Sponsor to take forward to the final approval authority.

The Policy Steward/Lead submits a Policy Approval Request (Appendix D) to the Policy Sponsor. The approval authority is determined by the Policy Sponsor on a policy by policy basis. Generally, regional policies are approved by SET as a whole.

A regional policy document which is used exclusively within a single corporate department or service area (e.g. Mental Health, Finance) can be approved by the Policy Sponsor at his/her discretion. Examples of these types of policies are; AQ1101 – Responsibility Code for IH Vehicles and AR0600 – Internet Access (in the Administrative Policy Manual) or PHF0100 – Drugs to Patients Discharged to Residential Care (in the IH Pharmacy Policy Manual.)

Policy Guide


Some of the criteria SET and/or the Policy Sponsor will need to be satisfied about as a condition of approval are:

have the appropriate stakeholders been consulted,

has the final draft and implementation plan been signed-off by the major stakeholders,

what are the risks of not approving and/or implementing the policy,

are there adequate resources allocated to implement the policy, and

will there be an audit and/or follow-up after implementation.

Policies will not be approved unless there is an acceptable implementation plan included. Once a policy has been approved the Policy Sponsor will advise the Policy Development Office and provide them with a copy of the approved version of the policy.

Phase 4 - Implementation

Implementation of a policy after approval is perhaps the most critical phase in the policy cycle. Any well intentioned and written policy will fail and put the organization at risk if not properly implemented. As general rule Regional policies will have a 90 day implementation period from the date of approval before the policy comes into effect (goes live). Complex policies (e.g. Consent, Smoke Free Environment and Disclosure) will require longer implementation periods. During the implementation period, education as required will be provided and new forms etc. will be introduced. Revisions to the policy and procedures may also be made during this phase.

Overall responsibility for implementation rests ultimately with the Policy Sponsor. An Implementation Plan is required as part of the policy package submitted to the Policy Sponsor for approval. The Policy Sponsor may designate an individual or group to take the lead for implementation.

Phase 5 - Auditing

Auditing of implemented policies will be required at the discretion of the Policy Sponsor and will be conducted by the Policy Development Office or the Director of Internal Audit as directed by the Policy Sponsor.

Phase 6 - Three Year Review

Policies which are not reviewed on a regular basis are a potential risk to the organization. A policy which is not reviewed/updated on a regular basis may not reflect current law or best practice and may no longer be effective or complied with. Regular reviews (a minimum of every 3 years) are required to ensure policies reflect up-to-date practice and legislation and are still necessary for the effective management of the organization. This is a minimum requirement. The Policy Development Office is responsible for managing and coordinating the 3 year review process. When a policy review is required the Policy Development Office will notify the appropriate Policy Sponsor. The Policy Sponsor or his/her designate will undertake the review using the Guidelines set out in Appendix E. A policy which requires substantive revisions will be revised following the same procedures as set out for new policies. A policy which requires only non-substantive edits (dates, names typos etc.) can be revised by the Policy Sponsor/Designate.

Policy Guide


link to Policy Cycle Checklist

Aboriginal Engagement

The Interior Health service area includes over 40,000 Aboriginal People. Our policies regardless of whether they are administrative or clinical in nature impact on services provided to our clients. Our Aboriginal Peoples unique cultures must be considered when developing policy. In consultation with Interior Health Aboriginal Programs an Aboriginal Consultation Framework was developed to ensure policies being developed included Aboriginal engagement throughout the Policy Cycle.

link to Aboriginal Policy Development Protocol

Effective Policy Writing

Policy Guide


The Interior Health Policy Template (Appendix F) includes 5 distinct sections. All regional policy documents must contain these 5 sections. An explanation of each section and suggestions on completing each section is set out below:

1.0 PURPOSE

The Purpose should inform the reader specifically what the policy is intended to do (e.g. To provide clear directions to medical staff and hospital employees who may be involved in taking blood alcohol samples from suspected impaired drivers pursuant to a demand under the provisions of the Criminal Code of Canada). A preamble outlining philosophy, rationale or background is not necessary.

2.0 DEFINITIONS

Definitions should only be included for words or terms used in the policy whose use may differ from commonly held interpretation (e.g. Staff means Employees and Non-Employees working or acting on behalf of the Interior Health) or those which are unique or highly specialized. In the foregoing example Employees and Non- Employees would be further defined.

