Standard Operating Procedure (SOP) and Documentation Policy

Jedi Group Holdings LLC and its subsidiaries (collectively, “Thrive”) are committed to achieving the highest standards of professionalism and ethical conduct in its operations and activities. These requirements (this “Policy”) establish guidelines for creating, approving, maintaining, reviewing, revising, and repealing any documented Thrive Standard Operating Procedures and processes to ensure that all are (i) effectively communicated and easily accessible to the appropriate individuals, (ii) appropriately reviewed and approved before implementation and (iii) up to date and in compliance with applicable legal requirements.

1. Scope of Policy

This Policy establishes rules and guidelines for creating, approving, maintaining, reviewing, revising, and repealing Thrive Standard Operating Procedures. This policy mirrors and supports the Thrive Operational Policy Requirements (Policy for Policies). The intent is to guide team members in updating existing documentation in Confluence for presentation through the Policy and Procedure URL.

2. Application of Policy

This Policy applies to all:

• Thrive standard operating procedures

• forms

• reference documentation

• SharePoint news posts

and any Team Member or department that proposes, drafts, reviews, approves, publishes, manages, revises, repeals, or otherwise engages in developing and disseminating these documents.

3. Definitions and Roles

For purposes of this Policy:

4. New SOP Requirements

1. Thoroughly review existing policies and procedures to identify the need for a new standard operating procedure. If necessary, consult Knowledge Management by ticket for assistance.

2. Reference the specific Policy highlighting the gap or the need for a new SOP.

3. Refer to the Template: For a new SOP, use Template+For+Policy+and+Procedure+Writing.dotx. Include the following components to reduce ambiguity:

4.1. SOP Review and Approval

1. Knowledge Management Review

   • Contact Knowledge Management to update existing or review new documentation for organizational consistency. Markups may occur at this level to address lapses in clarity or conflict with existing SOPs or Policies in print.

     • If clarity is needed, the Functional Specialists are responsible for responding with a documented resolution for the concerns raised.

2. Approval

   • The Functional Specialists submit the completed SOP and supporting documents to the Approving Officer for review.

3. Revision and Publish

   • The Functional Specialists address any feedback or concerns the Approving Officer/Knowledge Management raises during the review process and finalize the SOP based on the feedback received.

   • The Functional Specialists contact Knowledge Management for final publishing to Thrive Policies and Procedures.

   • Knowledge Management publishes the new SOP and adds it to the Revision Tracker (Smartsheets) for annual review. If changes are necessary outside the revision cycle, see Revision of an Existing SOP.

5. New SOP or Policy Creation

If a new document is necessary, there are a few ways to begin creation.

New Policies fall under the guidelines of the Organizational Policy Development and utilize the Template for Policy and Procedure Writing. Contact the Legal Department to begin.

• For Policies and SOPs, create your document in Word using the Template for Policy and Procedure Writing template, as you have previously, and import it into the space.

• An outline of the new document may be created in Confluence itself, reducing the need for multiple Word documents. Use Comments to alert your team to questions and solutions. Each team member must have access to Confluence. If a Confluence license is not available, the document may be downloaded into an unofficial Word format for review and revision.

• Contact Knowledge Management to create a template in the space and build your document without a Word Document.

6. Revision of an Existing SOP

Existing SOPs and Policies are tracked for annual review. Functional Specialists are requested to review and update these documents to reflect current processes as the business evolves OR to indicate that the process is stable.

1. If changes are required outside the standard revision cycle, contact Knowledge Management with the current Thrive Policies and Procedures URL of the SOP in effect and what changes are made.

2. Construct an entry in the Revision History chart to indicate major changes in the document and the responsible participants.

   • Once the new document is complete or updates are made, Knowledge Management will update the Last Update line in that header table to reflect the most recent update.

3. Contact Knowledge Management to proofread for consistency, apply the necessary compliance items, and publish the new piece to the appropriate location. The item will be published in the next publishing cycle.

