Who is running the policy and procedure ship?

The Patient Captain

Make sure you get a competent patient captain to run your policy and procedure ship!

It seems like common sense when it comes to getting the right person for the right task. Let’s face it, you wouldn’t take your new car to just any shop, nor would you go to just any doctor for a heart condition. You would take your car to a shop with trained mechanics that know your car brand, just like you would see a cardiologist who specializes in heart health.

It’s not that we lack this common sense; the reality is, that currently in healthcare, there are so many competing priorities and pressing matters that we often get anyone to fill the P&P captain position. Worse yet, with budget cuts, we might lean to consolidating the open position and add the tasks to the workload of an already overloaded employee.

Back To Basics

When we are talking about policies and procedure management, you don’t see a great deal of people fighting for the position. Personally, being one that enjoys this line of work, it saddens me to be in the conversations that begin, “So… what do you do exactly?” My response is that I wear many hats, one of which is to help develop policies and procedures, and evaluate the policy and procedure flow within an organization.

Their response is usually something along the lines of “How can you stand to do that kind of work? I find it so dry”.  I then get on my soap box and explain that policies and procedures guide all the work that is being done in the organization. From how payments are processed in accounts receivable to how to maintain a chest tube on a surgical patient.  Where do staff turn to find out the standard of how things are done? Without a policy or procedure, we would have no consistency and no baseline for which to evaluate competency fairly.

In addition, for legal purposes, the attorney bases his or her case around how we delivered services as compared to our policy and procedures, ie. the established way of doing things at our facility.

The Watchmen

Well, then who should be the person in the watch tower ensuring it is happening the way it should? If you look at the regulations, it is leadership that approves the nursing policies and procedures. So leadership would be key in the discussion about roles and responsibilities. The process in place has to work for them. It has to be realistic if they are going to be part of it’s success.

So, when someone asks me what I do to ensure policies and procedure management is made easy, one of the first things I tell them is that I engage leadership in the design and decision making. They need to be bought into the patient safety risks if the process doesn’t work well. They need to be involved in the IT piece and vendor selection. They need to discuss the plans with management and front line staff during safety rounds.  And they need to be involved in every piece of implementing a new application, including review of literature for best practices and for the ongoing maintenance of the system as well.

One For All & All For One

No, this doesn’t mean the CNO is doing all of this alone. There is delegation, of course, to other competent staff who find this job important and are passionate about patient safety. The bottom line is that the CNO should not just be the signature on the policy or procedure – their role as captain is critical to the success of an effective policy and procedure management process. If they are not already there – you can be the catalyst for change to help them at the stern.

Best regards,

Nicola Heslip | Policy & Patient Safety Specialist | PolicyMedical™

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