3.0 POLICY

Policy statements: a. express the values, intent, and expectations of the organization. b. establish realistic standards and expectations rather than setting impossible or unreachable

objectives. c. provide broad direction by describing the values, intent and expectations of the organization

rather than dealing with operational details. (leave the “how-to-do” details to the procedure section.)

Examples of policy document statements:

3.1 Abuse free Environment

Interior Health expects that Clients will be treated with respect and dignity, that the environment in which care/service is delivered will promote Client trust and well-being, and that Clients will be free from the threat of Abuse from Agents associated with Interior Health.

3.1 Signed Agreement Requirement

All non-resident patients, prior to receiving health care at Interior Health facilities and programs, are required to sign the Governing Law and Jurisdiction Agreement (Appendix A), which discharges their right to claim damages or costs under any jurisdictions other than those of British Columbia and Canada.

4.0 PROCEDURES

Procedure statements:

a. outline a series of steps that are to be followed by staff. b. describe a course of action or way of doing things. c. contain detailed and specific instructions rather than general guidelines.

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Procedure statements are grouped according to individual positions (not named individuals) responsible for acting on them. (e.g. Manager/Designate, Senior Administrator etc.) as in the following example:

4.1 Referring Physician

· contact Specialist Physician On Call at a receiving facility and arrange for transfer of critically ill or certified psychiatric patient, or

· call BC Bedline to arrange transfer to another health authority if no transfer within IH is available for critically ill patient,

· hold certified psychiatric patient until such time as a bed becomes available. 4.2 Receiving Physician

A Specialist Physician/Surgeon at a regional or tertiary hospital within IH who accepts a referral that they ascertain to be in the category of “critical illness” will:

· notify the Senior Administrator on-call or designate that he/she is accepting a critically ill patient;

· notify the Emergency Room of the anticipated arrival of the critically ill patient;

· notify the Anesthetist on-call and Operating Room if required (a second OR may need to be opened);

· notify the Intensive Care Unit of the requirement of a critical care bed for the anticipated admission, and

· complete a Transfer Accepted but Inappropriate form (Appendix C) if the accepted transfer is later deemed to be inappropriate and submit to facility Chief of Staff.

5.0 REFERENCES

References are included only when the particular document or resource has actually been relied upon in developing the policy document. (e.g. research papers, legislation etc.). References should include the name, author, name and date of publication.

Additional guidelines for formatting policy document can be found in Appendix G.

Guiding Principles

Fourteen principles and criteria are repeatedly referred to in the literature when describing the good practice that policy makers should be seeking to demonstrate in the policy:

1. Is driven by patient or population centred goals that users support and that will deliver tangible improvements to the service/society.

2. Adopts SMART goals – specific, measurable, achievable, realistic and timed.

3. Tests the goals and the policy document for its impact on the whole system of health and ensures a coherent, integrated set of policy documents that support an agreed strategy.

Policy Guide


4. Is evidence based or where evidence does not exist is built from a strong consensus of support from key stakeholders.

5. Develops policy documents with the full involvement of users, practitioners, managers, and others who may be implicated or have expertise to offer- from the outset and throughout the process.

6. Scopes the subject widely at the outset to see the opportunities, implications, risks and constraints – including existing good practice in BC, other jurisdictions, etc.

7. Is based on a sound understanding of current provision, practice and performance and relevant trend analyses including the variability across geographical areas, health service delivery areas.

8. Assesses for environmental, social, health and economic impacts using an approved methodology.

9. Seeks to ensure a good user or care experience by giving due regard to standards, equal opportunities, diversity, plurality and flexibility.

10. Creates policy documents that are fit for implementation and will deliver the required results in the requisite time – having addressed capacity issues, workforce, finance, IMT, communications etc.

11. Imposes no unnecessary burdens on front line service providers and devolves as much as possible to the front line.

12. Clarifies roles and responsibilities so that IH only does that which it has to do and the reporting and accountability requirements are proportional and justifiable.

13. Expresses policy succinctly, in plain, simple English – with drafts checked for interpretation and appropriateness with those for whom it is designed.

