TERESITA JOY SJ. DECATORIA, RN, MAN, MAEd, MHA, PhD
St. Jude College
 In Healthcare…
Policy is a …..

- course of actions
- agreed upon by group of people in the healthcare
institution that
- serves as guidelines for a particular situation that
- sets limit within which
- decisions must be made to achieve a desired effect
or change in accordance to the
- mission and vision of the healthcare
organization”.
 VISION:
HappyHospital

“Happy Hospital– the healthcare provider of choice”
MISSION:
“We are committed to provide expert care and quality
healthcare services to our community guided by Christian
values”
Happy Hospital
CORE VALUES: 
P – Professionalism
R – Respect
I – Integrity and Ethics
C – Commitment
E – excellence in the delivery of quality care
The Role of Policy
The role of policy in an organization is to:

 Provide general guidance about the organization's
mission
 Provide specific guidance toward implementing
strategies to achieve the organization's mission
 Provide a mechanism to control the behavior of the
organization
ROLE OF POLICY
Provide general
guidance about the
organization's
mission
SAMPLE POLICIES




Provide specific
guidance toward
implementing
strategies to
achieve the
organization's
mission
A policy that limits the areas of services and products in
which the healthcare organization will operate

A policy about patient‟s rights and obligations.
A policy about the general nature of the business i.e.
profit making, non-profit making, community recreation
or elite sport
A policy about affiliations with other organizations i.e.
affiliation with a national body or a peak industry body

A policy for staff development

A policy for recruiting, training, hiring employee

A policy for nurse: patient ratio

A policy for admission of patient

Decking system policy

A policy for promoting safe and quality patient care

Purchasing Policy
ROLE OF POLICY
Provide a
mechanism to
control the
behavior of the
organization
SAMPLE POLICIES

A policy for hospital bill discounts (employee, students,
senior citizen, affiliated doctors etc.)
A policy on punctuality and attendance
A policy on bonuses (performance-based, etc.)
A policy for dealing with complaints, incident and sentinel
occurrences.
A policy on Negligence
„On call Duty Policy‟
Policy on Exclusivity of Drugs and Medical Supplies
Policy on Doctor‟s Affiliation
Policy on Purchase Requesition or Stock Requesition
Happy Hospital Guidelines in Policy
Making
 General Guideline:
FONT :
Size :
Spacing:
Margin :

Arial
Heading ; Flow Chart & Approval Box = 10
Body: = 11
1.15
- may be adjusted to 1 or 1.5 depending on
space utilization
.5 in all sides ; if in table – may be beyond the
margin
Happy Hospital Guidelines in Policy
Making
 Heading
Title : All CAPS
Review or Revision : August 1, 2016
Document Class: (Your unit) Policies and Procedures
Document Number: Dept.-Unit – year policy formed- number
- number must be at least 3-digits
Effectivity date: Review – same as previous
Revision – 1 month after the revision date

Title:
ATTENDANCE AND PUNCTUALITY
Document Class:
Nursing Service Department Policies and Procedures
Page 1 of 1
Review
07-15-2016
Document No.
NSD-2007-005
Effectivity Date
January 1, 2007
Concerns
 If policy is revised? Do we
need to change the document
number (specifically the year?)
NO – we do not change the document number
because in the legal parlance that is already tagged as the
identification of such document.
- The document is known as revised according to
the REVISION or REVIEW part and the effectivity date.
For New Policy = write NEW on the review/revision box
- effectivity date will be one month after
conceptualization of new policy.
The Policy Body
 1.0 PURPOSE - the reason why the policy is formulated

 2.0 SCOPE – the coverage of the policy. (Who will
implement it; who must comply with it, what are the areas
or units affected)
 3.0 DEFINITION OF TERMS – unclear words used in the
policy must be defined for uniformity of interpretation
 4.0 RESPONSIBILITIES – who is responsible in the
interpretation of such policy; who will monitor compliance
and who will implement
The Policy Body
 6.0 FLOW CHART = composed of 3 columns
1st column – In-charge – who will be responsible in
doing such step

