13.MEP.7 |
Procedures for Policies
|
Type: Procedure
Category: QA/QI
Level: Community Care
Parties: Community Care employees and contractees
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Supporting References: COA Standard G4.13.02
Parent |
Effective Date |
Approval Level |
Revision Dates |
Last Reviewed |
13.ME.5 |
1-1-2004
|
Management Team
|
5/06
|
5-16-2006 |
Related Document Code |
Related Document Name |
Type |
13.MEP.4 |
Procedure for Procedures |
Procedure |
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 or 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 it to the Policy Review Committee for draft review. (The policy review committee is comprised of the Director of Quality Improvement, the Coordinator of Quality Assurance, a clinician, and a supervising staff member.)
c.Once reviewed by the committee, the Director of QI will present the policy/procedure to the appropriate oversight committee (Management Team, Program Manager Team, or Administrative Supervisors Team) for review.
d.Once reviewed by the oversight committee, the approved draft will be submitted to the Board of Directors for policy approval or to the Community Care Management Team for procedure approval. Newly created polices and procedures will be provided to employees and contractees through the electronic manual or in writing. All Community Care Policy/Procedures will be reviewed no less than every two years by the Office of Quality Improvement.