Medical Staff Portal
Corporate Services

Corporate Policies & Procedures Home Page

If you have questions, please contact Donna Osipow (780.735.9332)

P&P Development Worksheet & Review Flow Sheet

P&P Template Document

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Administration

Corporate Vehicle Policy (Nov. 1, 2012) I-55

Electrical Equipment (May 8, 2015) I-60

Emergency / Disaster Management Response (Feb. 10, 2017) - I-25

Ethical Decision-making Framework (Jan. 17, 2014) - I-30

Identification Cards (Nov. 7, 2014) - I-35 

Key and Lock Control (May 8, 2015) - I-65

Medical Emergency Response Policy (March 6, 2015) - I-45

No Smoking Policy (Jan. 13, 2017) - I-40 

Research (Sept. 11, 2015) - III-10

Spiritual / Religious Ceremonies (April 8, 2016) - I-50

Quality / Risk Management / Legal

Abuse of Patients, Residents or Clients (Jan. 14, 2013) - III-75  

Building a Just Culture  (Oct. 1, 2011) - III-35

Clinical Documentation (Feb. 9, 2019) - III-120

Conflict of Interest   (May 6, 2016) - III-15             
Personnel Declaration Form  June 2016      
CliC online module on Compliance and Business Ethics

Contracts (March 6, 2015) (includes Contract Checklist) - III-60  
Outsourcing Services Framework Document

Discharged Patient Health Records (in Paper Format) (Feb. 9, 2018) - III-115

Disclosure of Adverse Events, Close Calls and Hazards  (Oct. 1, 2011) - III-40

Disclosure of Wrongdoings and Protection of Persons who Disclose Wrongdoings  (Whistleblower) (Aug. 15, 2014) - III-70   
Resources: 
Disclosure of Wrongdoings Report    
Whistleblower Procedures Checklist   

Enterprise Risk Management (July 11, 2014) III-90 
Framework
ERM Risk Impact Categories   

Family Paid Private Duty Care Providers and Companions  (Mar. 11, 2013) - III-80
Authorization Form

Intellectual Property  (Dec. 5, 2011) - III-50 

Media Relations (July 15, 2013) - III-85  

Patient Concerns Resolution Process (Oct. 10, 2014) - III-95 
Resource Page

Records Management  (Oct. 15, 2012) - III-55        

Relationships with Industry  (May 6, 2016) - III-20 
CliC online module on Compliance and Business Ethics

Reporting / Investigating Legal Actions and Potential Legal Actions  (Feb. 5, 2016) - III-5  

Responding to Adverse Events, Close Calls and Hazards  (Jan. 14, 2013) - III-45 

Social Media (July 11, 2014) - II-155

 

Finance

Accounts Receivable Management (May 25, 2016) - IV-45

Cellular Telephones, Communication Personal Digital Assistants (PDAs) and Pagers  (Sep. 1, 2011) - IV-25

Delegation of Authority for Financial Commitments  (Jan. 3, 2012) - IV-15

Appendix A - Signing Authority Levels

Signing Authorities Form

Financial Assistance to Uninsured Patients  (Jan. 17. 2014) - IV-10 

Payroll Practices (Jan. 8, 2016) - IV-40        

Preferred Accommodation (Sept. 13, 2013) - IV-30  

Purchasing Card (P-Card) (November 4, 2016) - IV-35         

Travel, Hospitality and Working Session Expenses - Approval, Reimbursement and Disclosure (October 1, 2016) - IV-5
Finance Forms    

    

