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Policy & Procedure Review Process

Covenant Health policies and procedures are living documents that form the foundation of our service delivery within each healthcare setting. They are systematically developed and updated, evidence-based or consensus-based statements whose purpose is to help improve the quality and consistency of care in specified clinical or administrative situations, reflective of Covenant Health Mission and Values. A listing of Covenant Health policies can be found at Policies & Procedures or on CompassionNet (network access required).  

Medical directors and facility chiefs, possessing specific expertise, having a legitimate interest and whose area of practice may be impacted by the policy or which direct the actions or behaviours of a physician, are expected to review the policies/procedures prior to implementation and provide feedback based on their clinical perspective. We do not expect physicians to comment on the legislative, legal or staff impact of the policy/procedure being reviewed. As appropriate, facility chiefs may forward and request feedback from their department members.

This valued feedback is collated and forwarded to the Chief Medical Officer's office, then to the Covenant Health Policy Office to carefully consider, making revisions to the working draft as appropriate (where suggested revisions are considered by the author to add value and/or address legitimate concerns identified by the stakeholder, etc.).

Only after key stakeholder consultation and risk assessment is a policy/procedure implemented, along with an education and communication plan.


Policy & Procedure Review Process (PDF)