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Assessing gaps in policy management

How do you become well-equipped to navigate through the difficult process of assessing your organization for gaps in policy management?

I recommend using a tool such as a checklist to help you remember all the key points in the process. A complete assessment is necessary to ensure you don’t miss any vital information that would affect rolling out a new policy management system.

I recommend making a checklist for each audience. First the front line staff that accesses the policies to deliver patient care. Then the ancillary staff that likely has their department specific policies- for example: environmental services or pharmacy. The checklists would need to collect the same generic information such as:

Do you know where to find organization wide policies?
Do you know where to find your department specific policies?
How often do you access the policies?
How much time do you spend looking for the policies?
Can you please show me where the policies are kept (have them take you. In my experience staff may say the policies are where “they heard” they were kept and really don’t know if that is accurate) so this is a good test.
Once you are with the staff member and opening the binder or file- pick a policy title and have them retrieve it ( let’s say on complaints) or if you are not on a patient care unit- ask them to find an employee policy on vacation. Notice if they seek the table of contents or index or if the binder has tabs and they know which tab to go to. Notice if the book seems foreign to them (good indicator- they are not experienced with using it).
Ask them if they know the policy is still current? Can they locate the date of approval or revision?
Notice if there are multiple copies with the same title in the binder? Ask them if they know who keeps up the binder (purging the old and replacing with the new).
Ask them if they know about a policy committee or how policy changes are made and disseminated to the staff? Do they get an email with it attached? Do they get a copy? Do they read the staff lounge copy and initial is when they have read it?
For your leadership audience- ask the chief nursing officer about the approval of nursing policies and how that takes place? Is there a policy on policies? Does the CNO attend the policy committee to ensure the process is being followed? Have they performed a cost benefit analysis to determine how much time and money they spend managing policies they way they do? Just having 10 staff at a 4 hour policy committee meeting ($40/hr x 4 hrs is $160, x 10 is $1600), some organizations have all day meetings and the hourly wage can be more for senior leadership). This does not include staff time wasted accessing the binders and searching for the paper copy.

After collecting the information, you will now need to analyze and compile your findings!

Best practices committee: can you afford to not have one??

More often than not, the internal structure and existence of committees can be confusing. To avoid confusion and prevent “renegade” committees, the hospital should take a tally of what committees they currently have in place. They should check to see if a charter exists for each committee as well. Committees can begin with a purpose and then sub groups or “ad hoc” committees are formed to do the work of the larger “core” group. When the work is completed, the committee or team can disband. It is alarming to see some committees continuing to meet because they have not had closure. There is no need to meet just to meet.

Do you have committees doing similar work? Is there a nursing best practice committee working on blood administration policies at the same time the transfusion committee is revising the blood administration order set? The policy and order set go hand in hand, so each team is affecting the other and this causes confusion. The team working on the order set likely has the policy (that is current but in the works for revision!). The team working on the policy likely has gathered the relevant documents impacted, such as the most recent order set (which they don’t know is being revised!) There will be more work for each team as well, since changes will need to be made. This means more time and money for the organization!

There are committees that hospitals are expected to have in place, so in those instances the organization should ensure there is representation of those departments affected by the agenda items.

A strategy that helps hospitals limit those teams working in “silos” is the formation of a best practice committee. This is a multidisciplinary team of staff meeting regularly to address practices mandated by external agencies (such as CMS and The Joint Commission Core Measures (SCIP, AMI etc, or the NPSGs), as well as internal practices such as implementation of a bar-coding medication system to prevent medication errors.

This team should consist of staff who are content experts. In terms of membership; it should have an administrative sponsor, representation from nursing, medical staff, front line staff, and ancillary staff (i.e. pharmacy), as well as other departments on an ad hoc basis depending on the topic. If the organization encompasses a clinic network, there should be a clinic representative as well. Recruitment of the frontline staff should be a collaborative effort with the committee leader and department manager. Often the manager will know of staff that can be off the floor to participate, and know which staff has an interest in the type of work the committee will be doing.