Knowledge Management will publish updates to the Confluence URL each week on Monday or Friday, depending on the documents in draft or the case of PTO.

If the URL cannot be published, stakeholders will be informed by notification message in Teams.

7. SOP Dissemination

Once the Thrive SOP is approved, the Functional Specialist or Policy Owner is responsible for:

• Notifying the SOP Administrator.

• Ensuring an electronic copy of the policy or procedure is posted on Thrive Policies and Procedures.

• Coordinating the announcement and distribution of the new or revised SOP to Team Members and relevant stakeholders.

• Creating any relevant links to the appropriate Community page.

8. SOP Maintenance

Knowledge Management is responsible for:

• Maintaining, or if applicable, linking the most current, approved version of all policies on Thrive Community and Thrive Policies and Procedures.

• Maintaining an inventory of all Thrive Policies and Procedures and forms in circulation.

• Tracked revision history and compliance and coordinated with SMEs to manage documentation.

• Alert respective Functional Specialists of conflicting or duplicate documents are published and work to streamline these items.

• Providing a solution when documentation storage outside the official collection is needed.

Functional Specialists and Policy Owners are responsible to:

• Communicate with Knowledge Management when there is a change to process outside the revision cycle whenever possible.

• Assist Knowledge Management with the revision process to review and revise existing documentation.

• Record updates in Confluence or other means as necessary.

• Remove outdated information from Community (old PDFs, old forms, SharePoint news posts, etc.)

9. Documentation Review

The Functional Specialists are responsible for the documentation they oversee:

• Review each policy/SOP no less than once per year, or more frequently with changes in technology or process, to determine required revision, replacement, or repeal.

  • SOPs and Policies - Knowledge Management tracks all SOPs and Policies and will notify the appropriate Functional Specialist when the annual review is due. If no changes are necessary for this review, the tracker may be reset for another year.

  • Forms and Reference Assets on SharePoint/Community - Knowledge Management performs rolling audits to identify outdated news posts and non-compliant items. Document owners are asked to work with Knowledge Management to bring items into compliance. This effort is important to ensure our Team Members have direct access to the most up-to-date and reliable information. See https://pathwayvets.atlassian.net/wiki/spaces/TSH/pages/3103850497/Standard+Operating+Procedure+SOP+and+Documentation+Policy#12.1.-SharePoint%2FCommunity-News-Posts

10. SOP Training, Monitoring, and Enforcement

Functional Specialists are responsible for:

• Training all applicable Team Members, including senior management, on the SOP.

• Answering questions about the SOP.

• Specific guidelines for SOP training may be included in the SOP.

Knowledge Management is responsible for:

10.1. Document Presentation

• Items intended for the Public, including hospitals, are published to URL or as PDF in rare, select cases as outlined in the Overview.

• Items intended for the department only are in Confluence or a secured OneDrive not accessible to Community search. These will not be published to Community and will not be pulled through the URL.

• Interactive forms are saved to Community in the appropriate Central Document Library and are accessible through Community search.

URLs are pulled from Confluence using the Scroll Viewport tool. These are secured URLS requiring the user to be signed into Microsoft.

• All official Policies and Procedures for the organization: https://pnp.thrivepet.com/

Knowledge Management will publish updates to the Confluence URL each week on Monday or Friday, depending on the documents in draft or the case of PTO.

If the URL cannot be published, stakeholders will be informed by notification message in Teams.

11. SOP Revision

Using a revision system ensures accurate, up-to-date process documentation and reduces mistakes. This, in turn, increases our customers' confidence in us.

Each department is responsible for maintaining and following a revision cycle. Knowledge Management maintains a Smartsheet to track the revision cycle of every document published through the URL. When triggered, the Functional Specialist is notified that a revision is necessary.

The Functional Specialists are responsible for:

• Updating an SOP between scheduled review periods in response to applicable law or business practice changes.

