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Policies

Public accountability and communication of operational policies are components of our strategic priorities.

Administration & Organization

AA – Introduction

AA0100	Policy and Clinical Decision Support Tools
N/A	Policy Guide

AC - Communications and Public Affairs

AC0100	Visual Identity
AC0400	External Communications Consultants
AC0500	Social Media Guidelines
AC0500	Social Media

AD - Aboriginal Health

AD0100	Welcome and Acknowledgement of First Nation Traditional Territory
AD0200	Aboriginal Cultural Safety and Humility

AF - Freedom of Information

AF0100	Transparency and Freedom of Information
AF0500	Police Access to Clients and Client Information
ROIA0600	Access for Minors and Incapable Adults (MyHealthPortal)

AH - Patient/Client - Relations/Care

AH0100	Abuse Free Environment for Clients
AH0200	Requests for Care on Hospital Property
AH0210	Responding to Emergencies Outside Community Dialysis Unit
AH0300	No Refusal
AH0500	Medical Air Valves and Flowmeters Use of in Acute Care
AH0600	ED Requirement for Assessment of Outpatients who Receive Injectable
AH0700	Hand Hygiene Policy
AH0900	Visitation and Presence of Family and Partners-In-Care
AH1000	ED Triage and Reassessment in Waiting Room and Ambulance Stretchers
AH1010	ED Documentation of Patient Assessment and Reassessment
AH1020	ED Nurse to Nurse Hand Off of Patients at Shift Change
AH1030	ED Physician to Physician Hand Off of Patients at Shift Change
AH1040	ED Pre Discharge Review of Patients Who are Kept for Observation or Therapy
AH1050	ED Provision of Written Information Notification or Instructions to Patients at Discharge
AH1060	Discharge of Vulnerable ED Patients
AH1300	Medical Assistance in Dying (MAiD)
AH1500	Facility Identification Banding for Emergency Patients
AH1600	Identification of Newborns
AH1610	Newborn Adoption Surrogacy
AH1700	Venous Thromboembolism Prevention
AH2000	Point of Care Testing
AH2500	Least Restraint
AH3000	Assignment of Hospital Rooms
AH3500	Funeral Home Transfer Policy
AH3600	Repatriation Policy
AH4000	Medical Orders for Scope of Treatment (MOST) and Advance Care Planning (ACP)

AI - Surgical/Clinical

AI0100	Premium Hip Devices Patient Fees
AI0200	Surgical Waitlist Audit
AI0300	Surgical Safety Checklist
AI0400	Organ Donation
AI0500	Dental Assistants

AK - Quality & Risk Management

AK0100	Client Complaint Management
AK0200	Private Service Providers
AK0300	Claims Management
AK0400	Recognizing and Responding to Hazards, Near Misses and Adverse Events
AK0400	Guideline 1.1 Immediate Management of AEs
AK0400	Guideline 1.2 Ongoing Management of AEs
AK0400	Guideline 1.3 Disclosure of Harm
AK0500	Safety Alerts and Broadcasting System
AK0600	Client Special Indicators in Meditech
AK0700	Client Valuables and Personal Effects
AK0800	Medication Reconciliation
AK0900	Enterprise Risk Management
AK1000	Healthier Vending in IH Facilities

AL - Legal/Ethical

AL0100	Consent Adults
AL0200	Consent Persons Under 19 Years of Age
AL0300	Blood Alcohol
AL0500	Legal Court Documents and Proceedings
AL0700	Records Retention
AL1000	Governing Law and Jurisdiction
AL1600	Project Ethics

AP - Finance

AP0100	Reserves
AP0200	Client Rates For Long Stay Patients Awaiting Placement
AP0300	Travel Expense
AP0300a	Travel Expense - Quick Reference Guide
AP0300b	Travel Expense - User Guide
AP0400	Changes to Schedule of Fees and Charges
AP0500	Leased Space Management of
AP0700	Signing Authority
AP0900	Hardship
AP1000	Environmental Sustainability
AP1100	Research Finance
AP1110	Special Research Funds
AP1120	Clinical Research Overhead Rates
AP1200	Preferred Accomodation

