ADMINISTRATIVE POLICIES & PROCEDURES - INDEX
GMH Policy No. Department Policy Title Type of Policy 1=Admin 2=Departmental
6100-1 Administration Administrative Manual Distribution 1
6100-3 Security Alcohol, Use on Hospital Property 1
6100-5 Administration Reporting, Required by Government Agencies 1
6100-6 Administration Conflict of Interest 1
6100-7 Administration Dissemination of Information 1
6100-10 Administration Hospital Committees 1
6100-11 Administration Institutional Review Board 1
6100-12 Administration Mail Boxes 1
6100-13 Administration Mission Statement 1
6100-19 Administration Facsimile Policy 1
6100-20 Administration Ambulatory Care Program 1
6100-24 Administration Vision Statement 1
6100-25 Administration Statement of Values 1
6100-25 Administration Americans with disabilities act title II-Public Services 1
6100-26 Administration  Guam Physical and Wellness Program 1
6100-27 Administration The Visually Impaired with A service Animal 1
6100-28 Nursing Services Admin Stretcher Van Non-Emergency Transport Service 1
6100-29 Information Services Email Confidentiality Notice/Disclaimer 1
6100-31 Administration The Recovery Of Funds Due To The Guam Memorial Hospital Autrhority 1
6120-1 Planning Bed Capacity 1
6120-4 Planning New Programs/Services-Feasibility Guidelines 1
6120-5 Planning Patient Rights During Construction 1
6140-4 Education/Personnel American Heart Association and other Emergency Cardiac Care Competency Training Programs 1
6140-5 Patient/Family Education Committee Patient Family Education Program 1
6150-2 Safety Disposal of Hospital Wastes 1
6150-3 Safety Handling and Storage of Flammable and Non-Flammable Gases 1
6150-5 Safety Safety Inspection-Biweekly 1
6150-9 Safety Smoke Free environment at the Skilled Nursing Services Unit 1
6160-1B Security GMHA SNU Designated Smoking Areas 1
6160-5 Security GMHA Parking Permit 1
6170-2 Medical Staff Do Not  Resuscitate (DNR) Orders 1
6170-3 Medical Staff Disruptive Practitioners 1
6170-4 Medical Staff Impaired Practitioner Guidelines 1
6170-5 Medical Staff House Patient Payment Policy 1
6170-7 Medical Staff Medical Staff Meeting Agenda and Minutes 1
6180-2 Risk Management Occurrence Summary Reporting 1
6180-4 Risk Management Identification and Disposition of Potentially Cases 1
6180-5 Risk Management Subpoena of GMHA Employees 1
6190-3 Guest Relations Patient Satisfaction Survey 1
6301-4 Nursing Services Emotional or Mentally Ill Patients, Management of 1
6301-6 Nursing Services Organ and Tissue Donation/Tansplantation 1
6301-11 Nursing Services Withdrawal Of Life Support 1
6301-12 Nursing Services Patient Rights and Responsibilities 1
6301-14 Nursing Services Care of Dying Patient 1
6301-15 Nursing Services Medical Transport 1
6301-16 Nursing Services Emergency Medicine Department Visitation Policy 1
6301-17 Nursing Services Health Care Professional Hourly Per Diem Day Policy 1
6301-18 Nursing Services Initial Admission/Discharge Planning/Reassessment Process 1
6301-19 Nursing Services Emergency Medicine Department Base Station Form 1
6120-3 Planning Signs, Posters, Bulletin Boards  
6301-20 Nursing Services Well Born Baby Rooming-In 1
6301-21 Nursing Services Infant Security 1
6301-22 Nursing Services Visiting Policy 1
6301-23 Nursing Services Pain Management 1
6170-6 Medical Staff Directory of Medical Staff Practitioner 1
6100-17 Administration Policy development: Format , Approval and Distribution 1
6100-22 Administration Americans with Disabilities Act Transition Plan 1
6100-23 Administration The Use of Service Animals By Individuals with Disabilities 1
6140-1 Education Reserving Rooms for Meetings/Functions 1
6140-2 Education Employee Orientation 1
6100-2 Administration Administrator on Call 1
6100-21 Administration Americans With Disabilities Act 1
