Reviewed: 4/87 Revised: 1/85; 8/86; 5/88; 5/89; 5/90; 9/91; 7/92; 5/93; 2/95; 5/97; 3/98; 11/02;

02/05; 10/07; 8/10

Nursing Policy P-55 LSUHSC-Shreveport, LA

______________________________________________________________________________ POLICY AND PROCEDURE NURSING PURPOSE: To develop policies and procedures that define standards of performance for quality patient care. To systematically review policies and procedures triennially and/or as needed, making revisions as necessary. To coordinate policies between the Patient Care Services and Ambulatory Care Divisions and ancillary services as appropriate. To develop and review Nursing Standards of Care for general care units. POLICY: 1. Reviewing Policies The Nursing Policy and Procedure Committee shall develop and review/revise department wide policies and Standards of Care at least every three years and/or as needed, and shall be composed of RNs from within the Patient Care Services (PCS) and Ambulatory Care Divisions (ACD) and other departments as warranted. Policy Reviewers Policy and Procedure committee members shall be selected by Nursing Administration based on expertise and/or area of work both within PCS/ACD and other divisions. The Nursing Management Council, composed of Unit Managers, Administrative House Managers, and Administrative Directors may also review policies as appropriate. Chairperson of Nursing Policy & Procedure Committee The committee shall be chaired by the Quality Management Coordinator for Nursing Performance Improvement/Policy and Procedure who plans and coordinates review of policies and standards of care. Components of Policy and Procedures Written policy and procedures shall be structured to include three (3) components as applicable: A. Purpose of the Procedure B. Policy rules or statements governing implementation of the procedure, and/or C. Written direction or Action to be followed in implementing the policy/procedure.

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Procedure Explanation A. RESPONSIBLE PARTY (S) shall be identified in the left column. B. ACTIONS shall be identified in the center column and policy/procedure. C. RATIONALE/AMPLIFICATION statements shall be identified in the right hand column when action statements need additional clarification to implement actions correctly. Routing of Policies Department Policies and Procedures shall be: A. E-mailed to committee and/or other reviewers during meeting months. B. Reviewed/revised by policy committee. C. Submitted to Patient Care Services Council or other reviewers as needed. The chairperson shall incorporate approved comments/revisions into the policy draft. D. Submitted to the Administrative Nursing Director Psychiatry, Coordinated Care and Professional Practice/designee and the Assistant Hospital Administrator for Patient Care Services/designee for final comments, revisions and written approval. E. Nursing Unit Managers are e-mailed a list of additions/revisions to the Nursing Policy and Procedure webpage. The Unit manager is responsible for verifying that updated and/or revised policies have been reviewed with staff. Unit Specific Policies & Procedures and Standards of Care The Unit Manager is responsible for review/revision of Unit Specific Policies/Procedure and Unit Specific Standards of Care at least every three years and or as needed. The respective Unit Manager and Administrative Director of Nursing shall approve unit Specific Policies and Standards of Care for that unit or area. Standards of Care General Care Units The Nursing Policy Committee shall develop nursing Standards of Care for general care units as needed and existing standards reviewed/revised at least every three years. Updated Standards of Care A master copy of updated Standards of Care, including unit and division specific standards, shall be compiled by the Coordinator of Professional Practice and submitted to the Assistant Administrator for Patient Care Services.

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10. Archival Copies of Policy Manuals Archival Copies of Nursing Policy Manuals and historical copies of Nursing Policies shall be stored in the Office of the Coordinator of Nursing Performance Improvement and Policy and Procedures. Historical copies of Standards of Care for general care units shall be stored in the Office of the Coordinator of Professional Practice.

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Jamie Jett, MBA, RN Administrative Nursing Director Psychiatry, Coordinated Care and Professional Practice

__________________________________________ Signature

_______________ Date

Jean DiGrazia, MBA, RN Assistant Hospital Administrator and CNO Patient Care Services

____________________________________________ Signature

_______________ Date

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