What exactly is a "Nursing Policy"?

Hi fellow #HealthIT, #Informatics leaders, and other #clinicaljedi, 

Today's post actually started many years ago, when I was a Hospitalist taking care of a med/surg acuity patient on my service with a low magnesium level, and who needed intravenous (IV) magnesium replacement. After I entered the order for IV magnesium, the nurse taking care of the patient told me : "There is a new nursing policy on electrolyte repletion - If you want to give IV magnesium, you'll have to move the patient to a higher-acuity telemetry bed for monitoring, while we replace the magnesium." 

If you're not clinically trained, some brief explanation : Electrolytes are chemicals in your blood that you need to be healthy, and so too much or too little can be potentially life-threatening scenarios -  but the dose of magnesium I was looking to replace was a fairly common practice, often used in alcoholic patients undergoing detoxification, who have not kept up with their nutritional needs. So this nursing policy would mean that alcoholics undergoing detoxification would require me to transfer the patient to higher-acuity bed and nursing care, if they needed to get their magnesium replaced intravenously.

Wanting to understand and comply with the clinical standards of the organization, I sought more information and looked up this nursing policy. It basically stated, 'All patients requiring IV electrolyte replacement must be in a monitored telemetry bed.' Even if it might increase the demand for telemetry monitoring, the standard seemed to exist for a good reason - out of an abundance of caution for these patients - and so this nursing policy was signed off by nursing leadership.

And yet, I couldn't help but wonder - Was this really just a nursing standard? Or a nursing-and-doctor standard? If the nursing policy essentially changed how and where physicians ordered magnesium on alcoholic detox patients, should it not have been reviewed by one of our physician leaders, who might have educated me about this standard at our department meetings? And yet, there was no review or signoff by anyone in physician leadership, probably because it was identified as a "Nursing Policy".

It wasn't a big deal for me to transfer the patient to a higher-acuity, monitored telemetry bed, and the patient got the IV magnesium uneventfully, but they still had to find an available bed, and it still took me a little while to get my patient transferred. 

Since then, I've often wondered about this nursing policy, and how it impacts the configuration and use of Electronic Medical Records (EMRs) - Who exactly makes clinical standards, who reviews them, and who approves them? If nursing policies are standards only for nurses, should there also be doctor policies that describe the standards for doctors? 

Now entering my 10th year as a HealthIT professional (CMIO), I'm busy with EMR implementation, informatics design, and engagement of clinical staff, planning for workflows that deliver great medical care. And after engaging many physicians, nurses, pharmacists, and other clinical and administrative team members, I've still continued to wonder : What exactly is a "Nursing Policy"? What is a "Pharmacy Policy"? "Radiology Policy"? Are each of these tribes of modern healthcare living on their own islands, setting their own rules? What if we need to make workflow standards across these islands?

After a great deal of analysis and evaluation, I believe I have some insight about these questions, which ultimately help answer this common EMR governance question - Who exactly designs, reviews, approves, and maintains the workflows of a healthcare organization?

So I share what I think are the three key challenges that require discussion before we can have a better understanding of a typical policy manual.

A. THE FIRST CHALLENGE - Terminology - Clinical vs. Administrative : 
We need to start by first looking at two common terms used every day in healthcare : 

• 'Clinical Staff' - Term sometimes used to refer to those people involved in direct patient care, e.g. Doctors, nurses, respiratory therapists, pharmacists, dietitians, etc.
• 'Administrative Staff' - Term sometimes used to refer to those people NOT involved in direct patient care, e.g. Administrators, finance, safety, engineering, human resources, etc. 

The first problem is that these are loose terms, and not solid definitions -They fray around the edges. For example : 

• What about the Education department? Even if they don't provide front-line patient care, they are training the clinical staff on medical practice - So is that really an administrative function, or a clinical function?
• Or what about the Clinical Directors who run the clinical departments, but don't provide direct patient care? If they are designing order sets to update the care their staff provides in treating pneumonia, is that really an administrative function, or a clinical function?
• Often, roles that one might consider to be non-clinical, like supplies management, housekeeping, bed management, etc. actually do have a real impact in clinical operations. (E.g. Housekeeping technique can be very helpful in reducing infection rates.)

