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Quality Improvement: Policies (Provided via electronic download: edit by client)

This QA Module includes over 150 policies, ready for self-editing by client.

This product is provided in electronic format via electronic download to the licensing center.

All policies are written using Microsoft Word (2003). This product provides you the opportunity to customize CC-CQS's cross-referenced policies yourself at a reduced cost. All policies are color-coded, footnoted, and referenced to assist you while making your changes. When you see a red statement you may change the methodology of implementation but not the intent of the statement. This allows you the opportunity to customize your policies with the comfort of knowing that all community requirements are clearly designated.

Policies are provided in folders for the following categories:
1) General Policies
2) Department Policies
3) Employee Policies
4) Organizational Policies
5) Technical Policies
6) Physics Policies, and
7) Nursing Policies.


  • Define all processes performed in your organization.
  • Satisfy accreditation requirements of JCAHO and ACR.
  • Cross-referenced and footnoted, providing you with a direct reference to the corresponding standards for easy reference.
1. General Policies
  • The General Policy section includes 43 policies that address every aspect of compliance required for accreditation, such as processes for informed consent, advance directives, conflict of decision, etc. Although the hospital may have ‘general’ policies in regards to these policies, the General Policies provided in this component identify how processes are performed in your department.
  • 2. Department Policies
  • The Department Policy section includes 32 policies that follow the process of the patient encounter, beginning with a medical records policy and continuing through the final discharge of the patient. This section identifies all processes that may be performed, who is responsible, and how the procedure or process is documented in your department.
  • 3. Employee Policies
  • The Employee Policy section includes 15 policies that define how hospital policies are applied in your department. Policies range from film badge and exposure monitoring to staff breaks. These policies will compliment the HR policies and will reflect the customized processes followed in your department.
  • 4. Organization Policies
  • The Organization Policy section includes 16 policies ranging from shredding documents to dietitian referrals.
  • 5. Technical Policies
  • The Technical Policy section includes 14 policies ranging from scheduling patients on the treatment machine to irradiating blood products.
  • 6. Physics Policies
  • Churchill Consulting, Inc. does NOT provide a detailed physics program, but does provide 10 policies that outline TG40 guidelines written by AAPM to assist the organization in developing appropriate policies and schedules for physics services.
  • 7. Nursing Policies
  • The Nursing Policy section includes 14 policies that provide detailed information ranging from implementing nursing care plan objectives to obtaining pap smears.
  • If you are not performing or properly documenting a required task, CC-CQS will assist you in developing a protocol to properly comply with that requirement.

    A calendar of staff education and inservice requirements, which is based on your policies, will also be provided.

    A complete TQM program will result in multiple customized modules. All materials are provided to client in electronic format to enable client to edit materials as processes change. TQM is a dynamic process, it is imperative to update your materials regularly.

    Click here to download a PDF file that includes a summary of all QA products and services, or you may print the information directly from our web page. Prices are subject to change. Please contact Churchill Consulting, Inc. at 860-663-5630 to confirm current rates.

    This is only one of the QA program modules available for electronic download; allowing you the opportunity to edit the materials yourself. Combined, all materials will result in a comprehensive TQM program. Other program options are listed below:

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