Policy and Procedure

Development

12/13/18
Accreditation Preparation Process
Organizational Policy and Document Mock Survey
Assessment Procedure Technical
Review
Evaluate your Development Assess your
Assistance Reassess current
performance 6
current performance
against the Develop new plans, policies, Use experts to months prior to
standards and polices and and procedures address survey to allow you
create plans and procedures that for compliance persistent or enough time to make
structures to drive comply with JCI with JCI difficult last minute
improvement standards standards problems adjustments

Create New Processes Monitor Progress and Adjust

Develop and implement Evaluate effectiveness of
new policies, plans, and processes and refine as
procedures necessary

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Definitions
 Policy: a written course of action or rule.
 Procedure: a specific written method, routine, process,
or action used to comply with policies. Procedures are
normally tied to policies, but may simply be written
instructions for accomplishing a task.

 Policies and Procedures both:

• Prescribe how an organization will function.
• Are the rules and methods of operation in healthcare
services.
• Are an integral part of your organization’s structure,
which drives behavior
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Key Questions
Ask these questions before you get started:

1. Is this policy absolutely necessary?

2. Is this policy and/or procedure an accurate
and true reflection of what we do?
3. Is this policy and/or procedure easy to
understand and follow?
4. Is this policy accessible to everyone who may
need to reference it?

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Strong Policies Create

Strong Internal Controls
 Think of your policies as part of your internal control
structure. They help ensure:
1) the safeguarding of patients,
2) efficiency of operations,
3) control of assets,
4) achievement of goals,
5) the reliability of information reporting, and
6) compliance with laws and regulations.

 These elements form the framework of leadership,

proper governance, and successful healthcare
practices.
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Suggested Elements of Good Policies

Creating Titles for Policies
 Use a short, 2–4 word title that describes your
policy. For example:
Emergency Admission Policy
Intake and Admission of Emergent Patients Seeking
Care and Services

 Good policy titles are:

• Easy for everyone to understand quickly
• Clearly describe the content of the policy

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Suggested Elements of Good Policies

When Using Dates in Policies,
Include:
Initial date of policy
Revision dates
Expiration date (if applicable)

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Suggested Elements of Good Policies

Purpose of the Policy
A short description:
• Explains why this policy is important
• Summarizes the outcomes the
organization hopes to realize as a
result of this policy

Definitions
Clarify any words or unique terms used
in the policy document with clear
definitions. 113
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Suggested Elements of Good Policies
 Example of Purpose:

Purpose
To guide nursing staff in the safe disposal of
sharps, in order to:
1. Reduce the incidence of needle stick injuries
2. Maintain safe work spaces for all staff
3. Prevent illness and infection through unsafe
handling
4. Prevent injuries to patients and visitors

Even good policies can be improved. Take the time to

critically examine your policies to look for ways to be more
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clear and concise!

Suggested Elements of Good Policies
 Example of Purpose:

Purpose
To guide nursing staff in the safe disposal of
sharps, in order to:
1. Reduce needle stick injuries
2. Maintain safe work spaces
3. Prevent illness and infection through unsafe
handling
4. Prevent injuries

Even good policies can be improved. Take the time to

critically examine your policies to look for ways to be more
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clear and concise!

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Suggested Elements of Good Policies

Responsibility
Explain who must comply with the policy

Activities
List the required steps:
• Simple – Use words everyone understands
• Practical – Ensure steps are reasonable and
doable
• Specific – Leave no room for individual
interpretation 116
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Suggested Elements of Good Policies

 References: Any laws, regulations, or

other requirements such as JCI standards

 Attachments: Any forms used for

implementation, or procedures not
included in the body of the policy.

