Quality & Patient Safety

Policies, Procedures & Competencies - Oh My!

Patient Safety Quality Monthly, August 26, 2009

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"In our organization, we use policies and procedures as interchangeable words; they are just paragraph headings in the same document."

"We are trying to balance the amount of formal guidance we provide. On one side, we want lots of good guidance, but on the other, if we write all that down, it is a burden and a risk if we can't do it."

"A lot of the stuff is just good skills and competencies; they should know how to do that before we hired them. If they can't do it, procedures won't help—we need new people."

If our goal is to get it right the first time and every time, we need to make sure people know what to do. We can't just assume everyone knows all the steps in our processes, so we write it down in our guidance documents (i.e., policies and procedures). We need to train people on certain skills and competencies that they use repeatedly and have them demonstrate back to us that they can perform them.

We talk about policies, procedures, competencies, and skills all the time, but in many organizations, we haven't taken the time to step back and really look at the framework that makes it all fit together. This month, we will provide some thoughts on building your guidance framework and how all these parts fit together.

To ensure that our guidance helps us fulfill our goal of safe, effective, and satisfying care the first time and every time, we needs to do two things:

  • Capture and share our collective knowledge
  • Provide a standard with which to compare our performance

Our written guidance and training programs are key methods to share knowledge with those who use our processes. So how can we define these concepts so we can more effectively manage them? Lets try the following:

Policies: Our policies are our commitments to the outside world, our communities, and our accreditations and regulators. These are the binding corporate promises we make that define what they can count on. For example, when we commit to an EMTALA Policy or equal opportunity employment policy, we are committing that we will live up to the laws and requirements that have been defined outside our facility. Our policies should be short, carefully worded, inclusive of the regulations we will meet, relatively long-lasting, and difficult to change.

Tip: Consider pulling all the policy paragraphs together into one list. Does it accurately reflect what is important to your organization? Does it fit with your strategy? Your strategy and policies should fit together like a hand and a glove.

The outside world should judge us by our commitment and success in delivering on our policies.

Procedures: Procedures are our internal documents that provide the step-by-step sequence for how we should perform a procedurally controlled task. The level of detail of this guidance is dependent on the complexity of the task, the level of experience of the person performing the task, and the safety, risk, economic, or regulatory implications of not getting it perfect. We should be able to change our procedures as our process, people, and equipment change. This means that we probably need to change our procedures more frequently and more rapidly than we change our policies.

Tip: Be careful of combining your policies and procedures in the same document with the same change and approval cycle. This mixes two different levels of approvals together and can often cause long delays in changing your procedures, which results in poor guidance or even increased noncompliance.

Our procedures form the backbone of measuring compliance. If we don't write down a specific set of steps or a specific sequence we want things done in, we can't really complain if people do it differently. We compare how people perform a procedurally controlled task to the procedure to see if they met the standard.

Competency: Not every activity requires a formal written procedure. In fact, too many unnecessary procedures leads to excessive burden, regulatory/accreditation issues, and compliance problems. Your competency programs are designed to ensure that everyone has the skills and knowledge to perform all the tasks that are procedurally controlled and especially that they know what to do, and can do, all those tasks that are not covered by specific written guidance.

Tip: As you are developing your guidance solutions, carefully balance the procedurally controlled tasks with the portions of the process that should be controlled by a competency or by skills training. Consider annotating your process maps so it is clear if each action is guided by more formal written procedures or if it is fully covered by training and a demonstrated competency. If you see any activity that you can't trace the guidance back either to a procedure or trained competency (including all those job aids), you should give it another look and perhaps worry a little.

We evaluate competencies by both demonstration in a training setting and then by observation in a real-world environment. If we start to see problems in performance in our non-procedurally controlled tasks, we may decide to take a look at how effectively we are managing our competencies.

Building an effective approach to provide guidance to all those we are counting on to get it right the first time and every time requires that we understand and incorporate clear understandings of how we make sure they know what to do. If we can assist you in your policies, procedures, or guidance solutions, please give us a call.

Ken Rohde 08/25/09



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