Policy Publication Process Kevin Spruce, DNP, RN-BC, ACCNS-AG, CVN Clinical Nurse Specialist – CCMC Surgical and Cardiovascular Services

Objectives Purpose of policies Identifying policy needs Research and initial buy-in Document creation/revision Getting feedback Vetting process Disseminating education Policy publication Many of you may not own policies, but it’s important to understand the process in order to collaborate during any part that you may be involved with, which is inevitably a matter of time as educators. Some of you may be future policy owners or even may be asked to help revise one, so I’m here today to help you be more comfortable with these documents.

Purpose of Policies To drive practice A template for success Avoid ambiguity Regulatory requirement Enforce compliance To drive practice: solidifying our processes Template for success: A reference guide Avoid process ambiguity: provide specific parameters; clarify gaps of understanding

Identifying Policy Needs What was the trigger? New process Corrective action Regulatory requirement Is a policy the right approach? Other options Online procedure resources Education Order set

Identifying Policy Needs Preliminary research recommended Finding existing policies Searching: tips & tricks Like internet search engine  Results based on relevance Fielded searches id:12345 title:sedation text:vacation

Policy Research Using evidence-based practice Garner subject matter experts Regulatory mandates & legislation Professional & organizational guidelines Vendor-specific information Other policies as a reference Prof./Org. guidelines: e.g. AORN, ASPAN, AACN, etc. Vendor-specific information: Manufacturer’s instructions, Lippincott

Stakeholder Buy-In What areas are being affected? Policy/project champions Policy reviewers Policy signers

Document Creation Access to Lucidoc® Lucidoc ® interface Natalie Silva (Administrator) Lucidoc ® interface Lucidoc is compliance software that tracks the lifecycle of a document from creation to archival. - You may be assigned as “collaborator”

Types of Policies & Associated Documents Document Creation Types of Policies & Associated Documents Standardized Procedure Policy and Procedure Procedure Guideline Form Reference document Who or what does it affect Patient Care Policy Unit-specific Standardized Procedure – Allows one to practice an expanded role or scope of practice.

Document Creation PARTS OF A POLICY Purpose* Definitions Policy* Procedure Equipment Education Patient Teaching Documentation Quality Assurance* Addendum References Purpose - The reason or goal of the document. Required for all documents. Definitions – Describes specific names, acronyms, terms and processes. Policy - Policy statements govern practice and lists the rules that must be followed, competencies required to perform care as described in the policy, and categories of personnel who will perform a procedure. Policies influence decision-making and support actions required by law, regulatory agencies or an accrediting body. All standards of practice are to be research-based to the extent possible. Required for all documents. Procedure - Explains how a policy will be implemented and/or how tasks will be performed. Procedures are written as a set of instructions, a list of required actions, a checklist, or a series of tasks to be accomplished. Another word for procedure is “process”. A procedure will also state who is responsible for accomplishing tasks or actions. Equipment - Equipment required to perform a procedure, if applicable. Education – Describes education required for previously identified parties to carry out tasks or processes described in the policy. Patient Teaching - The process or method of education of the patient and family, if applicable. Documentation - Required documentation related to the document, if applicable. Should be clearly stated, such as format, location, frequency, etc. Quality Assurance – Describes on-going monitoring and reporting measures to mitigate and address patient and employee safety. Addendum – Usually a stand-alone addition to the policy that addresses subsequent updates or reference items. References - A list of references that support the policy & procedure. All data (e.g., title of article, date of article, etc.) related to the reference must be included. Regulatory references should include manual/regulation name only. * Req’d for all policies * Req’d for Standardized Procedures

Document Creation Rules of engagement: Writing a Policy Scope of the Policy What sections do I need? e.g. Standardized Procedure Formatting (I.  A.  1.  a.  i.) Acronym usage Avoid vendor or brand-specific information Written in the “active voice” E.g. Employees will write in the active voice. Reviewers Signer/Approvers

Document Creation There’s actually a policy on how to make policies! #14606 (id:14606)

Policy Revisions Policy review lifecycle Revision triggers Are the changes appropriate? Do changes affect more than one policy? Timing to implement revision

Policy Feedback Selecting appropriate feedback group Feedback communication Receiving feedback solicitations Feedback communication – Lucidoc members vs. non-Lucidoc members Feedback solicitations – either from other document owners or champions

Formal Vetting Process Required documentation New New Policy Approval Request Committee Approval Request for P&P (Patient Care policies) Existing (Patient Care policy) Committee Approval Request for P&P Oversight groups/Committees P&P Advisory Committee Service line-specific: Crit’ Care; P&T; Surgical; etc. Patient Care policies: IPPC/NPPC Administrative: CIDP; FEC/FEAC; MEC

Disseminating Education Amount of education needed Changes in practice? How many areas impacted? Level of risk that change(s) make Selecting appropriate modality E-mail; huddle; staff meetings; formal class Plan education before policy publication Always teach to the policy

Policy Publication Setting next review date Standard = 3 years (max) Can vary by department Sending a policy out for signature Notification process E-mail Lucidoc® vs. non-Lucidoc ® folks Practice Change alerts Next review date: e.g. Lab (Q 2 yrs); some Medical Staffing policies (yearly) Policy signature: triggered by doc owner after committee approval(s) Notification process: e-mail automatic for Lucidoc® users

References Community Medical Centers. (2015, August). Guidelines for developing/writing a policy and procedure. Retrieved from https://www.lucidoc.com/cgi/doc- gw.pl?ref=communitymc:14606 Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2014). Advanced practice nursing: An integrative approach (5th ed.). St. Louis, MO: Saunders Elsevier. Lucidoc Corporation. (2017). Compliance management solutions. Retrieved from http://www.lucidoc.com/web/index.html Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.