Create a Policy and Procedure Manual That Works and Is Survey-ready
Staff should find correct answers in P&P manual
September 1, 2017 6 minutes read
The major problem ASCs encounter with creating policies and procedures (P&Ps) is making these applicable to their facilities.
“Policies and procedures are written for the safety of patients, employee validation, quality improvement, risk management, and to guide behaviors in the workplace,” says Jo Vinson, RN, CASC, director of DeNovo Integration Management at Surgical Care Affiliates of Kernersville, NC. “That’s why it’s important to have your policies and procedures regularly reviewed and made applicable to your organization.”
Facilities that fail to make their P&Ps relevant to their organizations end up with a P&P binder that no one uses. The goal, particularly from an accreditation organization surveyor’s perspective, is for the P&Ps to be simple, direct, and thorough enough that employees could open them to the desired section and see exactly the policy they need to follow. Too often, a surveyor or someone questioning employees about specific policies will find that five different employees will give five different answers.
“No one knows the policy, or no one has changed the policy to reflect what they’re doing these days,” Vinson says. “I’ve walked in to do surveys and found maybe three different policies on the same procedure.”
For example, Vinson found that one ASC’s policies said the organization would save all records for seven years past the last date the patient was seen. Another P&P stated the records would be kept 10 years past the last date the patient was seen. A third P&P reflected that the records would be kept for seven years past the date the patient reached maturity.
“These were all in one policies and procedures book,” she says. “If someone read the seven-year policy, then they’d purge at seven years. Someone else might say they shouldn’t do that until 10 years. Policies should be current, thorough, consistent, and easy to follow.”
This type of P&P confusion occurs when an ASC writes new policies but does not remove the old policies. If the two disparate policies are not dated, no one will know which is the most current and should be followed.
“It’s recommended that prior policies and procedures should be pulled and retained in a way that you know which P&P was in place at a certain time,” Vinson says. “Potential legal issues, including lawsuits, may result in requiring you to produce policies that were in place at the time of a surgery. It is suggested that copies of prior P&Ps are archived for the period of the statute of limitations in your state.”
Any ASC that has not reviewed or updated its P&Ps within the past few years probably is overdue for an update. It can take six to 12 months to update them correctly, based on assembling a team and assigning one point person, who is working on the project about 10 hours per week, Vinson estimates.
Vinson suggests the following steps to revamping P&Ps:
• Step 1: Take small bites. Revising the policies and procedures can be overwhelming. Whether an organization is accredited by AAAHC or The Joint Commission, revise P&Ps by process, according to the accrediting body’s chapters, Vinson suggests.
The accrediting organization’s standards handbook is the best place to start. As the P&Ps are updated, the ASC also should keep state license requirements and Medicare Conditions for Coverage for reference, she says.
“You will want to make sure each policy is up to date, but this should be done by small bites and not with the whole pie at once,” Vinson explains.
• Step 2: Put together a team. One person cannot revise P&Ps. It requires a team effort, because some of the policies are based on the ASC’s workflow practices.
“You have to bring in members of the patient care team to provide input, such as ‘How are we transferring patients?’” Vinson says.
Start the team with the leader, the person who will be handling most of the work. Then, add team members as needed, depending on which policy is under revision, she suggests.
Team members can help answer questions about procedures and read over suggested policies to offer suggestions and clarity.
They also could help edit policies, keeping them as brief and to the point as possible.
“I’ve walked into facilities and have seen policies that were 24 pages long. I don’t even want to read it as a surveyor, much less as a nurse,” Vinson says. “I use the term ‘activities of daily operations’ — ADOs. It’s something I use because we need to make everything as user-friendly for daily operations in our facility.”
• Step 3: Keep accreditation, other standards on desk. There are many organizations that affect an ASC, and the P&P leader can check with those organizations’ requirements and regulations while revising his or her organization’s P&Ps.
“Always have those on your desk, so if there’s a policy that has to do with the lab or X-ray, you can find those,” Vinson says. “If it has to do with radiation safety, then find the state radiation safety rules.”
People might want to have just one book for reference to all P&P questions, but it isn’t that easy, Vinson says.
“It takes a little thought,” she notes. “There are several national guidelines, so read them and see which applies to you.”
For instance, ASCs in some states might have rules about disposing of medication. In another state, there are different requirements. Use a checklist to avoid confusion, especially at the beginning, Vinson says. The checklist could list each policy and all the standards that apply to each policy.
• Step 4: Write a first draft. Taking the revision one policy at a time and turning each into a chapter can help the P&P leader make progress in writing the first draft.
“When you finish it, it should be a pretty good draft of policies, and the administration can look at them and go through them,” Vinson says. “The medical director and staff also can look at policies that affect them.”
Once the draft is reviewed and revised, it’s time to complete the final version and submit it to the ASC’s governing board for final approval.
• Step 5: Review P&Ps annually. After the first major revision, the P&Ps can be reviewed once a year and updated as regulations, guidelines, and practices change. Vinson prefers conducting these reviews one chapter at a time throughout the year.
“A lot of people say they’ll look at all of it every December,” she notes. But finding time to review the entire book or books of P&Ps can be challenging, so a more pragmatic solution is to review one chapter each month. “Review chapter one in January, chapter two in February,” Vinson says. “It doesn’t have to be done all at once, and you can divide the chapters among three or four people.”
• Step 6: Archive old policies. Archive old electronic copies of P&Ps and scan all hard copies of files and P&Ps to retain in an electronic file for as long as necessary or required, Vinson advises. Within the P&P binder, the newest version should be readily available to staff and anyone who needs to find something in it.
“Policies and procedures should be user friendly and accessible,” Vinson says. “People will say they can’t get to them because they’re locked up in so and so’s office, but they need to be accessible to [anyone] who [needs to] use them.”
Vinson has divided P&Ps, placing pertinent information wherever they are needed. For instance, the P&P section on pathology would be kept in the lab; the old versions should be stored elsewhere.
“I used to keep the old binder with the new one, but it gets very bulky,” Vinson notes. “You just need to be able to get to the old version if you need to show someone what the changes are.”
Scanning by year that P&Ps were in place is great if you have hard copies. Or, instituting password access to archived electronic copies by year also allows you to maintain copies, she adds.
The major problem ASCs encounter with creating policies and procedures is making these applicable to their facilities. The goal, particularly from an accreditation organization surveyor’s perspective, is for the P&Ps to be simple, direct, and thorough enough that employees could open them to the desired section and see exactly the policy they need to follow.
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