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policy 0001 : Medical Center Policy on Policy Development, Review and Approval

One avenue by which the University of Virginia Medical Center can achieve its goals and support its mission, vision and values is to have a well-articulated and understandable set of policies and related procedures/documents applicable organization–wide, which outline the authorized approach to matters that affect patient care and the delivery of related services or conduct within or for the benefit of the Medical Center. This policy sets forth a standardized process for the development, review and approval of Medical Center Administrative and Clinical Policies.

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  1. effective date:

    January 1, 2016
  2. content:

    POLICY STATEMENT: 

    One avenue by which the University of Virginia Medical Center can achieve its goals and support its mission, vision and values is to have a well-articulated and understandable set of policies and related procedures/documents applicable organization–wide, which outline the authorized approach to matters that affect patient care and the delivery of related services or conduct within or for the benefit of the Medical Center.  This policy sets forth a standardized process for the development, review and approval of Medical Center Administrative and Clinical Policies.

     

    MEDICAL CENTER POLICY STANDARDS:      

    1.  Medical Center Policy is an approved formal written statement of how a governance, administrative and/or clinical care process is defined, organized and mandated to be carried out and is applicable organization-wide or significantly affects activities under two or more Medical Center Executives. 
    2. Medical Center Policies shall not conflict with or duplicate Health System Policies, which are applicable across the organization and are approved by Health System Leadership (see Health System Policy HSG-001 “Health System Policy Development, Review and Approval”). 
    3. Medical Center Policy should be based on law, regulation, accreditation standard, or a leadership decision of a strategic course of action, or a uniform or consistent approach to clinical or non-clinical practice. 
    4. Medical Center Policy will apply to all persons providing patient care or other services within or for the benefit of the Medical Center, regardless of employer (“Covered Persons”). 
    5. Medical Center Policy will be classified as either “Clinical” or “Administrative.”
      1. Clinical Policies are those policies that exclusively affect clinical staff or other healthcare provider decision-making and behavior.  For example and as illustration only, policies regarding pain assessment and management, “do not resuscitate” orders, foregoing treatment decisions, etc. are Clinical Policies.
      2. Administrative Policies are those policies that are not directly focused on clinical care decision making or clinical behavior, but may impact clinical care, and include general rules of conduct for all persons in the Medical Center (such as visitors to patients, identification, dress code, smoking, etc.), rules of conduct for employees (such as acceptance of gifts, travel reimbursement, etc.), use of Medical Center facilities by outsiders (such as solicitations, sales activities), human resources and finance policies applicable to all employees of the Medical Center and policies that conform to state or federal law and involve no discretion (such as use of lead shielded rooms in certain therapies involving radioactive materials).

     PROCESS FOR MEDICAL CENTER POLICIES:           

    1. Clinical Policy Process 
      1. All new Medical Center Clinical Policies or revisions to existing Medical Center Clinical Policies must originate from one or more of the Standing Committees of the Clinical Staff Executive Committee.  The Chair of the Clinical Staff Standing Committee or his/her designee must sponsor the new Clinical Policy or revision to existing Clinical Policy (the “Clinical Sponsor”). 
      2. Clinical Policy development shall follow the procedure as set forth below. 
      3. All Clinical Policies shall be approved by the Clinical Staff Executive Committee and shall be signed jointly by the President of the Clinical Staff and the Chief Executive Officer of the Medical Center or his/her designee.  Clinical Policies shall not be unilaterally adopted or amended, and shall only be adopted or amended as specifically provided in this Policy.  
    2. Administrative Policy Process: 
      1. All new Medical Center Administrative Policies or revisions to existing Medical Center Administrative Policies must originate from the office of a Medical Center Chief Executive who must sponsor the new Administrative Policy or revision to existing Administrative Policy (the “Administrative Sponsor”). 
      2. Administrative Policy development shall follow the procedure established below. 
      3. All Administrative Policies shall be approved by the Medical Center Operations Leadership Council and be approved and signed by the Chief Executive Officer of the Medical Center or his/her designee.

    PROCEDURE APPLICABLE TO ALL MEDICAL CENTER POLICIES: 

     

    Prior to initial development of any new Medical Center Policy or significant revisions to any existing Medical Center Policy, the idea may be submitted to the Medical Center Policy Coordinator for clearance, including a determination of the existence of potentially conflicting or related Medical Center, Health System or University Policy.  The Chief Executive Officer of the Medical Center shall designate the Medical Center Policy Coordinator from time to time.

     

    The applicable Clinical Staff Standing Committee is responsible for drafting any Clinical Policies or revisions thereto.  The applicable Medical Center Administrative Sponsor or designee is responsible for drafting any Administrative Policies or revisions thereto. 

     

    Each Medical Center Policy may include procedure applicable to the Policy.  A procedure provides a description of activities that implement a Medical Center Policy.  Each procedure shall include a reference, where applicable, to laws, rules, or regulations governing or relevant to the Policy.  These references will be reviewed and revised in accordance with this Medical Center Policy No. 0001 or as otherwise necessary to ensure that the Policy remains compliant. 

     

    After the proposed Policy and any applicable procedure is drafted and endorsed by the appropriate Clinical Staff Standing Committee or Administrative Sponsor, the applicable Clinical or Administrative Sponsor presents it to the Medical Center Policy Coordinator for review and input, including legal review.

     

    Upon completion of the review, the Policy, including any applicable procedure, is returned to the applicable Clinical or Administrative Sponsor for final draft.  The final draft is submitted to the Medical Center Policy Coordinator with the completed Medical Center Policy Review Form (Attachment A).

     

    The Medical Center Policy Coordinator will submit the final draft of any Clinical Policy, including applicable procedure, to the Clinical Staff Executive Committee for review and comment, or approval.  If necessary, the applicable Clinical Sponsor will make any revisions requested by the Clinical Staff Executive Committee.

     

    The Medical Center Policy coordinator will submit the final draft of any Administrative Policy, including applicable procedure, to the Chief Executive Officer of the Medical Center and those Medical Center Executives designated by the Chief Executive Officer for review and comment, or approval.  If necessary, the applicable Administrative Sponsor will make any revisions requested by the Chief Executive Officer and designated Executives.

     

    Upon approval of a Medical Center Policy, it is signed by the appropriate signatory as denoted above and included in the Medical Center Policy Manual.  The Medical Center Policy Coordinator will post the new or revised policies, together with an updated index, on the Medical Center Policy website at http://www.healthsystem.virginia.edu/docs/manuals/policies/mc

     

    The applicable Clinical or Administrative Sponsor is responsible for education necessary within the MedicalCenter to implement new Medical Center Policy or revision to Medical Center Policy.

     

    The Chief Executive Officer will retire any Medical Center Policy that is no longer required.  The Medical Center Policy Coordinator will archive retired Policies.

     

    Each Medical Center Policy is reviewed every three (3) years and revised as necessary in accordance with this procedure.

     

    Medical Center Policies shall be reviewed by the Medical Center Policy Coordinator as new and revised Health System or University policies are approved, for ongoing confirmation that Medical Center Policy does not duplicate or conflict with these other policies.   

  3. signature(s):

    Pamela M. Sutton-Wallace, CEO, UVA Medical Center
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