| 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 |