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Lamson, Dugan and Murray, LLP. Institute for Safe Medication Practices. Leadership in healthcare organizations: A guide to Joint Commission leadership standards, A Governance Institute White Paper. The Purpose of Policies and Procedures Formalized, written policies and procedures fulfill a number of important purposes: Facilitate adherence with recognized professional practices. Promote compliance with regulations, statutes, and accreditation requirements (e.

Standardize practices across multiple entities within a single a health system. Serve as a resource for staff, particularly new personnel. Reduce reliance on memory, which, when overtaxed, has been shown to be a major source of human errors or oversights. Definition of Terms There is little agreement Ibuprofen in Water for Injection (Caldolor)- Multum healthcare regulators, accrediting bodies, and provider organizations about the definitions for terms such as policy, procedure, and guideline.

Policy statement: A concise statement Fosaprepitant Dimeglumine Injection (Emend Injection)- Multum the context, goal, or purpose of a specific procedure. A statement that is the guide to any decision making in relation to processes or activities that regularly take place or might be expected to occur (Hollnagel et al.

Procedure: The desired, intentional action steps to be taken by specified persons to achieve a certain objective in a defined set of circumstances. Protocol: Synonymous with procedure. Often used when describing clinical patient care-related interventions. Guideline: Recommended actions for a specific situation or type of case. A clinical practice guideline could, for example, outline Fosaprepitant Dimeglumine Injection (Emend Injection)- Multum practices for patients who are taking anticoagulants.

Problematic Policies When a domain unknowingly develops a policy or procedure that already existsperhaps another domain issued a similar policy earlierthere will likely be differences, resulting in confusion as to which policy should be followed.

Corporate negligence on behalf of a hospital that failed to adopt appropriate policies, adequately train the staff with regard to these policies, implement them, or evaluate how they are used (Destache, 2013). The policy was inconsistent with the standard of care. Policies the organization stormwater in effect were contradictory to other organizational policies, differed across entities in the same system without a basis for the difference, or were inconsistent with applicable regulations.

Many healthcare organizations seem to misunderstand the purpose of policy statements and burden them with non-value-added or overly broad information. They opine highlights elsevier retrospect Fosaprepitant Dimeglumine Injection (Emend Injection)- Multum what a reasonable healthcare provider with similar training and experience would have done.

Problematic EMTALA policy statement: The federal government passed the Emergency Medical Treatment and Active Labor Act (EMTALA) in order Fosaprepitant Dimeglumine Injection (Emend Injection)- Multum require hospitals to offer treatment to all persons who seek care.

Preferred EMTALA policy statement (which precedes a detailed procedure): The procedure below is intended to promote compliance with the federal Emergency Medical Treatment and Active Labor Act, its amendments, regulations, and reporting requirements.

Disclaimer Statements Each policy should include a disclaimer statement to remind staff members that they must use their judgment to determine if Fosaprepitant Dimeglumine Injection (Emend Injection)- Multum parts of the policy and procedure apply to each situation or whether some type of modification is warranted. Typical disclaimer statements include the following (which should be approved by legal counsel): A policy statement is intended to describe the reason why the associated procedure has been issued and to explain the context for it.

Procedures are resources to assist staff in carrying out specific actions. Procedures do not specify all circumstances to which they apply. Procedures cannot, in themselves, guarantee safety. Safety is promoted by people being skilled at judging when and how (and when not) to adapt procedures to local circumstances. Clinical situations may warrant adaptation due to unique Fosaprepitant Dimeglumine Injection (Emend Injection)- Multum characteristics.

Extenuating circumstances may also necessitate adaptation. Implementing New or Revised Policies The organization has a duty to inform all affected personnel prior bayer 40 the effective Fosaprepitant Dimeglumine Injection (Emend Injection)- Multum of a new or revised policy.

Policy and Procedure Development Guidelines Recommendation Rationale Define all terms used within the policy. Performing instrument, sponge, and needle reconciliation counts during an invasive procedure. Before implementing red rules, a multidisciplinary team with representatives from senior leadership, the medical staff, and risk management, should carefully consider each suggested rule to determine if it meets the criteria outlined above.

Standardizing Policies across the System When there are multiple hospitals within a health system, there is little justification for allowing each hospital to independently develop its own policies. In the event a specific policy does not apply to one entity in the system (i. To optimize the usefulness of electronic libraries: Provide indices by policy name, subject, and sponsoring domain (administration, nursing, pharmacy, etc.

Do not prohibit access to policies of one domain to personnel cchd other domains. There may be legitimate reasons why persons in other departments may need to refer to those documents.

This will facilitate access in response to legal discovery requests. Check with your corporate compliance office regarding organizational document retention policies. Summary Healthcare risk managers are encouraged to collaborate with other senior leaders in their organizations in order to maximize the usefulness of policies and procedures and reduce potential associated risks.

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