  • When SOP changes are necessary, forward the proposed revisions to the Knowledge Management. Depending on the scope and nature of the changes, Knowledge Management may require that the revised SOP be reviewed by the Department Head or other responsible Departments affected by the change.

The expectation is that the document is reviewed promptly and either edits are made with associated entries in the Revision History section or the Revision History section is marked with Reviewed: no updates are necessary for this cycle, and the review date with the reviewer's name.

Updates may be made at ANY time there is a change in technology or process. Refer to the Organizational Policy Development Policy for details.

A review cycle is required at least once a year except in select instances.

12. SOP Repeal

It is crucial to prevent outdated versions from remaining in circulation once a new document is created. The policy or procedure may be transitioned to a secured OneDrive location, making it inaccessible to Community search. Alternatively, Knowledge Management can be archived in the designated Archive OneDrive, according to the Records Retention Policy and Schedule.

If the Functional Specialists determine when the SOP is no longer useful, applicable, or more effective if integrated with another, they may choose to retire or repeal the SOP. The Owner will:

• Consult with other key internal stakeholders to ensure the overall impact of repealing the SOP is considered.

The Functional Specialists are responsible for removing outdated items from Thrive Community and, when necessary, communicating with Hospitals about the change in process.

13. SharePoint/Community News Posts and Pages

To minimize legal liabilities and ensure the relevance of Community search results, we must define the length of data storage, ensure compliance with current regulations, and optimize storage space by preventing unnecessary data accumulation. This will ultimately improve operational efficiency and cost savings.

13.1. News

A Power Automate flow is applied to heavy news-producing Community Sites and works to offboard outdated news posts in Thrive Community.

• First-stage retention > 370 days From the First Published Date

• Second-stage (News Archive folder only visible to Owners and hidden from search) > 400 days from the First Published Date

• Final stage (Recycle Bin) 97 days in recycle bin before Microsoft purges.

If the information in a news post is required for longer than that time, create a SharePoint site page or Policy/SOP following the Thrive Policy.

13.1.1. News Exception

There is a build in ability to mark a News Post as an Exception. The content owner is responsible to mark the exception. Please refer to SharePoint Group Owner: News Page vs. Site Page for more information on this asset.

13.2. Pages

Outdated pages may be moved to the First-stage retention for further evaluation and eventual manual purge.

14. Exceptions

As per policy, no official policy or procedure is stored on SharePoint. These official documents are located at pnp.thrivepet.com unless a special exemption is granted and tracked by Knowledge Management and the Legal Department.

Knowledge Management performs rolling audits to identify non-compliant items and work with the document owner to bring them into compliance. This effort is important to ensure our Team Members have direct access to the most up-to-date and reliable information.

Exceptions to this document may be granted on a case-by-case basis with Knowledge Management consultation. Exceptions are deviations from the practices outlined in this Policy and are granted with the expectation that:

• the document is an interactive document - a form, excel spreadsheet, or illustrative PowerPoint provided for training and not intended to substitute for a Policy or Procedure.

• the requesting party will follow the annual revision/review cycle and update all hard-copy documents when modifications are made.

• all hard-copy PDFs will bear the exception mark provided by Knowledge Management.

• a documented business purpose and reason for the exception exists.

15. Related Policies and Procedures

Other Company policies and procedures relevant to implementing this Policy are:

• Thrive Operational Policy Requirements (Policy for Policies)

• Records Retention Policy and Schedule

• Exception Workflow

• SharePoint Group Owner: News Page vs. Site Page

16. Violation of This Policy

Any Employee, regardless of position or title, who violates any provision of this Policy will be subject to discipline, up to and including termination of employment.

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Amendment and Revision History

We are committed to continuously reviewing and updating our policies and procedures. The Company, therefore, reserves the right to amend, alter, or terminate this policy/procedure at any time and for any reason, subject to applicable law. When material changes are made, Thrive will post the changes on our internal website and provide Team Members with subsequent notice consistent with local laws or regulations.