Review Part 1:Developing Good Policies

A well written procedure provides guidance and guidelines for employees regarding how a particular activity is to be carried out. It provides enough information that anyone with the appropriate credentials and skills could utilize it to help to properly perform the designated activity. A healthcare organization normally has a manual of procedures for each department which contains the guidelines for every activity where consistency is important and variation can be detrimental to patient care or operations. Procedures should be reviewed will regularity to make sure they reflect current standards of practice. While policies are normally reviewed less frequently, procedures should be reviewed at least annually.

While policies tend to be general in nature and change infrequently, procedures are very detailed and can change with a high degree of regularity, particularly in an industry where technological growth is changing the standards of practice at an exponential pace. Some general guidelines to following when working with procedures are:

1. While detail is important, it is also important to keep the procedure short enough that it is a workable tool for the staff. A procedure should never exceed two pages and, whenever possible, it should be kept to one page. If it seems impossible to keep it to less that two pages, look for an opportunity to split it up into one or more procedures. If staff are in a hurry, they are less likely to refer a procedure if they have to search through a lengthy document.
2. The procedure should be clearly written and chronological. Procedures must be an easy read for employees. If the goal is to provide guidance and guidelines, the employee should not have to spend much time figuring out what to do and the next step. Steps should be written in the order that they are to be done and in simple outlines. The wording should be written to meet the needs of the audience. As many people read at a fifth grade level or below, simplicity in wording is important in many procedures.
3. Extraneous information such as the rationale for each step should be limited and is frequently best suited to the training materials about the procedure. Rationale or “why statements” do belong in a procedure if they provide important information to assist the employee in making “either or” decisions. Procedures outlining ACLS protocols are a good example of this. There are a series of treatment choices the staff must make depending on the cardiac rhythm that the patient is in and the patient’s response to prior treatment. The rationale for these choice must be part of the procedure.
4. Avoid “ly” words such as appropriately, adequately, and significantly in procedures. As procedures are designed to provide detail about how something is to be done, soft words such as these that require ranges in judgment are not best suited to procedures. As a procedure frequently needs to provide guidance to people who may have very little knowledge about the task at hand, detail is critically important.
5. Procedure statements are clearly action oriented and normally include:
   • Who is to perform the activity. If multiple people are involved with multiple skill levels, the procedure should clearly outline who does what. **When the activity is to be performed.
   • Where the activity is to be performed.
   • How the activity is to be performed.
   • Why the activity is to be performed if that information is important to making the correct choice in activity.
   • What activity is to be performed.
6. Not every procedure requires a policy. Often, value space is wasted in a procedure attempting to include a policy statement. While most policies have associated procedures as the procedures outline how the organization incorporates the policies into every day life, procedures do not always need to have a specific policy attached to them. For example, it may be a hospital policy that patients will receive high quality, state-of-the art care. From this one policy comes hundreds of patient care procedures across the organization that outline how each patient care activity is performed to assure that it is high quality and state-of-theart. It is not necessary to repeat that policy on every procedure form unless it serves some important value in helping staff to perform the activity.
7. Procedures must be written to benefit the staff. They must be written in as user-friendly a format as is possible.
8. Procedures must be well-organized and easily accessible. While there are limited circumstances when a patient or other is harmed if it takes a little time to locate a policy, patient and staff well-being can clearly be jeopardized if it takes too long to find a needed procedure. Staff should be able to retrieve a needed procedure at a moments notice.

Healthcare organizations should have a clearly defined procedure for staff education whenever a policy or procedure is added, updated or deleted. Records should be retained that demonstrate what training took place, the content of that training and who participated. Copies of all past policies and procedures should be retained with documentation of the date that it was deleted or revised. If a healthcare organization changes their policy and procedure management system (such as changing their numbering system), there should be documentation that clearly outlines how the new management system ties back to the prior system.