3.7.03 Procedural instructions

Goal and purpose

Instructions on how to draft procedural instructions for the hospital's QM manual. Explanation of the basic structure of the procedural instructions and the formal design Presentation of responsibilities so that the competences and tasks involved in the creation, review and approval of procedural instructions can be reliably recognised.

The management has the responsible organisational units draw up general procedural instructions for processes that apply equally to all departments. This avoids multiple development and regulation, creates clarity about the requirements and confidence in the fulfilment of the specifications. The procedural instructions define the framework within which the departments can make specific regulations (subsidiarity principle). Some procedural instructions require no further specification by the departments. Others are so open that the content of the procedure can only be determined by the departments.

The management fulfils its organisational duties with procedural instructions. The management does not thereby create new law. VAs take legal regulations into account and implement them for the hospital - but they do not release the hospital from the obligation to comply with laws or regulations. In this respect, VAs are comparable to instructions for use, which are intended to guide the operation of equipment. Handling is made easier: if you proceed as instructed, you can be confident that you will not make a grossly negligent mistake.

Where consequences under employment law must be observed, reference is made to this. Service instructions are to be enforced by the employer and have a different legal relevance.

Application

Procedural instructions to be included in the hospital's quality assurance manual.

Description of the process

Attachments