Code of Practice for Private Hospitals, Nursing Homes and Maternity ...

Chapter 6
Policies and Procedures
6.1 Overview
Policies provide the framework within which activities are to be
carried out within the establishment. There are general policies which
apply on an establishment-wide basis covering items such as patient
rights, ethics, health and safety. There are also specific procedures for
each service. These procedures provide clear directives as to the scope of
service, the responsibilities and activities of staff.
6.2 General Requirements
6.2.1 Policies and procedures are -
(i) clearly set out in an understandable language;
(ii) documented in a policy manual readily accessible to staff;
(iii) drawn up on the basis of adequate information and in
consultation with relevant professionals;
(iv) feasible of being implemented;
(v) in compliance with guidelines/codes/regulations/standards
issued by professional bodies and Government; and
(vi) not in conflict with relevant legislations.
6.2.2 Policies and procedures are developed in the following areas –
(i) admission policy for patients;
(ii) staff management;
(iii) patient care;
(iv) patients’ safety;
(v) risk assessment;
(vi) handling of information;
(vii) patients’ rights;
(viii) complaints handling;
(ix) charges;
(x) research activities;
(xi) quality assurance activities; and
(xii) specific requirements and handling procedures for each
service
6.2.3 There is a central register of policies and procedures that includes
the title, issue date and review date.
Code of Practice for Private Hospitals, Nursing Homes and Maternity Homes 28