ADMINISTRATIVE POLICY AND/OR PROCEDURE

APP ADMINISTRATIVE POLICY AND/OR PROCEDURE POLICY NUMBER HOSPITAL-03-0001(1) REPLACES NUMBER TITLE Policy on Policies & Procedures EFFECTIVE DATE NO. OF PAGES 7 pages REVISION DUE APPROVAL DATE APPLIES TO ALL HOSPITAL APPROVED BY Hospital Director SIGNATURE 1.0 PURPOSE To provide definitions of working documents used in delivery and support of care. To set guidelines for developing the HOSPITAL policies and procedures, approval, distribution, review, revision, and to provide the formats or frameworks used in administrative and patient care policies and procedures. 2.0 DEFINITIONS 2.1 Types of Documents: Policy 1 Medical Staff Bylaws: 2 Clinical Protocol/Practice Standard: 3 Administrative Policies (APP): 4 (IPP) Interdepartmental Policies & Procedure 5 (DPP) Department Policies: Description Bylaws that relates to the function of licensed physicians in carrying out their clinical roles as defined by their license, credentials and privileges granted. Course of action to be followed by the provider related to the assessment, reportable condition, specific care, safety issues, patient/family education and documentation for patient population described. APP is the Organizational Policy or Procedure which considered administrative in content; may direct a different level of management; and reflects the philosophy and objectives of the HOSPITAL that affecting All Departments Support policies in defining governance and relationships between two or more departments having an overlap of functions, or functional dependency on each other. They should serve as a guideline for present and future decisions. Since not all of the Hospital s departments may be affected, the policy gives guidance to only the appropriate departments regarding a particular subject matter. Policies specific to sections /departments and included in the department s policy and procedure manual.

6 Guidelines: Written outline that describes how forms, equipments, and documents are to be implemented. 7 Forms / Document A statement or form in conventionally written/electronic media, which presents policies, procedures, work instructions, and instructional materials made part, directly or by reference, of the Quality Management System. Examples include training manuals which provide step-by-step or general instructions stating how to perform specific duties. 3.0 RESPONSIBILITY: All Departments and Services: Initiator/ process owner, Department Manager or designee Hospital Director : Medical Director -CMO Medical Policy and Procedure Committee Hospital Policy and Procedure Committee Director of Nursing (DON) 1. All will be responsible for adhering to. Tracking process addressed in this policy 2. Tracking process: This includes developing, writing, reviewing, approving, and finalizing policies and procedures for the hospital wide policy and procedure manual. 3. Proposes changes as appropriate. 4. Endorses IPPs that do not require changes. 5. Forwards approved original policies and procedures to P&P coordinator for distribution. 6. If APP is identified, it will follow the same APP approval process as mentioned before. 7. Receive all approved P&P distribute them appropriately. 8. Initiates and coordinates policy through organizational approval process. Attends meetings to approve policy. 9. grants final approval of all organizational Policies and Procedures (APP) 10. Establishes group of clinicians for review of policies submitted 11. Approves Medical Staff and Patient Care Policies 12. Forwards approved Medical Staff Policies and Patient Care Policies to P&P coordinator for distribution. 13. Reviews all Medical Staff Policy drafts and Patient Care Policy drafts and revisions for content and format needs in compliance with policy guidelines. 14. Proposes changes as appropriate. 15. Endorses Patient Care Policies that do not require changes. 16. Forwards reviewed all Medical Staff Policy to CMO for his approval 17. Forwards reviewed Patient Care Policies to CMO and Director of Nursing for his approval. 18. to review all APP and multidisciplinary 19. Establishes group of nurses for review of all Nursing and Patient Care Policy drafts and revisions for content and format needs in compliance with policy guidelines.