Human Resources

Application of Human Resources Policies and Procedures (Jun 26, 2017) - II-1   

CPR Certification and Re-certification (November 4, 2016) - II-5

Change in Employee Personal Information (Nov. 8, 2013) - II-10

Compensation - Out of Scope Employees (July 20, 2013) - II-15

Criminal Records Check (September 27, 2017) - II-16

Discipline and Termination (Nov. 8, 2013) - II-20

Dress Code (Jun. 20, 2017) - II-25   

Employment Contract Relationships (Aug. 18, 2017) - II-30

Exit Interviews (Nov. 8, 2013) - II-35

Group Benefits (January 1, 2018) - II-40   

Human Resources Employee Files (Nov. 8, 2013) - II-52

International Recruitment (Dec. 6, 2013) - II-150

Job Evaluation and Titling Out of Scope Employees (Aug. 18, 2017) - II-50

Job Shadow (Nov. 1, 2012) - II-53

Leaves of Absence (February 12 1, 2018) - II-55   

Local Authorities Pension Plan (Jun. 20, 2017) - II-60   

Named Holiday and Floater Days (January 1, 2018) - II-70

Performance Development (Jun. 20, 2017) - II-75       

Personal Leave Days - Out of Scope (January 1, 2018) - II-80

Professional Registrations (May 8, 2015) - II-85

Recognition of Long Service and Retirement (December 9, 2016) - II-90

Recruitment (Posting, Selection and Hiring) (Nov. 8, 2013) - II-95

Recruitment Travel and Relocation Expenses (July 5, 2010) - II-100

Sick Leave and Salary Continuation (January 1, 2018) - II-105

Staff Education Fund (November 4, 2016) - II-110         

Student Clinical Placements (April 8, 2016) - II-115 

Termination of Employment or Department Transfer (Mar. 11, 2013) - II-118

Use of Cell Phones and Other Wireless Devices While Driving (Nov. 8, 2013) - II-120

Vacation Accrual and Utilization (August 12, 2016) - II-125

Volunteer Services Policy (Aug. 15, 2014) - II-160

Occupational Health and Safety

Occupational Health & Safety Page

Health and Safety Policy (December 9, 2016) - II-130      

bE LITE Safe Patient/Resident Handling Policy (Jan. 9, 2015) - II-170

Critical Incident Stress Management (CISM)  (Dec. 9, 2016) - II-18  

Influenza Immunization and Outbreak Management (Oct. 10, 2014) - II-165  

  • Resource Page

Reporting of Work-related Incidents, Injuries, Illness (December 9, 2016) - II-135     

Safe Use of Lasers (Nov. 10, 2017) - II-175

Working Alone (Oct. 9, 2015) - II-140     

Workplace Abuse and Harassment (Sept. 15, 2017) - II-145           

Continuing Care

Assistive Equipment (including Technology Aides and Medical/Surgical Supplies) (Aug. 18, 2017) - VII-C-35

Care Planning  (July 3, 2012) - VII-C-10 

Choking Prevention and Management (Aug. 12, 2016) - VII-C-30  

Cytotoxic Medications (Oct. 10, 2014) - VII-C-25

Maintenance Program (May 5, 2017) - VII-C-40

Managed Risk Agreement (Sept. 15, 2017) - VII-C-55         

Move In (Aug. 18, 2017) - VII-C-60    

Move Out (Aug. 18, 2017) - VII-C-65

Nail Care (Aug. 18, 2017) - VII-C-45

Pain Management (Aug. 18, 2017) - VII-C-70

Palliative Care Pathways (Oct. 10, 2014) - VII-C-20 

Resident Bathing and Safe Water Temperature (Aug. 18, 2017) - VII-C-15

Resident Immunizations:  Influenza and Pneumococcal (October 20, 2017) - VII-C-50

Staff Training (Aug. 18, 2017) - VII-C-75

Therapeutic and General Mobilization of Residents (Nov. 11, 2017) - VII-C-95

Transfer of Resident to Acute Care (Aug. 18, 2017) - VII-C-85


Transportation (Jan. 12, 2018) - VII-C-90

 

Infection Prevention and Control

Infection Prevention and Control Resource Page

Infection Prevention and Control (August 12, 2016) - VI-5    

Animal Visitation (August 12, 2016) - VI-25

Clostridium difficile Infection (CDI) (September 16, 2016) - VI-8    

Hand Hygiene (August 18, 2017) - VI-10                  

Immediate Use Steam (Flash) Sterilization (April 10, 2015) - VI-45 

Management of Patients with Suspected and/or Confirmed Pulmonary or Laryngeal Tuberculosis (May 6, 2016) - VI-32 

