Creating, Revising & Reviewing Documentation

Learn more about the process for PPGM (Policies, Procedures, Guidelines, Medical Directives), SOPs (Standard Operating Procedures) and Forms.

This includes process checklists, algorithms, an escalation plan and templates to use when developing pamphlets, clinical pathways, posters, policies, procedures, guidelines, medical directives, and all other forms.

 

Have a Question?

Sherri Franz 

PPGM Coordinator and Forms Committee Lead
Email: Sherri-Ann.Franz@wrh.on.ca
Extension: 37041
Cell: (519) 991-1856
PRE-STAGE: CHOOSING THE RIGHT PROCESS

What qualifies as PPGM & form documents?

  • PPGM (Policies, Procedures, Guidelines, Medical Directives)
  • SOPs (Standard Operating Procedures)
  • Forms (Pamphlets, Patient Handouts, Patient Chart forms, Forms to go on Digital Printshop Storefront, Corporate-wide Employee Health & OHS forms, Clinical Pathways, Non-WRH-made forms handed to patients, all forms attached to PPGM)

What documents do not qualify as PPGM & form process documents?

Order Sets (contact Clinical Pathways Order Set Coordinator, Irene Carson)

 

STAGE 1: REVIEW/PLAN

Stage 1.1: Steps to complete the draft of the content.

1.1-1 Check for similar documents:
  • If the document is NEW or a revision, be sure to save yourself and others unneeded work by first contacting PPGM & Forms Process Lead (Sherri Franz) to check if similar documents exist.
1.1-2 Draft content on correct template:
  • For PPGM, use the correct template. Click here for guide & templates.
  • For SOPs, contact PPGM & Forms Process Lead (Sherri Franz) for customized template/process.
  • For forms, contact PPGM & Forms Process Lead (Sherri Franz) or Printshop (Aaron Dolman). Design support is available upon request.
1.1-3 Draft clear, concise & appropriate content:
  • For PPGM & SOPs, best practices for writing content are built into the templates.
  • For Forms, click here for best practices & tips.
  • For all content, someone other than the author should:
    • Proof-read for grammar/spelling.
    • Proof-read to ensure content is written in clear & simple terms appropriate to the audience. Click here for the guide.

Stage 1.2 and 1.3: Steps to complete PPGM & forms process checklist.

1.2-1 Complete PPGM & Form Checklist.
  • PPGM & Form Checklist.
  • Guideline for completing the PPGM & Form Checklist.
A. Choosing Owner
B. Document Title
C. Status
D. Urgency & Risk
E. Type
F. Scope
G. Related Documents replaced/archived
H. Significant Changes & Rationale for changes
I. Monitor & Compliance Plan
J. Areas Impacted
K. Staff Impacted
L. Current Rollout Plan
M. Sustainability Plan
N. Next Review Date
O. Keywords
P. Target Audience
Q. Other Locations/Links
R. PPGM/SOP ONLY - Attached documents
S. Draft Check (Logos, Titles, Proof Read Spelling, grammar, clarity as per end user/target audience, shading)
T. FORMS ONLY – Part of Chart or Not
U. FORMS ONLY – Electronic Options
V. FORMS ONLY – Dangerous abbreviations (Med related only)
W. FORMS ONLY – Barcodes (non-daily PC only)
X. FORMS ONLY – Distribution (WRH & beyond WRH)
Y. FORMS ONLY – Print Instructions
Z. Stakeholder Table (explanation & guide under Stage 2)

1.2-2 If the document was recently created/updated, contact PPGM & Forms Process Lead (Sherri Franz) to update the latest completed checklists instead of completing a new Forms Checklist.

1.2-3 If the documents are part of bundled work involving more than 8 documents, contact PPGM & Forms Process Lead (Sherri Franz) for a customized checklist.

 

STAGE 2: APPROVAL

Stage 2.1: Steps to complete the stakeholder checklist

2.1-1 Complete the Appropriate Stakeholder Table (either simple or complex):
  • Simple Documents: The document is considered simple if only 1-3 departments are impacted and need to approve. (i.e. if a document only impacts Women & children plus ED or if the document is made by pharmacy and although it impacts many areas, only expertise of pharmacy is required.) Tip: Does the impacted area(s) need to know about the document only (simple), or should they have a say in the content too (complex). If impacted areas need to know but do not have a say in the content, then it is still simple and continues for approvals. (Only include the impacted areas in your rollout.)
  • Complex Documents: A document is considered complex if it impacts several departments and all/most should have a chance to review/approve. (i.e. if the document impacts all/most clinical areas and these areas should have a say in the content)
  • Stakeholder Guideline

Stage 2.2: Steps to request/gather approvals from the completed checklist & stakeholder table.

