Thursday, January 6, 2011

Policy Manuals Made Easy

Hi folks. Happy new year! May 2011 be even better than 2010 was! :)

So I've been asked recently about where informatics policies should live, ideally, and I answered, "In the clinical policy manual."

That led to a follow-up question : "Dirk, what exactly is a clinical policy?"

This gets to the heart of a really interesting conversation about healthcare : The difference between a clinical policy and an administrative policy.

First, a word about policies in general.

Policies are probably one of the most misunderstood things in healthcare. Most doctors shudder when talk centers around, "We should make a policy for that" or "Do you know what the policy is for _______?".

A policy is a written, agreed-upon goal. (The "procedure", often attached to the same document, are the steps about how-to-get-to-that-goal.)

Policies, then, are your organization's written goals. That's why The Joint Commission asks about them, during inspections - They want to know how you organize, how you think, how you operate, etc. They also want to make sure the policies reflect the practices in your hospital.

Policies, if well-written, don't need to be painful. Policies help guide your staff behavior, they help communicate goals, and if they're well-written, they can also be used for training.

They also help protect your staff - Their activities are backed up by the organization's support for that behavior.

"Aha. So you were talking about maintaining policy manuals?"

That's right, I was. Thanks for reminding me. :)

So an interesting thing about healthcare, unlike private industries - We have two policy manuals, whereas most non-healthcare industries only have one.

"And what are those two policy manuals...?"

Interestingly, to maintain an average hospital, you need two general types of organizational control :
  1. Clinical Policies - Those policies that refer to patients and patient care
  2. Administrative Policies - Those policies that refer to employees and employee issues
Why do you need two? Well, an average healthcare organization is usually run by a Board of Trustees, who at some point made the decision, "We would like to run a hospital here."

To accomplish this, then, the Board usually needs :
  1. A group of administrative people who are experts at running the hospital - Keeping it organized, hiring people, making sure supplies show up, paying the bills, setting up the budget, running the place, sending out bills to insurers, etc.
  2. A group of clinical people who are experts at delivering patient care - Performing surgery, seeing patients, taking vitals, giving drugs, managing ventilators, etc.
And that's why most hospitals typically have two wings of government :
  1. The Administrative Branch
  2. The Clinical Branch
... and the policy manuals that are used to help run these two branches of government are :
  1. The Administrative Policy Manual
  2. The Clinical Policy Manual
"I see... So what else do I need to know?"

Well, to run an average hospital, then, you need to have both clinical and administrative policies that help guide your daily activities. The conflicts that sometimes arise, between these two branches of internal government, are sometimes very complicated - And, as a result, not every situation calls for a clear administrative or clinical policy.

"So how do I recognize an administrative policy from a clinical policy?"

An administrative policy statement usually refers to employees or employee issues, so they typically start with something like this :
"All employees at Acme Healthcare will..." or
"All physicians at Acme Healthcare will..." or
"All nurses at Acme Healthcare will..." or
"All ED staff at Acme Healthcare will..."
The collection of these administrative policies is typically kept in an administrative policy manual.

A clinical policy statement usually refers to patients or patient care issues, so they typically start with something like this :
"All patients at Acme Hospital will..." or
"All pediatric patients at Acme Hospital will..." or
"All ED patients at Acme Hospital will..." or
"All terminally ill patients at Acme Hospital will..."
The collection of these clinical policies is typically kept in a clinical policy manual.

"Aha. So how do you organize these policies, then?"

Every hospital has a slightly different way of organizing them, but I recommend a very simple system of organizing them :

1. Administrative Policy Manual
     a. General Hospital-Wide Administrative Policies
          - Human Resources
          - Safety
          - Information Management / Medical Records
          - Quality Management
          - (Other organizational administrative policies)
     b. Department-specific Administrative Policies
          - ED
          - Medicine
          - Surgery
          - OB/GYN
          - Pediatrics
          - (etc..)

2. Clinical Policy Manual
      a. General Hospital-Wide Clinical Policies
           - General Clinical Policies 
           - Quality Management
           - Nursing
           - Medical Records / Informatics
           - Laboratory
           - Radiology
           - Infection Control
           - Dietary
     b. Department-specific Clinical Policies
          - Medicine
          - Surgery / OR
          - OB/GYN
          - Pediatrics
          - ICU
          - (etc. etc.)

Again, as I said, every hospital does this a little differently, to address their different needs, but the general theme is that they are all generally clinical or administrative policies, and they generally either apply throughout the hospital or in a specific department or physical area.

"Dirk... That sounds like a lot of work, then!"

It is a lot of work. If every policy has to be approved by a person or committee, there's a lot of work that goes into maintaining these policy manuals. Many hospitals struggle with doing this efficiently.

The good news is that it doesn't have to be torture. By delegating each branch of policies to the right person/committee, you can divide up the work efficiently, for example :

1. Clinical Policies
      a. Hospital-wide Clinical Policies
           - General Clinical Policies = Approved by Medical Executive Committee
           - Nursing Policies = Approved by Nursing Committee
           - Medical Records / Informatics = Approved by Med Rec / Informatics committee
           - Pharmacy Policies = Approved by P&T Committee
           - Infection Control Policies = Approved by Infection Control Committee
      b. Department-specific Clinical Policies
           - Medicine - Approved by Medicine Committee
           - Surgery / OR - Approved by OR/Surgery Committee
           - ICU = Approved by Critical Care Committee
           - Pediatrics = Approved by Pediatric Committee

You'll notice the theme : Every branch of clinical policies will either need a committee or a person, delegated to maintain and approve that particular chapter of the policy manual.

And you'll notice how much work it takes to maintain all of this. Every time a drug gets recalled, every time the government creates new billing standards, policies have to be adjusted and re-approved.

The good news, if you do this well, is that you can use the policy manual as an education tool :
- For new staff who are orienting to your hospital
- For existing staff who would like to quickly find out daily operations

Finally, an important part about maintaining all of these separate chapters is that even if you delegate the maintenance of these chapters to different committees, it's imperative that you publish all of these policies in the same place. (That means, that all "active policies" are kept in one common place, where everyone can look at them.) By keeping the entire manual (all chapters) in one place, it :
  1. Helps avoid policy conflicts between different departments, and
  2. Helps make the policy manual a tool of organization and education for your staff.
Again, as I've said before, my advice is free and you get what you pay for. Every hospital does this a little differently, but I hope I've communicated the major themes. Would love to hear your stories and thoughts about best ways to organize a clinical and administrative policy manual!

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