Administrative Policy Template (Departments/Offices under this category): | Clinical and Academic Policy and Procedure Templates (Departments/Offices under this category): | ||
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Guidance on Completing the Policy Template By Section
Policy Title | If the Policy Title is changed, the change must be noted in the version history section as “formerly titled …”
Do not include the word “policy” in the title. | ||
Policy Number | The Policy Number includes two parts: 1. Department acronym Examples: “CPO” – Compliance and Privacy Office “HR” – Human Resources “PO-QPS” – Physician Organization – Quality and Patient Safety “RI” – Research Integrity “ITS” – Information Technology Services 2. Assigned department # (100.-900.) (Ex. 430.1)
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Department | The policy owner. | ||
Effective Date | The date the first version of the policy was of issued. | ||
Last Reviewed Date | The most recent policy approval date ("N/A" for new policies).
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Approved By | The Committee or leadership responsible for final approval of the policy. | ||
Approval Date | Date the policy received final approval (the official "review" date).
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Policy |
| A high-level description of the policy that establishes the rule, expectation or guidelines to be followed. Considerations - The policy section should state the department(s)/Office(s) responsible for overseeing the policy and the laws/regulations the policy is based on (if applicable). For purposes of creating a searchable feature in the repository, please create a list of key terms for this policy. [This can be included in a comment in the policy draft. | |
Purpose | The reason(s) for the policy. Is it to comply with regulations/laws, establish clear guidance or requirements for a particular action, outline a workflow, etc.? Considerations - Are there multiple audiences of the policy? If so, who is the primary and secondary reader? | ||
Scope | Who does this policy apply to? Standardized scope for policies that apply institution-wide: "This policy applies to all Weill Cornell Medicine (WCM) workforce members as defined in this policy." | ||
Definitions | Define words/phrases used throughout the policy to help the reader clearly understand the policy. Include relevant legal/regulatory definitions, acronyms, uncommon terms, jargon, repeated terminology, etc. Note - Always include the "Workforce Members" definition if that is in the scope. | ||
Procedure | The process/steps/procedures that must be taken to implement or comply with the policy. Procedures must be tailored to the scope of the policy. Procedures should embody all action items, workflows, processes, contacts, etc. Considerations: - Outline the Procedure section based on main topics and sub-topics. Create a section for each main topic. Order the sections based on chronology, importance, etc. - Procedures must be generally applicable to the audience defined in the scope. If the procedures are specific to one department or group of individuals, then consider drafting internal SOPs or guidelines. | ||
Contact Information | Who is responsible for this policy? The department or Office that owns the policy must include their contact information. Do not include individual names in this section. Refer to individuals by title. Additional contact information may be included if relevant stakeholders may be contacted about this policy as well. | ||
References |
| List relevant WCM, Ithaca and NYP Tripartite policies as well as pertinent laws/regulations driving the policy. | |
Policy Approval |
| This section will be completed after the policy has received final approval. |