Vetting Policies


The vetting policy guidance is a resource to aid in determining the appropriate reviewers or review groups for policies.

View the keywords (in bold print) below and for those that are relevant to your policy, please consider vetting your policy with the recommended reviewers and review groups listed below.


Vetting Clinical Policies

Guidance

Then assign the following review group to review this policy:

#1

#2

#3

#4

#5

#6

Does this policy involve the administration, purchase, and/or storage of medication?

Director of the Pharmacy

CMO

CNO

 

 

 

Does this policy involve the use, purchase/lease, maintenance, and or disposal of equipment?

Facilities Services

Information Security Officer

Director, Hospital Epidemiology

 

 

 

Does this policy involve the diversion of patient care to other outside facilities, nursing unit, or intensive care units?

Emergency Department

CNO

MEC

 

 

 

Does this policy involve any aspect of the Emergency Treatment and Active Labor Act (EMTALA)?

Emergency Department

Medical Center Risk Management

MEC

 

 

 

Does this policy involve patient inter-facility transfers?

Emergency Department

MEC

CNO

Director, Hospital Epidemiology

 

 

Does this policy involve the use of physical or chemical restraint of a patient during the provision of care?

Emergency Department

MEC

CNO

 

 

 

Does this policy involve behavioral health care procedures?

Emergency Department

MEC

CNO

 

 

 

Does this policy involve the full capacity protocol?

Emergency Department

MEC

CNO

 

 

 

Does this policy involve directly identifiable patient health information (PHI) and/or patient billing information, in any format?

Enterprise Privacy Officer

Health Information Management

Revenue Cycle Director

 

 

 

Does the policy involve the access, use, disclosure, and/or transmission of confidential and/or sensitive information (i.e. PHI, research data, patient billing documents) to any entity, individual via an electronic method?

Enterprise Privacy Officer

Information Security Officer

Director, HIMS

 

 

 

Does this policy involve a business associate agreement?

Supply Chain

Legal Affairs

Enterprise Privacy Officer

Information Security Officer

 

 

Does this policy affect patient rights and responsibilities?

PFCC

Patient Care Services

Quality Management

Risk Management

MEC

 

Does this policy involve family presence?

PFCC

Patient Care Services

Quality Management

Risk Management

MEC

Enterprise Privacy Officer

Does this policy involve patient and family education or engagement?

PFCC

Patient Care Services

Quality Management

Risk Management

MEC

 

Does this policy relate to patient care quality or safety?

MEC (lastly)

 

 

 

 

 

Does this policy involve any aspect of Infection Prevention and Control (IP&C)? (i.e. environmental, equipment reuse/cleaning/disinfection/storage, safe medication use, use of infection prevention products, communicable disease management, patient exposure, contract services affecting IP&C)

Director, Hospital Epidemiology

 

 

 

 

 

Does this policy involve any aspect of Infection Prevention and Control (IP&C) that affects employees' health and safety?

Director, Hospital Epidemiology

Director of Employee Health & Wellness

 

 

 

 

Does this policy involve information that may impact the media or community at-large?

Division of Communications & Marketing

Enterprise Privacy Officer

 

 

 

 

Does the policy involve employee time and attendance?

Payroll

Human Resources

 

 

 

 

Does the policy involve paid time off (PTO)?

Payroll

Human Resources

 

 

 

 

Does the policy involve labor laws?

Payroll

Human Resources

 

 

 

 

Does the policy involve issuing a payment (any type of payment) to an active employee?

Payroll

Human Resources

 

 

 

 

Is this policy required by The Joint Commission?

Quality Management

CNO

CMO

 

 

 

Does this policy involve any aspect of applicant or workforce (employee-related) decisions and/or any state or federally-regulated aspects regarding employment? (i.e. IRS, DOL, FML, INS, ERISA, USERRA, etc.)

Human Resources