Methicillin-Resistant Staphylococcus Aureus (August 12, 2016) - VI-15

Multi-drug Resistant (MDR) Gram-Negative Organisms  (Mar. 11, 2016) - VI-20

Single-use Medical Devices (Sept. 12, 2014) - VI-30

Therapy / Recreational Aid and Toy Cleaning (March 9, 2018) - VI-35  

Vancomycin-Resistant Enterococcus (VRE)  (August 12, 2016) - VI-40

Medication

Automated Dispensing Machines (ADM, Pyxis) (October 8, 2016 ) - VII-A-55        

Bridge Supply of Medications for Discharged Patients (May 5, 2015) - VII-B-120      
Resources:  FAQ   
Ordering Info for Preprinted Medication Dispensing Labels and PPCOs

Clarification, Refusal to Implement Orders (July 11, 2014) - VII-A-5

Controlled Substances (December 11, 2015) - VII-B-245     
Memo
    Fact Sheet (Nov. 2015)
Forms:
Loss or Theft Report Form
           Discrepancy Reporting Form     
           Patient Specific Narcotic & Controlled Drug Record

High Alert Medications  (HAM) (Dec. 8, 2017) - VII-A-30
High Alert Medication List Poster

Independent Double Check (IDC) (July 10, 2017) - VII-A-70

Infusion Line and Tubing Verification (July 10, 2017) - VII-A-75

Medication Administration (March 6, 2015) - VII-A-50     

Medication Formulary (Feb. 7, 2014) - VII-B-345     

Medication Orders (Mar. 20, 2012) - VII-B-125     
Frequently Asked Questions

Medication Reconciliation at Key Transitions of Care (Oct. 10, 2014) - VII-B-235
Resource Page

Pre-Printed Medication Order Sets (PMOS) (Feb. 9, 2018) - VII-B-445
Resource Page

Pro Re Nata (PRN) Medication (Sep. 12, 2014) - VII-B-40

Prohibited Abbreviations, Symbols and Dose Designations (Oct. 10, 2014) - VII-A-25
Frequently Asked Questions
    Poster

Restrictions on the Sale of Pharmaceuticals to External Entities (Aug. 15, 2014) - III-30

Self Administration of Medication (SAM) (Sept. 1, 2017) - VII-A-65     
Resources for this policy/procedure available on the A-Z policy page

Standardized Medication Concentrations for Parenteral Administration  (July 2016 ) - VII-B-80
Resource page on CompassionNet

Tall Man Lettering (Dec. 8, 2017) - VII-B-340
Tall Man Lettering List         

Vaccine Storage and Handling (Sept. 16, 2016) - VII-A-60 

                                                                                

Clinical - Acute Care only

Early Induction of Labor (Aug. 18, 2017) - VII-B-10

Emergency Contraception in Cases of Sexual Assault (Mar. 7, 2014) - VII-B-15  

Glycemic Management Policy (Mar. 9, 2018) - VII-B-460

Hyperglycemic Management & Treatment Procedure (Mar. 9, 2018) - VII-B-465

Hypoglycemic Management & Treatment Procedure (Mar. 9, 2018) - VII-B-470

Perioperative Service Delivery Policy (February 10, 2017) - VII-B-250  

Procedural Sedation (January 1, 2018) - VII-B-430      
Procedural Sedation Checklist 
Procedural Sedation Record (Form #CV-0590 2016-09)

Restraints:  Physical Restraints (Sep. 21, 2011) - VII-B-85

Venous Thromboembolism Prophylaxis (Jan. 9, 2015) - VII-B-370

Clinical - applicable to Acute and Continuing Care

Accommodating Special Requests (Jan. 17, 2014) - VII-B-5

Advance Care Planning:  Goals of Care Designation (November 10, 2017) - VII-B-350
Resource page on CompassionNet

Allergy and Adverse Reaction - Communication and Documentation (Oct. 10, 2014) - VII-B-360
Poster
Caution Record Form

Assessment of Decision-making Capacity (November 10, 2017) - VII-B-35

Baby Friendly Initiative (BFI):  Breastfeeding Policy (Nov. 4, 2016) - VII-B-455  

Bladder Scanning Using Non-Ionizing Radiation (Nov. 6) - VII-B-425

Clinical Practice Textbooks (April 10, 2015) - VII-B-115

Communication of Critical Lab Results (July 8, 2016) - VII-B-450

Consent to Treatment:   link includes Corporate Policy, Procedures and Other Resources (eg. forms, education toolkits, decision algorithms, links to external sites, etc.)

