| ADMINISTRATIVE POLICIES & PROCEDURES - INDEX | ||||||||
| GMH Policy No. | Department | Policy Title | Type of Policy 1=Admin 2=Departmental | Effective Date | Last Reviewed | Last Revision | Next Review | Approved |
| 6100-1 | Administration | Administrative Manual Distribution | 1 | 08/05/92 | None | None | Aug-92 | |
| 6100-3 | Security | Alcohol, Use on Hospital Property | 1 | 10/01/92 | None | None | ||
| 6100-5 | Administration | Reporting, Required by Government Agencies | 1 | 08/11/92 | August-92 | None | Aug-92 | |
| 6100-6 | Administration | Conflict of Interest | 1 | 07/28/92 | None | None | Sep-92 | |
| 6100-7 | Administration | Dissemination of Information | 1 | 07/28/92 | July-92 | None | ||
| 6100-10 | Administration | Hospital Committees | 1 | 07/28/92 | None | None | Jul-92 | |
| 6100-11 | Administration | Institutional Review Board | 1 | 07/29/92 | None | None | Jul-92 | |
| 6100-12 | Administration | Mail Boxes | 1 | 07/01/92 | None | None | Jul-92 | |
| 6100-13 | Administration | Mission Statement | 1 | 04/15/92 | None | None | May-99 | |
| 6100-19 | Administration | Facsimile Policy | 1 | 04/08/97 | None | None | Apr-97 | |
| 6100-20 | Administration | Ambulatory Care Program | 1 | 12/29/92 | None | None | Dec-92 | |
| 6100-24 | Administration | Vision Statement | 1 | 05/19/99 | None | None | May-99 | |
| 6100-25 | Administration | Statement of Values | 1 | 05/19/99 | None | None | May-99 | |
| 6100-25 | Administration | Americans with disabilities act title II-Public Services | 1 | 10/11/94 | None | None | See 6100--21 | |
| 6100-26 | Administration | Guam Physical and Wellness Program | 1 | 07/01/00 | None | None | Jul-00 | |
| 6100-27 | Administration | The Visually Impaired with A service Animal | 1 | 10/11/94 | None | None | ||
| 6100-28 | Nursing Services Admin | Stretcher Van Non-Emergency Transport Service | 1 | 03/01/02 | March-02 | None | Apr-02 | |
| 6100-29 | Information Services | Email Confidentiality Notice/Disclaimer | 1 | 03/01/02 | None | None | Nov-02 | |
| 6100-31 | Administration | The Recovery Of Funds Due To The Guam Memorial Hospital Autrhority | 1 | 05/01/03 | None | None | May-03 | |
| 6120-1 | Planning | Bed Capacity | 1 | 03/01/91 | July-95 | None | Aug-95 | |
| 6120-4 | Planning | New Programs/Services-Feasibility Guidelines | 1 | 01/19/93 | July-95 | None | Aug-95 | |
| 6120-5 | Planning | Patient Rights During Construction | 1 | 01/20/94 | July-95 | None | Aug-95 | |
| 6140-4 | Education/Personnel | American Heart Association and other Emergency Cardiac Care Competency Training Programs | 1 | 06/25/96 | September-97 | None | Oct-97 | |
| 6140-5 | Patient/Family Education Committee | Patient Family Education Program | 1 | 08/04/02 | None | None | Jun-00 | |
| 6150-2 | Safety | Disposal of Hospital Wastes | 1 | 05/30/90 | July-92 | None | Aug-92 | |
| 6150-3 | Safety | Handling and Storage of Flammable and Non-Flammable Gases | 1 | 07/29/92 | None | None | Jul-92 | |
| 6150-5 | Safety | Safety Inspection-Biweekly | 1 | 03/26/92 | June-92 | None | Jul-92 | |
| 6150-9 | Safety | Smoke Free environment at the Skilled Nursing Services Unit | 1 | 12/01/99 | None | None | Dec-99 | |