6140-3 Education/Personnel Special Staff Development Programs 1
6160-1 Security GMHA Designated Parking Areas 1
6190-1 Guest Relations Patient Self - Determination ( Advance Directives ) 1
6190-2 Guest Relations Complaints 1
6180-1 Risk Management Reporting Adverse Medical Device Incident  1
6180-1A Risk Management Medical Devices Tracking Requirement  1
6100-16 Administration Patient Transfer Guidelines 1
6120-2 Planning Guidelines for Facility Improvements 1
6100-4 Administration Circulars, Memoranda and Signature Authority 1
6160-4 Security Key Control 1
6100-15 Administration Complaints 1
6130-2 Communications Overseas Calls 1
6301-13 Nursing Services Patient Self - Determination ( Advance Directives ) 1
6100-8 Administration Executive Management Council 1
6150-6 Safety Safety management Program 1
6301-1 Nursing Services Checking of Emergency Equipment and Supplies 1
6301-7 Nursing Services Patient Identification 1
6301-5 Nursing Services Ethics Committee Guidelines 1
6130-1 Communications Paging Codes 1
6160-2 Security Code 99- Bomb Threat 1
6160-3 Security Code 60 1
6200-1 Infection Control Infection Control Program 1
6200-2 Infection Control Infection Control Committee 1
6200-3 Infection Control Aids Guidelines 1
6301-10 Nursing Services Food Policy 1
6100-18 Administration Release of Information Guidelines 1
6301-2 Nursing Services Code 72 1
6301-8 Nursing Services Patient Valuables 1
6301-9 Nursing Services Visiting Policy 1
6100-14 Administration Organizational Chart 1
6150-1 Safety Safe Handling of Cyotoxic Drugs 1
6150-4 Safety Holiday Decorating/Celebrating Guidelines 1
6150-7 Safety Smoke-Free Hospital 1
6170-1 Medical Staff Determination of Death 1
6301-3 Nursing Services Chief Medical Examiner Cases - Reportable Deaths 1
6150-8 Safety Safety Management Committee 1
6100-30 Administration Confidential Information 1
6410-1 Administrator/Personnel Employee and Medical Staff Licensure 1
6410-2 Personnel Work Planning and Performance Evaluation 1
6410-3 Personnel Employee and Medical Staff Practitioner Identification 1
6410-4 Personnel Employment  1
6410-5  Administrator EEO 1
6410-6 Employee Health Drug Free Workplace 1
6410-7 Personnel Request for GG1 1
6410-8 Personnel Safety Performance Evaluation 1
6410-9 EEO Sexual Harassment 1
6410-10 Personnel Off-Island Recruitment 1
6410-11 Medical Director Employee Health 1
6410-12 Personnel Leave - Types and Requirements 1
6410-13 Personnel Pay Differential Categories 1
6410-14 Personnel Pre-Employment Physical Examination 1
6140-15 Personnel Part-Time Employment 1
6140-16 EEO Officer Americans with Disabilities Grievance Procedures 1
6410-17 Personnel Monthly Evaluations 1
6410-18 Personnel Disciplinary Action Policy and Procedure 1
6410-P-18 Personnel Outside Employment 1
6410-19 Personnel Restriction of Unauthorized Visitors During Regular Working Hours 1
6410-20 Personnel Entitlement to Overtime or Compensatory Time OFF 1
6410-22 Personnel Equal Employment Opportunity Officers Oversight of Employment Interviews 1
6410-23 Personnel Hospital-Wide Dress Code 1
6410-24 Personnel Recall Policy 1
6410-25 Personnel Language In the Workplace 1
6410-26 Personnel Exit Interviews 1
6410-P-27 Personnel Interview Process 1
6420-1 Information Services Computer Program Requisition Guidelines 1
6420-2 Information Services Keying of Patient Charges and Accounts 1
6431-1 Social Services Adoption Protocol Overview 1
6431-2 Social Services Referral to Adult Protective Services 1
6431-3 Social Services Communication Barriers 1
6431-4 Social Services Discharge Planning Program 1
6431-4A Social Services Discharge Panning Program Implementation Policy 1
6431-4B Social Services Patient Care Planning Implementation Policy Acute Care Wards 1
6431-5 Social Services Fetal Burial 1
