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Greeley Reflections

Accreditation Connection, September 28, 2009

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Prudence or wisdom? Can your policies pass muster?

Part 2 of 4

Approximately 5% of the Joint Commission elements of performance (EP) are frequently cited. These are the Joint Commission EPs and CMS requirements that have the seemingly the greatest impact on an organization’s ability to consistently deliver quality and safe care. Consistency is the key and this can be driven by a successful policy and procedure review process.

When developing or revising a policy, “tag” that policy with the corresponding Joint Commission standard and EP as well as creating a link to the CMS Condition of Participation “A” Tag. Once you have this set up as a system, as requirements and regulations are updated or change, it is easy to find the policy or policies and make the necessary changes.

During the revision or review process, take the policy to the bedside. Talk with the staff about the requirements and the methods they are currently using. Identify short cuts that staff have developed. Sometimes these are reasonable and still maintain compliance. Other times, these short cuts can lead to missed steps, resulting in non-compliance. Take the time to talk with the staff to understand why the short cuts or "workarounds" were implemented and help to keep the process sensible to the end user. This will ensure compliance and consistency. Practice will match policy.

Policies that are created from textbooks or in isolation often can create unreasonable expectations of the end user. Implementation of the policy when put into practice and then placed under scrutiny can result in non-compliance because the steps did not make sense and therefore they were not followed. Keep the process simple. Review the minimum expectations and align the policy accordingly. Just because something sounds good on paper does not mean it can be easily and consistently accomplished.

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