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13.MEP.4 |
Procedure for Procedures
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Type: Procedure
Category: QA/QI
Level: Community Care
Parties: Community Care Employees and Contractees
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Supporting References:
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Parent |
Effective Date |
Approval Level |
Revision Dates |
Last Reviewed |
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13.ME.5 |
12-1-1997
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Management Team
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9/03; 5/06
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5-16-2006 |
|
Related Document Code |
Related Document Name |
Type |
Procedure: All Community Care personnel have the right to access and review the Community Care Policy/Procedure Manual at any time. All Community Care personnel have the right to submit a request to the Office of Quality Improvement for policy/procedure review or change. Whenever a request or a need for review, change, addition, or deletion of a policy/procedure is received, the Director of Quality Improvement will do the following:
1.Review the request or stated need.
2.Determine a response, and act accordingly as stated below:
a.Due to a regulation standard of accreditation, the request cannot be granted and the Director of QI will communicate this action to the sender.
b.The Director of QI will draft the change or request in policy/procedure format and submit to the Management Team for review. Procedures approved by the Management team will be posted and notice will be provided through email to the effected workforce.
c.Once reviewed by the Management team, policies will be submitted to the Board of Directors for approval. Policies approved by the Board of Directors will be posted and a notice will be provided through email to the effected workforce.
3.All Community Care Policy/Procedures will be reviewed no less than every two years by the Office of Quality Improvement or designated departments.