So the first step in understanding the policy chapters is accepting that these general terms may not be strict definitions, but somewhat ambiguous terms to loosely describe two different concepts - Clinical work (providing care?), and Administrative work (somehow supporting that care?). 

B. THE SECOND CHALLENGE - WHAT EXACTLY IS A POLICY/PROCEDURE? 
Surprisingly, the definitions for policies and procedures can vary. Legal dictionaries, technical dictionaries, and even HealthIT dictionaries all offer slightly different definitions. As of this writing, Google currently offers these :

While these are perfectly reasonable, it's worthy to note that the definition of "Procedure" does not identify "workflow" as a synonym. So even if you accept the Google definitions, I'd still like to offer these slightly refined, functional definitions : 

1. POLICY = A documented organizational standard
2. PROCEDURES (aka workflows) = How you will achieve those standards, or "an ordered set of tasks that uses people, time, and resources to achieve a desired outcome."

Generally, both policies and procedures are often found on the same document, for good reason : 

• If you are documenting an organizational standard with a policy statement,
• It's important to make sure you have planned and agreed about how to achieve that standard (procedure) 

So by outlining your standards, and how you achieve them, these policies and procedures can be very helpful documents. But given the ambiguity behind the terms "clinical" and "administrative", this can make their categorization (secondary definitions) a little difficult : 

• CLINICAL POLICIES - Are these policies for "clinical people" to follow? (Does that include education?) 
• ADMINISTRATIVE POLICIES - Are these policies for "Administrative people" to follow? (Does that include education?)

C. THE THIRD CHALLENGE - WHO EXACTLY ARE THEY WRITTEN FOR?: 

This third challenge starts to show up when you look at the typical chapters one finds in the "Clinical" and "Administrative" policy manuals : 

A. Clinical Policies :

1. Nursing Policies
2. Pharmacy Policies
3. Radiology Policies
4. Laboratory Policies
5. Infection Control Policies
6. Respiratory Therapy Policies
7. ...and so on...

B. Administrative Policies : 

1. Finance Policies
2. Human Resources Policies
3. Safety / Engineering Policies
4. Information Technology Policies
5. ... and so on...

Looking at this index, it's only logical to ask - Who are these documents for? Are the nursing policies just for nurses? If so, where are the physician policies, outlining the physician standards? Don't we all work together to take care of patients? Where are the documents that span nursing AND pharmacy AND laboratory?

SOME THOUGHTS :
There is a fundamental truth that's important to consider before we move on. Healthcare is a team sport - We all work together. Having standards on separate islands does not seem to help us all function together, so the idea of these standards all applying to (serving) different islands does not seem conducive to good teamwork and collaboration.

So how does the Informaticist approach this challenge, and create clarity and definition? By reviewing the definitions, archetypes, and indexing for these documents!

THE INDEXING CHALLENGE : 
IF a "Nursing Policy" were really just standards for nurses, then it would be OK to have only nurses writing, reviewing, and approving them. But in my IV magnesium example above, this "Nursing Policy" impacted my (physician) ability to care for the patient in that location, and so I had to transfer the patient to another bed to get the IV magnesium. So I'd like to offer the argument that, perhaps, "Nursing Policies" are not simply 'standards for nurses only' - This nursing policy created a standard for my physician activities, too.

The same argument would also apply to "Finance Policies" and "Human Resource Policies" - If the policy manual chapters only describe the people expected to follow them, then doctors and nurses would not have to honor Finance or HR policies. (We know this is not true.)

And so I believe this is a compelling argument to say that the policy chapters are not describing who's expected to follow the policy. If that's so, then what exactly are the chapters describing?

Before we can offer up an answer, there are two final definitions to ponder and consider :

1. Policy Author/Owner - The person responsible for writing, monitoring, and upkeep of a policy
2. Policy Stakeholder(s) - The person(s) impacted by the policy standard, who for review and education, are responsible for reviewing (vetting) the policy before approval

If we assume that the policy author/owner is a stakeholder too, then we could potentially refine these definitions slightly : 

POLICY STAKEHOLDER(S) - The person or people impacted by the policy standard. These are categorized as : 

• PRIMARY STAKEHOLDER (aka "Policy Author" or "Policy Owner") - The stakeholder with the time, training, expertise, and responsibility for creating, maintaining, and updating the policy.