6431-6 Social Services Social Services Consultation and Referral Procedures 1
6431-7 Social Services Child Protective Services (CPS)-Referrals 1
6431-8 Social Services Patient /SNU Resident Abuse and Neglect Prevention 1
6431-9 Quality Management Home Health Care Services Referral 1
6432-1 Quality Management Regulatory Agency Compliance 1
6432-2 Administrator Plan For Performance Improvement 1
6432-2 Quality Management Hospital-wide Quality Improvement Plan 1
6432-3 Quality Management Twenty-Three Hour Observation Service 1
6432-4 Quality Management Admission and Discharge Criteria 1
6432-5 Quality Management Medical Staff Peer Review Process 1
6433-1 Medical Records Abbreviations 1
6433-2 Medical Records Informed Consent 1
6433-3 Medical Records Medical Records, Release of Information 1
6433-4 Medical Records Retention of Records 1
6433-5 Medical Records Forms Management Committee 1
6433-5 Medical Records Medical Record Form Policy/Procedure/Guidelines 1
6434-1 Medical Library Library Services 1
6440-1 Fiscal Services Contracts-Procedure and Evaluation 1
6440-2 Fiscal Services Patient Room Charges 1
6440-3 Fiscal Services Travel 1
6440-4 Fiscal Services GMHA Chart of Accounts 1
6440-5 Fiscal Services Special Payment Request 1
6440-6 Fiscal Services Leave Sharing Program 1
6440-7 Fiscal Services Processing Patient Charges 1
6440-8 Fiscal Services Auditing of Charges Policy 1
6440-9 Fiscal Services Skilled Nursing Services Unit Notice of Bed Hold and Re-Admission Policy 1
6440-10 Fiscal Services General Timekeeping Guidelines 1
6450-1 Materials Management Loan/Borrowing of Hospital Equipment and Materials 1
6450-2 Materials Management Product and Equipment Evaluation and Standardization 1
6450-3 Materials Management Product Recall and Alerts 1
6450-4 Materials Management Sale of Supplies 1
6450-5 Materials Management Solicitation and Acceptance of Gifts 1
6450-6 Materials Management Supply Requisition 1
6450-7 Materials Management Disposition of Hospital Property 1
6450-8 Materials Management Donations 1
6460-1 Laundry Linen Control 1
6460-2 Laundry Scrub Clothes Policy 1
6460-3 Laundry Linen Control Citation Form 1
6480-1 Facilities Maintenance Aluminum Container Recycling Program 1
6480-2 Facilities Maintenance Reporting Malfunction and Failures 1
6480-3 Facilities Maintenance Electrical Extension Cords 1
6480-3 Facilities Maintenance Extension Cord Usage 1
6480-5 Facilities Maintenance Electrical Safety 1
6480-4 Facilities Maintenance Lock Out/ Tag Out Program 1
6480-6 Facilities Maintenance Signs 1
6480-7 Facilities Maintenance Personal Electrical Equipment 1
6480-8 Facilities Maintenance Bulletin Boards/Public & Staff Information 1
6480-9 Facilities Maintenance Refrigerator/Freezer Temperature Log-Sheet 1
6540-1 Dietary Cafeteria Information and Special Event Requests 1
6570-1 Pastoral Care GMHA & Pastoral Care Mission 1
6570-2 Pastoral Care Scope 1
6570-3 Pastoral Care Objectives 1
6570-4 Pastoral Care Location and Schedules 1
6570-5 Pastoral Care Special Liturgical Services 1
6570-6 Pastoral Care Educational and Professional Organizations 1
6570-7 Pastoral Care Pastoral Care Personnel & Volunteers - Their Specific Duties 1
6570-8 Pastoral Care Pastoral Care Referrals 1
6570-9 Pastoral Care Outside Agencies 1
6570-10 Pastoral Care Pastoral Care Inservice 1
6570-11 Pastoral Care Administration of the Sacrament of the Anoininting the sick 1
6570-12 Pastoral Care Emergency Baptism 1
6570-13 Pastoral Care Death/Dying Parents 1
6570-14 Pastoral Care Infection Control in the Pastoral Care Department  1
6570-15 Pastoral Care Safety Policy and Procedure 1
6570-16 Pastoral Care Pastoral Care Guidelines for the Care of the Cardiac Patient 1
6570-17 Pastoral Care Religious/Pastoral Visitation 1
3637 EMS,Safety Mgmt. Committee Typhoon Preparedness Plan: Pastoral Care 1