Wednesday, February 2, 2011

The Policy that will realign your hospital's tires

So I've been writing a lot recently about governance, and policy manuals, and how these are poorly understood mainly because nobody writes an instruction manual for a hospital. (That is, of course, with the exception of this blog.) :)

I figured I'd give insight, tonight, by giving you the clinical policy that will lay out the framework to :
  1. Realign your governance
  2. Re-engage your committees and physicians
  3. Improve communication
  4. Streamline policy development
So if your Policy Manual is your "sacred text" whereby your hospital operates...

And if your :
   1. Clinical policies - Refer to patients and patient care issues
   2. Administrative policies - Refer to employees and employee/hospital issues

Then you will want a Clinical Policy #1 that lays out your clinical policy manual, and an Administrative Policy #1 that lays out your administrative policy manual.

So for tonight, I present : The DRAFT CLINICAL POLICY #1 that will inject your hospital with new life. Look at it, and feel free to comment! Let me know what you think. (Remember, this is for education / discussion only - Your mileage may vary, and remember, with any free discussion - You get what you pay for!) :)


I. Purpose : To outline the organization, development, publication, implementation, and monitoring of clinical policies at Acme Hospital

II. Policy Statement : All clinical policies at Acme Hospital will be owned, designed, formatted, tested, approved, published, implemented, and updated according to the procedures outlined in this document.

III. Scope : This document applies to all clinical policies at Acme Hospital.

IV. Definitions :
  1. Policy - A written goal for the organization. Policy statements should be short and succinct, and written in clear, concise, and simple language. 
  2. Procedure - The detailed outline of steps staff members should take to achieve the policy goal. Procedures should be written with the user in mind, and should be developed by users.
  3. Clinical Tools - Documents and other tools which are used to guide the delivery of safe and effective patient care. These may include, but are not limited to clinical policies, procedures, documentation, order sets, protocols, guidelines/pathways, templates, staff schedules, patient education modules, staff education modules, clinical committee minutes, and committee charters. 
  4. Clinical Policy Coordinator - The person responsible for the overall functioning of the clinical policy mechanism at Acme Hospital.
  5. Chairperson of Medical Executive Committee - Traditionally, this is the President of the Medical Staff.
  6. Owner - The person responsible for the timely review, updating, and dissemination of policies and procedures.
  7. Builder [Informaticist, if your hospital is that progressive] - A trained person responsible for the design and testing of clinical tools before they are brought to a committee for approval.
  8. Testing - The phase of policy development where a policy is checked for accuracy, safety, and reviewed by at least two end users before being brought to a committee for approval.
  9. Approval Committee - A committee with the delegated authority to approve clinical policies, as designated by the Medical Executive Committee through a committee charter approved by the Medical Executive Committee.
  10. Approval Committee Chairperson - The chairperson responsible for conducting meetings of an approval committee.
  11. Publication - The process by which a clinical policy is published in a common clinical policy manual.
  12. Implementation - The process by which a clinical policy is educated to front-line staff and enforced by directors and managers.
  13. Monitoring - The process by which the owner continuously monitors the effectiveness and safety of a clinical policy.
V. Procedure : All clinical policies will be :
  1. Owned : By a department director assigned by the Chairperson of the Medical Executive Committee.
  2. Built : By an assigned builder [informaticist], assigned by the Clinical Policy Coordinator.
  3. Formatted : According to the format outlined in Attachment A : Format of a Clinical Policy.
  4. Tested : By the assigned builder [informaticist] and the owner, before presentation at an approval committee, using at least two front-line clinical staff members provided by the owner.
  5. Presented : Shall be presented by the builder and owner to an approval committee assigned by the clinical policy coordinator. 
  6. Reviewed : Shall be reviewed by the assigned approval committee. 
  7. Approved : If a motion is raised to approve the tool for use, and the motion is approved, the approval committee chairperson shall document a vote of approval by signing the clinical policy during the meeting. In the event of a tie vote, or if the committee chairperson feels the policy has been incorrectly assigned, the policy may be referred back to the MEC president and Clinical Policy Coordinator for reassignment. 
  8. Published : In a common policy manual organized by chapters outlined in Attachment B : Organization of the Clinical Policy Manual.
  9. Implemented : By the assigned builder [informaticist] and owner.
  10. Monitored : By the owner
VI. Owner :       President of the Medical Staff

VII. Builder :      Chief Medical Informatics Officer

VIII. Tested by : 
             Regulatory Affairs, December, 2010
             Senior Leadership, December, 2010
             Chief Nursing Officer, December 2010
             Chief Medical Officer, December 2010

IX. Keywords : Clinical Policy Manual, Clinical Policy, Administrative Policy, Owner, Builder, Testing, Approval, Approval Committee, Chairperson, Medical Executive Committee, Publication, Implementation, Monitoring

