Medical
Hospital Policy and Procedure
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Hospital Policy and Procedure

1
Identify the need for a new or revised policy
2
Designate a task force
3
Research current medical guidelines
4
Draft policy or procedure
5
Get feedback from hospital staff
6
Approval: Compliance Officer
7
Accuracy and Relevance check
8
Approval: Medical Director
9
Arrange hospital wide communication
10
Train staff on new policy procedure
11
Prepare policy for implementation
12
Implement new policy or procedure
13
Monitor and evaluate impact
14
Gather feedback post-implementation
15
Make necessary modifications
16
Approval: Board of Directors
17
Archive older versions of the policy
18
Validate and have the final draft signed by the Chief Executive Officer (CEO)
19
Officially release the policy to all hospital staff
20
Review policy and procedure annually