2.2-1 Send completed PPGM & Form Checklist/Summary, along with final draft of document(s) to selected stakeholders using the following guidelines:
  1. Always use critical judgment when deciding to request approvals via email or in person/meetings.(i.e. Minor and small changes are appropriate for email but major changes, completely new material, controversial/sensitive/high-risk material is best in person.
  2. If sending by email, send one group at a time.

    Rationale: All but the first group is hierarchical. It can be both confusing and wasteful time-wise to send to higher groups before it is ready for them. (i.e. if the reviewer made changes, then you may need to send it to VP again and they will wonder why they are seeing it again. Plus, the higher the level, their focus is more on the overall changes and who approved. Senior Leadership’s role is to ensure the changes are known, acceptable and that it is reviewed/approved.)

    Use critical judgment. If all/most of the stakeholders have already reviewed/approved verbally, then send to everyone all at once. Rationale: Everyone is already aware and in agreement up to this point; therefore, all you are getting is the proof of the approval.
  3. If sending via paper or part of a meeting, print the PPGM & Form Checklist (with Approval table completed) and have folks initial in the checkbox next to their name.

2.2-2 Troubleshooting, Escalation Plan, FAQs & Tech Tips:

What a reasonable reply time?

  • Reply time is determined by the Urgency & Risk level along with the size of the document bundle needing approval. If unsure, contact PPGM & Forms Lead (Sherri Franz).

What if a stakeholder requests changes?

  • If championing the approval process for the owner, send the request to the owner to make the changes/resolve.
  • If changes are acceptable, make the changes. Then ask, who should approve (again if necessary) based on the latest changes.
  • If changes are problematic, discuss with the change requester and escalate if not able to resolve.
  • Tech Tip: It is common to mix up draft versions. In order to avoid this, make sure the draft version is updated and the old draft is either deleted or placed in a separate file. Only the latest version should be in your main process file.

What if the stakeholder is on vacation?

  • Whenever someone is on vacation, an alternative should be available. This is usually stated in their “out of office” notice. On the Stakeholder table, Reviewer & Standard names all have alternatives listed next to their names. If unsure, contact PPGM & Forms Lead (Sherri Franz).
  • For PPGM & Forms Lead alternative, contact Linda Morrow.

What do I do if stakeholder does not reply or if the document’s Urgency/Risk Level is 1 or 2 (Escalation plan)?
  • For Urgency/Risk Level 1 & 2 documents: Send an approval request email to the approvers (groups 1-3, then groups 4-7), marking it “high importance” and putting “Level 1/2 Urgency Approval Required”. If no reply within 1 hour, contact them by phone. If no reply by deadline, escalate to your supervisor by phone & by forwarding them the email you sent. See escalation plan for details.
  • For Urgency/Risk Level 3 & 4 documents: Send an approval request email to approvers one group at a time, unless meeting with or previously met with stakeholders. If meeting with or previously met, send to stakeholders all at once (or print the checklist & have folks initial next to their names). Include the due date if emailing.
  • If no reply by the due date, call & send a follow-up email (with 2 days added). If still no reply, call & send a follow-up email (with 2 days added). If still no reply, escalate to your supervisor by phone & by forwarding the last email you sent.
  • Tech Tips:
    • Keep a file (Outlook or in a drive) that contains the responses & requests made regarding the document.
    • When sending out email Approval Requests, add a Follow-up Reminder with the due date so you do not forget.
Escalation Plan Algorithm

 

STAGE 2: APPROVAL ALTERNATIVE - MINOR CHANGES

Minor qualifying criteria and process.