| 6160-1B | Security | GMHA SNU Designated Smoking Areas | 1 | 01/08/01 | January-01 | None | Jan-01 | |
| 6160-5 | Security | GMHA Parking Permit | 1 | 05/31/95 | None | None | May-95 | |
| 6170-2 | Medical Staff | Do Not Resuscitate (DNR) Orders | 1 | 05/15/90 | None | None | Jun-92 | |
| 6170-3 | Medical Staff | Disruptive Practitioners | 1 | 07/15/92 | 3*93 | None | Jul-92 | |
| 6170-4 | Medical Staff | Impaired Practitioner Guidelines | 1 | 07/15/92 | March-93 | None | Mar-99 | |
| 6170-5 | Medical Staff | House Patient Payment Policy | 1 | 01/02/99 | January-99 | None | Mar-99 | |
| 6170-7 | Medical Staff | Medical Staff Meeting Agenda and Minutes | 1 | 12/15/00 | August-01 | None | Sep-01 | |
| 6180-2 | Risk Management | Occurrence Summary Reporting | 1 | 06/01/89 | September-92 | None | Oct-95 | |
| 6180-4 | Risk Management | Identification and Disposition of Potentially Cases | 1 | 06/01/89 | September-92 | None | Sep-92 | |
| 6180-5 | Risk Management | Subpoena of GMHA Employees | 1 | 01/14/99 | None | None | Jan-99 | |
| 6190-3 | Guest Relations | Patient Satisfaction Survey | 1 | 11/07/94 | None | None | ||
| 6301-4 | Nursing Services | Emotional or Mentally Ill Patients, Management of | 1 | 07/28/92 | None | None | Aug-92 | |
| 6301-6 | Nursing Services | Organ and Tissue Donation/Tansplantation | 1 | 11/20/91 | July-92 | None | Nov-91 | |
| 6301-11 | Nursing Services | Withdrawal Of Life Support | 1 | 12/16/92 | None | None | Dec-92 | |
| 6301-12 | Nursing Services | Patient Rights and Responsibilities | 1 | 06/01/88 | None | None | Oct-92 | |
| 6301-14 | Nursing Services | Care of Dying Patient | 1 | 07/01/94 | None | None | Jul-94 | |
| 6301-15 | Nursing Services | Medical Transport | 1 | 05/01/98 | None | None | Jul-98 | |
| 6301-16 | Nursing Services | Emergency Medicine Department Visitation Policy | 1 | 09/14/99 | None | None | Sep-99 | |
| 6301-17 | Nursing Services | Health Care Professional Hourly Per Diem Day Policy | 1 | 01/25/00 | None | None | Jan-00 | |
| 6301-18 | Nursing Services | Initial Admission/Discharge Planning/Reassessment Process | 1 | 05/01/90 | October-99 | None | Oct-99 | |
| 6301-19 | Nursing Services | Emergency Medicine Department Base Station Form | 1 | 04/01/99 | August-00 | None | Aug-00 | |
| 6120-3 | Planning | Signs, Posters, Bulletin Boards | 11/08/90 | None | April-04 | Apr-94 | ||
| 6301-20 | Nursing Services | Well Born Baby Rooming-In | 1 | 07/01/03 | None | July-01 | Jul-01 | |
| 6301-21 | Nursing Services | Infant Security | 1 | 11/01/00 | November-99 | July-01 | Nov-00 | |
| 6301-22 | Nursing Services | Visiting Policy | 1 | 11/01/99 | November-99 | July-01 | Jul-01 | |
| 6301-23 | Nursing Services | Pain Management | 1 | 07/11/01 | November-00 | July-01 | Dec-01 | |
| 6170-6 | Medical Staff | Directory of Medical Staff Practitioner | 1 | 06/26/00 | May-00 | May-00 | Jul-00 | |
| 6100-17 | Administration | Policy development: Format , Approval and Distribution | 1 | 07/29/91 | March-97 | September-99 | Sep-99 | |
| 6100-22 | Administration | Americans with Disabilities Act Transition Plan | 1 | 10/11/94 | September-97 | September-97 | Oct-97 | |