14. Has been anticipated in planning and is resourced to ensure good program and project management.

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Policies on InsideNet All Regional policies are accessed from a central location on InsideNet. This page is maintained by the Policy Development Office. The page contains all Regional Policy “Manuals” and the policies therein are the “official” policies of the organization. Approval from the Policy Development Office is required prior to a policy being posted on InsideNet Physical copies of policy manuals are not supported by the Policy Development Office. The “official” versions are posted on InsideNet.

http://inet.interiorhealth.ca/infoResources/policies/Pages/default.aspx

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Tool & Templates The tools and templates in the following Appendixes are for illustrative purposes only. The official version of the templates can be accessed from the Policies and Procedures Home Page. For convenience links to required forms are imbedded in this Manual.

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Appendix A - Policy Request Form

Policy Request Form (link to form)

SECTION A (to be completed by the individual requesting a new/revised Regional Policy)

Name of Proposed Policy:

Name of Policy Sponsor:

Is this a new or revised Policy? New Revised

Describe the Issue the Policy address:

Rationale for Policy Document: Check all that apply. Ensure that you have checked all existing Regional and

Ministry of Health policy documents to ensure no duplication or conflicts. The policy contact person at Interior Health is Tony Yip, Leader, Policy Development & Freedom of Information, (250) 870-4785 or [email protected]

Critical occurrence recommendation

Change in practice or technology

Conflicting policy documents exist that need to be replaced

Regulatory requirement Inquest recommendation Accreditation requirement

Identified gap or need Response to legislation

Other Please Specify:

Background:

If conflicting policy document exists that needs to be replaced, list exiting policy document replaced or impacted by this policy document (Indicate policy document name(s) and location):

Describe actions or activities that have been taken to ensure that the policy document does not conflict with any existing policy document:

Will this policy document impact departments other than the Policy Sponsors? Yes No

If YES, please identify:

Name of Manual(s) in which the Policy will reside? (Circle or highlight - P = Primary & CR = Cross Referenced)

Administrative P CR

P CR

P CR

P CR

P CR

P CR

Identify appropriate Section of Primary Manual:

http://insidenet.interiorhealth.ca/infoResources/policies/Documents/Policy%20Request%20Form.docx

mailto:[email protected]

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Content Experts: Please indicate individuals or groups who can provide advice on the policy content and/or who may be users of the policy. These individuals or groups may be asked to participate as members of the Policy Document Working Group or be asked to provide feedback on policy document drafts. Please complete the attached Stakeholder Consultation Groups form. (This list may not contain all potential stakeholders. Please revise as necessary.)

Does the Policy Document impact or involve external stakeholders? (e.g. contractors/vendors) Yes No

If yes, please identify.

Supporting Evidence: Is there current evidence to support the content of the policy document? Yes No

If YES, please specify:

Estimate of Cost to Implement: (include staff resources and impact on other portfolios)

Individuals Consulted to Determine Costs:

Author of Policy Request:

Reviewed by: Date:

Date:

Date:

Date:

Submit to Policy document Sponsor

SECTION B (to be completed by Policy Sponsor)

Approved development of new/revised policy? Yes No

Name of Policy Lead:

Policy required by:

Implementation Costs allocated from:

Audit of Policy Implementation required? Yes No

Policy Approval Authority: Policy Sponsor SET

Policy Sponsor:

Position: Date:

Send signed copy to Policy Development Office

Policy Guide


STAKEHOLDER CONSULTATION GROUPS FORM (Indicate as per recommended level of involvement - Working Group Member, Consultation - modify as required)

NAME OF GROUP NAME OF PERSON WORKING GROUP CONSULTATION

CLINICAL

Acute Care

Cardiac

Chronic Disease Mgmt. and Allied Health

Community Care

Diagnostic Imaging

Emergency Services

Infection Control

Laboratory

Mat/Child

Medical Directors

Mental Health & Substance Abuse

Pharmacy

Physicians

Primary Health Care

Professional Practice

Residential Care

Social Work

Surgical

OPERATIONAL

Aboriginal Health

Admitting

Audit

Communicable Disease Mgmt.