MINOR - Qualifying Criteria:

For PPGM / SOPs:
  • i. PPGM is up-to-date (i.e. is not overdue for review); and
  • ii. All requested changes fall under the following: changes to sentence structure, altering awkward wording, changes to steps/rules processes that are only CLARIFYING, AND/OR minor change to: formatting; name, phone #, address, extension, logos, brand/generic/equipment (i.e. the company has a new name).
For Forms:
  • i. The form has been formally revised since 2017; AND
  • ii. All requested changes fall under the following changes: spelling, grammar, typos, changes to sentence structure, altering awkward wording, adding clarifying words, minor formatting changes; updates to names, address, phone number, extensions & logos, brand/generic/equipment name changes.
MINOR – Process:
  1. The owner submits a request for a MINOR change to PPGM & Forms Process Lead (Sherri Franz) that includes the requested changes/rationale.
  2. PPGM & Forms Lead reviews requests and if the PPGM & Forms Lead confirms the change(s) to be MINOR the approval to proceed will be required:
  • For forms: owning dept.'s Director & Chief/Med. Director approvals (include VP if item is distributed beyond WRH)**
  • For all policies, procedures & guidelines: owning dept.'s Director & Chief/Med. Director approvals (include VP if item is distributed beyond WRH)**
  • For medical directives: owning dept.'s Director AND Medical Affairs Director approval (include VP if item is distributed beyond WRH)**
**If the requestor is VP or higher no approvals needed but cc owning Director/VP/Chief when the notice for posting is emailed.

If the PPGM & Forms Lead confirms the change(s) to NOT be MINOR, BUT urgency/risk is Level 1, follow PPGM & Forms Process:
  • Approve temporarily & post/publish (INFORMING them of a two week-window to complete formal PPGM & Forms Process) once the following approvals are received***:
  • Complete 2a. Bullets.
***If approved due to Urgency/Risk Level 1, the time frame to complete remaining PPGM & Forms Checklist requirements are noted and follow-up completed.

If you think you qualify for the MINOR process or have questions, please contact PPGM & Forms Lead (Sherri Franz).

 

STAGE 3: SUBMISSION & REVIEW

Stage 3.1: Submit a package to the PPGM & forms lead for review.

3.1-1 Submit the following to PPGM & Forms Lead:
  1. Final Draft of the document(s)
  2. Tip: Review draft one last time to ensure:

    - You have the final version

    - Highlights/editing mode is removed

    - Numbers/nomenclatures are correct

    - Header is completed


  3. Proof of all Approvals/Reviews
  4. Tip 1: The following is acceptable:

    - Scanned initials/signatures next to typed names

    - Emails of approvals

    - Minutes/proof from Leads/admin assistants to Leads of committees

    Tips 2: The following is not acceptable:

    - Verbal approvals

    Tip 3: In the event of time crunches:

    - Verbal approval may be accepted, but signed/email proof must be received within two weeks of PPGM & Form posting/approving.

  5. Completed PPGM & Forms Checklist

Stage 3.2: PPGM & forms lead reviews submission.

3.1-2 As per Risk/Urgency Level timeframe, PPGM & Forms Lead will review & provide a response to a submission request.

For PPGM & SOPs:
  • If not approved, PPGM & Forms Lead will send a request for more information to the owner. It is then the owner’s responsibility to respond as per their timeline. If the request is Urgency/Risk Level 1, the response will be made to the owner via email & via cell phone.
  • Once approved, a posting notice & review will be sent to owner & champion. It is the owner’s responsibility to review the posting & summary. It is also the owner’s responsibility to ensure roll-out, sustainability, and monitor & compliance plans are set up. 
For Forms:
  • If not approved, PPGM & Forms Lead will send a request for more information to the owner. If Level 1 request will be made to the owner via email & via cell phone, then it is the owner’s responsibility to respond as per their timeline.
  • Once approved, an approval request will be sent to remaining Forms Committee team to complete their portion. Urgency/risk timelines will be included. PPGM & Forms Lead will be responsible to escalate any Forms Committee delays. PPGM & Forms Lead will also send a notice to the owner (so they know it was approved).
  • Printshop will send the final approval notice & review request to the owner as per the Urgency/Risk Level timeline. It is the owner’s responsibility to review & approve the final draft & summary as per timelines. It is also the owner’s responsibility to ensure roll-out, sustainability, and monitor & compliance plans are set up.
  • Once final approval from the owner is received, Printshop will print any orders made & place on Printshop Storefront as directed.