Scope of Service · for Department directors, quality, accreditation
What each unit is there to do, on record and kept current.
Every unit has a scope of service: the patients it serves, the services it provides, the hours, the staffing and equipment it needs, and what it does not do. Surveyors ask for it by name. Here it is a document with an owner, approvers, a version and a review date, held to the same loop as a policy.
- Unit name and code, department, facilities
- Patient populations served
- Services provided
- Exclusions and limitations
- Hours of operation
- Staffing and equipment requirements
- Owner, approvers, effective date, next review date
- Draft
- In review
- Approved
- Retired
The surveyor asks the ICU director for the unit’s scope. It is one click, it says who approved it and when, and the version they read is the version that was in force.
Intensive Care Unit
- Populations
- Adult critical care, step-down
- Hours
- 24 / 7
- Next review
- 2027-06-01
Forms & Attestations · for HR, compliance, education, infection prevention
The things staff must declare or agree to, asked and kept exactly as answered.
Annual conflict-of-interest declarations, confidentiality agreements, influenza attestations, training sign-offs. Build the form once from plain fields, publish it, assign it to everyone, a department, a role or named people, with a due date. Each person’s answers are stored with the version of the form they answered, and a signature field is a signature.
- Fields: short and long text, number, yes or no, checkbox, choice, date, file, signature, acknowledgement
- Audience: everyone, departments, roles or named people
- Assignments with due dates, chased by reminder
- Submissions kept against the form version
- Waivers, with who waived and why
- Draft
- Published
- Retired
"Show me every clinician’s conflict-of-interest declaration for last year." The list is the answer, with the dates and the ones still outstanding.
Confidentiality and Acceptable Use, 2026
- Assigned to
- All staff · 1,204
- Completed
- 1,131
- Overdue
- 9
Competency & Training · for Nurse educators, unit managers, HR
Skills a role must prove, with the evidence attached and the manager’s sign-off.
Define a competency, say what counts as proof: the person attests, or uploads a certificate, or a manager verifies, or all three. Assign it by role with a due date. The person completes it from their own task list; the manager approves; the record holds the evidence. When the competency is revised, the new version asks again.
- Competency with a version and a review date
- Evidence required: attestation, file upload, manager approval, in any combination
- Assignments by role or person, with due dates
- Evidence files, kept with the assignment
- Manager verification, with name and time
- Draft
- Published
- Retired
- Assignments: pending, completed, overdue, waived
A surveyor picks a nurse and asks for her restraint competency. Her record shows the attestation, the uploaded certificate, and the manager who verified it in March.
Restraint and Seclusion
- Evidence
- Attestation + certificate + manager
- Assigned
- RN, LPN · 412
- Verified
- 398
Exceptions & Variances · for Quality, risk, compliance, medical staff office
When practice has to differ from a policy, the departure is approved, bounded and watched.
A unit cannot meet a policy for a while: equipment on back order, a construction phase, a staffing gap. Instead of an unwritten understanding, a request: which policy and version, why, what mitigates the risk, how risky it is, which departments it touches, and until when. It goes up an approval chain sized to the risk, comes into force with an expiry date, is reviewed on a schedule, and is renewed or revoked on the record. If the policy changes underneath it, the exception is flagged.
- Type: exception, variance or waiver
- The policy and the exact version it departs from
- Justification, mitigating controls, impact assessment
- Risk level: low, medium, high, critical
- Approval chain with each decision and comment
- Effective and expiration dates, review interval, renewals used and allowed
- Regulatory standards affected, attachments, conditions
- Draft
- Pending approval
- Approved
- Active
- Under review
- Renewal pending
- Expired
- Revoked
- Rejected
"Your policy says two-person verification; the pharmacy did it single-handed in April." Here is the variance, approved by the CNO and the pharmacy director, active April to June, with the compensating controls, and the review that ended it.
Single-verifier chemotherapy dispensing, Pharmacy
- Departs from
- POL-2025-031 v6
- Active
- 2026-04-01 to 2026-06-30
- Approvals
- 2 of 2
Also available
Lippincott Procedures, linked to your policies.
For hospitals with a Lippincott subscription, procedure content is synchronized daily and linked from the policies it supports, so a nurse reads the hospital’s policy and the current procedure in one place. Requires the hospital’s own Lippincott agreement; ask us about it.