Managing Policies and Procedures in Your Surgical Facility

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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 and/or maintained on a master paper policy manual.

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.

Site 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 SPD department, you may want to cite the  AORN standards, CDC recommendations  and AAMI standards  that were utilized for policy development.

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.

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.

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 so that polices are an integrated part of the culture of the organization. Surgical hospitals and ambulatory surgery centers are praised continually for their flexibility. 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 vice president of clinical operations for Surgical Management Professionals (SMP), which offers many resources that can help improve the policy and procedure management process. 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, please visit www.smpsd.com or call 605.444.8297.

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