C-Spine Suite of Policies/Procedures:
Spinal, or Suspected Spinal, Injury (Nov. 6, 2015) - VII-B-150
Logrolling Technique with C-Spine Precautions (Nov. 6, 2015) - VII-B-155
Logrolling Technique without C-Spine Precautions (Nov. 6, 2015) - VII-B-160
Application and Maintenance of Extrication Collar (Nov. 6, 2015) - VII-B-165
Philadelphia® Collar Care (Nov. 6, 2015) - VII-B-170
Surface to Surface Transfer (Nov. 6, 2015) - VII-B-175
General Care of the Patient (June 6, 2014) - VII-B-180
Spinal Signs Measurement (June 6, 2014) - VII-B-185

Death (Dec. 8, 2017) - VII-B-410     

Ethics Framework for Long Term Medically Administered Nutrition (Tube Feed) (July 11, 2014) - VII-B-35
Decision Making Guidelines
     Patient and Family Guidelines

Falls Risk Management (October 7, 2016) - VII-B-435
Resource Page

Family Presence During CPR (Jan. 9, 2015) - VII-B-365

Full Scope of Practice (Sept. 16, 2013) - VII-B-110

Identification of Patient, Resident or Client Using Two Identifiers (April 8, 2016) - VII-B-25

Interpretive Services (Feb. 6, 2015) - VII-B-20

Latex Allergy Precautions - Care of the Patient/Resident (August 18, 2017) - VII-B-105

Neurological Determination of Death (Aug. 7, 2015) - VII-B-400

Organ and Tissue Donations (Aug. 7, 2015) - VII-B-415

Oxygen Equipment Used by Patients/Residents/Clients (May 15, 2012) VII-B-130

Patient Request for Specific Health Care Provider (Feb. 5, 2016) - VII-B-30

Peritoneal (PleuxR) Catheter - Drainage and Care of the Inpatient (Aug. 7, 2015) - VII-B-90

Personal Directives (Aug. 7, 2015) - VII-B-405

Pleural (PleurX) Catheter - Drainage and Care of the Inpatient (Aug. 7, 2015) - VII-B-95

Responding to Requests for Medical Assistance in Dying (Sept. 15, 2017) - VII-B-440 
Resource Page

Safe Surgery Checklist (August 12, 2016) - VII-B-240
Link to Learning Videos
     SSC PowerPoint
User Manual
     Covenant Health Safe Surgery Checklist (with leads and responsibilities noted)
AHS Safe Surgery Checklist
     Safe Surgery Checklist for C-Section
     Safe Surgery Checklist for Opthalmology

Suicide Risk Assessment and Management (Dec. 9, 2016 ) - VII-B-200     
Forms:          

 

Suicide:  Inpatient Attempted Suicide (Dec. 9, 2016 ) - VII-B-205

Suicide:  Inpatient Death by Suicide (Dec. 9, 2016 ) - VII-B-210

Transfer of Patient/Resident Information and Accountability Policy (June 10, 2013) - VII-B-255
Transfer of Accountability - Internal Transfer form (2015/07)
Sample Forms:
Labour & Delivery transfer to Post Partum
                Labour & Delivery transfer to Antepartum  

Transfusion of Blood Components and Products (Jan. 12, 2018)  - VII-B-395

Urinary Catheter Insertion with Lidocaine 2% Jelly (Aug. 7, 2015) - VII-B-100

Addictions & Mental Health Program Only:
Environmental Risk Assessment (Dec. 9, 2016) - VII-B-220
Observation Levels (Dec. 9, 2016) - VII-B-215
Privileges and Passes (Dec. 9, 2016) - VII-B-217
Photograph of Admitted Mental Health Patients (July 10, 2015) - VII-B-420
Search of Patient Property (Dec. 9, 2016) - VII-B-225
Transfer or Discharge of Patients (Dec. 9, 2016) - VII-B-230