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

2. 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.

3. 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

4. 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

5. 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

6. 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

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

8. 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”

9. 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.

10. 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

11. 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

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

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

14. 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

15. 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

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

17. Policy Publication Setting next review date
Standard = 3 years (max)
Can vary by department
Sending a policy out for signature
Notification process
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: automatic for Lucidoc® users

18. References
Community Medical Centers. (2015, August). Guidelines for developing/writing a policy and procedure. Retrieved from 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
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.