Prudence or wisdom? Can your policies pass muster?

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After reading this article, you will be able to:

  • Identify ways of preventing “work-arounds” by the staff
  • Discuss “tagging” policies
  • Describe ongoing education needs to maintain staff member compliance with hospital policies

Editor’s note: WendySue Woods, RN, MHSA, CSHA, is a senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Each month, an expert from The Greeley Company will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. Have a question for our experts? E-mail Matt Phillion at

In 1751, Dr. Thomas Bond and Benjamin Franklin founded the first hospital of the 13 colonies. At that time, Philadelphia was the fastest growing city, boasting a population in 1730 of 11,500 that grew to 15,000 in 1750. The mission of Pennsylvania Hospital, as it was then known, was “to care for the sick, the poor, and the insane who were wandering the streets of Philadelphia.”

Patients were expected to follow strict rules and policies. They had to comply exactly with orders given by physicians and nurses. There was no talking allowed on the wards when the physicians were present. Patients could not be in the bed unless they were in bedclothes— no street clothes were allowed. There was to be no profane language, gambling, or spitting on the floors. And my personal favorite: If you were able, you were expected to help the nurse with her duties.

Imagine updating those policies to match standards of practice today?

Don’t just go through the motions

Organizations have developed processes to ensure that policies are reviewed and revised as appropriate. This practice can vary greatly from one organization to another. Many organizations divide the policies, which are often reviewed and revised by people who do not have firsthand knowledge of the process. Others may choose to accomplish this by committee, which results in policies being revised without the input of those who must comply with the policy.

Approximately 5% of The Joint Commission’s elements of performance (EP) are frequently cited. These are the Joint Commission EPs and CMS requirements that have the seemingly greatest effect on an organization’s ability to consistently deliver quality and safe care. Consistency is key, and this can be driven by a successful policy and procedure review process.

Organize your policies

  • “Tag”—you’re it. When developing or revising a policy, “tag” that policy with the corresponding Joint Commission standard and EP as well as creating a link to the CMS Conditions of Participation “A” Tag. Once you have this set up as a system, as requirements and regulations are updated or change, it is easy to find the policy or policies and make the necessary changes.
  • Practice = Policy. During the revision or review process, take the policy to the bedside. Talk with staff members about the requirements and the methods they are currently using. Identify shortcuts that staff members have developed. Sometimes these are reasonable and still maintain compliance. Other times, these shortcuts can lead to missed steps, resulting in noncompliance. Take time to talk with your staff to understand why the shortcuts or “workarounds” were implemented and help keep the process sensible to the end user. This will ensure compliance and consistency. Practice will match policy.
  • Keep it simple. Policies that are created from textbooks or in isolation can often create unreasonable expectations of the end user. Implementation of the policy when put into practice and placed under scrutiny can result in noncompliance because the steps did not make sense and, therefore, were not followed. Keep the process simple. Review the minimum expectations and align the policy accordingly. Just because something sounds good on paper does not mean it can be easily and consistently accomplished.
  • Take it for a test drive. Once a policy has been developed or reviewed and revised, take it for a spin. Think about what it would have been like to test the policy of “no talking when the physician is on the ward.” How could patients communicate their needs? How would the nurse have discussed the patient’s condition and response to treatments? Make sure the steps outlined in the policy make sense to the staff members who will need to ensure implementation. Only then is the policy ready for the stamp of approval.
  • Educate and assess. Once the policy has been developed, reviewed, or revised and you have taken it for a test drive, your work is not done. Ensure that your staff is educated or reeducated on the policy and any changes or nuances that need to be discussed. This piece of paper is only as good as the end user’s ability to consistently comply with the requirements and demonstrate competence.

258 years later

If you were one of the lucky ones setting up the first hospital in the United States, you would have been writing the rules from scratch. That groundwork has long been established, but there are guidelines that can serve as valuable resources. A chapter in the 2009 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook, “Required Written Documentation,” provides a list of all of the Joint Commission EPs requiring written documentation for hospitals. Not all of the items listed require policies—many are references to logs, licenses, annual reports, etc.—but this is an excellent starting place for the prioritization process.

However your organization manages the process of developing, reviewing, and revising policies, invest the time to evaluate it to ensure it can pass muster. Your process should give you the confidence that your patients are consistently being provided safe and quality care.