Mission
The Nursing Policy & Procedure Committee in association with the Nurse Practice Council (NPC) addresses program-wide patient care and nursing-related issues through the facilitation of the development of nursing policies and procedures, which serve to define and communicate appropriate clinical practice. These policies and procedures are to be used by the clinical staff but do not replace the use of individual clinical judgment or consideration of individual clinical competencies or scope of practice decisions based on competency.
Vision
Through its structure and program, the committee will:
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Provide a forum for achieving consensus on the content, methodology, approval, communication and presentation of nursing policies and procedures.
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Serve as a strategic partner to the Nurse Practice Council to facilitate the identification, development and communication of nursing policies and procedures to support appropriate clinical practice.
Membership
The Nursing Policy & Procedure Committee is chaired by the Practice Lead, Nursing Quality & Systems Management* and is composed of the following nursing representatives:
Standing Members |
Ad Hoc Members |
Nursing Administration |
Behavioral Health |
Ambulatory Surgery |
Environmental Health & Safety |
Compliance |
Home Health Care |
ED/CDU |
Member Service Center |
KP HealthConnect |
Patient Safety / Risk Management |
Medical Management |
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Nursing Education |
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Primary Care
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Medical Specialties |
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Surgical Specialties |
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Quality |
Each member serves for an unlimited term. Request for replacement comes from the individual member or from regional nursing leadership. Each manager is expected to identify a primary participant and an alternate.
* The Practice Lead, Nursing Education & Competency will serve as the alternate for the Practice Lead, Nursing Quality and Systems Management.
Member Responsibilities include but are not limited to:
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Regular attendance at scheduled meetings to be held monthly. Assignment of an alternate is expected if the primary participant is unable to attend.
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Active involvement in the work of the committee which includes participating and/or providing leadership for select activities sponsored by the committee or as requested by NPC, i.e., participation in communication and roll-out of select policies and procedures.
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Oversee, initiate, champion and evaluate implementation of all new and revised policies and procedures.
Manager Responsibilities
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Managers are expected to ensure that their assigned Nursing Policy & Procedure Committee participants are available for all scheduled meetings or to ensure that the assigned alternate participates.
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Managers are expected to provide the Nursing Policy & Procedure Committee with all information required to complete the development of requested policies and procedures.
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Managers will provide review and revision decisions, and submit completed documents to the Chair of the Nursing Policy & Procedure Committee within 7 days of receipt.
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Managers will ensure that all required review and revision steps are completed as articulated in the Ambulatory Nursing Policy Update Plan.
Policy Approval
A quorum, consisting of half the membership plus one, is necessary for approval of new policies or revisions to existing nursing policies. Once approved by the Nursing Policy & Procedure Committee, a policy moves forward for ratification by the Nurse Practice Council. In the case where the Nursing Policy & Procedure Committee is creating or revising a joint regional policy, both the Nurse Practice Council and the Quality Clinical Operations Leadership Team (QCOLT) must approve the policy.
Reporting Relationship
The Nursing Policy & Procedure Committee is directly accountable to the participating regional leadership within the Nurse Practice Council.
Meetings
The Nursing Policy and Procedure Committee will meet monthly.