X. Approval Committee :
         Medical Executive Committee, January 2011

XI. Approval Date :     

Approval Body Chairperson :   _________________________________________________
                                                  Chairperson, Medical Executive Committee             Date 
                                                   President, Medical Staff

Effective Date : ____/____/_____
Reapproved : ____/_____/_____

Attachment A : Format of a Clinical Policy :
1. All clinical policies should contain the following headings :
          I.      Purpose
          II.     Policy Statement
          III.    Scope
          IV.    Definitions
          V.     Procedure 
          VI.    Owner :
          VII.   Builder :
          VIII.  Tested by :
          IX.     Keywords :
          X.      Approval Committee :
          XI.     Approval Date :
2. Should be formatted on 8.5" x 11"
3. Should be clearly labeled "CLINICAL POLICY - ACME HOSPITAL"

Attachment B : Format of the Clinical Policy Manual :
The clinical Policy Manual will be organized into the following sections and chapters :

       a. Chapter 1 : General Clinical Policies     (Approved by Medical Executive Committee)
       b. Chapter 2 : Nursing Policies                  (Approved by Nursing Committee)
       c. Chapter 3 : Infection Control Policies    (Approved by Infection Control Committee)
       d. Chapter 4 : Laboratory Policies             (Approved by Laboratory Committee) 
       e. Chapter 5 : Pharmacy Policies               (Approved by P&T Committee)
       f. Chapter 6 : Radiology Policies               (Approved by Radiology Committee)
       g. Chapter 7 : HIM/Informatics Policies    (Approved by HIM/Informatics Committee)

        a. Chapter 1 : Medicine                            (Approved by Medicine Committee)
        b. Chapter 2 : Surgery / OR                     (Approved by Surgery Committee) 
        c. Chapter 3 : Pediatrics/Neonatal            (Approved by Pediatric/Neonatal Committee)
        d. Chapter 4 : Labor and Delivery           (Approved by L&D Committee)
        e. Chapter 5 : Behavioral Health             (Approved by Behavioral Health Committee)
        f. Chapter 6 : Pediatrics / Neonatal          (Approved by Pediatric Committee)
        g. Chapter 7 : Critical Care                      (Approved by Critical Care Committee)

Now remember, your hospital's Clinical Policy #1 may vary. 

To provide proper oversight, then, the President of your Medical Executive Committee should meet with all of these chairpersons on a regular basis (once every few weeks/months) to talk about the health of the policy mechanism and any issues which arise. If the committee minutes, from all of these committee meetings, are published in a central location - The minutes will then also help communicate the overall state of affairs on your front line to senior leaders. (In this way, your policy mechanism becomes a tool of organizational communication.)

Anyway... One of the first questions you'll get, after you examine this draft, is, "What about my policies?", for example, Quality Assurance might argue "We need QA policies that help guide the enforcement of error reporting...!"

Your Medical Staff President and Clinical Policy Coordinator will have two options, when faced with this argument from various places in your hospital :

1. Create a new chapter in your policy manual for QA policies (in this case, probably under hospital-wide clinical policies) :
     BENEFITS : 
             - QA will have their own chapter in the policy manual
             - They can approve QA policies without discussion at the Medical Executive Committee
     COSTS : 
             - You will need a new committee to approve the policies in this chapter
             - You will need a charter delegating authority to that committee
             - You will still need to oversee the subcommittee through regular meetings with the subcommittee chairperson.
2. Approve this sort of policy as a "General Clinical Policy" :
     BENEFITS : 
             - Fewer committees needed to maintain this manual = Less staff needed to fill committees!
     COSTS : 
             - Medical Executive Committee may spend time reviewing and approving many policies -

So : If Medical Executive Committee is spending too much time reviewing/approving QA policies, the Chairperson of the MEC should consider creating a QA subcommittee and approving a charter delegating that committee with the power to approve their own QA policies.

Would love to hear your feedback! Leave comments about your own Clinical Policy #1 stories! :)


Andy Oram said...

Sounds like a complicated procedure for staff to remember and follow. Do you provide templates and--even better--some automated tools so they can be assured they follow the appropriate workflow?

Dirk Stanley, MD, MPH said...

Very good point - And no, unfortunately, I don't have any automated tools. This fits a classroom lecture better than it does a blog, but I'm trying to explain the relationship between hospital governance and performance.

M.Shellenberger said...

I agree with your intent, and I support a strong structure and process when it comes to co-developing EHR, Clinical and Administrative Policies. Do you think that such a process as you propose could be managed primarily by non-clinical staff? A dedicated policy manager might ensure that clinicians focus on intent whilst the policy manager focuses on the process. This might also address Mr. Oram's call for automation and adherence to appropriate workflows. One FTE could save clinical leaders many hours of process work. We have such roles at our organization that coordinate the various committees and shepherd changes through the various process. and in fact have an official "workflow librarian" that maintains all of the EHR clinical workflows (each with an associated test script, policy and owner). It frees up Clinical folks to focus on clinical design.