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Administration Department Polices

Home Administration Department Polices

 

DEPARTMENT/ POLICY POLICY EFFECTIVE REVIEWED/ NEXT REVIEW
UNIT NO. TITLE DATE REVISED DATE
GENERAL
Administration A-100 Mission Statement 06/27/16 06/2016 06/2017
Administration A-110 Vision Statement 01/27/16 06/2016 06/2017
Administration A-120 Statement of Values 06/27/16 06/2016 06/2017
Administration A-200 Scope of Services 06/27/16 06/2016 06/2017
Administration A-300 Organizational Chart 06/27/16 06/2016 06/2017
Administration A-400 Authority After Hours and in Absence of the Hospital Administrator 10/02/17 08/2017 08/2018
Administration 6100-20 Ambulatory Care Program 12/29/92 12/1992 12/1995
LEADERSHIP
Administration A-LD100 Conflict Management Among Leadership Groups 07/20/11 07/2011 07/2014
Administration A-LD200 Conflict of Interest 06/13/16 05/2016 05/2019
Administration A-LD300 Code of Ethical Conduct 05/01/15 05/2015 05/2018
Guest Relations A-LD400 Customer Service Guidelines 05/01/14 05/2014 05/2017
Administration A-LD500 Disruptive and Inappropriate Behavior 05/01/15 05/2015 05/2018
Compliance Office A-LD600 Unannounced Survey Readiness Plan 10/02/17 08/2017 08/2020
Administration A-LD700 Management and Oversight of External Service Provider Agreements 11/01/16 11/2016 11/2019
Fiscal Services 6100-35 (A-LD800) GMHA Medical Lien 09/01/07 08/2007 08/2010
Fiscal Services A-LD900 The Recovery of Funds due to the Guam Memorial Hospital Authority 05/01/14 05/2014 05/2017
Risk Management 6180-3 Claims Management 03/17/83 09/2012 09/2015
Risk Management 6180-4 Identification and Disposition of Potentially Litigious Cases 06/30/89 09/21/01 09/2004
Administration A-LD1200 Executive Management Council 02/15/17 02/2017 02/2020
Administration A-LD1300 Hospital Committees 05/02/14 05/2014 05/2017
Administration A-LD1310 Committee Meeting Reporting, Review and Approval Process 05/02/14 05/2014 05/2017
Materials Management Department Manual 1.9 Solicitation and Acceptance of Gifts 01/30/91 06/2009 06/2012
Quality Management Department 6432-1 Regulatory Agency Compliance 07/29/92 1992 1995
Planning Office 6120-4 New Programs/Services–Feasibility Assessment, Evaluation and Approval, and Implementation Procedures 01/19/93 09/2012 09/2015
Fiscal Services Manual 6440-1 Contracts – Procedure and Evaluation 10/01/92 09/2012 09/2015
DOCUMENT GMHA Board of Trustees Bylaws
MEDICAL STAFF
Medical Staff Office Manual 6170-3 Disruptive Practitioners 04/10/09 01/2009 01/2012
Medical Staff Office Manual 6170-4 Impaired Practitioner Guidelines 07/1992 03/2009 03/2012
Medical Staff Office Manual 6170-6 Directory of Medical Staff Practitioners 05/26/00 05/31/00 05/31/03
Medical Staff Office Manual 6170-7 Medical Staff Meeting Agendas and Minutes 12/15/00 08/2001 08/2004
Medical Staff Office Manual 6170-8 Confidentiality of Medical Staff Records 01/2007 09/19/08 09/19/11
Medical Staff Office Manual 6170-9 Medical Staff Credentials and Peer Review Files 01/2007 09/19/08 09/19/11
Medical Staff Office Manual 6170-11 Credentialing of Medical Staff 09/01/07 03/2009 03/2012
Medical Staff A-MS300 Ongoing Professional Practice Evaluation 01/23/17 01/2017 01/2020
