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C&W Document Development Process

I want to...

  1. ‎Download and complete the Document Development Checklist (see below under Resources)
  2. Determine the type of document and download the corresponding template (see below under Resources)
  3. Identify the scope of applicability and the appropriate approval committee (see below under Resources)
    • If your document contains medications it must be approved at PTN. Contact lxtaylor@cw.bc.ca
  4. Notify policycoordinator@cw.bc.ca if a new document is being developed.
  5. Draft your document with content experts and relevant stakeholders
  6. Send your document and checklist to the  committee chair for approval once finalized
  7. The Document Development Checklist must be signed by the designated approver
  8. Summary of process steps
 
  1. Request an editable version of the document from ‎policycoordinator@cw.bc.ca
  2. Download and complete the Document Development Checklist (see below under Resources)
  3. Identify the scope of applicability and the appropriate approval committee (see below under Resources)
    • If your document contains medications it must be approved at PTN. Contact lxtaylor@cw.bc.ca
  4. Use the appropriate new document template (see below under Resources)
  5. Notify the policycoordinator@cw.bc.ca if a document is being revised.
  6. Revise the document with content experts and relevant stakeholders
  7. Send your document and checklist to the committee chair for approval once finalized
  8. The Document Development Checklist must be signed by the designated approver
  9. Summary of process steps
 
  1. Download and complete the Document Development Checklist (see below under Resources)
  2. Send the document and checklist to the appropriate committee chair for approval to archive the document
  3. The Document Development Checklist must be signed by the designated approver
  4. Summary of process steps


Once your document has been approved
  1. Send the completed Document Development Checklist and finalized document to the Policy Office
  2. Your document will be uploaded onto ePOPS by the Policy Office
    • You and the program chair will be notified
  3. Implement your education & communication plans Knowledge translation in action
  4. Policy Office provides a monthly report with metrics‎ (see below under Resources)
 
 

Resources

Every document must be accompanied by a completed Document Development Checklist. Individual names and roles must be identified in the checklist.


Note: 

Download the checklist and open with Adobe Acrobat. 

Do not fill in the pdf using the browser (Chrome/IE) or your information will not be saved.


 

Procedure (template): Description of a series of steps required to complete a specific task, intervention or activity.


Protocol (template): A set of required actions to manage a clinical condition, operational issue or population occurrence. Any deviation requires documented rationale.


Algorithm (template): A process flow depicted in a graph. Can include a decision process or work process. An algorithm must be accompanied by a policy or procedure.

 

Guideline (template): Systematically developed, evidence-based strategies and principles that direct actions and decisions for management of specific circumstances. They provide direction for decision-making as well as allow for professional judgment. Generally broad based they describe roles and responsibilities for each professional.

 

Order Set (see Develop/Revise and Order Set): A set of precise instructions detailing actions for prevention, care and/or treatment of a clinical condition. On order set must be made client specific and signed by an authorized health care provider (prescriber). Frequently referred to as Pre-printed orders (in paper charts).


Policy (template): Is a clear, concise, non-negotiable, formal statement directing staff decision-making. It enables and guides informed action, prescribes limits, assigns responsibilities and accountabilities and is secondary to legislation and by-laws. It must align with the mission and vision of the organization. ALL staff are required to comply with the policy.


Standard Work (template): A precise description of a work activity including the sequence of tasks and the application of best practice to complete the activity.  They ensure everyone know their roles and responsibilities and performs the procedures or tasks the same way each time.  May be used to operationalize administrative tasks and/or care delivery in a specific area. 


Reference Care Plan (template): An evidence-based care plan for a specific patient population/situation with embedded references that cite best practices.

 

Standard (template): A desired and achievable level of performance against which actual practice can be compared. It provides a benchmark below which performance is unacceptable. Standards are developed by expert and/or authoritative bodies.


Clinical Pathway: Defined plans of care for specific patient populations during a well-defined period of time. Interdisciplinary with criteria to guide care delivery they define the optimal timing and sequencing of interventions and treatments. Used to reduce variation in patient care they contain defined milestones with established outcomes. Any variances from the pathway are documented.

 

Form: A fillable sheet with demographic information and other related collected data.

 

‎Changes to committee structure are being implemented across C&W and will be reflected here once finalized. 


Below is the list of current document approving committees. Contact policycoordinator@cw.bc.ca to confirm which committee should approve your document.


  • BCCH Committees
    • BCCH Ambulatory Leadership Committee
    • PICU Quality & Safety Committee
    • SunnyHill Quality & Safety Committee
    • Procedures and Surgery Quality & Safety Committee
    • BCCH Mental Health Quality & Safety Committee
  • BCW Committees 
    • Ambulatory Leadership Committee
    • Neonatal Leadership Committee
    • Perinatal Best Practice Committee
      • Chair: Melanie Basso & Dr. Julie Robertson
      • Signing Authority: Anne Margaret Leigh & Dr. Janet Lyons

The Policy Office monthly report contains all the documents and useage metrics for recently posted documents as well as metrics for the website. (Staff access only)

 

 

Style Guide

  • 2017
  • 2018‎ *pending*
 
  

Content



SOURCE: C&W Document Development Process ( )
Page printed: . Unofficial document if printed. Please refer to SOURCE for latest information.

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