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Leadership Manual

MCN Healthcare's Leadership Manual provides over 280 ready-to-implement policies, procedures and forms. MCN takes each Joint Commission standard and provides sample policies that demonstrate compliance with that standard. The Leadership Manual also includes policies that demonstrate compliance with the Transplant Safety standards. This manual is also cross-referenced to NIAHO standards.

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Table of Contents - TJC Standards Table of Contents - NIAHO Standards Table of Contents - JCI Standards Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION 01

Leadership Structure

1001 - Leadership Structure 1002 - Hospital Leadership Structure 1003 - Organizational Leadership Structure Chart (Example)1004 - Plan for the Provision of Patient Care and Services 1005 - Staffing - General

Leadership Responsibilities

1101 - Leadership Responsibilities 1102 - Leadership Groups Accountabilities 1103 - Medical Staff Committees

The Governing Body

1201 - The Governing Body 1202 - Scope of Services 1203 - Position Description/Performance Evaluation - Chief Executive Officer, Acute Care Hospital 1204 - Position Description/Performance Evaluation - Chief Operating Officer 1205 - Position Description/Performance Evaluation - Chief Financial Officer 1206 - Organizational Decisions - Corporate Level

Chief Executive Officer Responsibilities

1301 - Chief Executive Officer Responsibilities 1302 - Information Management Plan 1303 - Position Description/Performance Evaluation - Information Management Services Director 1304 - Staff Retention and Recruitment Plan 1305 - Position Description/Performance Evaluation - Nurse Executive 1306 - Authority in Absence of Administration 1307 - Administrative Call

Medical Staff

1401 - Medical Staff 1402 - Organized Medical Staff 1402A - Medical Staff Bylaws 1403 - Rules and Regulations Relating to Administrative Functions 1404 - Resident Duty Hours

Leadership Orientation

1501 - Leadership Orientation 1502 - Orientation of Governing Body, Senior Management, Medical Staff Leaders

SECTION 02

Hospital Mission, Vision and Goals

2001 - Hospital Mission, Vision and Goals 2002 - Organizational Strategic Plan 2003 - Mission, Vision, Values and Goals Statement 2004 - Communication Process 2005 - Sample Patient Brochure 2006 - Insert Your Organization s Patient Care Brochure

Conflict of Interest Involving Hospital Leadership

2101 - Conflict of Interest Involving Hospital Leadership

Communication

2201 - Communication 2202 - Governing Body Meeting Quarterly Agenda 2203 - Example of Medical Staff Committee Minutes Reflecting Evaluation of Performance Improvement 2204 - Patient Satisfaction Questionnaire Form 2205 - Cardiopulmonary Services Patient Questionnaire Form 2206 - Patient Satisfaction Questionnaire Form - Physical Therapy Services 2207 - The following are methods for aggregating patient satisfaction survey results 2208 - Patient Satisfaction Survey Results Form 2209 - Patient Satisfaction Survey - Individual Comment Report Form 2210 - Patient Satisfaction Questionnaire Trend Sheet 2211 - Patients' Negative Perceptions Identified on Patient Satisfaction Questionnaires Form

Conflict Between Leadership Groups

2301 - Conflict Between Leadership Groups 2302 - Conflict Management Among Leadership Groups 2303 - Conflict Management Among Staff

SECTION 03

Culture of Safety and Quality

3001 - Culture of Safety and Quality 3002 - Code of Conduct - Sample 3003 - Culture of Safety and Quality 3004 - External Employee Reporting of Safety and Quality of Care Concerns 3005 - Disruptive and Inappropriate Behavior 3006 - Disruptive Staff Member Incident Report Form - Sample 3007 - Incident Reporting Staff Questionnaire Form 3008 - Examples of Survey Tools to Survey a Culture of Safety and Quality

Data and Information Tools

3101 - Data and Information Tools 3102 - Survey Assessment Tools 3103 - Organizational Assessment of Information Management Needs

Planning

3201 - Planning 3202 - Performance Improvement Committee Annual Program and Leadership Evaluation Form 3203 - Organizational Leadership (Governing Body) Self-Assessment Form