The committee’s charter should be specific, with all members clear about why they are being asked to work on the team, and what they can expect.

This team should be the “filter” of what is going on in the organization. The warehouse of information about what needs to happen and recommending an existing team do they work or do the work themselves.

Making the connection: bringing together IT and patient safety staff to improve systems

I have experienced a disconnect between healthcare IT departments and the quality/patient safety departments within those organizations. A hospital is a large entity made up of systems. Within those systems are systems and so on. The entire hospital can be affected by what happens/doesn’t happen in those subsystems since all of them put together make up the whole. In our daily operations we are used to living in our “silos” and it is only when the outcome we get is not expected do we really look outside our silos and work together to solve the problem.

An example of this was when a nurse expressed her concern that she had to share a dept printer for obtaining medical record information. She had to leave her patient, walk through the secured double doors down the hall about 75 feet to the other printer to retrieve that document. She then walked back to her area and placed the form in the patient record and proceeded with patient care. Was the document important enough to have to go to that trouble? Answer: yes. The information on the form was obtained upon admission and vital for her assessment and patient history. It was great that our IT system built that form and had data dumping ability. ADT feeds are great and automating documents for nurses is time saving. The problem was that in her dept they did not have a printer. The new space they were in was not configured for a printer. At the time the space was designed the automated form had not been developed so nobody thought to ask how the staff would get it.

I looked at the entire process and potential risk to patients when the nurse would have to leave the patient alone (often only two nurses were on the floor at the time). I asked the manager about the flow and concerns from staff and it was agreed that the current set up could be improved. Many times apparently IT was notified that another printer was needed. The nurses in the dept voiced the need to IT but did not explain the rationale behind the need. IT felt the nurses were calling to complain and there was a rift between them. IT did not get a printer initially because of other IT priorities and projects going on at the time. Budget was also a reason to hold off unless “urgent”.

When I mapped out the unit’s flow and current system and met with IT, I explained the scenario - if their mother was admitted and the nurse left her to go get the electronic info from a printer 75 feet away etc. IT staff stated that if they had known the context of the need they would have made it a priority. In addition, they said they had appreciated the “data” and process mapping that was done to help them prioritize and be able to justify cost and dropping other pressing projects to meet the staff needs. Immediately a call was made to get an outlet created and another printer installed in that dept. They began to understand how critical IT’s role is to improving patient safety- and also how to work with quality/patient safety staff in the planning phases as projects are being initiated. Today, the nurses are satisfied that they were heard, less time and money is being wasted with staff walking to get documents and patients are getting the safe care they deserve

Do's and dont's of policy writing

Patient safety is truly the foundation of any healthcare organization. It is a way of thinking. A way of acting. Really, it’s a vision to do no patient harm. When we think about how documents like policies and procedures guide patient care, our thought process is that, by following them, there will be a positive outcome, eg. patient safety. But in truth, excellent care given is a reflection of a well-written policy or procedure.

Healthcare policies and procedures are molded and shaped by many factors. One is healthcare regulations, like state and federal mandates. Another is evidence-based practices, as we have seen with the patient safety movement. Lastly, there are accreditation standards that impact the content of policies and procedures, such as those set by The Joint Commission. Creating these documents is an art and with any form of art, we know that the expertise doesn’t develop overnight. That being said, here are some key points to consider when creating the tapestries that guide our healthcare providers.

Finding a Thought Expert
Policies and procedures should not be written by those that are not experts on the topic. Consider the organization who asks their compliance officer to single-handedly write policies related to informed consent. Yes, there are some compliance officers with a background in healthcare law, who know about consent and what is required by the State or CMS; for example, they’ll know that only a licensed provider can obtain informed consent. But consider this: do they know…

What the current process in the organization is?
How the informed consent form gets to the physician for use during the process of obtaining consent from the patient?
How the copy finds its way into the chart if consent is obtained in the doctor’s office?
When the nurse witnesses the consent?
How to meet the needs of non-English speaking patients during the consent process?
Whether the interpreter witnesses the consent?
What auditing is done to ensure that the forms are being completed per CMS guidelines?