Communications

Contracted Services

Document Services

Ethics

Facilities Management

Finance

Health Protection

Health Services Admin

Human Resources

IMIT

Information Privacy & Security

Licensing

Material Management

Organizational Development

Quality & Patient Safety

Public Promotion and Prevention Programs

Patient Representative

Risk Management

Violence Protection

Workplace Health & Safety

EXTERNAL

CMPA

HCPP

Ministry of Health Counsel

Policy Guide


Appendix B - Stakeholder Consultation Framework

YES YES

YES

YES

NO

NO

QUALITY IMPROVEMENT & PATIENT SAFETY COMMITTEE (QIPS)

· recommend Interdisciplinary membership of Policy Working Group (PWG)

· identify stakeholder consultation groups (from attached list)

physician input

req’d?

MEDICAL LEADERSHIPMEDICAL ADMINISTRATION

· consult with IH & HSA Medical Directors on physician members for PWG

· identify members to QIPS

QIPSadvise Policy Development Office

(PDO)

PDO/PWG· consult with stakeholder/physician

group leads in drafting working paper· finalize working paper into draft policy· draft policy reviewed/endorsed by

stakeholder groups

HAMAC

confirmation

req’d?

STAKEHOLDER/PHYSICIAN GROUP LEADS

· consult with respective group, and

· provide feedback to PWG

STAKEHOLDER GROUP LEADSdistribute to membership

STAKEHOLDER GROUP MEMBERS

review and send feedback to PDO/PWG

PDO/PWGdistribute for physician input

PHYSICIANS/LOCAL MACs/HSA MAC's

review and send feedback to PDO/PWG

POLICY DEVELOPMENT OFFICE/PWG· collate feedback and revise draft as appropriate· redistribute revised draft with response to feedback to everyone who

provided feedback (repeat if required)· PWG sign-off

HAMAC

confirms?

REGIONAL POLICY RECOMMENDED BY POLICY SPONSOR

Advise HAMAC

NO

NO

NO

HAMAC

endorsement

req’d?

YES HAMAC

endorses?

YES

NO

POLICY DEVELOPMENT OFFICE

deliver policy and implementation plan to Policy

Sponsor

QIPS endorses?

NO

YES

Policy Guide


Appendix B1 – Aboriginal Policy Development Protocol

Aboriginal Programs will:

· consult with AHWAC and/or other appropriate aboriginal partners when determining degree of participation in the policy development process.

· consult with AHWAC and/or other appropriate aboriginal partners when providing feedback to a consultation draft of a policy

The aboriginal representative will consult with Aboriginal Programs, AHWAC and/or other appropriate aboriginal partners during all phases of policy development process.

PERSON COMPLETEING POLICY REQUEST FORM

· consider aboriginal representation on Working Group

· submit form to Policy Sponsor

POLICY SPONSOR

· Review aboriginal representation on Working Group

POLICY DEVELOPMENT OFFICE Consult with Aboriginal Programs to determine whether:

· Aboriginal representation on Working Group is beneficial, and/or

· Aboriginal Programs will receive consultation drafts of the policy as part of IH wide consultation process

WORKING GROUP MEMBER

DECLINE PARTICIPATION

CONSULTATION ONLY

End

Send consultation drafts of policy to Aboriginal Programs for feedback

Invite aboriginal member to Working Group meetings

Policy Guide


Appendix C - Stakeholder Feedback Form

Stakeholder Consultation & Feedback Form (link to form)

To:

From:

Date:

Subject:

Attached is a Regional policy that has been: Developed Revised

The above noted policy has been identified as requiring consultation with the above noted stakeholders. Please review the attached policy and provide feedback on:

Editorial review to improve overall quality of the writing, including clarity and consistency of style, punctuation, spelling, grammar, tone and tense (without changing content or meaning).

General content for accuracy and appropriateness to ensure the level of detail and content is practical, reasonable workable and understandable.

What is required to implement this policy? (education, signage etc.)

If you will be responding electronically please make your comments directly on the MS Word document using the Insert Comment function.

If responding manually with a hard copy please ensure legibility.

To assist you, points that should be considered in your review are found attached to this form. Attach any reference or resource materials required to substantiate your remarks.

Please leave this cover letter attached when returning the document and check the appropriate box below indicating whether you require the revised document returned to you for further review.

