10 Thoughts on Managing Policies and Procedures in Your Surgical Facility

Almost universally, creating and maintaining policies and procedures is on the top five list of things avoided and reviled in the healthcare leadership responsibilities list. Is it possible to make this chore into a process that is almost painless?  Well, perhaps not painless, but at least manageable. When done correctly and in an efficient manner, management of the policies and procedures in your facility can be a tolerable and controllable process.

1. Necessary evil or integrated safety and quality tool?

As you are most likely aware, many polices are borne out of a need to meet a regulatory or accreditation mandate. But they are also the means to hardwire processes in your organization. When "on boarding" new staff, it is no longer safe or acceptable to allow casual transfer of information between mentor and the new hire. Polices are your organization's opportunity to hardwire best practice in your facility. In the absence of a leader or manager, employees should be able to find the policy that will assist them in navigating through a situation or process.

2. Governance
While boards of directors will not generally get involved in the nitty gritty of policy development and review, it is important from a regulatory and accreditation point-of-view to be able to demonstrate that your governing body is aware and driving policy management in your hospital or ambulatory surgery center. Make policy revisions and/or additions as ongoing board meeting agenda item.

The adoption or change in some policies may be controversial or will have significant impact on existing practices for surgeons or staff. Making sure your board members are fully educated on these, and involved in the decision, will help ensure they will be champions for telling the story to other stakeholders.

3. Tap into talent
Seek out employees who enjoy and have the talents needed for implementing policies. I had been the director of nursing at an ASC for about five years when one day I was using the PACU nurse's station desk as my office one afternoon. As I was working on updating policies and procedures, one of the staff nurses noticed the grimace on my face, asked what I was struggling with and when I told her that I was working on policies and procedures, she said  "Oh, I love working on policies and procedures." At first I thought she might be teasing me; but, no, this nurse really liked doing policies and procedures. From that point forward, she was my wingwoman for policies — a win for her, for me and the organization. Staff that gravitate toward projects requiring attention to detail and organization and like "wordsmithing" typically thrive in policy and procedure management.

4. Top down or bottom up model ?
Certain regulatory and/or accreditation mandates are relatively clear cut. Managers in the organization will often be the ones to "lead the charge" with these initiatives. For instance, the human resources policy on what pre-employment screening processes your organization utilizes can typically be managed by administrative decision makers.

Other needs for policy development may be more of a bottom-up approach. For example, if a staff member brings something to your attention that needs to have processes better defined in order to promote safety, deliver improved patient care or advance efficiency.

Regardless of the reason for the policy development, make sure the right members of the organization are included in any policies that involve patient care or work flow. The staff in the trenches work need to validate that what is developed in a policy is pragmatic and doable in the real life world of your hospital or ASC. Administration needs to weigh in on any expense or regulatory issues associated with policy implementation or changes. Collaboration between staff and managers will typically result in the "best practice."

5. Paper vs. electronic policy management?
The size and sophistication of your facility will likely influence your ability to offer electronic access to policies and procedures management.  Electronic management of policies is a thing of beauty — it provides "real time" updates — no more travelling to several department policy manuals to switch out obsolete paper policies on a regular basis. It can be particularly helpful in organizations with several departments.  In order for electronic policy access to be successful, you need someone in the organization (or an outsource company) to manage the web server and Intranet. Like other aspects of information technology, the policies will need to be backed up on a regular basis or maintain a master paper policy manual.

6. Frequency of updates
Other than specific policy additions and revisions, an annual review is typically a good frequency to review polices. Again, get staff members involved for their specific department areas to validate that polices reflect current practice and processes. In a larger organization, annual departmental policy reviews can be daunting to tackle simultaneously. It can work very well to develop a monthly calendar to review a couple of departments per month on an ongoing basis.

7. Cite the source
Whenever possible, name the source or resource for the policy. This helps all involved understand the rationale and meaning behind the policy and also gives credibility to the policy. For instance, if you are developing a policy for instrument decontamination in your sterile processing department, you may want to cite the  AORN standards, CDC recommendations and AAMI standards that were utilized for policy development.

8. Getting the word out
As new policies are developed or existing policies are revised, make sure that there is a mechanism in place to inform staff. Consider using email blasts or staff newsletters. More complex policies or changes may need discussion and review at staff meetings.

9. Keep an audit trail
From a risk management perspective, make sure that the policy manager in your organization has a process in place to memorialize policy implementation and revisions. Should an adverse outcome result in litigation, it will be important to document what policies were in place and followed on any specific date.  

10. Walk the walk
With such a focus on quality and patient safety in healthcare, it is important that leaders "walk the walk" with all parties that polices are an integrated part of the culture of the organization. Healthcare leaders are continually making discretionary decisions for the organization based on individual circumstances and situations. However, don't take shortcuts and don't circumvent the policies that are in place, unless there is justification or an unusual circumstance needing flexibility. If staff perceive that it is acceptable for managers to not follow policies, it is an invitation for employees to create their own rulebook.

Overall, the policy and procedure management process can be a daunting endeavor. When managed appropriately and communicated in an effective manner, the process can seem much less overwhelming.

Mary Sturm is the senior vice president of clinical operations for SMP. Ms. Sturm has over 25 years of experience in management of clinical operations. SMP provides a full range of clinical operations process management solutions including policies and procedures management, infection prevention and control, accreditation preparation, quality improvement, compliance and risk management, materials management and much more. For more information, visit www.smpsd.com or call us at (605) 444-8297.

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