Resources

 

Purpose of policies & procedures:

Organizations work best when there are consistent methods to handle various issues. Policies are used to establish the standard and expected approach to managing the hospital’s business. Policies must be approved by both the Administrative Committee and Board of Directors of the hospital.

Procedures are guidelines for how to carry-out of fulfill the policy. These are not “policies” but rather the method of how to apply the policy in the hospital setting. Procedures should be kept up to date.

These documents should be reviewed regularly to ensure that they are up to date with current technology, information flow, and able to meet the current needs of the hospital. Each hospital Administrative Committee should assign a “Policy Manager” to be in charge of the policy manual, ensuring that it is contextualized and appropriate for your setting. Any current policies in place should be reviewed and where needed, combined or integrated with the policy templates provided in this document.

Policy Templates:

Following is a compilation of policies and procedures that have been developed as templates for hospitals to establish operating policies in the instances when there are none in place or they are in need of updating. In general the policies here are “best practices” and provide guidance of how these situations should be handled. However they should modified to fit the local context. Administrative judgment should be used carefully to maintain the controls necessary while adjusting the process to fit the local setting. It is suggested the “Policy Manager” contextualize these policies and procedure to fit the local situation. If there are management policies in place currently they should be reviewed and integrated or updated as needed.

NOTE: Patient care policies and procedures are not included here but should be in place following a similar format in compliance with the national standards and clinical quality expectations.

STEPS TO MODIFY:

  1. Replace the [HOSPITAL NAME] or “hospital”with the appropriate name. (Click “replace” on the tool bar on the Editing menu, enter “[HOSPITAL NAME]”, replace it with your hospital name).
  2. Note places where there is a ______________ or yellow highlight and address those for your context.
  3. Carefully read through each policy and make wording changes to fit the local context. Or use these policies to update or modify the policies currently in place. (For instance B-2.6 has an amount for capital expenditures in US Dollars. This should be converted to a reasonable amount in local currency.)
  4. Bring policies to local ADCOM for approval (see policy F-2). Make any changes recommended by ADCOM and finalize the document.
  5. Note in the document the signature and date when it was approved.
  6. Create a printed policy and procedure notebook that records the current policy in place. Maintain and electronic copy in the Administrative office for future updates.

If you have any questions please contact Elisa Blethen at: eblethen@llu.edu

 

Download Graphic Identity Guide here. 

Download Policy Templates here. 

Download Hospital Policy Table of Contents here. 

 

Table of Contents  |  Click on each policy to download

A

ORGANIZATION & RESPONSIBILITY

Effective Date

A-1

Mission, Vision, and Values

 

A-2

Organizational Chart

 

A-3

Job Descriptions

 

A-4

Administrative Committee

 

A-5

Standing Sub-Committee Policy

 

 

 

 

B

FINANCE

Effective Date

B-1

Hospital Budget

 

B-1.1

Budget Procedure

 

B-2

Financial Reports and Controls

 

B-2.1

Financial Report Review Procedure

 

B-3

Expenditure of Funds

 

B-4

Expense Reports / Travel

 

B-5

Personal Use of Hospital Equipment & Vehicles

 

B-6

Fixed Asset Capitalization Policy

 

B-6.1

Fixed Asset Acquisition Procedure

 

B-7

Borrowing and Lending of Funds

 

B-8

Key Authorization

 

B-9

Disposition of Surplus Assets

 

B-10

Bank Reconciliation

 

B-10.1

Bank Reconciliation Procedure

 

B-11

Purchasing Policy

 

B-11.1

Purchasing Process Procedure

 

B-12

Procurement Committee

 

B-13

Inventory Management Process

 

B-14

Managing Bank Accounts

 

B-15

Petty Cash

 

B-15.1

Petty Cash Procedure

 

B-16

Funds for Charitable Patient Care

 

B-16.1

Charitable Care Procedure

 

B-17

Payroll Management

 

B-17.1

Payroll Preparation Procedure

 

 

 

 

C

PERSONNEL

Effective Date

C-1

Conflict of Interest

 

C-2

Employee Dress Code Policy

 

C-3

Employee Lifestyle Policy

 

C-4

Recruitment and Hiring of Personnel

 

C-4.1

Recruitment and Hiring of Personnel Procedure

 

C-5

Employee Handbook

 

C-7

Employee Discipline

 

C-8

Violence in the Workplace

 

C-9

Drug Free Workplace

 

C-10

Employment of Relatives or Close Friends

 

C-11

Employee Evaluations

 

C-12

Possession of Firearms

 

C-13

Personnel Records

 

C-14

Sexual -Harassment

 

C-14.1

Sexual Harassment Reporting Procedure

 

C-15

Computer, Internet, Telephone & Email Usage

 

C-16

HIV/AIDS Workplace Policy

 

 

 

 

D

RISK MANAGEMENT

Effective Date

D-1

Insurance

 

D-2

Safety

 

D-3

Disaster Plan

 

D-4

Fire Response Plan

 

 

 

 

E

PUBLIC RELATIONS

Effective Date

E-1

Communication with the Media

 

E-2

Advertising

 

E-3

Release of Hospital Information

 

E-4

Use of the Hospital Name and Logo

 

 

 

 

F

GENERAL ADMINISTRATION

Effective Date

F-1

Standards for the Administrative Handbook

 

F-2

Format and Coding for Policy Handbooks

 

F-3

Contractual Relation Policy

 

F-4

Strategic and Business Plan Policy

 

F-5

Retention and Destruction of Documents