Medical Staff Office Manual 6170-16 Focused Professional Practice Evaluation 10/22/12 10/2012 10/2015
Medical Staff Office Manual A-MS500 Medical Staff Peer Review 01/23/17 01/2017 01/2020
DOCUMENT GMHA Medical Staff Bylaws 05/10/12 05/2012 2015
DOCUMENT GMHA Medical Staff Rules and Regulations 08/01/09 2009
HUMAN RESOURCES
Equal Employment Opportunity Office 6100-38 (A-HR100) Volunteer/Volunteen Program 09/2006 02/2012 02/2015
Human Resources Department Manual 8650-1.201 Position Description 08/2009 08/2015 08/2018
Human Resources Department Manual 8650-1.203 Competency Assessment/Validation 03/2012 08/2015 08/2018
Human Resources Department Manual 8650-1.204 Probationary and Scheduled Performance Evaluation No Date 08/2015 08/2018
Human Resources Department Manual 8650-1.207 Contracted Staff (Off-Island/Local) 05/29/12 2015 2018
Human Resources Department Manual 8650-1.208 Preceptorship – Students/Individuals 05/29/12 2015 2018
Nursing Services Manual 6301-I D-6 GMHA Volunteer Services in Nursing 07/2012 11/2015 11/2018
Education Department Manual 6140-2 Employee Orientation 12/28/12 11/2015 11/2018
Safety and Security Manual 411 Forensic Patient Policy 06/28/11 08/2015 08/2018
Human Resources Department Manual 8650-1.209 Special Staff Development Programs 08/1989 2015 2018
Education 6140-5-1 Training and Education Files 09/18/09 12/2012 12/2015
EEO Office A-HR1100 Equal Employment Opportunity 09/25/15 07/2015 07/2018
EEO Office A-HR1200 Sexual Harassment Policy 02/14/17 02/2017 02/2020
EEO Office A-HR1300 Religious Accommodations Policy 09/25/15 07/2015 07/2018
EEO Office A-HR1400 Equal Employment Opportunity Officer’s Oversight of Employment Interviews 02/14/17 02/2017 02/2020
EEO Office A-HR1500 Exit Interviews 02/14/17 02/2017 02/2020
Human Resources Department Manual 8650-1.211 Identification Badge 05/29/12 05/2012 05/2015
EEO Office A-HR1700 Hospital-wide Dress Code 02/14/17 02/2017 02/2020
EEO Office A-HR1800 Language in the Workplace 02/14/17 02/2017 02/2020
Human Resources A-HR1900 Outside Employment 02/15/17 02/2017 02/2020
Human Resources A-HR2000 Safe Hours of Work 02/15/17 02/2017 02/2020
Human Resources A-HR3000 Workplace Violence Prevention Plan 02/10/17 02/2017 02/2020
Human Resources Department Manual 8650-1.219 Restriction of Unauthorized Visitors During Regular Working Hours 2012 2015 2018
Human Resources Department Manual 8650-1.221 Recall List 10/1999 2015 2018
Human Resources Department Manual 8650-1.216 Leave Sharing Program 05/1993 2015 2018
Fiscal Services Manual 6440-3 Travel 09/19/12 09/2012 09/2015
Payroll 6440-10 General Timekeeping Guidelines 01/2001 01/2001 01/2004
Employee Health Services Manual 6202-10 Employee Health Services Program 02/14/93 09/2011 09/2014
Human Resources Department Manual 8650-1.210 Drug Free Workplace 05/29/12 2015 2018
Employee Health Services Manual 6202-23 Get Up and Move Program 12/24/09 12/2009 12/2012
6100-32 Domestic Violence in the Workplace 09/2004 09/2004 09/2007
Risk Management Manual 6180-5 Subpoena of GMHA Employees 01/14/99 09/2012 09/2015
DOCUMENT Government of Guam Personnel Rules and Regulations 10/01/96 1996
ENVIRONMENT OF CARE
EEO Office A-EC100 Vending Machines Policy 05/01/14 05/2014 05/2017