| 6100-23 | Administration | The Use of Service Animals By Individuals with Disabilities | 1 | 10/11/94 | September-97 | September-97 | Oct-97 | |
| 6140-1 | Education | Reserving Rooms for Meetings/Functions | 1 | 07/01/92 | August-97 | September-97 | Oct-97 | |
| 6140-2 | Education | Employee Orientation | 1 | 06/23/92 | August-97 | September-97 | Oct-97 | |
| 6100-2 | Administration | Administrator on Call | 1 | 07/28/92 | July-97 | July-97 | Jul-04 | |
| 6100-21 | Administration | Americans With Disabilities Act | 1 | 10/11/94 | March-97 | March-97 | Jul-97 | |
| 6140-3 | Education/Personnel | Special Staff Development Programs | 1 | 08/09/89 | November-95 | June-96 | Jun-96 | |
| 6160-1 | Security | GMHA Designated Parking Areas | 1 | 06/23/92 | June-96 | June-96 | Jun-96 | |
| 6190-1 | Guest Relations | Patient Self - Determination ( Advance Directives ) | 1 | 09/01/92 | September-95 | September-95 | See 6301-13 | |
| 6190-2 | Guest Relations | Complaints | 1 | 06/01/89 | September-95 | September-95 | See 6100--15 | |
| 6180-1 | Risk Management | Reporting Adverse Medical Device Incident | 1 | 06/03/92 | July-95 | July-95 | Oct-96 | |
| 6180-1A | Risk Management | Medical Devices Tracking Requirement | 1 | 08/01/93 | July-95 | July-95 | Oct-95 | |
| 6100-16 | Administration | Patient Transfer Guidelines | 1 | 07/15/92 | None | June-95 | Jul-95 | |
| 6120-2 | Planning | Guidelines for Facility Improvements | 1 | 05/01/95 | None | May-95 | May-95 | |
| 6100-4 | Administration | Circulars, Memoranda and Signature Authority | 1 | 12/10/87 | None | February-95 | Apr-94 | |
| 6160-4 | Security | Key Control | 1 | 11/01/90 | None | September-94 | Aug-92 | |
| 6100-15 | Administration | Complaints | 1 | 06/01/89 | None | April-94 | Apr-94 | |
| 6130-2 | Communications | Overseas Calls | 1 | 04/13/93 | None | April-94 | Apr-94 | |
| 6301-13 | Nursing Services | Patient Self - Determination ( Advance Directives ) | 1 | 09/01/92 | None | April-94 | Oct-92 | |
| 6100-8 | Administration | Executive Management Council | 1 | 05/05/92 | None | May-93 | May-93 | |
| 6150-6 | Safety | Safety management Program | 1 | 05/19/90 | None | March-93 | May-93 | |
| 6301-1 | Nursing Services | Checking of Emergency Equipment and Supplies | 1 | 07/01/72 | July-72 | March-93 | Mar-93 | |
| 6301-7 | Nursing Services | Patient Identification | 1 | 07/28/92 | None | March-93 | Mar-93 | |
| 6301-5 | Nursing Services | Ethics Committee Guidelines | 1 | 08/01/92 | None | February-93 | May-93 | |
| 6130-1 | Communications | Paging Codes | 1 | 10/07/92 | None | October-92 | Oct-92 | |
| 6160-2 | Security | Code 99- Bomb Threat | 1 | 05/19/90 | None | October-92 | Oct-92 | |
| 6160-3 | Security | Code 60 | 1 | 07/01/92 | None | September-92 | Sep-92 | |
| 6200-1 | Infection Control | Infection Control Program | 1 | 04/14/75 | November-91 | September-92 | Sep-92 | |
| 6200-2 | Infection Control | Infection Control Committee | 1 | 04/14/75 | November-91 | September-92 | Sep-92 | |
| 6200-3 | Infection Control | Aids Guidelines | 1 | 04/24/92 | November-91 | September-92 | Oct-92 | |
| 6301-10 | Nursing Services | Food Policy | 1 | 08/10/88 | None | September-92 | Jan-93 | |
| 6100-18 | Administration | Release of Information Guidelines | 1 | 04/05/88 | 1988 | July-92 | Aug-92 | |