Return revised document Do not return revised document If you have any questions, please feel free to contact:

Name: at: or:

Please return to: FAX: EMAIL:

Please return by: Review completed by:

HAMAC

HSAMAC __________________________

Local MAC __________________________

Group __________________________

Committee __________________________

Individual __________________________

http://inet.interiorhealth.ca/infoResources/policies/Documents/Policy%20Stakeholder%20Consultation%20Framework.pdf

Policy Guide


NOTE: In addition to the draft policy, XX documents are attached which provide the background and context for the policy.

Thank you for your participation in the development of this important policy.

Points to consider in reviewing the attached draft policy/guideline:

1. Does the policy meet/exceed/contravene any standards set out by your professional licensing body?

2. Does it reflect the mission, vision, values and strategic direction of IH?

3. Is it in conflict with any other IH policies or guidelines, existing regulatory requirements or legislation?

4. Is it reasonable and can compliance be enforced?

5. Is it easily readable and understandable? If not, suggest how to make the policy more clear (e.g., improve poorly worded sections, eliminate ambiguity)

6. Is the level of detail appropriate to meet the needs of the target audience (i.e., not excessive or inadequate)?

7. Does it assist in making decisions about patient care?

8. Does it reflect current best practice? Do the references appear to be appropriate?

9. Does it address all relevant points? If not, what additional points should be included?

10. Are the steps in the correct sequence? Logical? Complete?

11. Does it reflect accurately the materials/equipment required and available?

12. Are there accompanying documents that have not been included?

13. Are there related documents that may be impacted by this policy?

Attachments:

Policy Guide


Appendix D - Policy Approval Request

Policy approval requests will be made on the approved IH Decision Brief template EXECUTIVE SUMMARY Title <insert title> Purpose <insert purpose>

Impact Quality of Care Human Resources Financial

Neg n/a X Pos Neg n/a X Pos Neg n/a X Pos

Top 3 Risks 1. <name & describe risk and mitigating strategy> 2. <name & describe risk and mitigating strategy> 3. <name & describe risk and mitigating strategy> Author <name and position> Sponsor <name and position> RECOMMENDATION (include funding source)

BACKGROUND

DISCUSSION

OUTCOMES

ALTERNATIVES

CONSULTATION Position Date of Completion

<name>, Director of Business Support <date>

<group or individual> <date> <group or individual> <date> <group or individual> <date> TIMELINES Milestone Lead Date of Completion

Preparation of issue paper <name and position> <date>

Presentation to <insert name> <name and position> <date>

Communication <name and position> <date>

<Measurable outcomes> <name and position> <date>

Education & support <name and position> <date>

ENCLOSURES

REFERENCES

http://insidenet.interiorhealth.ca/infoResources/forms/Documents/Briefing%20Note%20Template%20(Final).dot

Policy Guide


DECISION

Decision of on .

X Approved Not Approved Accepted as Information

For a Policy not approved please provide a brief explanation:

ADDENDUM Attached: Implementation Plan

Policy Guide


Appendix D1 - Implementation Plan (link to form)

Implementation Plan

Name of Policy: Policy Sponsor (Designate): Policy Steward: Implementation Objectives

· Create awareness and understanding of the Policy throughout the organization. · Explain the rationale and objectives of the Policy. · Explain impacts and responsibilities to Interior Health employees and physicians. · Provide education to staff and physicians where required · Introduce new forms etc. if required

Background

Key Stakeholders (internal and external e.g. contactors/vendors) PORTFOLIO (VP) PROGRAM PRACTICE

CHANGE (PC)/FYI

Key Messages

Challenges / Issues

Performance Monitoring

If this Policy significantly changes current practice or introduces a new practice a Risk Assessment must be completed. If the new practice is rated as high risk, ongoing monitoring is required. (complete the following) Position of individual(s) responsible for day to day monitoring: (e.g. case managers, quality leads, etc.)

http://inet.interiorhealth.ca/infoResources/policies/Documents/Policy%20Implementation%20Plan.doc

Policy Guide


To whom will these individuals report? How often will these individuals report? Daily Weekly Monthly Other Specific monitoring instructions:

Communications Action Plan (click here for further information on How to Write Effective Key Messages and for the Communication Plan Template With Action Plan form)

Target Audience: Tool/Tactic: Prime: Timeline:

http://insidenet.interiorhealth.ca/aboutIH/IHdepts/deptComm/Documents/How%20to%20Write%20Effective%20Key%20Messages.doc

http://insidenet.interiorhealth.ca/aboutIH/IHdepts/deptComm/Documents/Communication%20Plan%20Template%20with%20Action%20Plan.doc

Policy Guide


Education Action Plan

Target Audience: Tool/Tactic: Prime: Timeline:

Policy Guide


Appendix E - 3 Year Review Framework and Guidelines

Policy Guide


3 YEAR REVIEW GUIDELINES

Review, Evaluation and Compliance Guidelines

Review Considerations

· has legislation on which policy is based changed?

