Policy and Procedure Manual Flashcards

1
Q
A
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2
Q

statement or memo that outlines the institutions position on an administrative or operational issue

A

Policy

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3
Q

instructional document that provides explanations and step by step directions

A

Procedure

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4
Q

Manual that contains policies

A

Policy Manual

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5
Q

Manual containing procedures

A

Procedure Manual

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6
Q

general policies that are relevant to the whole institution

A

Hospital Policy Manual

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7
Q

topics that may have particular relevance to the area, specific departmental policies

A

Laboratory Policy Manual

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8
Q

two types of policy manual

A

Hospital Policy Manual
Laboratory Policy Manual

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9
Q

Procedures are often referred to as “SOP”, a term adopted from military

A

Procedure Manuals

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10
Q

meaning of ‘SOP’

A

Standard Operating Procedure

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11
Q

examples of technical manuals

A

Procedure for Performing test
Operating Test
Processing quality control information

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12
Q

primary objective of procedure manual is

A

STANDARDIZATION OF THE WAY THAT TASKS AND TESTS ARE PERFORMED

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13
Q

represent a major investment of time and effort and are in constant need of revision

A

laboratory procedure manuals

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14
Q

Laboratory procedure manuals are in constant need of revision because of?

A

continually evolving work situation

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15
Q

two types of policy and procedure manuals

A

external manual
internal manuals

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16
Q

two types of external manual

A

specimen collection manual
laboratory service manual

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17
Q

required by inspection agencies to be distributed to all areas in which specimens are collected for submission to the laboratory

A

specimen collected manual

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18
Q

include policy statements concerning hours of operation for outpatients, collection and courier pick ups, etc

A

Laboratory Service Manual

19
Q

4 types of internal manuals

A

administrative manuals
technical manuals
safety manuals
quality management manuals

20
Q

policies that apply to the entire lab

A

administrative manuals

21
Q

work scheds, vacation, holiday staffing, dress codes

A

administrative manuals

22
Q

maintains plans and procedures for purchasing and ordering supplies

A

administrative manuals

23
Q

step by step instruction for operating instruments

A

technical manuals

24
Q

organized according to discipline

A

technical manuals

25
Q

includes procedure for calibration, specimen collection, quality control, safety, etc

A

technical manuals

26
Q

ease and access and regulatory requirements

A

safety manuals

27
Q

procedural precautions

A

safety manuals

28
Q

contains overall policies

A

Quality Management Manuals

29
Q

address issues of specimen acceptability, administrative and technical review of quality data

A

Quality Management Manuals

30
Q

coordination and integration with institutional quality plan

A

Quality Management Manuals

31
Q

assignment of authority and responsibility for ensuring quality standards

A

Quality Management Manuals

32
Q

organized by topic and composed accdng to standard writing styles

A

POLICY MANUAL FORMAT

33
Q

presented using an outline model, with subject headings highlighting the relationship of the material

A

POLICY MANUAL FORMAT

34
Q

written and organized with topic and subject headings

A

POLICY MANUAL FORMAT

35
Q

detailed and comprehensive documents

A

PROCEDURE MANUAL FORMAT

36
Q

specific guidelines governing the information that must be provided

A

PROCEDURE MANUAL FORMAT

37
Q

must adhere to the rules and guidelines of a variety of agencies governing the hospital and laboratory itself

A

PROCEDURE MANUAL FORMAT

38
Q

JCAHO

A

Joint Commission on Accreditation of Hospitals

39
Q

CAP

A

COLLEGE OF AMERICAN PATHOLOGISTS

40
Q

AABB

A

AMERICAN ASSOCIATION OF BLOOD BANK

41
Q

CLIA’88

A

CLINCAL LABORATORIES IMPROVEMENT AMENDMENT

42
Q

OSHA

A

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

43
Q

NCCLS

A

National Committee for Clinical Laboratory Standards

44
Q
A