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Policy and Procedure Development

1. Who owns the process? Policy
Committee? What is their makeup and
authority?
2. Do you have an accurate and practical
policy on policies (MOI.8 and 8.1)?
 Defines responsibility, organization,
revision frequency, structure, and
elimination, among others
3. Is there a master list of all required 118

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Organizing Your
Policies and Procedures
JCI suggests organizing policies into 3 categories:
1. Clinical
 Hospitalwide (do not include department-specific
policies)
 Based on scope of services, best practices, local
laws, and local customs
2. Managerial
 Hospitalwide (do not include department-specific
policies)
3. Regulatory
 Can include in above or separate and cross- 119

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Organizing Your
Policies and Procedures
 Can be hard copy or electronic format
 Should be organized for easy access:
—alphabetical, numerical, clinical and
managerial, or by topic (blood and blood
products), etc.
 Should be indexed and cross-referenced in
multiple ways for easy access (title, topic,
number)
 Should not be based on a system that may
change frequently, like JCI standards chapters.
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Creating Policies
and Procedures
Two options for creating policies:

The Easy Way The Harder Way

1. Find another 1. Develop your own
organization’s policy.
policy.
2. Replace that 2. Revise the policy
organization's based on actual
name with yours! performance.
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What’s Wrong with the Easy Way?

 No organization functions exactly like yours.
Copying from another organization is an easy way to get
your staff to ignore your policies.
 Instead, developing your own policies will give
you an opportunity to really examine:
• Accuracy
• Effectiveness
• Impact on patients and staff
• Opportunities for improvement

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Creating Policies
and Procedures
Two options for creating policies:

The Easy Way The Harder Way

1. Find another 1. Develop your own
organization’s policy.
policy.
2. Replace that 2. Revise the policy
organization's based on actual
name with yours! performance.
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Writing Policies and Procedures

How long does it take?
 1-4 hours per page for a new policy from start
to final edit
Before you write the policy:
 Learn about the subject.
 Observe the practice.
 Interview staff about the practice. Ask what they
would need to be more efficient or safe.
 Research evidence-based practices and
procedures for the topic. 124
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Tools for Developing

Policies and Procedures
Process Mapping
 What are all the steps that we need to
consider in this process?

Machines
Machines Cause 1
Materials
Materials Cause 1
Materials Cause 2
Root Cause Analysis
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Sub-subcause

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Machines Cause 2 Sub-subcause

au

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Sub-subcause

 How did our policy or procedure fail us

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Sub-subcause
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Sub-subcause
au

Sub-subcause
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se
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Sub-subcause
Sub-subcause Sub-subcause
au
a

Machines Cause 3
se

The basic
explanation of
Methods Cause 1
the problem.

during a specific incident?

se

Sub-subcause
au

Methods Cause 2 Sub-subcause

bc

Sub-subcause
Manpower Cause 1
Su
se

Sub-subcause
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Sub-subcause
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l ca
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leve
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Sub-subcause
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Sub-subcause
4 th

au

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4 th

au
4 th
Su

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Sub-subcause Sub-subcause

Manpower Cause 2
bc

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Sub-subcause
Sub-subcause

Methods Manpower
e
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leve
leve

4 th
4 th

Failure Modes and Effects Analysis

 How might our new policy or
procedure fail us during a future
incident? 125
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8 Policy and Procedure Pitfalls

The most common reasons policies and
procedures are ignored or fail, include:
1. They are out of date.
2. They are too long and wordy.
3. They are unclear, complicated, or difficult to
understand.
4. They are too generic or general.
5. The formats are inconsistent.
6. They are poorly designed or hard to read.
7. They are difficult to find (individual policies) or hard
to locate (locked, few copies, denied access).
8. They were developed “The Easy Way”. 126
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Implementing Policies and Procedures

 Implementing policies and procedures is more difficult
than writing them.

 You will spend:

• 10% of your time in development
• 90% of your time in implementation

 The better the policy, the easier the implementation.

 When a new policy requires a change in practice, allow

sufficient time for education, coaching, and monitoring.
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Planning Implementation
⎻ Key questions to answer as you create your
implementation plan:

1. Who will design and present the training?

2. How and when will the training be done? In what forums

(orientation, annual training day, quarterly)?

3. How will information about training be communicated to

staff? Who will monitor attendance?
4. What is the process for on-site coaching?
5. Who will monitor compliance with policies?
 How frequently?
 Reported to whom?
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The Bottom Line About Policies

⎻Most organizations spend a great deal of
time focusing on what they want their
policy to do, and very little time focused
on how to express it.

Short Read
Direct
Clear
= Followed
Understood
⎻ 129
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Questions?
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