Acute care hospitals must keep policies and procedures up to date to run safely and effectively. However, organizations frequently are cited for failing to review policies and procedures or similar documents within a specified time frame.
Acute care hospitals must keep policies and procedures up to date to run safely and effectively. However, organizations frequently are cited for failing to review policies and procedures or similar documents within a specified time frame.
To ensure policies are evidence-based, follow national standards of practice, and comply with state and local laws, rules, and regulations, each organization must have policies and procedures reviewed and approved by the appropriate committees at the defined frequency stated in the standards and in accordance with hospital policy.
Unless specifically indicated by state, federal regulations, or elsewhere in the Acute Care Hospitals Manual, policies and procedures are to be reviewed at least every three years. Many Accreditation Commission for Health Care (ACHC) Standards outlined throughout the manual specify which policies require committee approval, including medical staff and governing body approval.
Facilities have flexibility to determine how the medical staff will approve policies. This approval may be achieved by a Medical Director approving and then forwarding a policy to the medical executive committee (MEC), a function solely of the MEC. Or it may be achieved through a separate committee consisting of medical staff who would hold the responsibility of policy and procedure approval. The policy approval process should be outlined in organizational policy. Remember that medical “staff” approval does require having more than one medical staff member approving policies.
Listed below are standards that require policy approvals by various committees, including the medical staff. Other policies or documents not listed below should be defined in the policy and procedure approval policy. This is not an all-inclusive list, so be sure to refer to specific standards for detailed guidance.
Standard 01.01.25: Policy and Procedure Review and Approval
The organization has a formal policy that establishes the process for policy and procedure approval. The organization identifies the policies and procedures that require approval by one or more of the following:
Governing Body
Chief Executive Committee
Medical Executive Committee
Chair, Medical Department
Chief Nursing Executive
Chapter 1 − Administration
Standards 01.02.03 and 01.02.04: The medical staff has written emergency service policies which are adopted by the medical staff.
Chapter 3 − Medical Staff
The medical staff has the responsibility to oversee patient care throughout the facility. One way to achieve this is through the approval of various policies and procedures. See the following standards for additional information:
03.00.10: One of the medical staff responsibilities is to approve policies and procedures as required under other conditions of participation, as well as through its leadership participation in the organization and through its implementation of the hospital’s quality assessment and performance improvement program required in accordance with 42 CFR §482.21.
03.01.11: Policies of the medical staff shall be supportive of and congruent with the Medical Staff Bylaws, Rules, and Regulations.
03.13.01: The medical staff has a process to review and adopt blood and blood products administration practices based on current national guidelines.
03.14.01: Medication preparation and administration policies are approved by the Pharmacy and Therapeutics committee or function of another committee, as well as the medical staff, at least every three years.
Chapter 7 − Infection Control and Antibiotic Stewardship
The infection control committee must oversee and approve infection control policies throughout the organization. See the following standards for additional information:
07.00.05
07.03.02
Chapter 10 − Medical Records
The medical staff policies and/or rules and regulations govern various elements required in the medical records. See the following standards for additional information:
10.01.02
10.01.16
10.01.24
10.01.29
10.01.30
Chapter 14 − Organ Procurement
14.00.01: The governing body has approved the hospital’s organ procurement policies.
Chapter 16 − Nursing Services
Various leaders and committees must approve policies related to nursing services. The Director of Nursing (DON) approves the nursing service patient care policies and procedures at least every three years. In addition to the DON approval of policies, any policies related to medication administration practices must be approved by the Pharmacy Committee. See the following standards for additional information:
16.00.03
16.01.01
16.01.09
16.01.10
Chapter 17 − Respiratory Therapy
The medical staff must approve respiratory therapy policy and the scope of services. See the following standards for additional information:
17.00.01
17.00.04
17.00.06
Chapter 18 − Anesthesia Services
18.00.02: The hospital must have policies and procedures, consistent with state scope of practice law, governing the provision of the types of anesthesia services.
Chapter 19 − Radiology
Radiology policies, which are consistent with state law when applicable, must be approved by the medical staff and radiation safety committee at least every three years. See the following standards for additional information:
19.00.03
19.00.09
19.00.11
19.00.13
Chapter 20 − Emergency Services
20.00.03: Policies and procedures governing medical care provided in the Emergency Service are established and approved by the Medical Staff.
Chapter 22 − Laboratory Services
The scope of services and policies related to examination of tissues must be approved by the medical staff. See the following standards for additional information:
22.00.05
22.00.02
Chapter 23 − Nuclear Medicine
Nuclear medicine scope of services must be approved by the director of nuclear medicine and the medical staff. In addition, nuclear medicine policies must be approved by the radiation safety committee and medical staff at least every three years. See the following standards for additional information:
23.00.01
23.00.05
23.00.14
Chapter 24 − Nutritional Services
24.00.08: A current therapeutic diet manual is approved by the dietitian and medical staff at minimum every three years.
24.01.03: Food safety policies have been approved by the Infection Control Committee.
Chapter 25 − Pharmacy Services
Various pharmaceutic policies are required to be approved by the hospital Pharmacy and Therapeutics Committee and the medical staff. A drug formulary and protocol orders must be approved by the medical staff annually. See the following standards for additional information:
25.00.00
25.01.09
25.01.13
25.01.16
25.02.01
Chapter 26 − Therapy Services
The medical staff are required to approve various policies, the scope of services, and staff qualifications for therapeutic services. See the following standards for additional information:
26.00.01
26.00.03
26.00.05
Chapter 30 − Surgical Services
Surgical services policy approval requirements differ based on the type of document. For example, surgical and post-anesthesia care unit (PACU) service policies are developed and approved by the Surgical Services Supervisor, Chief of Surgery or Anesthesia, administration, Infection Control Committee, Pharmacy Therapeutics Committees, and the medical staff. The scope of services, various policies such as the comprehensive medical history and physical assessment (H&P) requirements, documentation requirements, and PACU policies, among other policies, require approval by the medical staff. Medical Staff Rules and Regulations and/or policies address first assists, when the surgical team is all non-physicians, and discharge criteria from the PACU.
See the following standards for additional information:
30.00.09
30.00.01
30.00.07
30.00.08
30.00.10
30.00.11
30.00.20
30.02.03
30.02.10
30.02.11
30.02.13
Chapter 31 − Outpatient Services
31.00.00: The facility has medical staff-approved policies that address the professionals that are eligible to order outpatient services.
31.00.11: Outpatient service policies are approved by the medical staff and governing body at least every three years.
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