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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 Vice-President, Medicine'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)