| 6301-2 | Nursing Services | Code 72 | 1 | 07/08/88 | September-89 | July-92 | Nov-92 | |
| 6301-8 | Nursing Services | Patient Valuables | 1 | 08/01/92 | None | July-92 | Aug-92 | |
| 6301-9 | Nursing Services | Visiting Policy | 1 | 03/25/00 | Year of 1989 | July-92 | Aug-92 | |
| 6100-14 | Administration | Organizational Chart | 1 | 06/22/92 | None | June-92 | ||
| 6150-1 | Safety | Safe Handling of Cyotoxic Drugs | 1 | 05/01/90 | None | June-92 | Aug-92 | |
| 6150-4 | Safety | Holiday Decorating/Celebrating Guidelines | 1 | 12/03/91 | None | June-92 | Jun-92 | |
| 6150-7 | Safety | Smoke-Free Hospital | 1 | 09/25/90 | None | June-92 | Aug-99 | |
| 6170-1 | Medical Staff | Determination of Death | 1 | 06/17/92 | October-95 | June-92 | Jun-92 | |
| 6301-3 | Nursing Services | Chief Medical Examiner Cases - Reportable Deaths | 1 | 01/02/85 | June-05 | June-92 | Jul-92 | |
| 6150-8 | Safety | Safety Management Committee | 1 | 05/19/90 | March-93 | March-92 | May-92 | |
| 6100-30 | Administration | Confidential Information | 1 | 03/01/03 | Mar-03 | |||
| 6410-1 | Administrator/Personnel | Employee and Medical Staff Licensure | 1 | 06/01/92 | None | None | Jun-92 | |
| 6410-2 | Personnel | Work Planning and Performance Evaluation | 1 | PL 16-23 | None | April-94 | Apr-94 | |
| 6410-3 | Personnel | Employee and Medical Staff Practitioner Identification | 1 | 11/01/92 | September-00 | September-00 | Nov-92 | |
| 6410-4 | Personnel | Employment | 1 | 06/01/92 | None | April-94 | Mar-94 | |
| 6410-5 | Administrator | EEO | 1 | 06/01/88 | November-00 | November-00 | Nov-00 | |
| 6410-6 | Employee Health | Drug Free Workplace | 1 | 04/01/91 | June-92 | None | Apr-91 | |
| 6410-7 | Personnel | Request for GG1 | 1 | 04/01/91 | None | April-94 | Apr-94 | |
| 6410-8 | Personnel | Safety Performance Evaluation | 1 | 04/15/91 | July-92 | June-92 | Jul-92 | |
| 6410-9 | EEO | Sexual Harassment | 1 | 11/20/91 | None | June-92 | Nov-91 | |
| 6410-10 | Personnel | Off-Island Recruitment | 1 | 10/01/92 | None | April-94 | Apr-94 | |
| 6410-11 | Medical Director | Employee Health | 1 | 06/23/92 | None | February-93 | Apr-94 | |
| 6410-12 | Personnel | Leave - Types and Requirements | 1 | 10/07/92 | None | April-94 | Apr-94 | |
| 6410-13 | Personnel | Pay Differential Categories | 1 | 10/27/92 | September-99 | September-99 | Sep-99 | |
| 6410-14 | Personnel | Pre-Employment Physical Examination | 1 | 02/09/93 | None | April-94 | Apr-94 | |
| 6140-15 | Personnel | Part-Time Employment | 1 | 02/09/93 | None | April-94 | Apr-94 | |
| 6140-16 | EEO Officer | Americans with Disabilities Grievance Procedures | 1 | 02/23/93 | None | None | Mar-93 | |
| 6410-17 | Personnel | Monthly Evaluations | 1 | 11/01/93 | November-93 | April-94 | Jan-94 | |
| 6410-18 | Personnel | Disciplinary Action Policy and Procedure | 1 | 01/01/94 | None | None | ||
| 6410-P-18 | Personnel | Outside Employment | 1 | 11/01/92 | November-92 | November-92 | ||
| 6410-19 | Personnel | Restriction of Unauthorized Visitors During Regular Working Hours | 1 | 03/01/94 | None | None | Mar-94 | |
| 6410-20 | Personnel | Entitlement to Overtime or Compensatory Time OFF | ||||||