· have practice standards related to policy changed?

· can the policy statement or related procedures be made clearer or more concise?

· is the terminology still current?

· are changes, if required minor (wording that doesn’t change the values, intent or authority) or substantive?

· what would be required to implement any changes?

Evaluation

The objective of a policy and the indicators of success and compliance should be measurable. Some questions to consider before and during an evaluation include:

· was the policy effectively implemented?

· has the policy been effective? How do you know?

· have the intended goals of the policy been achieved?

· is the policy now redundant or still applicable?

· have there been any unintended outcomes?

· is there a better way to achieve the desired outcomes?

· Compliance

· does policy apply all across the organization?

· has policy been complied with? How do you know? (audit, anecdotal)

Policy Guide


Appendix F - Policy Template (Policy Template Form)

http://inet.interiorhealth.ca/infoResources/policies/Documents/Policy%20Template.doc

Policy Guide


Appendix G - Policy Formatting Guidelines

The following guidelines were developed to provide organizational consistency in style, presentation and format of Health Authority Wide policies.

A well-written policy and procedure will have clarity, consistency, simplicity and brevity.

Simplicity

Avoid extensive vocabulary and complex sentence structure. Use single idea sentences. Keep it simple with the readability level at Grade 9 (for readability statistics go to Tools in Word).

Brevity

Short documents are easier to understand and more apt to be used. Avoid unnecessary words, i.e., “In the event that…” should be replaced with “If…”

Active Voice

The active voice is more concise, direct and vigorous than the passive voice. Use a directive tone in the active voice and present tense. Avoid using immeasurable verbs, such as understand and encourage, for example:

Active voice – Book a follow-up appointment prior to patient’s discharge.

Passive voice – The Clerk will book a follow-up appointment prior to the patient’s discharge.

Font

Arial, size 10.

Gender References

Avoid gender references.

Headings

Use headings and subheadings to group information logically and designate responsibility. Do not shift back and forth as the procedure progresses.

Abbreviations

Avoid using abbreviations. To use an acronym, the first reference must have the words written in full followed by the acronym in brackets.

Reference to Names and Locations

Refer to titles and positions rather than specific individuals. Refer to Department and Service or Company names rather than use of addresses and phone numbers.

Words to Avoid

shall, may, could, would, should, might, can, and ought to avoided wherever possible.

Policy Guide


Generic Names

Use generic names for medications, cleaning agents, solutions, etc.

Numbering

Follow logical and continuous numbering sequence (number each subheading) in the template; e.g., numbering of Section 3 “Policy document” might appear as follows:

3.0 POLICY

3.1 Scope of Policy document

3.2 Application for ….

3.3 Approval of Application

3.4 Exceptions

Emphasis

Do not underline for emphasis; use italic or bold.

Spelling

Use the spell check function to ensure correct spelling within the document.

Punctuation

The use of a coma is appropriate in the following situations:

Between words or phrases in a list or series (e.g., The lab is open Mon., Wed., and Fri.).

After an introductory clause (e.g., Before contacting any patient, hands must be washed.).

To set off expressions which are not essential to the meaning (e.g., All patients, including day hospital patients, are responsible for….).

The use of a colon in a sentence implies "as follows".

It can be used after a statement that introduces a list of items (e.g., The lab is open on the following days: Monday, Wednesday and Friday.); or

Introduces a formal rule or principle (e.g., The goals of the program are: 1. to improve patient safety...); or introduces an explanation or an example (e.g., All patients must have medication administered at the following time intervals….).

The use of a semicolon is appropriate in the following situations:

To separate items in a series when one or more items are already punctuated (e.g., the following members must attend: the Director who will chair the meeting; the Administrative Assistant, who will take minutes; and the managers, who will represent their respective areas.

