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Quality Governance Documents

This page contains a variety of documents such as policies, guidelines and care plans help to guide clinicians in providing the best evidence-based care for their patients. Below is a glossary of documents that support health-care providers at Island Health to make the best treatment decisions for their patients.

Bylaw
A law or rule adopted by the organization to fulfil legislative requirements.

Professional Code of Conduct
A set of rules outlining the responsibilities and expected practices of a person who is a member of a particular professional group.

Policy
Clear, concise, non-negotiable, formal statement directing decision-making. It enables and guides informed action, prescribes limits, assigns responsibilities and accountabilities and is secondary to legislation and by-laws. It must align with the mission and vision of the organization. All staff members are required to comply with policy statements. Typically answer the question of ‘what’ is to be done.

Procedure
A specified sequence of actions undertaken to achieve the desired outcomes of an overarching Policy. Typically answer the question of ‘how’ something is to be done. Every procedure must have a related Policy but not all Policies have related Procedures.

Standard Operating Procedures (SOP)
A document used to provide the details for a given procedure such that personnel can repeat the process correctly each time with no operator-variability.

Protocol
A set of required steps to be followed in a study, investigation, or patient care intervention. Focus on process, assessment, intervention and evaluation and dealing with issues requiring professional judgment and decision making.

Guideline
A suggested course of action for care of the typical patient in the typical situation that affords the clinician capacity to utilize their own professional judgment in complying with the provisions. Guidelines are less authoritative than Procedures. Identify range of decisions to assist decision-making.

Decision support tools
Elements incorporated into processes that are designed to improve their safety and efficiency. Two specific subsets of decision support tools include:  1) clinical decision support tools, such as Clinical Order Sets; and 2) electronic decision-support tools built into data systems that enable access and analysis of information to guide decision-making.