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The process for creating, reviewing, approving, and promulgating San Francisco Department of Public Health (DPH) policies and procedures. It includes definitions, instructions for writing and revising policies, and information on policy approval and distribution. Policies must support DPH's mission, promote efficient operations, ensure compliance with laws or regulations, reduce institutional risk, and be clear and easy to understand.
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The mission of the San Francisco Department of Public Health is to protect and promote the health of all San Franciscans. ~ Educate the public and train health care providers ~ Provide quality, comprehensive, culturally-proficient health services ~ Ensure equal access to all ~^ We shall ~ Assess and research the health of the community ~ Develop and enforce health policy ~ Prevent disease and injury ~
Policy & Procedure Title: DPH Policy & Procedure Policy (GAD3) Category: General Administration Effective Date: September 30, 2011 Last Reissue/Revision Date: DPH Unit of Origin: Office of Policy & Planning Policy Contact: Colleen Chawla, Deputy Director of Health, Director of Policy & Planning Contact Phone Number(s): 554- Distribution: DPH-wide Other Distribution: _All sections in table required._*
1. Purpose of Policy
This document describes the process for the creation, review, approval, and promulgation of San Francisco Department of Public Health (DPH) policies and procedures (P&P). In order to make policies easily accessible to all DPH employees, these documents will be made available online (DPH Internet), organized by topic area and by the unit responsible for the policy.
2. Policy
A. Purpose of Policies/Procedures:
When conceptualizing and writing a P&P, the following should be considered. P&Ps must:
B. Reasons for Improving the Policy & Procedures System
DPH’s online Policy & Procedures Library (Library) was created in 2011. This collection of documents focuses mostly on DPH-wide policies meant to improve day-to-day operations and experiences of employees. It will allow for easy access to important guidelines and instructions for a variety of
City and County of San Francisco Edwin M. Lee, Mayor
Barbara A. Garcia, MPA Director of Health
requirements and DPH priorities. By actively organizing these documents, DPH will ensure that the P&Ps are up-to-date and relevant.
3. Definitions
A. Office of Policy & Planning: DPH’s section within Central Administration responsible for the coordination of internal policy and procedures.
B. Policy: A set of principles designed to guide actions. (A policy document may or may not be connected to a procedure.)
C. Policy & Procedure Detail: The table included at the top of the Policy & Procedure Template.
D. Policy & Procedures Library (Library): The online collection of documents available to all DPH staff, containing policies and procedures, clarifying a variety of different topics. All DPH-wide policies will be included in the Library.
E. Policy & Procedure Template: The preferred format for all P&P. Use of this template is required for all DPH-wide P&P created after September 30, 2011.
F. Policy Owner: The primary author or administrator of the P&P with responsibility to update the policy, as required. Will answer questions and provide guidance on the P&P.
G. Procedure: A series of steps to be followed, or particular actions to implement and/or perform a function and may comply with a policy.
H. Unit: A section within DPH (ex. Community Behavioral Health Services/CBHS).
4. Procedures
This section explains the steps to follow when writing, revising, and/or instituting a DPH P&P.
A. Template
P&Ps created after September 30, 2011, and meant for all DPH employees, must use the DPH Policy & Procedure Template. If the policy stands on its own, without need of Section 4 (Procedures), or Section 5 (Attachments) the unnecessary section(s) may be removed. If the P&P is not meant for all DPH employees, the author may use a different style or template established by their unit. All DPH- wide P&Ps must include the required information found in the table at the top of the template (Policy & Procedure Detail). P&Ps specific to individual units are encouraged to use the same format.
v. DPH Unit of Origin: The name of the unit that is responsible for the P&P on an ongoing basis.
vi. Policy Contact: The name and contact information of the author and/or the DPH unit responsible for creating and administering the policy.
vii. Policy Contact Phone Number: The phone number of the Policy Contact.
viii. Distribution: Please check the available box if this is a DPH-wide policy, or complete “other” box by adding one or more units if the P&P pertains to a certain unit or units within DPH. While the Library is mostly meant for policies that are DPH-wide, P&Ps that originate from units that do not have their own way to post these documents may also use the Library. Laguna Honda Hospital and San Francisco General Hospital are required to post their policies on their dedicated intranet sites.
C. Writing a new policy & procedure
It is important to write a new policy when there is an observed or identified need to provide detail on a new or existing rule or regulation that is important to DPH operations and employee interests. The policy may interpret a regulation or a public health or governmental-related decision made within or outside of DPH. The Policy Owner shall send the completed P&P document to the DPH Office of Policy & Planning.
The following should be taken into consideration when writing a new P&P. P&Ps should:
i. Use clear, concise, simple language. (Avoid jargon and unnecessary verbiage.) ii. Address the rule (policy) and how to implement it (procedure). iii. Be developed with the user in mind. Well-developed and thought-out procedures provide benefits to the end user. Complex procedures will benefit from the input of users before finalizing the P&P. iv. Not be too technical, and should be understandable to a new employee. v. Use a flexible outline so that revisions are simple. vi. Spell out acronyms upon first usage. vii. Avoid information that may become quickly outdated. viii. Ensure that the Policy Owner (identified in each document), or a designee, is readily available to interpret policies and resolve problems.
D. Revising a policy & procedure
Existing policies and procedures must be reviewed once every three years. The Policy Owner, or someone delegated by the unit manager, is responsible to review the document in a timely manner, and send to the Office of Policy and Planning for reposting. This must be done even if no changes are made to the document. It will be reposted with the new date, so DPH employees know that it is current.
E. Policy Approval
All P&Ps to be posted in the Library shall be submitted to the Director of Policy & Planning for review and approval.
i. P&Ps Applicable Only to Individual DPH Units Policies that are applicable only to individual DPH units require approval by the unit supervisor. If they are to be posted in the Library, the Office of Policy & Planning will review these P&Ps to ensure that the required Policies & Procedure Detail section is included and complete, and may suggest other edits, if necessary.
ii. DPH-wide P&Ps
All DPH-wide P&Ps must be submitted to the Office of Policy and Planning in draft form. The Director of Policy and Planning will present all draft DPH-wide P&Ps to the Director’s Cabinet for review and discussion. After feedback from Director’s Cabinet, the Office of Policy and Planning will contact the Policy Owner and they will together make any necessary revisions and finalize the P&P.
F. Making P&Ps accessible
All approved P&Ps that are applicable to a general DPH audience shall be included in the Library. Other P&Ps, written for certain units within DPH, may be posted online in the Library, or made available elsewhere. The Office of Policy & Planning will submit P&Ps for posting in the Library and announce new DPH-wide P&Ps in Fast Facts. The Library will include a section highlighting the newest P&Ps.
G. Training
For P&Ps that significantly alter normal operating procedures and/or are complex in nature, Policy Owners should consider creating a training plan for the employees most impacted. It is the responsibility of the Policy Owner and the supervisor of the originating unit to develop and implement training plans with stakeholders, as necessary. The training plan need not be included in the P&P.
5. Attachments
**3. Definitions