Communication of Safety and Quality Information

3301 - Communication of Safety and Quality Information 3302 - New Employee Orientation 3303 - Inservices/Continuing Education 3304 - Mandatory Inservice Meetings 3305 - Voluntary Inservice Meetings 3306 - "Hand-Off" Communication 3307 - Departmental Staff Meetings 3308 - Departmental/Unit Staff Meeting Format 3309 - Course Objectives - Hospital Annual Review and Update 3310 - Hospital Annual Review Class Agenda - Sample 3311 - Course Evaluation - Hospital Annual Review and Update 3312 - Post Test - Hospital Annual Review 3313 - Departmental Inservice Record 3314 - Staff Inservice/Continuing Education Record 3315 - Department Inservice Training Staff Development Program 3316 - Hospital Memorandum Form 3317 - Interhospital Memorandum Form 3318 - Communication Survey Form 3319 - Community Outreach Programs 3320 - Community Outreach Programs (Example)3321 - Sample Organizational Flyer

Leaders Implement Changes to Improve Performance

3401 - Leaders Implement Changes to Improve Performance

Improving Safety and Quality

3501 - Improving Safety and Quality 3502 - Staff Qualifications and Competency 3503 - Maternal Child Health Unit Staffing Plan 3504 - Cardiopulmonary Services Department Staffing Pattern Guidelines 3505 - ICU/CCU Staffing Plan 3506 - Staffing Patterns - Post Anesthesia Care Unit 3507 - Position Description/Performance Evaluation - Medical Surgical Unit Nurse Manager 3508 - Position Description/Performance Evaluation - Respiratory Therapist 3509 - Position Description/Performance Evaluation - Maternal Child Health Nurse Manager 3510 - Annual Competency Clinical Skills Assessment - Surgical Services Circulating RN 3511 - Annual Competency Clinical Skills Assessment - Medical Surgical Unit Registered Nurse 3512 - Annual Competency Clinical Skills Assessment - Critical Care Registered Nurse 3513 - Performance Evaluation - Population-Specific/Age-Related Competency - Labor and Delivery Registered Nurse 3514 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Surgical Unit Registered Nurse 3515 - Performance Evaluation - Population-Specific/Age-Related Competency - Pediatric Registered Nurse 3516 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol 3517 - PACU Orientation Checklist 3518 - Skills Inventory/Orientation Checklist - Nursery 3519 - Surgical Services Clinical Competence and Professional Development Form 3520 - ICU Charge Nurse Evaluation of Staff Member Form 3521 - Blood Glucose Monitoring 3522 - Blood Glucose Monitoring Competency Checklist 3523 - Arterial Blood Gas Specimen Collection - Competency Checklist 3524 - Quarterly Report to Governing Body - Personnel Evaluations Form 3525 - Competence of Individuals Under Direct Responsibility of LIP 3526 - Application Checklist - Allied Health Practitioner 3527 - Appointment Application - Allied Health Practitioner 3528 - Delineation of Clinical Privileges Form - Allied Health Practitioner 3529 - Delineation of Clinical Privileges Form - Nurse Practitioner 3530 - Fatigue Management Plan 3531 - Management of Students 3532 - Volunteers

SECTION 04

Complying with Law and Regulation

4001 - Complying with Law and Regulation 4002 - Standards and Methods of Review 4003 - Corporate Compliance Plan 4004 - Title VI of the Civil Rights Act of 1964, and Section 504 of the Rehabilitation Act of 1973 4005 - Education on the Federal False Claims Act, the Federal Program Fraud Civil Remedies Act, State False Claims Laws and Whistleblower Protections 4006 - Health Data Integrity 4007 - Confidentiality of Information - General Issues 4008 - Uses and Disclosures of Protected Health Information - General Rules 4009 - Uses and Disclosures of Protected Health Information - Minimum Necessary and Incidental Disclosures 4010 - EMTALA Guidelines for Emergency Department Services 4011 - EMTALA Community Call Plan (CCP)4012 - Waived Testing 4013 - Physician Coverage 4014 - Identity Theft Prevention Program Overview 4015 - Preventing Medical Identity Theft - A Guide for Patients 4016 - Stark Policy 4017 - Retention of Medical Information 4018 - Guidelines for the Use of Social Media 4019 - Use of Social Media for Organizational Purposes 4020 - ADA Accessible Medical Equipment 4021 - ADA Compliant Medical Examination Rooms

Operational and Capital Budgets

4051 - Operational and Capital Budgets 4052 - Budget Process 4053 - Capital Budget Request Memorandum Form 4054 - Governing Body Financial Meeting Quarterly Agenda

