The 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.