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.

Templates and Guides

Hospital Operating Policy and Procedure Template

Individual Hospital Policy and Procedure Templates

AHI Graphic Identity Guide

Steps to Modify Templates

  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.