As of August 16, 2019, we will no longer be selling or renewing individual subscriptions to our policy and procedure manuals. The Brigham Way means that we go above and beyond what is required of us to make Brigham and Women's Hospital a … Policies and procedures demonstrate compliance with Joint Commission International Accreditation Standards for Hospitals. Mercy Hospital's policies are available to download below. When appropriate policies and procedures are in place, an incident is easier to navigate (Kenyon 2018). Contact us or find a patient care location. For additional policies and practices, visit the HR Portal policies and procedures page (login required). 5. TABLE OF CONTENTS . It also summarizes your rights and responsibilities and the general conditions of employment. Policies and procedures are particularly crucial in healthcare as it is an industry that is very familiar with crisis; healthcare organisations endure a high rate of liability risks. Select an option . MCN Healthcare takes each JCI standard and provides sample policies that demonstrate compliance with that standard. International Hospital Policy and Procedure Manual, 1001 - Goal 1 - Identify Patients Correctly, 1002 - Patient Identification for Clinical Care and Treatment, 1003 - Goal 2 - Improve Effective Communication, 1004 - Telephone, Verbal and Written Orders for Medication, 1005 - Critical Results of Diagnostic Tests - Reporting of, 1007 - Goal 3 - Improve the Safety of High-Alert Medications, 1009 - Look-Alike, Sound-Alike Medication Management, 1010 - Concentrated Electrolyte Solutions and Other Drug Concentrations, 1011 - Goal 4 - Ensure Correct-Patient, Correct-Procedure and Correct-Site Surgery, 1012 - Surgical Site Identification, Time-Out, Sign-Out, 1013 - Invasive/Surgical Procedure Verification/Time-Out/Sign-Out Checklist, 1014 - Goal 5 - Reduce the Risk of Health Care-Associated Infections, 1016 - Goal 6 - Reduce the Risk of Patient Harm Resulting from Falls, 1018 - Assessment of Adult Patient at Risk for Falls Form, 2001 - Screening for Admission to the Hospital, 2002 - Plan for the Provision of Patient Care and Services, 2004 - Patient Referral When Admission Criteria Not Met, 2104 - Emergency Department Patient Registration, 2106 - Critical Care - Admission/Discharge Criteria, 2204 - Clinical Practice Guideline Development and Implementation, 2206 - Physician Responsibility for Patient Care, 2208 - Patient Transfers - Documentation in the Medical Record, 2304 - Discharge Planning Assessment/Evaluation Form, 2310 - Patient Leaving Against Medical Advice (AMA), 2402 - Patient Transfers and Referrals - Required Information for Follow-Up Care, 2403 - Patient Transfer to Another Facility, 2404 - Transfer Summary and Certification, 2405 - Transfer Summary and Certification Form, 3004 - Confidentiality of Information - General Issues, 3007 - Patient Possessions Inventory Form, 3010 - Pain Assessment, Reassessment and Management, 3014 - Patient Compliant, Conflict or Difference of Opinion Process, 3101 - General Consent and Informed Consent, 3203 - Organ/Tissue/Eye Donation - Nursing Staff Responsibilities, 4003 - Assessment and Reassessment - Nursing, 4005 - Assessment and Reassessment - Emergency Department, 4006 - Assessment and Reassessment - Surgical Patient, 4007 - Preoperative Testing/Assessment for Inpatients, 4009 - Nutritional Assessment of Patients by the Registered Dietitian, 4010 - Functional Assessment and Reassessment of the Patient, 4011 - Pediatric Assessment and Reassessment, 4012 - Assessment by a Registered Nurse to Determine Labor Status, 4017 - Behavioral Health - Patient Assessment, 4018 - Behavioral Health - Nursing Admission Assessment Form, 4019 - Assessment - Alcohol or Other Substance Use Disorders, 4020 - Child, Adult, Disabled Person or Elderly Abuse - Recognition and Reporting, 4022 - Patient Reassessment by a Physician, 4103 - Scope of Services - Laboratory Services, 4107 - Infection Prevention and Control - Laboratory, 4109 - Laboratory Equipment - Inspection, Testing and Maintenance, 4115 - Transport of Specimens to the Clinical Laboratory, 4119 - Proficiency Testing for Non-Waived Testing, 4120 - Outside Reference Laboratory Authorization, 4201 - Blood Bank and/or Transfusion Services, 4301 - Radiology and Diagnostic Imaging Services, 4302 - Scope of Services - Imaging Services, 4304 - Imaging Services Radiation Safety Program, 4305 - Infection Prevention and Control - Imaging Services, 4306 - Critical Test Results - Imaging Services, 4308 - Quality Control - Imaging Services, 5002 - Hospital Program, Service, Site, Department Leadership, 5003 - Prescribing/Ordering - General Practices, 5004 - Verbal and Written Orders - General, 5101 - Care of High-Risk Patients and Provision of High-Risk Services, 5201 - Recognition of Change to Patient Condition, 5302 - Cardiopulmonary Resuscitation (CPR), 5304 - Blood/Blood Components - Obtaining and Verifying from the Blood Bank, 5305 - Blood/Blood