Policies, Procedures & Guidelines

All policies/procedures, protocols, pathways, and guidelines that include medications require review by the P&T Committee.  

Submissions 

To submit a policy/procedure, protocol, or guideline for consideration consider: 

  • If new, provide the new document (and designate it as new) 
  • If a revision, provide the original document and the proposed updated document using track changes 

Requirements 

Submission requirements for review by P&T: 

1. Protocols/pathways or guidelines should use the UCSF Guidelines template. Any corresponding algorithms or decision trees may be added as supporting material [Appendix] 

2. New administrative and pharmacy policies should be reviewed by compliance, regulatory affairs, legal and other groups before being submitted for P&T consideration 

3. Revisions or updates to policies/procedures may be submitted for P&T review 

4. New or revisions to a program or initiative should use the PowerPoint template provided below, 

5. All documents submitted for consideration should include a PowerPoint presentation that outlines key features 

The document should also include these components using the Policies, Guidelines, Protocols PowerPoint template. 

  • Champion or their designee 
  • Presenting on behalf of [committee, group, service, department, etc.] 
  • Relevant background 
  • The current issue (update/change) 
  • Relevant data/supporting material 
  • The requested action [e.g. vote to approve] with the exact recommendation that the committee will vote on
  • The committees, services, individuals, etc. who have reviewed and approved the recommendations thus far
UCSF Guidelines template can be directed to the Formulary Coordinator, [email protected]

Review & approval process 

These requests are presented during the recurring Pre-P&T Committee meeting live. If approved, the request would be placed on the P&T Committee Consent Agenda. This means that the P&T Committee members would receive the background and recommendation via email ahead of the meeting without a live presentation. During the P&T Committee meeting, committee members may ask for clarification or follow-up. If there are no questions, the P&T Committee will vote privately and you will be notified of the outcome within 10 days of the P&T Committee meeting vote.