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

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

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 (Nov. 8, 2013) - II-16

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

Dress Code (Jun. 20, 2017) - II-25   

Employment Contract Relationships (Nov. 8, 2013) - II-30

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

Group Benefits (Jun. 20, 2017) - II-40   

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

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

Job Evaluation and Classification (Dec. 6, 2013) - II-50

Job Shadow (Nov. 1, 2012) - II-53

Leaves of Absence (Jun. 20, 2017) - II-55   

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

Named Holiday and Floater Days (May 9, 2014) - II-70

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

Personal Leave Days - Out of Scope (April 1, 2015) - 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 (September 16, 2016) - 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     

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

Workplace Abuse and Harassment (Feb. 5, 2016) - II-145      

Continuing Care

Continuing Care Admission Documents:
- Pre-admission Screening Worksheet
- Admission Information Sheet
- Admission Process Tree                        
- Family Admission Information Form

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

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

Resource:  Choking Prevention and Management PowerPoint  August 2016

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

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

Palliative Care Pathways (Oct. 10, 2014) - VII-C-20 
Palliative Care Pathway - 8 Hour Shifts    
Palliative Care Pathway - 12 Hour Shifts    
Hospice Palliative Care Education Resources   
Family Information Sheet        
Staff Guidelines  

Resident Bathing and Safe Water Temperature (Feb. 6, 2015) - VII-C-15
AHS Safe Bath Temperatures Education Materials (located in the Policies, Procedures & Guidelines folder)

Resident Immunizations:  Influenza and Pneumococcal (May 5, 2017) - VII-C-50

 

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 (May 8, 2015) - VI-35  

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

Clinical - Fluid / IV / Parenteral Therapy

Home Parenteral Therapy Program - Prevention and Treatment of Upper Extremity Catheter-Related Thrombosis (Edmonton Zone)

Quick Reference Sheet - Vascular Assess Device - November 2016

Care and Removal of Central Venous Catheter - Non-Tunnelled (Oct. 9, 2015) - VII-B-380

Care and Removal of Central Venous Catheter - Tunnelled (Oct. 9, 2015) - VII-B-385

Care and Removal of Peripherally Inserted Central Catheters (PICC) (July 11, 2014) - VII-B-305     

Central Venous Catheter - Blood Collection (Oct. 9, 2015) - VII-B-300
Learning Module
Order of Draw Poster
Vacutainer Posters
Scrub the Hub Video
Prevent Central Line Infections, "Getting Started Kit", from the Pateint Safety Institute, dated June 2012

Hypodermoclysis (HDC) Administration (Oct. 9, 2015) - VII-B-315

Implantable Venous Access Device (IVAD) - Adult (April 8, 2013) - VII-B-320
Demonstration Checklists
Scrub the Hub Video
     Chlorhexidine-alcohol Swabstick Cleaning Method Video
     Pre-printed Patient Care Order for IVADs
     Bard SafeStep Huber Needle Set - FAQ
     Bard Safety Infusion Set Catalogue
     Bard SafeStep Information Wall Chart
      Copy and paste this link to your browser:
http://www.bardaccess.com/products/infusion/safestep-huber

Insert ion of Peripherally Inserted Central Catheters (PICC Insertion) (Apr. 6, 2016)

Maintenance of IV / Hypodermoclysis Equipment (Oct. 9, 2015) - VII-B-330

Occlusion Management of Central Venous Catheters (Feb. 10, 2017) - VII-B-335
PowerPoint Learning Module     
Performance Checklists and Tests          

Peripheral IV Catheter (Oct. 9, 2015) - VII-B-390
Manufacturer product information available through Google search.  For example, check YouTube for videos on application and removal of: 
3M Tegaderm Transparent Film
ProtectIV Safety IV Catheter
Accuvance Safety IV Catheter
BD Insyte Autoguard Shielded IV Catheters
BD Nexiva 
Tegaderm IV Securement Dressing for Nexiva Catheters
BD DecisIV Educational Brochure - Complications of Peripheral IV Access
BD DecisIV Educational Brochure - Phlebitis - Inflammation of the Intimal Lining of the Vein
Layers of the Vein
StatLock IV Premium Stabilization Device

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 (Feb. 2, 2015) - 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

Management of High Alert Medication:  High Potency Narcotics (Feb. 2, 2015) - VII-A-40

Management of High Alert Medication:   Heparin (Feb. 2, 2015) - VII-A-35

Management of High Alert Medication:  Concentrated Electrolytes (Feb. 2, 2015) - VII-A-10

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) (July 8, 2016) - 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     

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

Tall Man Lettering (Dec. 6, 2013) - 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  

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

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 (May 9, 2014) - 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 (Sept. 12, 2014) - 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, 2015) - 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 (May 24, 2016) - 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:
Adult  - VII-B-395
Pediatric / Neonate - VII-B-397

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