Browse Document Library by Leadership
The documents in the Document Library which match your selected category are alphabetically sorted and listed below. If you need to search on a specific key phrase, just use our handy search tool on the main Document Library page.
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Conflict of Interest, Board, Policy
Release Date: July 24, 2009
Document Type: Policies and Procedures
Board Conflict of Interest policy delineates the expectations of disclosure of conflict of interest and how to resolve the issue when it occurs.
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Conflict of Interest, Medical Staff, Policy
Release Date: July 24, 2009
Document Type: Policies and Procedures
Medical Staff Conflict of Interest Policy delineates the expectations of disclosure of conflict of interest and how to resolve the issue when it occurs.
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Conflict of Interest, Organization Wide, Policy
Release Date: July 24, 2009
Document Type: Policies and Procedures
Organization wide Conflict of Interest Policy delineates the expectations of disclosure of conflict of interest and how to resolve the issue when it occurs.
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Contracted Services Checklist
Release Date: June 29, 2009
Document Type: Tools
Checklist for review of contracted services.
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Contracted Services Evaluation Tool
Release Date: June 29, 2009
Document Type: Tools
Checklist for review of contracted services.
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Credentialing, Board Oversight: Safeguarding the Foundation of Quality, White Paper
Release Date: October 25, 2006
Document Type: White Papers
Educational hand out outlining hospital board of director's responsibilities related to credentialing and privileging.
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Disruptive Behavior - Sentinel Event Alert #40
Release Date: July 9, 2008
Document Type: Regulatory Analysis
Discussion of Sentinel Event Alert Number 40 regarding healthcare organization responsibilities for effectively managing disruptive behavior. A well structured code of conduct is recommended, as is strict enforcement.
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Governance Model Poster
Release Date: October 4, 2005
Document Type: Tools
Poster that can be disseminated as a handout to governing board members, outlines responsibilities of directors and impact on board.
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Informed Consent Policy
Release Date: April 30, 2010
Document Type: Policies and Procedures
Model policy supports CMS and Joint Commission requirements for informed consent prior to procedures.
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Joint Board, Hospital and Medical Staff Professional Conduct, Model Policy
Release Date: February 11, 2009
Document Type: Policies and Procedures
This is an institution-wide professional conduct policy. It includes definitions of unprofessional behavior and a step-wise approach of how to deal with the affected practitioner.
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Leadership Orientation & Education Requirements Form 2009
Release Date: September 16, 2008
Document Type: Forms
Leadership Orientation, Education Requirements for 2009 Checklist
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Medical Staff Professional Conduct Policy
Release Date: February 11, 2009
Document Type: Policies and Procedures
This is a Medical Staff policy dealing with unprofessional/disruptive conduct of practitioners with privileges. It includes definitions of disruptive/unprofessional behavior and a step-wise approach of how to deal with the affected practitioner.
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Moderate and Deep Sedation Non-anesthesia Providers
Release Date: April 29, 2010
Document Type: Policies and Procedures
This model policy establishes the standard for sedation practices throughout the institution.
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Moderate and Deep Sedation Record Form
Release Date: April 29, 2010
Document Type: Forms
This form allows for documentation of a brief history and physical, the elements of the universal protocol, the presedation assessment and immediate reevaluation of the patient prior to procedure as well as providing an area for documenting the monitoring of the patient during procedures. This form is meant to be utilized for outpatient procedures, GI procedures and bedside/ED procedures which require sedation or when the universal protocol is required.
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Patient Complaints & Grievances - Model Policy
Release Date: April 29, 2010
Document Type: Policies and Procedures
The model policy complies with CMS and Joint Commission standards regarding the implementation of a process for prompt resolution to complaints and grievances. It also includes suggested language for patient admission kits and Board resolution language for a Complaint Committee.
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Patient Complaints & Grievances - Sample Letter - 7 Day
Release Date: April 29, 2010
Document Type: Forms
Supporting documentation to patient grievances including a 7 day extension letter.
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Patient Complaints & Grievances - Sample Letter - Grievance Conclusion
Release Date: April 29, 2010
Document Type: Forms
Supporting documentation to patient grievances including a grievance resolution letter.
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Patient Complaints & Grievances - Sample Letter - Receipt of Grievance
Release Date: April 29, 2010
Document Type: Forms
Supporting documentation to patient grievances including an initial grievance receipt letter.
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Patient Complaints & Grievances Requirements Overview
Release Date: April 29, 2010
Document Type: Tools
Patient Complaints & Grievances Requirements Overview
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Privileging Guidelines for Moderate and Deep Sedation
Release Date: April 29, 2010
Document Type: Policies and Procedures
Provides guidance for privileging providers for administering moderate and deep sedation.
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Solutions to Assist in Culture of Safety Surveys and Assessments
Release Date: August 27, 2008
Document Type: White Papers
Description of solutions offered by The Greeley Company Patient Safety & Quality Consultants to assist in Culture of Safety Surveys and Assessments. Provides an overview of the Greeley approach to culture surveys as well.
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Solutions to Assist in Facilitation of FMEAs
Release Date: August 27, 2008
Document Type: White Papers
Description of solutions offered by The Greeley Company Patient Safety & Quality Consultants to assist in Facilitation of Failure Modes & Effects Analysis (FMEA) teams and projects. Provides an overview of the Greeley FMEA approach as well.
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Solutions to Assist in Improving Compliance, Accountability & Culpability Management
Release Date: August 27, 2008
Document Type: White Papers
Description of solutions offered by The Greeley Company Patient Safety & Quality Consultants to assist in improving compliance, accountability and culpability management. Provides an overview of the Greeley accountability improvement process as well.
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Solutions to Assist in Improving Reporting & Occurrence Trending
Release Date: August 28, 2008
Document Type: White Papers
Description of solutions offered by The Greeley Company Patient Safety & Quality Consultants to assist in improving reporting and occurrence trending.
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Solutions to Assist in Improving the Cause Analysis Process
Release Date: August 27, 2008
Document Type: White Papers
Description of solutions offered by The Greeley Company Patient Safety & Quality Consultants to assist in improving the cause analysis process including RCA and Apparent Cause Analysis teams and projects. Provides an overview of the Greeley Cause Analysis approach as well.
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Question of the Month | Expert Advice & Guidance
Our medical staff is having difficulty with focused professional practice evaluation related to licensed independent practitioners that do not perform surgical or other invasive procedures. Do you have any suggestions about ... Read More...
Your question is understandable, as many hospitals have difficulty with the medical staff standard requiring focused professional ... Read More...