Components - Transfusion, 5306 - Blood/Blood Components - Transfusion Reactions, 5402 - Scope of Services - Nutritional Services, 5504 - Pain Scale - Behavioral-Physiological Scale for Nonverbal or Preverbal Patients, 5701 - Organ and/or Tissue Transplant Services - Transport Programs Using Living Donors, 5702 - Organ Transplantation, Recovery, Receipt and Patient Management, 6202 - Pre and Post Anesthesia Evaluation Policy, 6203 - Pre And Post Anesthesia Evaluation Form, 6204 - Assessment Prior to Induction of Anesthesia/Sedation, 6205 - Guidelines for Administration of Anesthesia, 6209 - Patient Assessment and Reassessment - PACU, 6302 - Documentation of Operative and Other High-Risk Procedures, 7003 - Antimicrobial Stewardship Program Implementation Plan, 7204 - Refrigerator and Freezers - Drug Storage, 7206 - Radioactive Materials - Ordering, Receiving and Handling, 7208 - Patient's Own Medication (Storage and Destruction), 7302 - Medication Information and Reconciliation, 7303 - Medication Information and Reconciliation Form, 7306 - Legibility of Medical Record Documentation, 7504 - Self-Administration of Medications by Patients, 7602 - Monitoring Effects of Medications on Patients, 7606 - Performance Improvement Analysis - Medication Incident, 8002 - Organizational Patient/Family Education Plan, 9001 - Management of Quality and Patient Safety Activities, Measure Selection and Data Collection, Analysis and Validation of Measurement Data, Gaining and Sustaining Improvement, 9002 - Organizational Performance Improvement Plan, 10001 - Prevention and Control of Infections, 10002 - Infection Prevention and Control Program, 10003 - Emergency Preparedness Program - Global Communicable Diseases, 10004 - Infection Prevention and Control Plan, 10006 - Infection Prevention and Control Incident Tracking, 10008 - Medical Device Reprocessing - General Infection Control Guidelines, 10009 - Event-Related Shelf Life - Sterile Storage, 10010 - Reprocessing of Single-Use Devices, 10015 - Infection Prevention and Control - Food Services, 10016 - Transmission-Based Precautions (Isolation Precautions), 10017 - Response to an Influx of Infectious Patients, 10018 - Personal Protective Equipment - Use of, 10019 - New Employee Infection Prevention and Control Orientation, 11003 - Hospital Organizational Chart (Example), 11004 - Organizational Leadership (Governing Entity) Self-Assessment, 11005 - Operational Responsibilities of the Governing Entity, 11101 - Chief Executive(s) Accountabilities, 11102 - Position Description/Performance Evaluation - Chief Executive, 11201 - Hospital Leadership Accountabilities, 11204 - Staff Retention and Recruitment Plan, 11301 - Hospital Leadership for Quality and Patient Safety, 11401 - Hospital Leadership for Contracts, 11402 - Oversight of Contractual Agreements, 11501 - Clinical Staff Organization and Accountabilities, Direction of Hospital Departments and Services, 11502 - Hospital Program, Service, Site, Department Leadership, 11503 - Scope of Services - Medical Surgical Unit, 11504 - Scope of Services - Surgical Services, 11505 - Development of Departmental Policies and Procedures, 11506 - Development of Interdepartmental Policies and Procedures, 11507 - Development and Review of Clinical Guidelines, 11601 - Organizational and Clinical Ethics, 11602 - Patient Admission to the Hospital, 11603 - Financial Incentives/Clinical Decision Making, 11606 - Physician-Owned Hospitals Notification Statement Policy, 11609 - Convening of the Ethics Committee, 11702 - Clinical Trials/Research Projects - Conduct of, 12001 - Leadership and Planning, Safety and Security, Hazardous Materials Disaster Preparedness, Fire Safety, Medical Technology, Utility Systems, Facility Management Program Monitoring, Staff Education, 12005 - Construction/Renovation Guidelines, 12006 - Accreditation Surveyor Verification, 12007 - Hazardous Materials and Waste Management Plan, 12008 - Emergency Management Program (EMP), 12011 - Medical Equipment Management Plan, 13002 - Staff Qualifications and Competency, 13009 - Workplace Violence Prevention Plan, 13101 - Determining Medical Staff Membership and The Assignment of Medical Staff Clinical Privileges, 13102 - Credentialing and Privileging Process - General Guidelines, 13103 - Third Party Verification Organization, 13201 - Ongoing Monitoring and Evaluation of Medical Staff Members, 13202 - Ongoing Monitoring of a Practitioner's Performance, 13301 - Reappointment and Renewal of Clinical Privileges, 13302 - Medical Staff Reappointment and Renewal of Clinical Privileges, 13502 - Other Healthcare Practitioners' Requirements, 14003 - Confidentiality of Information - Electronic Health Record, 14005 - Documentation and the Use of Abbreviations, Acronyms and Symbols, 14006 - Unacceptable Abbreviation and Symbols List, 14007 - Data Center Protection/Emergency/Recovery Plan, 14101 - Management and Implementation of Documents, 14102 - Policy and Procedure Development, Review and Approval.