TIPS FOR WRITING EFFECTIVE POLICIES

1. TIPS FOR WRITING EFFECTIVE POLICIES Jennifer Cowel, RN MHSA Patton healthcare consulting

2. Reasons for Writing Policies and Procedures • Helpmake instructions and guidelines definite and help in the interpretation of policies and procedures • Provide quick settlement of misunderstandings • Help reduce the range of individual decisions and discourage management by exception • Cover recurring situations such that managers can begin to make decisions that will be consistent every time • Set boundaries for jobs so that each employee knows in advance what response he or she will get from others when taking actions, making decisions, and giving responses • Provide protectionin the event of an audit or lawsuit

3. Do’s and Don’ts

4. Definitions

5. Basic Steps: • Identify policy/procedure topics • Conduct research • Ensure current regulations are taken into consideration • Ensure evidence based practices are taken into consideration • Write the first draft and getting it reviewed and revised • Obtain approvals, publish, and distribute documents • Issue communications and conduct training • Audit to ensure policy is being followed • Analyze documents for improvements and make revisions • And the cycle continues...from writing to revising to writing to revisions...

6. SECTION HEADINGS • Header – Logo, title, number, dates, approvals • Subject • Purpose • Table of Contents • Policy • Definitions • Procedure • Documentation • Monitoring • References • Approval of policy and procedure

7. COMPONENTS OF A POLICY AND PROCEDURE SUBJECT The title of the Policy and Procedure PURPOSE OR DESCRIPTION A summary or explanation describing the philosophy for the content of the document/process. TABLE OF CONTENTS For lengthy (greater than 5 pages) Policy and Procedure, it is recommended to have a Table of Contents to assist the user in navigating the content of the P&P. POLICY A policy statement identifies the non-negotiable elements of a process. The policy statement address what is the “rule” rather than how to implement the “rule”. Example of a policy statement: Only Registered Nurses who have demonstrated competency may administer intravenous medications. DEFINITIONS Many processes have unique terms. In order that the end-user is able to understand the intended language/concepts, it is recommended that pertinent terms be defined as the beginning of the P&P. PROCEDURE The procedure section should provided the end-user with complete information required to complete the task/process/function.

8. Writing a Procedure The procedure should: • Be developed with the end-user in mind. • Be written to that the process can be easily followed by all users. • Designate all that is required in a process. • Include a particular course of action intended to achieve a result. • Be a written set/sequence of defined steps and detailed elements to produce a specified result. • Be an evidenced based way to accomplish an objective. • Be a written instruction for a task that outlines the preferred and safest method of undertaking a task. • Be “hyperlinked” with related policy and procedures.

9. Tips for Doing it Right • Address only one topic per policy. • To close the gap between policy and practice, the first step is to write a well-crafted policy that actually reflects the elements of care at the bedside. • Writing policy calls for more than knowledge of the policy content – it requires an understanding of how to communicate the information most effectively. The goals of an effective policy are different from the goals of the education associated with communicating the policy. • Keep it clear and brief • Use clear, direct language – delete unnecessary words. • Use short, declaratory sentences. • Keep policies as brief as possible • Use positive language whenever possible. • NO acronyms or abbreviations that are not defined. • Use a consistent style and terminology. • Make sure the title accurately reflects the topic. • Test the policy – ask people to tell you what they think it says. • Avoid “reinventing the wheel” – review sample policies before drafting a new policy. • Establish the minimum expectations surrounding a particular activity or action;

10. Tips for Doing it Right • Outline the responsibilities of the individuals involved; and, • Set minimum rules for documentation or communication (as applicable). • Policies communicate concepts, while procedures are a set of steps. • Procedures should be logically communicated, indicating what should be first, second, and third. Consider creating a flowchart of the process prior to converting it to policy format. • Before writing, determine essential messages, such as regulatory elements, what to do, safety aspects, and important documentation elements.

11. Tips for Doing it Right • Establish actions and “rules” to comply with regulatory requirements in the context of your organization. Consider the use of regulatory language, as it is a general guideline with flexibility on implementation • Joint Commission • CMS • CDC • AORN • Do not set expectations that cannot be met in a live patient setting, as policies and procedures should set only minimum expectations for care.

12. Tips for Doing it Right • Be cautious when copying policies from other organizations or policy templates. They often contain references to parallel processes not in place in your organization. Change references to other hospitals and procedures that do not apply at your organization. • Ask a “non-healthcare” person to review the final version of the policy for clarity. Does it pass the “essential messaging” test? • What am I expected to do and not do? • What comes first, second, third? • What should I watch our for? • Assessment guidelines, side effects, warning signs • What do I do if . . . ? • When to call the physician or administration • What do I document? • Documentation guidelines • Where can I go for more information? • References • Once the policy has been finalized, it must be communicated to clinicians. Whether or not a policy is followed can have as much to do with the way it is communicated as the policy itself.

13. Questions: Jennifer Cowel JenCowel@PattonHC.com