In a compound sentence to divide two closely related clauses (e.g., Apply soap; rub hands vigorously.)

The use of parentheses is appropriate in the following situations:

To enclose information that is not essential to the meaning of the sentence.

» Example: Record vital signs (including blood pressure, respiratory rate and temperature) on the flow sheet graph.

Policy Guide


To enclose information that is serving as an illustration.

» Example: Times should be recorded in the 24-hour time keeping system (e.g., 18:30 hours).

For references to material such as diagrams, charts, texts, articles, page numbers.

» Example: (figure 2), (page 1-10).

Options for punctuation within lists:

Use commas between items if sentence structure is simple (i.e., no commas within each sentence in the list). Example:

» Before and after contact with a patient: a) wash hands with running water, b) apply soap and wash all surfaces of the hands vigorously for 15 seconds, and c) rinse thoroughly under running water.

Use semicolons between items if list contains compound sentences (i.e., punctuation such as commas exists within sentences in the list). Example:

» Before and after contact with a patient: a) wash hands with running water; b) apply soap and wash hands, including the backs of the hands and in between fingers, vigorously for 15 seconds; and c) rinse thoroughly under running water.

Use open punctuation. Example:

» Before and after contact with a patient: a) Wash hands with running water. b) Apply soap and wash all surfaces of the hands vigorously for 15 seconds. c) Rinse thoroughly under running water.

Bookmarks and Hyperlinks

Include bookmarks, where appropriate, in your document. A bookmark is an item or location in your policy document that a reader can jump to while reading through the document. When you click onto this link, you jump directly to the heading in this section. Book marking tables, diagrams and algorithms assists readers in easily viewing these items and quickly returning to the section of the document they were reading.

A few IH policies contain hyperlinks to other documents on the Intranet or the Internet. These links direct the reader to related sources of information or assist in locating other information or forms associated with the policy document. If your policy needs hyperlinks to existing documents on the IH InsideNet, identify these by typing the text in blue. If you need assistance with using the bookmark and hyperlink features, contact the IH IMIT Help Desk.

Policy Guide


Appendix H - Library of Policy & Clinical Practice Documents

(link to Home Page)

http://inet.interiorhealth.ca/infoResources/policies/Pages/default.aspx

Policy Guide


Appendix I - Policy Cycle Checklist

Initiating Policy Development

consult with appropriate authority to determine if policy is recommended check for existing policy (Policy Development Office) check to see if policy already under development (Policy Development Office) identify content experts identify stakeholder groups complete Policy Request Form deliver Policy Request Form to Policy Sponsor Policy Sponsor approves, appoints Policy Lead/Steward

Development and Consultation

Policy Lead/Steward consults with Policy Development Office Policy Lead presents to Quality Improvement and Patient Safety Committee and/or Professional

Practice Office (if required) Working Group formed Working Group develops “Working Paper” (using IH policy template) and implementation plan in

consultation with their respective stakeholder groups Working Group consults with external experts if applicable Working Group finalizes working paper for regional consultation “Consultation Draft” and support materials distributed (using Stakeholder Consultation form) to

identified stakeholder groups for feedback Working Group reviews feedback and revises “Consultation Draft” as appropriate distributes to

stakeholders for further review and feedback Consultation process repeated as necessary until Working Group satisfied “Consultation Draft” and

implementation plan ready for approval Approval

Policy Lead/Steward presents “Approval Draft” to Quality Improvement and Patient Safety Committee, Integrated Care Coordinating Committee and/or HAMAC if required

Quality Improvement and Patient Safety Committee, Integrated Care Coordinating Committee and/or HAMAC endorse if required

Policy Lead/Steward prepares Policy Approval Form (Issue Paper) and Implementation Plan for Policy Sponsor

Policy Sponsor approves or takes to SET for approval Policy Sponsor delivers approved policy and implementation plan to Implementation Lead and

Policy Development Office Implementation

Policy Implementation Lead implements policy as per the Implementation Plan Auditing

Policy Steward and/or Internal Audit conduct audit if required Results of audit delivered to Policy Sponsor

Three Year Review

Policy Development Office maintains 3 year policy review register Policy Development Office advises appropriate Policy Sponsor when policy(s) require review Policy Sponsor undertakes review and advises Policy Development Office of result

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