• You need policies and

procedures for the

simple reason that

without them nothing

can be achieved.

• Organizations will

plunge into chaos

without them and daily

operations will halt.

• Policies and

procedures reflect the

way an organization

operates.

policies and procedures valus

• Establish the system.

• Decrease variation among staff.

• Staff execute their duties without managerial

oversight.

• Legal protection for staff

• Assign responsibilities.

• Training tools.

policies and procedures

policies and procedures• The problem for organization is they

often struggle to define three key

elements:

Policy

Process

Procedure

policy• the list of rules or the framework for the task.

• Define your organization culture and regulations

• A Policy is a concise formal statement that outlines

non-discretionary governing principles and

intentions.

Process

• The process is the high level view or the map of the task. • The map is the process laying out how you will achieve the goal or

complete the task.• the road map example.

Procedure• The procedure is the step-by-step instructions for

how to complete the task.

• This would be the exact turns a driver would take as

they drive to reach a destination.

• This is the final step in the policy, process and

procedure implementation.

Drafting a Policy and procedure• all policies must follow a standard format to ensure

consistency between policies.

• Policy Title

• Issue date

• Policy Number

• Effective and Revised Dates

Policy Nameسياسة الجراحة االمنة

Issue DateOR-002POLICY Number

Effective DateApproval Date

2Number of PagesRevision Date

Reviewed by

Dr.Adel Nabeeh

Dr.Ahmed AwadPrepared by

Approved byQuality Coordinator

Drafting a Policy and procedure• Purpose– a brief statement of the purpose of the policy which

many include a basic explanation for the policy if not apparent on its face.

• Scope – to who or what does the policy apply? For example, all employees,

• Responsible Party – list unit, department, college or other pertinent area responsible for administering or enforcing policy.

:الهدف•

.الحفاظ على سالمة المريض قبل وأثناء وبعد االجراءات التداخليه•

(.االجراء الخطأ-المكان الخطأ-المريض الخطأ)الحد من احتمالية حدوث األخطاء الجراحيه•

:المسئوليات•

يحدد رئيس العمليات (.......مشرفة العمليات) ممرضة االفاقه-1•

طبيب التخدير -2•

الجراح-3•

Policies and Procedure• Multidisciplinary team.

• Process owner

• Process mapping

• Standardize outline

• Drafting

• Training and orientation

• Implement in pilot

• Collect reviews

• Correct and update

• Full scale orientation

Drafting a Policy and procedure

• Definitions

• References

• Attachment

:المراجع•

دليل التفتيش الفني واالدارى•

•WHO Surgical Safety Checklist

•

:الملحقات•

االمنهكشف الجراحه •

Drafting a Policy and procedure

• Procedure:

(:(TIME OUTقبل فتح الجلد فى غرفة العمليات •

فى حضور جميع ( (TIME OUTتقوم الممرضه المناوله بأخذ وقت مستقطع •

:الفريق الجراحي وطبيب التخدير من التأكد من اآلتى

يق الجراحيالتأكد شفويا من اسم المريض ومكان العملية والعملية ليعلم جميع الفر•

يتاكد طبيب التخدير من اعطاء جرعة وقائية من المضاد الحيوى•

هل االشاعات المطلوبه تم عرضها•

Differences• The differences between policies and procedures

can be summarized as follows:1. Policies guide decision making, while procedures drive actions.2. Policies leave some room for managerial discretion, while procedures are detailed and rigid3. Policies are an integral part of organizational strategies, while procedures are tactical tools.4. Policies are generally formulated by top management, while procedures are laid down at lower organizational levels in line with policie

•