• SECONDARY STAKEHOLDER(S) - Additional stakeholder(s) impacted by the policy standard, who for development and education purposes, are responsible for reviewing ('vetting') the policy before final approval.

And if we can accept these expanded definitions for policy stakeholders, which separate the primary stakeholder from the secondary stakeholders, then we have a much better chance at decoding the policy manual! Maybe that "Nursing Policy" is in the chapter of "Nursing Policies" NOT because it's a 'policy that only nurses have to follow', but because nursing is the primary stakeholder - They had the time, training, expertise, and responsibility to create, update, and maintain the policy. And so as the physician who had to move my patient because of this policy, am I a secondary stakeholder, still required to follow the policy...?

SO WHAT EXACTLY IS A "NURSING POLICY"?
If these arguments are compelling to you, and your organization formally accepts the definitions I've proposed (ask your legal counsel), then we can first summarize some of our findings here :

1. Healthcare is a team sport - We all work together to take care of patients.
2. The terms "Clinical" and "Administrative" are not as well-defined as we wish they were - There are plenty of examples of roles and functions that overlap both.
3. The chapters of the policy manual are probably not just describing the 'people expected to follow the standard'.
4. More likely, the chapters of the policy manual are describing the primary stakeholders, with the time, training, and expertise to create, maintain, and update the policy. But each policy may have additional secondary stakeholders.

If the above (#4) is true, and a policy can have multiple secondary stakeholders, then the policy chapters are more likely describing only the primary stakeholders - Those expected to create and maintain the policies. And so the chapters could maybe be better described as: 

A. Clinical Policies - policies maintained by clinical departments
B. Administrative Policies - policies maintained by administrative departments

And so we might further describe the policy manual as : 

A. Clinical Policies - Organizational policies maintained by clinical departments

1. Nursing Policies - Clinical Policies maintained by the Nursing Department
2. Laboratory Policies - Clinical Policies maintained by the Laboratory Department
3. Pharmacy Policies - Clinical Policies maintained by the Pharmacy Department
4. Radiology Policies - Clinical Policies maintained by the Radiology Department
5. Infection Control Policies - Clinical Policies maintained by the Infection Control
6. ... and so on...

B. Administrative Policies - Organizational policies maintained by administrative departments

1. Finance Policies - Administrative policies maintained by the Finance department
2. Human Resource Policies - Administrative policies maintained by the Human Resources department
3. Safety Policies - Administrative policies maintained by Safety department
4. Education Policies - Administrative Policies maintained by the Education Department

And each of these policies, both clinical and administrative, could apply to physicians if the physicians are one of the secondary stakeholders in the policy. This now helps us [DRAFT] some answers to some common policy questions : 

• Q : "What exactly is a clinical policy?" - A : It's an organizational standard that is maintained by a clinical department and listed in the clinical section of the policy manual.
• Q : "What exactly is a nursing policy?" - A : It's a clinical policy maintained by the nursing department.
• Q : "Do doctors have to honor nursing policies?" A : If physicians are a secondary stakeholder in the policy, and the procedure was reviewed and vetted by physician leadership, the answer is clear - absolutely, yes.
• Q : "If there are nursing policies, why are there no physician policies?" A : Probably because of the definition of the primary stakeholder (aka policy author / owner) - E.g. "A person with the time, training, and expertise to create, maintain, and update the policy." While physicians may have expertise about evidence-based practice, they also cost a lot in salary, and generally don't have the time, training, or responsibility to create or update policies. As long as healthcare continues to see this function as a nursing-only responsibility, these policies will probably continue to be published in the chapter of nursing policies. 
• Q : "What's about education policies? Are they clinical or administrative?" - A : They can be either, it doesn't matter so much about which section (clinical or administrative) they are found in. What really matters is that they create standards to ensure reliable education of all employees on important operational issues.
• Q : "So do we really need to divide the policy manual into clinical and administrative policies? What good does this serve?" - A : I think many in healthcare have historically made this distinction because, in general, it's hard to be good at both, e.g. there are not many people who are good at both financial planning and treating pneumonia. The terms loosely describe a focus, with different skill sets that both require a long and different educational pathways. So using these terms may loosely help us plan for resources, such as the general hiring/training of staff. But it's still important to note that these terms are somewhat vague, and may also create unnecessary divisions and confusion when it comes to shared decision-making across the organization. 
• Q : "So if I want to write a policy, how do I do it?" A: It probably makes sense to first identify the standard (policy), and the steps you will use to accomplish it (procedure). Once you have the procedure written, it should help you figure out all of the stakeholders involved - Nursing, physician, pharmacy, lab, education, HR, housekeeping, finance, etc. Once you have all of the stakeholders identified, then you'll need to figure out who will be the primary stakeholder, responsible for getting all of the secondary stakeholders together, talking about the policy, and securing their buy-in, working out the details, getting it approved, and then finally, publishing it in your chapter of the policy manual so that you will revisit it regularly and make sure it's still meeting your needs.

