DEVELOPING POLICIES & PROCEDURES Presented by Lynn L. Buchanan President Buchanan & Associates Consulting For Alaska Association Medical Staff Services June 2010

THERE’S NO REASON FOR IT- IT’S JUST OUR POLICY

OBJECTIVES  Understand the importance of having working policies & procedures  Identify key processes that require P&Ps  Determine what should be included in your P&P Manual  Learn how to get started!

POLICY STATEMENT POLICY: A statement of fact that refers to a standard that must be maintained or to a guideline that must be followed. (eg: It is the policy of this organization to reappoint each practitioner every two years according to birth date.) (WHAT IS THE END RESULT?)

STATEMENT OF PURPOSE Purpose: The reason for the stated policy (e.g., related to reappointment) To comply with TJC’s reappointment standards for evaluating a practitioner’s performance and assessing competence for the previous two year period.

PROCEDURE  Procedure: A set of instructions as to how the policy will be achieved. Who What How When Where How Often DETAILS, DETAILS, DETAILS

TYPES OF P&Ps  General / Administrative Office Security Mail Office Hours / Phone Coverage  Medical Staff / Credentialing Verification Sources & Instruction Access to Files Minutes Format

WHY DO WE HAVE THEM?  Provide consistency in process No longer just “brain trust” Deviations are easier to capture and eliminate at the earliest stage  Orientation / Training manual  Reference for non-routine tasks  Provide compliance with regulatory/accrediting bodies

WHY DO WE HAVE THEM (con’t)  Processes are optimized when best practices are documented  Better understanding of P&P ensure compliance and consistency among employees

WHAT IF WE DON’T HAVE THEM?  Inconsistency in process, which could lead to organization liability  Management by crisis  Important omission in procedures  Repetitive work (reinventing the wheel)  Poor or incorrect training

HOW DO I BEGIN ???  Develop major headings in a Table of Contents (use Bylaws, Standards, industry resources  Under each major heading, list all of the P&Ps you need to know in each category and label a folder for each

Beginning… Begin collecting forms, checklists, flow charts, form letters, etc. that you already have and include in folder Include samples from other organizations Review resource books for samples Ask your colleagues

Beginning…  Prioritize the list (critical, routine)  Do one a day / a week based on the tasks you are currently performing OR  Establish a schedule Use Gantt chart Spread out work (people & time) Schedule in daytimer

Beginning…  Include other information for reference Current Bylaws, Rules & Regs, Medical Staff Policy Manuals NPDB Guidebook Pertinent JCAHO/NCQA standards AMA/AOA Masterfile Instructions Applicable State Statutes Federal legislations (HCQIA)

SUGGESTED GUIDELINES  Utilize a standard format Title of Policy / Procedure Department Policy Number (if applicable) Policy statement Purpose statement Procedure outline Effective / Revision dates Approval signature, date Attachments (list by name)

Guidelines…  Include all details (that’s why you’re writing it in the first place!!!)  Write as though explaining to someone new to your area  Include terms, flow charts, forms, letters, checklists as attachments (and date them!!)  Include timelines for each step, where applicable – e.g. on 15 th day send 2nd request, etc.

Guidelines…  Have someone review draft E.g. someone familiar with process or someone new to process  Make modifications as needed  Distribute to those who need them  Review / keep CURRENT on on-going basis  Add new P&Ps as needed  At least annually, review all

AND REMEMBER All this hard work, all this good information, will not do you or your organization ANY GOOD… if you don’t routinely USE and UPDATE these P&Ps!!