Management of Programs, Services, Sites or Departments

4101 - Management of Programs, Services, Sites or Departments 4102 - Hospital Program, Service, Site, Department Leadership 4103 - Position Description/Performance Evaluation - Cardiopulmonary Services Manager 4104 - Position Description/Performance Evaluation - Outpatient Surgery Nurse Manager 4105 - Example of Medical Staff Rules and Regulations Wording 4106 - Interdisciplinary Computerized Planning for Patient Care 4107 - Cardiopulmonary Resuscitation Protocol 4108 - Intrafacility Transfer Process 4109 - CQI Storyboard - Improvements in Food-Drug Interaction Management 4110 - Food-Drug Interaction Education Flowchart

Policies and Procedures

4151 - Policies and Procedures 4152 - Development of Departmental Policies and Procedures 4153 - Development of Interdepartmental Policies and Procedures 4154 - Policy and Procedure Conflicts 4155 - Example of Medical Staff Committee Minutes Reflecting Approval of Policies and Procedures 4156 - Policy and Procedure Manual Approval Sheet (Example)4157 - Patient Identification for Clinical Care and Treatment 4158 - Informed Consent 4159 - Assessment and Reassessment

Space and Equipment

4201 - Space and Equipment 4202 - Purchases, Capital Expenditures - Equipment, Renovation, Supplies 4203 - Capital Expenditure Form 4204 - Space, Equipment and Resources 4205 - Grounds Safety 4206 - Grounds and Outside Premises Safety Survey Checklist 4207 - Risk Assessment Program

Conflict of Interest Involving LIPs and/or Staff

4251 - Conflict of Interest Involving LIPs and/or Staff 4252 - Conflict of Interest 4253 - Sample Conflict of Interest Disclosure Letter 4254 - Contract Services 4255 - Financial Incentives/Clinical Decision Making 4256 - Code of Ethics 4257 - Physician-Owned Hospitals Notification Statement Policy

Ethical Business Practices

4301 - Ethical Business Practices 4302 - Example of Medical Staff Bylaws Outlining Ethics Committee 4303 - Convening of the Ethics Committee 4304 - Staff Meeting Agenda (Example)4305 - Marketing Practices 4306 - Patient Admission to the Hospital 4307 - Billing Practices 4308 - Resolution of Conflict Related to Patient Billing 4309 - Staff Rights and Ethical Dilemmas in Patient Care 4310 - Request for Revised/Excused Duty Form

Provision of Ongoing Care, Treatment and Services

4351 - Provision of Ongoing Care, Treatment and Services 4352 - Patient Rights and Responsibilities 4353 - Utilization Management Plan 4354 - Denial of Treatment by HMO 4355 - HMO Treatment/Authorization Consent Form

Services Provided

4401 - Services Provided 4402 - Community Needs Assessment 4403 - Community Needs Assessment Survey Tool/Questionnaire 4404 - Population Analysis Form 4405 - Marital Status With/Without Dependents Analysis Form 4406 - Education/Income Analysis Form 4407 - Race Analysis Form 4408 - Emergency Services Availability

Standard of Care, Treatment and Services

4451 - Standard of Care, Treatment and Services 4452 - Standards of Patient Service 4453 - Standards of Care - Admission: Labor and Delivery 4454 - Standards of Care - Comfort: Labor and Delivery 4455 - Standards of Care - Education: Labor and Delivery 4456 - Standard of Care - PACU Services - Management of Spinal Anesthesia Recovery 4457 - Sedation 4458 - Sedation Monitoring Form 4459 - Interpreter Services 4460 - Translator Referral List 4461 - Psychosocial, Spiritual and Cultural Beliefs and Values

Contractual Agreements

4501 - Contractual Agreements 4502 - Oversight of Contractual Agreements 4503 - Companies/Individuals Contracting With _______ Hospital Form 4504 - Telemedicine Services 4505 - Contracted Service Provider Evaluation Form 4506 - Department Member Evaluation of Outside Services Form 4507 - Outside Reference Laboratory Authorization 4508 - Use of Outside Reference Clinical Laboratory Services - Clinical Laboratory 4509 - Use of Outside Reference Clinical Laboratory Services - Pathology 4510 - Use of Outside Imaging Services 4511 - Example of Excerpt From Medical Staff Committee Minutes

Management of the Flow of Patients

4551 - Management of the Flow of Patients 4552 - Managing Patient Flow 4553 - Ancillary Support Services 4554 - Managing Emergency Department Excess Volume 4555 - Emergency Department "On-Call" List 4556 - Emergency Department Diversion 4557 - Bed Assignment - Prioritizing Admits 4558 - Position Description/Performance Evaluation - Patient Flow Coordinator 4559 - Delayed ED to Med Surg Unit Admissions Flowchart 4560 - Admission Delays from ED to Med Surg Unit CQI Team Cause/Effect Diagram 4561 - CQI Storyboard - Delays in Admissions from ED to Med Surg Unit