All of these elements – and more! – need to be incorporated into the policies and procedures for healthcare staff to reference. Is the officer writing your policies equipped to answer these questions?

One Size Does NOT Fit All
Policies and procedures should not be written under the assumption that one size fits all! For example, a hospital may have read the requirements for the Joint Commission’s National Patient Safety Goal on Hand Off, and they may have decided that SBAR (Situation Background Assessment and Recommendations), a model that is evidenced-based and commonly used for physician-nurse communication, is the right one to cite in the general policy related to Hand Off in that hospital. However, an area of the hospital may be using a different tool that meets the intent of this safety goal, and precautions need to be taken to make sure that all other policies on Hand Off should cross- reference this department-specific policy.

Too often, a policy committee will sit down anxiously and work on a new policy without first identifying any existing policies on that topic. If there is an ambulatory center or primary clinic under the hospital’s license, those areas are considered another “department”, and the hospital policy committee needs to ensure that those departments’ policies are reviewed as well. A big mistake is to make a generic house-wide policy on Hand Off that ignores what is being done elsewhere. During the survey, the surveyor will surely visit those other areas and find a completely different policy on Hand Off. This is when you’ll get caught for your lack of oversight. But as long as the generic policy acknowledges or reference the department specific policy, and there is some way to link them, then you avoid those “silos”.

Originality is Underrated
A common problem in the world of policies and procedures is the existence of a document that is just a copy and paste of the literature source. Policies and procedures should not be merely a page torn out from a textbook! Yet, too often, I see clinics that have guidelines from the same reference book that just lists all the policies and procedures in order, based on the patient’s condition. In practice, if the patient calls with stomach pains, they look at the guideline that states see pg 125 of reference X. The nurse then looks at pg 125 and sees the protocol to follow for that patient. They would document in the triage record that they used Reference X per protocol and pg 125.
There have been policies that mimic the content from The Joint Commission’s CAMH (Comprehensive Accreditation Manual for Hospital) word for word. Having language from regulatory texts is not the problem - it shows the surveyor reading the document that the organization is aware of the requirement. The difficulty, however, is when the copy and paste text includes so much irrelevant information that it discourages the staff from reading the policy in the first place. It gives the staff incentive to sign off on it without reading it thoroughly. Even worse, there are times when staff has been instructed to carry out a procedure in a way that is standardized to that hospital, but the copy and pasted material utilizes a completely different method. When the surveyor comes, staff is asked about the policy and they state something different from the actual policy.

It is useless to simply ensure that the policies and procedures in your hospital reflect the requirements stated in reference books if they’re not written in a way that’s easy for your front line staff to interpret and apply. In between surveys, hospitals complete the Joint Commission PPR (Periodic Performance Review), which is a self assessment of how they are meeting the standards. Sadly, it is a disservice to the hospital if they score themselves compliant because the policy contains the wording of the requirement but that is not actually how it is done in the organization.

Standardized Formats
Time management is a key issue for all staff that cares for patients. Having the policy or procedure easily accessible is great, but can the staff find the information that they are looking for within the document with ease? Policies and procedures should be written using a standardized writing format or style, so that staff members looking up any policy will know what section they need to go to for the right information. The organization needs to choose a format and stick with it.

There are experts in this field like Stephen Page, who have excellent resources for writing policies and procedures. His format consists of eight parts: Purpose, Persons Affected, Policy, Definitions, Responsibilities, Procedures, Document Approvals and Change History. His books explain what content goes in each of these sections. Having all the policies and procedures in a standardized format also makes them easier to revise. For example, if The Joint Commission changes their standard on Hand Off, and it means a change in nursing practice, that information would be added to the procedure section of the document. The individual revising it would just go to that section versus reading through the document and plugging content in it. Often, there is a lot of narrative text in a procedure that doesn’t flow well and someone may have to fumble with where they are supposed to insert the information. Adding words to a document that guides patient care is not a crap shoot.