Chairman / Directors The Policy and Procedure (P&P) Coordinator: 20. Review / approve all departmental P&P. 21. Is responsible for guiding departments through the policy and procedures writing and approval process. 22. Oversight HOSPITAL document management which include, adding, deleting, and revising the HOSPITAL on-line Policy and Procedure Manual. 23. S/he tracks replacement of the old policy by the new and adds it to the appropriate manual. 24. S/he update the general HOSPITAL P&P Status Report list every first Saturday from each month as will as s/he update the intranet IPP list in coordination with the IT. 25. Distribution will be on the every second Saturday from each month. 4.0 CROSS REFRENCES POLICIES 5.0 POLICY 4.1 The P&P format, templates structure and numbering system (HOSPITAL-QM-002). 5.1 Policies/procedures will be given effective dates 4 weeks minimum after dissemination to allow sufficient time for staff education and planning for operational changes unless it needs more time this should be clarified in the Tracking Form by the approving committee(s) or and individual. Except in the emergency cases, the effective date should be exactly after making sure that all parties are aware and trained about the content. 5.2 For creation or alteration Policy and Procedures, Tracking Form and the drafted policy must be completed and forwarded with the draft P&P to the authorized committee(s) as addressed in the tracking form. 5.3 Each department should have all manuals needed according to the HOSPITAL APP Departmental Manuals. 5.4 All department(s) is/are encouraged to file all new material promptly and to call to the attention of the P&P Coordinator if any missing issues. 5.5 RETENTION OF POLICY/PROCEDURES 5.5.1 The original approved policy and procedure along with draft copies, revisions, concurrence, non-concurrence forms and other documentation related to the development and approval of said policy and procedure shall be kept at the TQM department in the appropriate departmental file including the historical file for legal and reference purposes. 5.5.2 The old and deleted policy will be kept in the same file under historical index for a period of 3 years. 5.5.3 An electronic copy will be posted in the web to be accessed, as a Read-only document, by the originating and all departments. 5.5.4 All the electronic copies will be in a PDF format. 5.6 Format of Documents: following the P&P format, templates structure and numbering system HOSPITAL-03-0002(1) 5.7 Review of Documents: 5.7.1 Patient care policies are to be reviewed annually, or as needed. 5.7.2 Administrative policies will be reviewed every three (3) years or as needed

5.7.3 Each P&P signatures and review dates shall appear on each Medical policy and procedure attesting the annual other review date. 5.7.4 If the entire manual is reviewed, a cover page attesting the annual or other review shall accompany manual with the reviewers signatures and date. 5.7.5 All forms used in the HOSPITAL (Patient Medical Record) will be approved by the Medical Record Review Committee. The Marketing communication department will be responsible for the form design after the approval of the responsible committee. 5.8 Policy and Procedure Major Revision Process: 5.8.1 Any and all changes to existing policies and procedures that alter the original affect intended are subject to new approval 5.8.2 Committee or special task force review and revise making the necessary changes. 5.8.3 All changes are presented to the appropriate committee(s) / individual(s) for review before going to approval. 5.9 Approval Signatures: Approval is required (according to policy content) as follows: 5.9.1 Administrative Policy or Procedure (APP): Organizational (all policies that applies to ALL HOSPITAL) approved by: 5.9.1.1 Hospital P&P Committee 5.9.1.2 Chief Executive Officer, 5.9.2 Institutional Policy & Procedure: 5.9.2.1 Departmental P&P: To be reviewed and signed-off by Department Director/ chairman. 5.9.2.2 Interdepartmental P&P: approval by 5.9.2.2.1 Responsible Departments or and committee(s); and /or 5.9.2.2.2 division chief(s) 5.9.3 Clinical and Patient Services Manual: 5.9.3.1 Reviewed by the Medical P&P committee 5.9.3.2 Approved by: 5.9.3.2.1 Nursing Director 5.9.3.2.2 Medical Director, Type of Policy Developed by Reviewed by Approved by Departmental Initiator/ process owner / Director Director / Chair person director Interdepartmental Owner / director Team / Task Force Clinical and Patient Services Manual All affected Departments and committees Chairman of the Medical P&P committee The committee chairman And/or the Division(s) chief Nursing Director Medical Director, 5.10 Training: It is each Department Chairman / Director s responsibility Develop a training plan to include who needs to be trained, how will training occur, how will it be documented

