hospital employees

Hospital Issues Memorandum Regarding the Revised Policy for Procedure Revisions

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hospital employees

To All Hospital Employees:

This memorandum is being issued as notification regarding the revised Policy for Procedure Revisions. The Policy for Procedure Revisions outlines the standards by which procedure revisions are managed. The procedure for revising procedures, as outlined by the Procedure for Procedure Revisions, has not been revised. Furthermore, the revised Policy for Procedure Revisions does not apply to policy revisions, which are revised according to the standards of the Policy for Policy Revisions.

The revisions to the Policy for Procedure Revisions were proposed during a pre-planning meeting of the Hospital Procedures Committee, a subcommittee of the Hospital Policies Committee (as defined by the Hospital Committees Committee). The Hospital Procedures Committee held a subsequent meeting to revise the proposed revisions to the Policy for Procedure Revisions, before presenting the proposed revisions at the Hospital Policies Committee meeting, in accordance with the Procedure for Policy Revisions.

The revised policy corrects a deficiency found during a weekly procedures audit, which identified an outdated Procedure for Policy Revisions document in the Hospital Procedures Manual. The outdated Procedure for Policy Revisions stated that revised policies would be incorporated into Policy Manuals within three weeks, even though two weeks ago the procedure was revised to “one week”.

The revised policy now requires a form to track procedure revisions, the Procedure Revisions Form. Note that while policies and procedures for revisions of forms are not being revised, revisions of forms associated with procedures will require a corresponding revision of the procedure, which will need to be tracked on the Procedure Revisions Form. A similar Form Revisions Form is being proposed to the Hospital Forms Committee, though this will require revision of the Policy for Form Revisions. A revised memorandum will be issued if and when this policy is revised.

We hope this memorandum clarifies the revised Policy for Procedure Revisions. Please sign and return the attached Acknowledgement of Revised Policy for Procedure Revisions Memorandum Form, and retain a copy to file with previous Acknowledgement of Memorandum forms.


Your Friendly Hospital Administrator

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