Developing Effective Policies and Procedures for Healthcare Organizations

February 18, 2016   |  Tags: Blog   |  Tags: QI , FQHC
Akira Templeton

Do your organizational policies and procedures enhance daily operations, or do they just seem to fall flat? To address this, OPCA recently held a webinar entitled, “Developing Effective Policies and Procedures for Healthcare Organizations.” Policies and procedures (P&Ps) are used in a variety of workplaces, and even in the health care setting, P&Ps may not necessarily be clinical in nature. Bearing this in mind, we started off by focusing on fundamental concepts around P&Ps and gave a framework for understanding how to best develop these for your specific organization. Later in the webinar, we shifted gears to focus on clinical applications using examples of colorectal cancer screening P&Ps from Oregon and Washington Federally Qualified Health Centers (FQHCs). 

In order to best understand the purpose and value of P&Ps, it’s important to recognize the various types and ways in which they can be used. Additionally, while often used interchangeably, policies have different purposes and uses than procedures. They are not the same thing! Let’s look at the differences.

Policies can be used as high-level guidance for Board strategic efforts, for organizational management, or for employee conduct. Policies provide a link between organizational strategies and day-to-day operations as well as help guide decision making at all levels of an organization. Procedures tend to focus on routine, step-by-step actions that staff can follow in order to put a policy into action. Procedures can be organization-wide, such as a grievance policy that applies to all staff, or job-specific, such as how nurses should conduct a colorectal cancer screening (e.g. standard operating procedure). Regardless of your target audience, the critical distinction between the two is that policies generally tell staff what to do and why it’s important, while procedures focus on the when and how staff should perform certain activities to accomplish an end result.

Staff engagement and adherence become essential to ensuring that P&Ps are successfully implemented and effectively utilized. Ultimately, it comes down to how the organization disseminates, communicates and follows up on P&Ps. To assure that staff is engaged and thoroughly understands P&Ps, there are five key steps to follow during creation, including development, writing, approving, implementing and monitoring. During each step, here are some best practices to follow:

  • Consider QI methods (e.g. Plan Do Study Act cycles/PDSAs) for testing and implementation
  • Consider adult learning style when disseminating to staff; diversify training methods
  • Repeat and remind staff of existing P&Ps
  • Get leadership buy-in and support for all P&Ps
  • Consider enforcement practices; hold staff and managers accountable
  • Create an oversight committee and/or tracking system for regular reviews
  • Implement a staff feedback mechanism; allow dedicated time for staff input and Q&A
  • Train managers on P&Ps creation and uses

To learn more about the five steps, download the presentation recording and slides here.

Additional material and examples related to colorectal cancer screening can be found on the OPCA website and in the Steps for Increasing Colorectal Cancer Screening Rates manual developed by the American Cancer Society and National Colorectal Roundtable.

You may also find additional clinical examples and P&P templates on the CHAMPS website.

Akira Templeton received her MBA in Human Resource Management and Organizational Behavior at the University of New Mexico’s Anderson School of Management. During this time, she also developed a special interest in working for non-profit organizations, which has been the focal point of her career to date, most recently in the healthcare field. Currently, Akira works as Quality Initiatives Coordinator for the Oregon Primary Care Association, where she supports the Data Transparency Project and other quality improvement initiatives among community health centers throughout Oregon. Akira has a strong background in process improvement, standard workflow development, relationship management and coaching. Additionally, she recently received her Green Belt Lean Certification, which allowed her to gain practical experience in applying Lean methodology in a healthcare setting.