2nd column – flow chart
Oblong – start and end of the process flow
Rectangle – for every process of the procedure
Diamond – decision points. Area where you need to decide.
Must be answerable with YES or NO
- Must write Mode (number) in every process
3rd Column – Forms/machines/ logbooks to be used
In – Charge
Nursing Personnel
Flow Chart
Forms to be used
Notification of the Nurse manager
about possible change of schedule
Mode 1
Change of schedule
Form
Check the staffing of the requested date of
change of schedule.
Mode 2
Monthly staff Schedule
Approval of request
Change of schedule
Form

Nurse Manager
Chief Nurse
Nurse Manager
Mode 3
Submission of Change of Schedule
Form to the Human Resource
Department
Mode 4
END
Change of schedule
Form/
Change of Schedule &
Leave Logbook
In – Charge
Flow Chart
AP/ ROD
Forms to be used
Doctor’s Order Sheet
Doctor’s order
Mode1

NOD
YES
Monitoring: Does
Patient manifest IV
complication?
Mode 2
IV Monitoring Sheet/
Nurse’s notes
NO
NOD
Referral to ROD/AP
Mode 3
Continuous monitoring of
Patient
Mode 3
Documentation
Mode 4
IV Monitoring Sheet/
Nurse’s notes
The Policy Body
 7.0 PROCEDURES – INTERPRETATION OF THE FLOW
CHART
- Detailed interpretation of the flow chart.
- Detailed activity per step – must include who is
responsible in such step; the sheets or forms/ logbook/ equipment
(computer) to be used

 8.0 REFERENCES
- Previous Policies and Procedures
- Republic Acts, Aos, EOs
 9.0 ATTACHMENTS – forms to be used as identified in the flow
chart
Approval Section
 composed of 3 columns
 1st column – Prepared By: - the Unit Head
 2nd column – Reviewed By: - the Department head
- if such policy affects other units or departments must be
concurred by the department Head
ex. Policy on Skeletal Duty of Nursing Service
- must be concurred by HRD

 3rd column – Approved By:
- VPO
- COO
- President /CEO

PREPARED BY:
REVIEWED BY:
APPROVED BY:
Teresita Joy SJ. Decatoria, RN, MAN,
MHA, MAEd, MHA, PhD
Chief Nurse/ TQMO
Jose V. Corpus Jr, MD, MHA
Medical Director
Paul C. Brigino, MD, MHA, MBA, PhD
Vice President for Operations
Concurred By:
Victor A. Lacandola, MD, MHA
Director for Admin Services
Ma. Rosario Medalla-Lacson, MSHROD
Chief Operating Officer
Evangeline A. Del Rosario, MD,
MS Hyg HA, PhD
President/CEO

Thank you for
listening!!
FINAL EXAM

 Formulate at least 1 policy related to each 6
International Patient Safety Goals
 Follow the format of Policy Making as discussed
 To be submitted NLT than September 30- hard copy
(Badet) and soft copy via email
 Use short bond paper for the hard copy
 Email address: joysjdecatoria77@gmail.com
 Cp No. 09332449989 (SUN)

09176053705 (globe)
FORMAT OF OUTPUT

I.
INTERNATIONAL PATIENT SAFETY GOALS
- identify the 6 international patient safety goals
II. POLICIES AND PROCEDURES (related to the
IPGs)
Note:
- Coupon Bond: short
- Font: Arial Size 11
- Submit with cover page:
COVER PAGE

Issues and Concerns and Policies and Procedures
In Partial Fulfillment of the Requirements
For the course: Policy analysis and Development
For the Program: Master in Hospital Administration
St. Jude College, Manila
Submitted by:
Your Name
Submitted to:
Dr. Teresita Joy SJ. Decatoria
Professor
Graduate School