Please remember, this is all just an educational discussion, and since I'm not a lawyer, the [DRAFT] answers I've offered above depend largely on your organization's willingness to adopt some of the [DRAFT] definitions and processes I've offered in this post. Your mileage may vary considerably, and so before making any changes, changing any definitions, or answering these questions in your own organization - Please make sure to discuss with your senior leadership and review these definitions with your own legal and clinical informatics teams, to make sure they make sense to your organization, before you consider  formally adopting them.

A big special thank you to mentor and quality guru Dominick Lepore, MS CTRS for sharing every lesson learned.

Have any thoughts or comments you would like to contribute? Feel free to respond in the box below. 

Linguistic issues in Healthcare

I'll admit it - I was flattered when Mark Hagland of Healthcare Informatics recently gave me my second interview about CMIO life. During our discussion, he asked me a lot of questions about "What does it mean to be a CMIO?" and "What makes a good CMIO?". And as I was responding, I told him that I feel like a lot of my job is about offering translational services between the clinical side, the administrative side, and the IT side of healthcare.

As a multilingual person who grew up in a multicultural household, I learned a lot about interpreting :

• How culture, context, and language all interplay and influence each other.
• How hard it is to pin down which of the three is more influential in communicating a message.
• How language is sometimes unable to convey a specific message. (* - IMHO, this is why art, poetry, and music exist - To help send those messages where language fails.)

So I feel like a lot of my the CMIO role is like being a United Nations Interpreter - I have to consider the culture, context, and language that each member of a team is using, and try to make sure that the "same message" is being received at the other end of the line.

I can only say that quietly, I see a lot of confusion happening in the national healthcare discussion because we don't appreciate the linguistic issues which contribute to that confusion. We don't see it because we're all speaking English... right?

To give an example of what I'm talking about, I sometimes act as an interpreter between the German and American members of my family. This is a fairly straightforward act, where :

• At dinner, one of my German family members will say something in German.
• I listen to what they said, and have to consider both the context of the message, and the German cultural perspective of what they said
• I have to mentally prepare a translation with a similar theme in English with an American perspective.
• I have to help verify the context and quality of my mental translation by comparing it with a similar American cultural context (if one exists). 
• Sometimes, despite your best efforts, there is no way to do this 100% effectively - This is why there are words that 'cannot really be translated', like "Kindergarten" and "schadenfreude" which make their way into the English/American lexicon.
• I deliver the best English translation I can that, hopefully, is as close to the content, context, and spirit of the original message.

This process of translation is fairly intuitive to most people when speaking different languages because, well, they are different languages - There is virtually no way my American family and German family can talk to each other without an interpreter.

The problem in many healthcare discussions is that we're all speaking English - So the context and cultural perspectives of different members of the healthcare workforce are not as apparent, and so it's not as immediately clear that you've crossed cultural boundaries. In short - It's very easy for messages to get mixed up because people aren't always aware when they have crossed a cultural boundary. People may have experienced this in any business, but healthcare is particularly susceptible to this due to the many cultures that interplay in healthcare - Clinical, administrative, technical, business, etc.

As a CMIO who grew up multilingual, however, I'm keenly watching for those cultural boundaries, and playing so many roles, I try to act as an interpreter and watch to make sure the right message was received on both sides of the fence.

