Shared on behalf of Dawna Perry, Michelle Addison, Policy & Procedure Committee Chairs

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Effective April 24, 2023 a new downtime procedure will be implemented for accessing policies, procedures, medical directives and PPDOs. We will move to having a backup of these documents on a memory stick and away from having binders on units and in departments. The reasons for this change are due to the rarity of needing a downtime procedure, and the excessive photocopying and paper that goes into the current process.

The memory stick will be stored with Karen Larmand, the Policy & Procedure Secretary, who can print off copies as needed during downtime. She will also keep one binder with paper copies of these documents at her desk. In case there is downtime after normal business hours, a second memory stick will be stored in the Utilization Coordinators’ office.

The process for Standard Operating Practices (SOPs) will not change, as these are locally stored and owned by the unit/department. For those with SOPs, we highly recommend you create your own downtime procedure, such as keeping a current copy of your SOPs on a memory stick and/or keeping a binder with paper copies.

For those of you with binders containing organizational policies, procedures, medical directives and PPDOs, please dismantle your binders by April 24, 2023. This is a critical step, as having these documents, which will be outdated, is a risk to the patients, staff and organization.

If you have any questions, please contact Karen.Larmand@tbh.net.