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Consult these six tips for streamlining your policy process

Nurse Leader Weekly, July 11, 2003

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Coordinating updates of your policies and procedures can seem like a bad dream-one that threatens to turn into a nightmare as you ramp up for the massive changes to standards that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is planning for 2004 and beyond.

"We have about 2,500 policies. Now, do we need to have all these 2,500?" asks Linda Donahue, RN, JCAHO coordinator at Saint John's Hospital in Jackson, WY. "I start thinking about this and I almost get palpitations."

Donahue's facility is working on a performance improvement project that aims to streamline its policy development, approval, and storage process. The goal is for every policy and procedure to be updated, accessible, complete, and easy to read. How do you tame the paper policy monster? Here are nine ideas from your peers:

1. Keep your manual online. Update policies instantly online, eliminating the problem of departments accidentally using outdated versions.

2. Don't completely kiss paper goodbye. If you take the electronic route, keep a paper version or two for backup in case of a computer failure-or a court case.

3. Require that all policies be created online if you don't have the resources to create an entirely electronic manual. Every department at Bacharach Institute for Rehabilitation in Pomona, NJ, for example, keeps a hard copy of the policy and procedure manual, but they update changes easily on the computer. After a change is final, Bacharach sends a hard copy to each department to insert in its manual.

4. Sort your policies and procedures by the key functions listed in the JCAHO's Comprehensive Accreditation Manual for Hospitals. That's what Bacharach has done for the past nine years. Sections in the manual are designated for policies and procedures on "information management," "patient care," and the like. How do surveyors like the approach?

5. Create a policy on policies. If you don't control new policies and updates, your manual can quickly degenerate into a disorganized mess. Bacharach solves the problem by making everyone adhere to very specific guidelines in-you guessed it-a policy on creating policies. All new policies, for instance, must include the date of the update and the action.

6. Require that new policies reference a relevant standard. That means a standard from the JCAHO, the Centers for Medicare & Medicaid Services, the state's department of health, and the Commission for Accreditation of Rehabilitation Facilities.

Adapted from: Briefings on JCAHO, www.hcmarketplace.com/Prod.cfm?id=16&S=ENMW.

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