Ask the Nursing Expert about ... policies and procedures

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Amy Franklin, RN,  DNS-MT, QCP-MT
Amy Franklin, RN, DNS-MT, QCP-MT

How can I simplify the policies and procedures at my facility to make them more user-friendly?

Policies and procedures (P&Ps) can be user-friendly and also support compliance on a daily basis. When performing your policy review, consider these:

1. A policy identifies issues and scope. You and your staff will be held accountable for adhering to your P&Ps, as written, in day-to-day operations, during both survey and litigation processes.

2. It's not necessary to include workflows. You don't need a P&P for every action in the facility, and certainly not for all workflows. In fact, many workflows can be taken out of policies and included in protocol documents. Examples include ordering labs and completing a requisition form for medical equipment.

3. A policy should not be too exclusive. Sometimes policies stipulate that only an RN can perform certain tasks, when, in fact, under the state's nurse practice act, a trained LPN also would be appropriate. 

4. Procedural manuals are helpful resources. Instead of writing out each P&P to exhaustion, it is sometimes appropriate to refer to a current, evidence-based resource, such as Lippincott procedures for LTC.

5. Short-and-simple is better than all-encompassing. Policies should be one to two pages long. If a policy has more than two pages, it likely needs to be divided into separate policies, or a workflow needs to be removed.

Effective policies and procedures are crucial for compliance, as you and your staff will be held to them. Policies that lead to better outcomes are those that are accurate, clear, concise and flexible enough that your team can adjust workflows to best meet the care needs of residents.

Please send your nursing-related questions to Kathy Owens at ltcnews@mcknights.com.