Policy Templates

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.

Policiy Templates
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-6  Employee Discipline  
 C-7  Violence in the Workplace  
 C-8  Drug Free Workplace  
 C-9  Posession of Firearms Policy  
 C-10  Employee Evaluations  
 C-11  Employment of Relatives or Close Friends  
 C-12  Personnel Records  
 C-13  Sexual - Harassment   
 C-13.1  Sexual Harassment Reporting Procedure  
 C-14  Computer, Internet, Telephone & Email Usage Policy  
 C-15  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