5.10.1 to ensure that his/her staff understands and implements the policy/procedure/form changes within his/her department, through (Meetings, presentations, and consultation) and to enforce policy requirements 5.10.2 Training Material: write any associated training material to complete the procedure 5.11 Distribution and Maintenance of Documentation 5.11.1 Distribution of a policy/procedure by the TQM department is made according to the list in the tracking form which should be reflected in P&P Status Report. 5.11.2 The copies of all policies/procedures are sent only to the department Directors/ chairman listed in the HOSPITAL P&P Status Report under the column of applies to. 5.11.3 Finalized documents are returned to the Department Chairperson / Director for copying, distribution, and implementation. 5.11.4 To obtain a copy of a policy, contact 6751, TQM department P&P@HOSPITAL.med.sa, 5.12 Archiving: All Directors/ chairman are responsible to: 6.0 PROCEDURE: 5.12.1 Update appropriate manual 5.12.2 Retrieve policies and being replaced by the new document 5.12.3 Send the original old documents to the TQM 5.12.4 Destroy all copies of the old documents 6.1 Policy and Procedure Initiation, Revision, Distribution and Deletion The following steps describe the process for creating a new P&P or changing an existing: 6.1.1 Once topic is identified, the process owner will obtain the electronic Tracking Form with approved format prior to initiating a policy from HOSPITAL intranet - TQM Link online or from (P&P) Team Coordinator. 6.1.2 The reasons of initiation, revision, and deletion should be documented on the TRACKING FORM. (Part B) 6.1.3 The Process Initiator/ process owner communicate with P&P coordinator to search for existing and/or cross references policy and procedure in place at HOSPITAL before starting the process. 6.1.4 In case of interdepartmental policies, all affected parties and committees are consulted and included in providing input prior to finalizing policy, which will be documented on TRACKING FORM. 6.1.5 The Initiator/ process owner should consult the Infection control, Risk Management and Safety officers as needed about proposed policy 6.1.6 Prepare draft of policy using approved format. 6.1.7 In case of the Departmental Policies and Procedures, the complete Tracking Form with the supporting documentation and drafted policy will be submitted to the Director form the process owner, for final review the documents, then send them to the Chair person for approval. 6.1.8 In case of the Interdepartmental policies, the complete tracking form with the supporting documentation and drafted policy will be submitted to the responsible committee 10 days before their regular meeting for review. 6.1.9 The process owner might be invited to present the policy draft to appropriate organizational committee(s) and make necessary revisions as directed.

6.1.10 The Initiator/ process owner submits the final Policy & Procedure with drafted P&P, Tracking Form to appropriate Committee for final review and approval signature. 6.1.11 The Chair person of the committee will send the Tracking Form and the approved P&P to the appropriate chiefs for final approval. 6.1.12 Policies are to be signed in blue ink. the electronic signature 6.1.13 After approval, the Chief forwards approved Department policies and procedures P&P coordinator. 6.1.14 The original policy, and Tracking Form, will be sent by the Initiator/ process owner to the P&P coordinator at the TQM department to maintain the document management. 6.1.15 P&P coordinator distribute the P&P electronically according to the list of the departments which supposed to receive the P&P as addressed in the Tracking Form part - Distribution List (E). 6.1.16 Distribution List: List of the departments Chairman /directors that are involved in the process and/or affected by the policy using the Tracking Form as a tool to ensure that all parties being received the updated P&P. 6.1.17 Distribution will be on the every second Saturday from each month. 6.1.18 The web site policies and procedure will be posted on the same day. 6.1.19 Upon policy/procedure implementation and publication, it becomes the responsibility of the P&P coordinator to track annual reviews and contact policy authors and task force members for policy/procedure reviews. 7.0 FORMAT: Attachment I: Policy and Procedure Tracking Form Attachment II: The P&P format, templates structure and numbering system Attachment III: Administrative Policy And/Or Procedure Template Attachment IV: Institutional Policy and Procedure Policy and Procedure (departmental and interdepartmental) Attachment V: Departmental IPP process flow chart Attachment VI: Interdepartmental IPP process flow chart Attachment VII: Hospital Wide - IPP process flow chart Attachment VIII: Signature Sheet for P&P 8.0 REFERENCES 8.1 Medical Consultant Network (MCN) 8.2 Vanderbilt University Medical Center P&P system (VUMC) 8.3 King Abdul Aziz Medical City APPROVAL:

Name Signature Date Prepared By 15-12-2005 Approved By Latest Revision Approved By