Editor-in-Chief, Associate Executive Director, Patient Care Services/Nurse Executive, Lenox Hill Hospital/North Shore-LIJ Health System, New York, N.Y.
Involving staff in policy development promotes evidence-based competency and engagement.
What's on my mind this month? Policies! Maybe they're on your mind, too. If not, they should be. Have you experienced the frustration of challenging clinical policy manuals? Sometimes it seems like they can be the bane of our work life, especially when they're outdated and unrealistic. On the other hand, these manuals are extremely meaningful when developed to guide safe practice in an evidence-based way with full stakeholder support. If you've been through any regulatory or accreditation surveys recently, the importance of your clinical policies was most likely underscored.
You're held accountable for compliance with your policies as written. They're foundational and contribute to high reliability. It may be better to have no policy at all than a bad one. What makes a “bad” policy? One clue is that no one is following it. Another is if a policy is used as an excuse for not doing the right thing. These may be symptoms of a dysfunctional organizational culture; however, they're still wrapped around the issue of policy frustration.
Ensure that staff education, practice, and all relevant and guiding policies are consistent, vetted, and appropriately approved. Every organization has a different process for endorsement and it can be surprisingly complicated—don't let it be a deterrent. If you don't have a clear process, work on creating one. If you're part of the approval process, be true to it and double check before you agree. Stakeholders aren't only in your departments: Think of the entire interprofessional team that may be affected by the practice you're defining.
Make sure that policies are reasonable and realistic. Besides the common sense factor, staff input is critical to success in terms of practicality at the point of care. Involving staff in policy development promotes evidence-based competency, as well as engagement. This is a win-win for all. Remember that writing to the minimum of standard isn't a cause for professional alarm. Better that performance exceeds written policy than to have compliance fall short. Content may be both prescriptive for safety or regulatory issues and flexible to meet patient needs and situations.
In the spirit of a just culture, don't punish an individual for not following a policy that many others aren't following either. System issues should be dealt with at a system level, not focused on individuals. Our job as leaders is to make things work for patients and staff, and to support variations that make sense, are well intended, and don't put anyone at unjustified risk of harm.
Lastly, ensure that policies are available and accessible. The advent of online procedure manuals, as well as using organizational portals and intranets for posting policy manuals, is a tremendous step forward from the days of cumbersome, easily lost binders. A simple yet overlooked factor contributing to accessibility is the naming of the policy and the table of organization. Looking for central line policies should be easily found under “c” and not buried elsewhere.
Let's be levelheaded about our clinical policy manuals and make sure they're current, realistic, and support best practice. When asked “What does your policy say?” you shouldn't have a feeling of dread. Instead, you should be confident that it reflects what your staff know and practice. Get involved. Make it happen. The devil really is in the details.