Still, even with my experience, I was recently humbled when I inadvertently crossed a culture boundary  - I tried to let a family member know I moved their mother to the ICU just as a precaution :

Me : "I moved your mother from the floor to the ICU just as a precaution."

Family : "What was my mother doing on the floor? Did she trip and fall?" 

(Same word, different culture and context - Good thing this person asked for clarification! What if the family hadn't asked for clarification?)

An interesting parallel to this discussion - UN interpreters are generally expected to study both of their languages equally well and to live in both cultures, so they understand the cultural context, jargon, slang, and idiomatic expressions in both languages. In the same way, I think that's why it's helpful for me to work both clinically and administratively - It helps me understand the language, jargon, slang, and idiomatic expressions of both cultures.

So Mark, as a multicultural, multinational, and multilingual guy himself, totally understood this issue and wrote this really interesting blog post where he spoke about an experience he had while visiting South Korea, when he participated in a 'translational daisy chain' where a diverse group of visitors were trying to help a French-speaking Belgian woman buy tickets. Using a combination of people, all bilingual but speaking different languages, they established a French <> English <> German <> Korean translation chain, and by each person working on their part of the translation, this French-speaking woman was able to buy tickets from a Korean-speaking vendor.

It's one of the craziest stories I've ever heard, but it beautifully demonstrates both the value of bilingualism and the work it takes to get even a simple message across four languages and four cultures. Anyone who has played the game "Telephone" just using English knows how easy it is to fail to relay a message - Imagine doing it across four languages and cultures!

I suppose this might be one of the reasons I see a lot of CMIOs from diverse backgrounds, where something about their life experience taught them to be comfortable crossing cultural boundaries and 'seeing both sides of the coin'. This seems to be a fairly common trait among the other CMIOs I meet. For me, it's part of the reason why I so enjoy helping to further define and clarify the CMIO role - to help healthcare evolve and adapt.

Remember, this is just academic banter, and your mileage may vary. Always enjoy comments, questions, thoughts, and discussion!

The problem of "Feature Bleed"

Another common question I get asked is, "What can we do to prepare for 'going electronic'?"

Most hospitals will, in these times, gather their order sets, in the hope of "making them electronic".

It's then, that you may notice the first problem. I like to call it "Feature Bleed".

"Feature Bleed" is when you have order sets that have pieces of :

1. Order sets
2. Protocols
3. Documentation

This is VERY, VERY common - Most paper-based hospitals aren't disciplined enough to have their order sets and protocols and documentation well-separated.

Take a look at your paper order sets - See something called "Advance Diet as tolerated" or "Up ad lib" or "Do not start any other CNS depressants without checking with the anesthesiologist first"? These are all protocols!

Take another look at your paper order sets - See something like "Write patent's PTT here : ___ ___ ___" or "Write patient's neuro checks q6h here : ____ ____ ____" - These are all documents!

Take one last look at your paper order sets - Are they labelled something like "Alcohol Withdrawal Protocol / Order set / Flowsheet"? This is a sign that you may have feature bleed. (Ask yourself which tab in the paper chart you have been putting this order set into - If you're not sure, that's a warning sign of "Feature Bleed")

How does this happen, and why is it so common? In the paper world, it's very easy to make an order set where :

[ Order set ] = [ Order set ] + [ Documentation ] + [ Protocol ]

The problem is, when you go electronic, you will have different places ("buckets") where you need to organize those things.

1. The "Order set" bucket
2. The "Protocol" bucket
3. The "Documentation" bucket

And to organize this, it will mean :

1. Significant redesign of your paper order sets
2. Significant redesign of your clinical protocols
3. Significant redesign of your clinical documentation

And to handle this? You'll need to define, for each of these informational tools :

1. A good policy definition of the informational tool (to help guide builders in the right direction and prevent future "Feature Bleed")
2. How will the informational tool be built? (By who, and how? What format?)
3. How will the informational tool be tested before it "goes live"?
4. How will the informational tool be approved in your organization?
5. How will the informational tool be published
6. How will the informational tool be tracked.

If your organization was very disciplined in the paper world, and you have good policy definitions of these tools, your conversion to EMR will go a lot easier.

And if not, you're like about 80% of the places I talk to. :) Just be prepared to deal with this organizational redesign issue at some point - Preferrably earlier, rather than later.