1. Implementing Policies and Procedures Fadwa Bawazir, CPHQ Director, TQM Dept. Hera General Hospital

2. The basic purpose of establishing systems, processes and guiding them in policies and procedures is to implement them well.

3. Failing to implement, is wasting time, money, effort and other resources.

4. It is encouraged to have a minimum of two (2) weeks between the date of issue and the date of effect for orientation and in-service training Policy Implementation

5. Implementation process involves a period of three (3) months to give time for distribution, familiarization, actual practice and monitoring

6. All the hospital staff shall sign in the Acknowledgement Sheet to signify that they have read and understood the Policies and Procedures (Hospital Wide, Departmental, Safety, Infection Control, etc.). Original Copy filed as page 3 in the Manual kept in every department

7. Acknowledgement Sheet KINGDOM OF SAUDI ARABIA Ministry of Health Directorate of Health Affairs Holy Makkah المملكة العربية السعودية وزارة الصحة مديرية الشئون الصحية بالعاصمة المقدسة مستشفى حر اء العام HOSPITALWIDE POLICIES AND PROCEDURE STAFF ACKNOWLEDGEMENT SHEET I, the undersigned, have read and understood the contents of this Hospital- wide Policy and Procedure Manual. NAMEID NO.SIGNATUREDATE Note: Original Copy in the Hospital Wide Policies and Procedure Manual. Duplicate Copy to be forwarded to the Total Quality Management (TQM) Department.

8. Accrediting bodies require that policies are: Documented Approved Communicated/educated Implemented

9. Implementing the Various Types of Policies

10. Philosophical Code of Ethics Mission Vision Organizational values Code of Conduct Dress Code Communication culture

11. Methods Distribution of the policy Departmental meetings announcements Posting Quiz and questions for the staff Staff attitude Provision of uniforms Staff adherence

12. Resources Deployment Allocation of resources: Manpower: staff distribution Equipment Space Financial

13. Methods Staffing plan per unit Pull out process Leave plan Actual distribution of spaces amongst services Distribution of equipment according to priority criteria Budget and reimbursement process

14. Working /Departmental/ Multidisciplinary policies Processes Guidelines Daily work/ services

15. Methods Departmental meetings announcements In-service training Workshops Presentations and discussions Posting of process flowchart Quizzes Competence checks (periodically)

16. Administrative General Rules and regulations Leaves, personnel processes Smoking policy Security policies Staff development TQM policies

17. Methods Departmental meetings announcements Posters and signs Process flowchart Handouts Facility Rounds

18. Memo policies Management notification, General distribution, Delegation of authority

19. Methods Bulletin board Departmental meeting announcement

20. Verbal and Telephone Order Policy Staff need to know when they are acceptable How to document them What is the patient safety goal related to this policy Communication with the doctors Nurses related responsibilities in implementing the policy

21. Occurrence Variance Report/ Incident Report Posting of the flowchart Knowing the process flow Ability to identify reportable events Practice of using the form Actual use of the form Corrective actions-short and long term Trends review and recommendations Receipt of concerned departments and units Enhancement of long term measures.

22. It costs organizations a lot of time, money and effort to work on policies and procedures and establish systems and processes.

23. Not living those policies may lead to unsafe patient care as well as jeopardize the wellbeing of the staff.