20 de outubro de 2020 , por
Institute for Safe Medication Practices. Guidelines & Recommendations When a new policy or procedure pertains to the use of a new medical device, pharmaceutical agent, or clinical procedure, hands-on training may be warranted, in addition to sharing information about the written policies. By reporting them to management, with the expectation that they will be investigated and addressed, the potential for patient harm may be reduced. The purpose of healthcare policy and procedures is to provide standardization in daily operational activities. There is little agreement among healthcare regulators, accrediting bodies, and provider organizations about the definitions for terms such as policy, procedure, and guideline. Ensure responsibility for carrying out each action step is explicitly stated, not implied. Whether your facility is a multi-state hospital, a small podiatry practice, or a regional rehab center, you should have facility-specific policies that cover the way in which your facility cares for patients. In such circumstances, the staff member must understand the need to document the rationale for that decision—and the manner in which the procedure was modified—in the patient’s medical record. For instance, stating that “X action shall be taken” does not specify which staff member is responsible for carrying out the task. It may also be helpful to put a URL link to those statutes. Policy and Procedure Development Guidelines. Simplify Compliance LLC | Copyright © 2020 HCPro. HIPAA, EMTALA, CMS Conditions of Participation, DNV/Joint Commission). Health care policy and issues can affect providers and the patients they serve at different levels and in many different ways, some critical. Medication Safety Alert! Rather than develop its own policies on this subject (which would likely be shorter and oversimplified when compared to this manual), a hospital-based radiology department may wish to endorse the staff’s use of this manual, with the proviso noted to the right. The Corporate Compliance Office and the Legal Department are well-suited for this responsibility since many policies pertain to regulations. Clinical situations may warrant adaptation due to unique patient characteristics. Promote compliance with regulations, statutes, and accreditation requirements (e.g. Put the policy title/number in the header of each page. The following strategies represent best practices observed by the author: The risks associated with writing, updating, and implementing policies and procedures are often under-appreciated by healthcare managers. Citing a reference as the policy may be appropriate in a narrow range of situations. Issue policy development guidelines and train managers in their use. Create a system-level policy and procedure oversight committee with multidisciplinary membership and representatives from all entities. Corporate negligence on behalf of a hospital that failed to adopt appropriate policies, adequately train the staff with regard to these policies, implement them, or evaluate how they are used (Destache, 2013). Put the policy title/number in the header of each page. Creager, R. T. (2008). Policies and procedures of the following types lend themselves to being “system” policies: In the event a specific policy does not apply to one entity in the system (i.e., Hospital X does not have an emergency or OB department so EMTALA may not apply), the system policy can specify that it does not apply to Hospital X. To optimize the usefulness of electronic libraries: Healthcare risk managers are encouraged to collaborate with other senior leaders in their organizations in order to maximize the usefulness of policies and procedures and reduce potential associated risks. Healthcare risk managers, particularly those shifting to an Enterprise Risk Management approach, may wish to draw upon the ideas in this article as they: a) collaborate with system leaders in developing “system-wide” policies and procedures (modified to meet a unique characteristic of a specific entity); b) meet with department or service line managers to identify optimal policy formats and content; and c) offer input to corporate leaders regarding policy review and updating practices. Some red rules shouldn’t rule in hospitals. In years past, paper policy manuals often included a “cover sheet” as a sign-off page, which showed the date of approval and signature of the approving leader, in lieu of him/her signing each policy. should appear in a single EMTALA policy. Include discussion of each staff person’s duty to exercise judgment in specific situations and determine if any part of the policy or procedure warrants modification. Preferred EMTALA policy statement (which precedes a detailed procedure): The procedure below is intended to promote compliance with the federal Emergency Medical Treatment and Active Labor Act, its amendments, regulations, and reporting requirements. It is important to remember, however, that if a hospital’s procedures differ from those outlined in a professional association-issued guideline on the same subject, without a bona fide reason, that disparity may be called into question. Destache, D. M. (2013, April 30). National health policies, strategies, plans. Implement a feedback mechanism so staff can report situations to management that resulted in a near miss event or necessitated some form of workaround. A healthcare policy covers a range of issue including public health, chronic illness and disability, long-term care, the financing of health care, preventive health care … The development of National Health Policies, Strategies and Plans is a … Hospital policies: Will they be a burden or a benefit to you in litigation? The healthcare industry requires a lot of its professionals, even those who work in policy rather than in patient-facing positions. The ‘peer review privilege’ should not shelter hospital policies and procedures from Discovery. Situations that prompt staff to use a workaround indicate possibly unreliable processes or practices. Retrieved from http://www.ismp.org/newsletters/acutecare/articles/20080424.asp, Schyve, P. M. (2009, winter). Policies and procedures may become outdated, and those who adhere to outdated policies may carry out actions that are no longer consistent with industry-recognized practices. Through our many years working with policies and procedures it has become clear to us that they are essential in providing clarity when dealing with issues and activities that are critical to health and safety, legal liabilities and regulatory requirements. Establish a committee to review the policies of any newly-acquired business units or practices and compare them to those already within the health system. Practices worthy of classification as red rules may include: Before implementing red rules, a multidisciplinary team with representatives from senior leadership, the medical staff, and risk management, should carefully consider each suggested rule to determine if it meets the criteria outlined above. There may be legitimate reasons why persons in other departments may need to refer to those documents. Alternatively, they may simply elect to disregard the policy. Designate a senior leader to oversee policy development, approval, and periodic review by the appropriate policy owner(s). And of course, in the face of a global pandemic, high on the list of priorities for many Americans is the Democratic nominee’s position on healthcare. The following definitions are based on the author’s experience. Failure to do so may cause a staff member to follow an outdated policy, possibly comprising patient care as well as potential allegations of corporate negligence. If a hospital implements a policy that goes beyond what is the prevailing practice in the industry, the organization will be held to the higher standard. The use of the word “policies” throughout this article shall refer to policies, procedures, and guidelines. such as: a) Highest, safest, best (level of care) Procedures are resources to assist staff in carrying out specific actions. For example, a chemotherapy protocol or The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. We use cookies to ensure that we give you the best experience on our website. Hollnagel, E., Braithwaite, J., & Wears, R. L. Check out our new podcast for insight and analysis about the latest patient safety and quality issues! Members should contact their local customer service representative for specific coverage information. All rights reserved. While regulations, third-party payer requirements, and licensing/accreditation standards contribute to this complexity, formalized policies and procedures can mitigate it by promoting workplace safety, regulatory compliance, and the delivery of safe, high-quality patient care. 5. Identify policy disparities and develop a plan for standardization, unless there are legitimate reasons why the system’s current policy needs to be modified in whole or in part, because of different jurisdictional statutes or different services offered by a particular organization. Immediately remove a policy that has been officially retired or replaced from the “active” database and transfer it in the designated archives. Another advantage is that it demonstrates the policy was developed with awareness of recognized professional guidelines and evidence-based best practices. Promote compliance with regulations, statutes, and accreditation requirements (e.g. The answer depends on the laws in effect in the jurisdiction where the health provider organization is located, the scope of its “peer review privilege” statute(s), if any, and precedent-setting judicial decisions. 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