Performance Improvement

4601 - Performance Improvement 4602 - Organizational Performance Improvement Plan 4603 - Sentinel Event 4604 - MRI Patient Screening 4605 - MRI Patient Safety 4606 - MRI Safety - General Requirements 4607 - MRI Patient Screening Tool 4608 - Performance Improvement Project Priority Determination Form 4609 - Performance Improvement Measurement Selection Criteria Form 4610 - CQI Team Project 4611 - CQI Management Team Attendance Sheet 4612 - CQI Small Team Minute Format 4613 - CQI Storyboard - Transitional Unit Admits from Acute Care 4614 - Continuous Quality Improvement Team Activity Report Form 4615 - Occurrence Report Form (Incident Report)4616 - Performance Improvement Indications and Notification Form - Surgery/Anesthesia/PACU 4617 - Medication Inadvertent Incident Report Form 4618 - Performance Improvement Analysis - Medication Inadvertent Incident Form 4619 - Performance Improvement Monitoring and Evaluation Plan (Blank)4620 - Performance Improvement Trending Sheet (Blank)4621 - Performance Improvement Outcome Evaluation (Blank)4622 - Performance Improvement Volume Measures/Statistics (Blank)4623 - Cardiopulmonary Services PI Monitoring and Evaluation Plan 4624 - Cardiopulmonary Services PI Trending Sheet 4625 - Cardiopulmonary Services PI Outcome Evaluation 4626 - Cardiopulmonary Services PI Volume Measures/Statistics 4627 - Medical Surgical Unit PI Monitoring and Evaluation Plan 4628 - Medical Surgical Unit PI Trending Sheet 4629 - Medical Surgical Unit PI Outcome Evaluation 4630 - Medical Surgical Unit PI Volume Measures/Statistics 4631 - Surgical Services/Operative and Invasive Procedure Review PI Monitoring and Evaluation Plan 4632 - Surgical Services/Operative and Invasive Procedure Review PI Trending Sheet 4633 - Surgical Services/Operative and Invasive Procedure Review PI Outcome Evaluation 4634 - Surgical Services/Operative and Invasive Procedure Review PI Volume Measures/Statistics 4635 - Staffing Effectiveness Indicators - Clinical/Service Related 4636 - Staffing Effectiveness Indicators - Human Resources 4637 - Staffing Effectiveness - Correlation Between Patient Care Hours and Patient Falls Chart 4638 - Medical Staff Performance Improvement Activity Report 4639 - Medical Staff Performance Improvement Activity Report - (Example)4640 - Performance Improvement Program Annual Evaluation 4641 - Hospital Indicator Reporting Program Form 4642 - Performance Improvement Governing Body Quarterly Summary Form 4643 - Performance Improvement Governing Body Quarterly Report Form

Patient Safety Program

4651 - Patient Safety Program 4652 - Patient Safety Plan 4653 - Risk Management Plan 4654 - Risk Management Report (Example)4655 - 2013 Joint Commission National Patient Safety Goals 4656 - Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery 4657 - Conducting Root Cause Analysis 4658 - Failure Mode and Effects Analysis Form 4659 - Position Description/Performance Evaluation - Patient Safety Coordinator - RN

Clinical Practice Guidelines

4701 - Clinical Practice Guidelines 4702 - Development and Review of Clinical Guidelines 4703 - Clinical Practice Guideline Development and Implementation 4704 - Clinical Practice Guidelines Selection Criteria 4705 - Clinical Practice Guideline Implementation Methodology

Organ and Tissue Donation, Procurement and Transplantation

4751 - Organ and Tissue Donation, Procurement and Transplantation 4752 - Organ/Tissue/Eye Donation 4753 - Organ Donation After Cardiac Death 4754 - Authorization for Anatomical Gift Form 4755 - Living Person Organ Donation 4756 - Organ and Tissue Transplant Responsibilities 4757 - Organ and Tissue Transplant Programs - CMS Regulations 4758 - Organ Transplantation, Recovery, Receipt and Patient Management - CMS Regulations 4759 - Organ Transplant Waitlist Management 4760 - Organ/Tissue/Eye Donation - Nursing Staff Responsibilities 4761 - Organ/Tissue/Eye Donation - Staff Education