AQ - Purchasing

AQ0100	Architects and Engineers Use of
AQ0300	Authority and Responsibility of Purchasing
AQ0500	Identification and Access Control
AQ0600	Corporate Credit Card Code of Responsibility
AQ1101	Vehicles Responsibility Code for Use of IH Vehicles
AQ1200	Products Equipment Being Brought in for Trial and Evaluation
AQ1400	Capital Planning Acquisition and Billing
AQ1800	Surplus Equipment Disposal
AQ1850	Transfer or Disposal of Assets Externally Funded

AR - Information Privacy & Security and Releases

AR0100	Information Systems Acceptable Use of
AR0200	Information Security
AR0300	Wireless (WiFi) Network
AR0400	Privacy and Management of Confidential Information
AR0450	Managing Privacy-Security Breaches-Violations
AR0500	Email and Text Messaging
AR0600	Internet Access
AR0700	User Identification and Password
AR1000	Photography Videotaping and Audio Recording

AT - Information Systems/Telecommunications

AT0200	IMIT Acquisition and Implementation
AT0300	Software
AT0600	Mobile Worker Technology

AU - Human Resources

AU0100	Standards of Conduct for IHA Employees
AU0200	Substance Use Disorder Procedural Guidelines
AU0200	Substance Use Disorder
AU0250	Post Retirement Employment
AU0400	External Consultants Use of
AU0500	Print Copy Management
AU0600	Position Titles
AU0800	Dress Code, Personal Appearance
AU0900	Employee Information Release of
AU1000	Workplace Environment Procedural Guidelines
AU1000	Workplace Environment
AU1100	Clinical and Practice Education - Student Placements
AU1150	Learning and Development Request - Policy Guide
AU1150	Learning and Development Requests
AU1200	Vacation - Contract Employees
AU1300	Flexible Work Location Guidebook
AU1300	Flexible Work Location
AU2000	Representative Aboriginal Workforce
AU2100	Diversity
AU2200	Anti-Racism
AU3000	Conferences Approval and Funding of
AU4000	Theft, Fraud and Corruption

AV - Workplace Health and Safety

AV0100	Occupational Health and Safety Program
AV0200	Persons Working Alone or in Isolation
AV0300	Management of Occupational Exposure to Blood or Body Fluid
AV0400	Workplace Hazardous Materials Information System (WHMIS)
AV0500	Transportation of Dangerous Goods
AV0600	Latex Sensitivity Prevention Program
AV0900	Prevention and Management of Exposure to Communicable Diseases
AV1000	Attendance Enhancement Policy
AV1100	Employee Incident Reporting and Investigation
AV1300	Respiratory Infection Outbreak Staff Management Policy
AV1300	Staff Influenza Immunization and Exclusion
AV1300	Staff Respiratory Infection Outbreak Management
AV1350	Influenza Prevention Policy
AV1700	Disability Management Program
AV1900	Respiratory Protection Program
AV2000	Smoke Free Environment
AV2200	Management and Use of Recorded Closed Circuit Video Systems (CCTV)
AV2500	Violence Prevention
AV2510	Threat Management - The Assessment and Management of Targeted Violence
AV2520	Active Deadly Threat Response Policy
AV2530	Restricted Access Policy
AV2600	Fatique Policy
AV2800	Safe Patient Handling Policy
AV2900	Managing Disrespectful, Aggressive or Violent Behaviours of Visitors
AV3000	Psych. Health and Safety
AV3100	COVID-19 Immunization Requirement

AW - Facilities Management

AW0200	Laundry Services
AW0300	Parking Policy
AW0500	Facilities and Asset Naming
AW0650	Prohibited Items
AW0800	Art in IH Facilities
AW1000	Public Use of Interior Health Facilities