Finding the Right Policy Reviewer
Policies and procedures need to be reviewed by a regulatory expert, and preferably someone who has experience in patient safety. One who can also filter for risk/legal issues would also be of benefit. The person writing policies should have experience with and the skills to facilitate policy development, which means ensuring that all the right people review the documents. In addition, this person could wear several hats, such as clinical risk management, regulatory compliance and patient safety. By wearing these hats, this person will be able to map out work flow processes and perform gap analyses based on the requirements. They can read the policy or procedure and determine what is not currently being done by staff and what should be tweaked to make the actual process match the document. If a requirement dictates a complete change in how care is delivered then that will mean communicating the behavior change to the educators for implementation. A likely place to find this individual is in the quality department.

Front Line Staff Involvement
A critical component of policy and procedure writing is front line staff involvement. This can be represented by having a consultant and/or a standing member of a policy and procedure committee during the initial phase of policy and procedure development and the pilot/pre- rollout phase of implementation. The bedside caregiver uses the policies and procedures and knows best in terms of what is current practice. A group of leaders and compliance staff can meet and come up with an “ideal” process, but they need to find out what is really happening on the floor. Involving staff can help avoid the hassle of re-working policies and procedures that were a result of assumptions.
They also are more prone to buying in to the change that comes from a new policy or procedure, if they were allowed to provide feedback and insight in the beginning. After all, it impacts their work flow. We should work with them to intermix what has to be done with how we can best make it happen.

Often the nay-sayers appear whenever there is a change in practice because they feel overlooked in the whole decision-making process. To them, it appears that without warning, they come to work one day, to find that the policy and procedure they use regularly has been changed and they are told it has to be done this way. They see it coming from “higher ups”, and if the change is not realistic or it doesn’t appear that they have considered “x, y, z”, then there will be considerable push back from the nursing staff. These are the situations in which we find that nurses are not “compliant” with carrying out the practices stipulated in the policies, or are not documenting in the records as expected. Later we find out that the policy was rolled out without communicating the impact on the charting piece or the forms. Nurses need to be involved to make this a win-win situation.

In Conclusion
To summarize, many organizations feel they are “compliant” with regulatory requirements because they have a policy or procedure that is appropriately titled after the name of the regulation or standard they represent. Having a policy or procedure titled Hand Hygiene is a starting point, yes. But has the content been written by an Infection Control practitioner? By someone who is an expert on the subject, and has been on the floors rounding for Infection Control surveillance? Is the policy written to cover the hospital as well as outpatient areas? Does it ensure that the content is specific and relevant to those settings? Remember: one shoe size doesn’t fit them all. Is the policy content a word-for-word version of Mosby’s textbook for nursing practices? Or does it incorporate how the process is actually practiced in the facility? Is the policy in a standardized format so that staff can quickly scroll through it to find the information they need? Has the Hand Hygiene policy for example, been looked over by a patient safety expert who has that regulatory/legal eye? After all, this person is key to interpreting the standards. They can decipher what the standard is really going for, and make sure that – for example – we don’t make our policies and procedures more stringent than necessary. And at the end of the day, they can translate what the policy stipulates, aka what needs to happen, into a realistic process. This individual knows the organization from doing safety rounds on the units and has a close relationship with the staff.

Lastly, look into whether the policy or procedure had been tested on the staff. The patient outcome is determined by the policy or procedure. Nurses carry out what those documents state. Engagement and trust are key to a successful rollout. Let them be part of decision making when it comes to practice. Bring them on board. You are sure to move into a culture of policies and procedures that makes compliance and getting ready for the next survey, as natural as getting ready for the next patient.