Planning 6120-1 Bed Capacities: Acute Care, Skilled Nursing Unit, Urgent Care Unit, Airborne Infection Isolation & Negative Pressure Bed Capacities 03/01/91 06/2015 06/2018
Planning Department Manual 6120-D20 Guidelines for Capital Improvements–Approval Process 05/1995 12/2014 12/2017
Planning Department Manual 6120-D21 Guidelines for Capital Improvements – Implementation 09/1989 12/2014 12/2017
Facilities Maintenance 6480-10 Work Order Request System 01/2009 12/2012 12/2015
Risk Management 6180-1 Reporting Adverse Medical Device Incident 06/03/92 07/1995 07/1998
Risk Management 6180-1A Medical Devices Tracking Requirement 08/1993 07/1995 07/1998
Materials Management Department Manual A-LD1320 Product Standardization Evaluation Committee 06/01/92 06/2014 06/2017
Materials Management Department Manual 9 Products Recalls and Alerts 09/2001 06/2009 06/2012
Materials Management Department Manual 8.1 Equipment Loan 11/1989 06/2009 06/2012
Materials Management Department Manual 8.2 Disposition of Assets Equipment 09/2001 06/2009 06/2012
Materials Management Department Manual 8.4 Donation of Equipment and Supplies 10/01/92 08/2009 08/2012
Materials Management 6450-4 Sale of Supplies 06/01/92 06/1992 06/1995
Materials Management 6450-6 Supply Requisition 10/1990 04/1994 04/1997
Laundry Department Manual 6460-3.60 Clean Linen Control 07/28/92 03/2013 03/2016
Laundry Department Manual 6460-3.70 Linen Control Citation 07/28/92 03/2013 03/2016
Laundry Department Manual 6460-3.80 Scrub Clothes Policy 07/28/92 03/2013 03/2016
Facilities Maintenance Department Manual 6480-1 Aluminum Container Recycling Program 04/23/92 01/2013 01/2016
RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
Administration A-RI100 Ethics Committee Guidelines 01/11/10 01/2010 01/2013
Guest Relations A-RI200 Patient’s Rights and Responsibilities 05/01/16 05/2016 05/2019
Guest Relations A-RI210 Patient Rights for Children/Adolescents 01/11/10 01/2010 01/2013
Patient Safety A-RI300 Informed Consent Process 04/2013 01/2013 01/2016
Guest Relations A-RI400 Patient Self-Determination (Advance Directives) 04/15/16 03/2016 03/2019
Guest Relations A-RI500 Do Not Resuscitate (DNR) Orders 09/11/13 09/2013 09/2016
Nursing A-RI600 Withdrawal of Life Support 06/28/13 06/2013 06/2016
EEO Office A-RI700 The Americans with Disabilities Act of 1990 and the Americans with Disabilities Act Amendment Act of 2008 02/14/17 02/2017 02/2020
Social Services A-RI800 Patient/SNU Resident Abuse and Neglect Prevention 06/06/16 No Date 06/2019
Guest Relations A-RI900 Patient Visitor Policy 08/2014 08/2014 08/2017
Guest Relations A-RI1100 Food Policy 11/16/15 11/2015 11/2018
Guest Relations A-RI1000 Grievances/Complaints 05/01/16 05/2016 05/2019
FAC, CIP, & IT Committee 6120-5 Patient Rights During Construction 01/20/94 07/1995 07/1998
Social Services Manual 6431-3 Communications Barriers 07/28/92 08/2015 08/2018
Social Services Manual 6431-10 Referral to Adult Protective Services 08/1989 08/2015 08/2018
Social Services Manual 6431-7 Child Protective Services 08/1989 08/2015 08/2018
6100-11 Institutional Review Board 07/29/92 07/1992 07/1995
Fiscal Services 6440-2 Patient Room Charges 07/14/92 07/1992 07/1995
Fiscal Services 6440-7 Processing Patient Charges 04/01/97 04/1997 04/2000

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