Board of Directors

1.0 General

1.2 Overview of the Interior Health Authority

1.3 Vision Mission Goals Values and Principles

2.0 Governance

2.1 Terms of Reference for Board of Directors

2.2 Terms of Reference Board Chair

2.3 Terms of Reference for President and Chief Executive Officer

2.4 Terms of Reference for a Director

2.5 Terms of Reference for the Secretary to the Board

2.6 Director Orientation and Continuing Development

3.0 Guidelines and Policies

3.01 Board of Directors Guidelines

3.02 Directors Standards of Conduct and Conflict of Interest

3.03 Public Presence at Meetings of the Board

3.04 Limits of Spending Authority

3.05 Communications

3.06 Directors Retainers Fees and Expenses

3.07 Director Liability Indemnification

3.08 Financial Management Policy

3.09 Acquisition and Disposition of Property Assets

3.10 External Auditor Independence

3.11 Risk Management

3.12 Corporate Conduct

3.13 Research and Research Ethics - Replaced by Policy 3.19 Research

3.14 Clinical Ethics - Obsolete, refer to Research Section of Policy Manual

3.15 Safe Reporting

3.16 Director Engagement of Independent Counsel

3.17 Paper Reduced Board Meetings Policy

3.18 Research Ethics Terms of Reference

3.19 Research

4.0 Committees and Task Forces

4.1 General Guidelines for Committees

4.2 Terms of Reference Board Audit and Finance Committee

4.3 Terms of Reference for Governance and Human Resources Committee

4.4 Terms of Reference for Strategic Priorities Committee

4.5 Terms of Reference for the Quality Committee

4.6 Terms of Reference for the Stakeholder Relations Committee

4.7 Task Force Guidelines

4.8 Terms of Reference for the CEO Recruitment Task Force

5.0 Key Review Processes

5.1 Performance Evaluation Process for the President and CEO

5.2 Board, Committee and Director Evaluation Process

5.3 Succession Planning Process

5.4 Long Term Board Renewal Plan

6.0 Administration

6.1 Board of Directors

6.2 Committee Chairs and Memberships

6.3 Board and Committee Meeting Schedules

6.4 Board Calendar

8.0 Reference Documents

8.1 Government Mandate Letter

8.2 Organization and Procedure Bylaws

8.3 Health Authorities Act

8.4 Hospital Act

9.0 Medical Staff Rules

9.1 Medical Staff Bylaws

9.2 Medical Staff Rules - Part I

9.3 Medical Staff Rules - Part II

Research

RA - Research Ethics Board Administration

RA0100	REB Policy Table of Contents
RA0200	Membership
RA0300	Training and Education
RA0400	Meeting Administration
RA0500	Records Management
RA0600	REB Signing Authority
RA0700	Confidentiality of Information
RA0800	Conflict of Interest
RA0900	Reportable Events
RA1200	External Audits for REB-Approved Research

RD - Research

RD0100	Research Integrity
RD0200	Researcher Qualifications and Responsibilties
RD0300	Operational Approval to Conduct Research
RD0500	Information Requests for Research

RR - Review of Research

RR0100	Activities Requiring Research Ethics Review
RR0200	Harmonized Ethics Review
RR0300	Initial Review Research
RR0400	Amendments
RR0500	Renewals
RR0600	Research Completion
RR0700	Obtaining Consent for Research
RR0800	Documentation of Consent for Research
RR0900	Safety and Serious Adverse Events Reporting
RR1100	REB Management Non-Compliance
RR1200	Suspensions and Terminations
RR1300	Appeal of REB Decision
RR1400	Research Participant Concerns

RS - Special Categories of Research

RS0200	Secondary Use of Human Biological Materials
RS0300	Populations for Special Consideration in Research
RS0400	Research in Emergency Health Situations
RS0500	REB Review During Publicly Declared Emergencies

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