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!) :)

DRAFT VERSION - CLINICAL POLICY #1


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 :

1. SECTION I : HOSPITAL-WIDE CLINCIAL POLICIES

       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)

2. SECTION II : DEPARTMENT-SPECIFIC CLINICAL POLICIES

        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! :)

On the Importance of Policy Mechanisms and Governance

Healthcare is going through change. Tremendous change.

Pay-for-performance, ACOs, EMRs, and a rapidly growing buffet table of regulatory bodies are forcing hospitals to adapt, and quickly. Hospitals and medical systems that can change quickly, adopt new standards, implement new tools, and provide low-cost, high-quality care will survive. Those that can't, won't.

So recently I've had several conversations with healthcare leaders who are looking for help making change. Some of the questions I've heard :

1. "What can I do to help us make change faster?"
2. "Why aren't our physicians (or committees) engaged?"
3. "What can I do to help improve communication?"
4. "What can I do to help standardize care in our organization?"
5. "What can I do to help us work together as a team?"
6. "What can I do to help us implement our Electronic Medical Record?"

Believe it or not, all of these questions are related by a thing called "hospital governance", and probably the most important tool for hospital governance is your policy manual.

Q : "Dirk, what is hospital governance? It sounds like a civics lesson, or something from Schoolhouse Rock."

Every organization, from Apple to IBM to small businesses to hospitals, have some form of governance - A set of tools to make decisions and take actions. Why? Someone has to make decisions, and then someone has to get work done. Unfortunately, organizing those people, who may have conflicting opinions, and getting them instead to work together can be challenging.

It's not enough to just have "talented staff". If your staff isn't working together the way you want them to, it might be a sign that you need to look at your governance structure.

So what is the biggest tool you have to govern yourself? Your policy manual. Unfortunately, the governance, policy manual, and policy mechanism of most hospitals is probably one of the least taught subjects in healthcare management.

Bear with me, I'm going to explain it in simple language. :)

Q : "So, Dirk, what's a policy? What's a procedure?"

A policy is a written goal of your organization. The procedure is the list of steps you take to achieve that goal. 

Good policy statements are short and sweet and clear. (A really good reference for this is Writing Effective Policies and Procedures : A Step-by-Step Resource for Clear Communication, by Nancy J. Campbell, 1998). Policy statements should not be paragraphs long - One or two sentences maximum. They should be clear and confident, e.g. :

     "All patients will get kosher meals..." or

      "All ED patients will get screened for influenza..." or

       "All pediatric patients will get weighed daily..." or 

        "All female patients over age 40 will be offered screening for..."

(You'll notice all of the above samples refer to subsets of patients, so they are all samples of clinical policies.) Good policy statements create clarity out of confusion, and help your staff understand your organizational goals.

The procedure, then, are the steps you take to achieve the goal stated in the policy, e.g. :

   "All pediatric patients will be weighed using the following procedure :

          1. Patient will stand on a digital scale

          2. Nurse will read digital readout on scale 

          3. Nurse will document the patient's weight in the patient's chart."

If you're not used to writing policies, it pays to invest in someone with training and experience. A good policy writer is worth their weight in gold. It's part art, part language, part human behavior, part communication, and part understanding workflows enough to write a good policy. Good policy writers can help create clarity out of confusion, and save your organization lots of money.

And you'll know if you have a good policy because someone on your front-line staff can read it, clearly understand it, and feel educated by the policy. 

When should you make a policy for something? Anytime your organization needs to standardize something.
      - Need everyone to get weighed on admission? Write a policy.
      - Need all patients over 50 to be given cancer screening? Write a policy.
      - Need all order sets to look the same? Write a policy.
      - Implementing a new tool that everyone will use the same way? Write a policy.

The danger, of course, in bad policies is that sometimes you can write too much. If you write too much, you can "paint yourself into a corner". This can be a problem when a regulatory body comes to look at your policies - In general, they look to make sure your policies reflect your practice. If you write too much, you can end up with policies that are too long, or that don't reflect your current practice, or that you have to keep amending/updating too frequently.

Again, this is why you should invest in someone trained in the art of policy writing, to help you write short, well-constructed, thoughtful, and clear policies. 

Q : "Can you give me a good teaching example of a policy and procedure?"

Sure. My favorite teaching example is this one :

POLICY : All patients will get a cupcake on admission.


PROCEDURE :

1. Kitchen staff will bake 100 cupcakes daily.
2. Couriers will bring cupcakes to floors.
3. Nurses will hand patients a cupcake when they are admitted.

What I like about this teaching example is it shows the thought that needs to go into a good procedure -

• It is a simple example which, while somewhat comical, people usually don't forget.
• It shows which staff will play which role (this is very helpful when figuring out who should review a policy before it is approved)
• "100 cupcakes" - It shows the thought that needs to go into writing an effective procedure. The trick : to include as much detail as is needed, and no more - (How many cupcakes will you need a day? How many admissions do you usually have?) 

This simple, well-written policy then helps directors budget for the time of their employees, and finance people to budget for the materials needed to make this policy work.

Q : "So what about the policy manual?"

The policy manual, then, is your total collection of policies. It should be treated like a sacred text. A good policy manual isn't torture - It's a source of education and communication across your organization. 

     - Have new staff you need to train? Use your policy manual!
     - Have old staff that you need to train? Use your policy manual!

     - Have directors who need to know "what's happening on the front"? Use your policy manual!
     - Have staff who need to know what the organization's rules/objectives are? Use your policy manual!

Q : "That seems pretty simple, is that it?"

Hardly.

Q : "What else do I need to know?"

Everything you do with those policies determines how your organization functions.

1. The way you organize your policies is important.

In a large organization, it's not enough to simply put all policies into one binder. You'll want to make a table of contents that guide your front-line staff to the policies they are looking for. Often, you'll want hospital-wide policies (apply to patients regardless of location), and department-specific policies (apply to patients in a specific location). And then you'll want to subdivide those chapters. (See my post about Policy Manuals Made Easy for an example of how you might divide your policy manual.)

2. The way you test your policies is important.

Before your policies are brought to a committee for approval, you'll want the policy writer to "test" them. That means, you'll want to know that the policy has been checked for accuracy, that the workflows are realistic, that the spelling has been checked, that the formatting is correct, that the proper stakeholders have been asked about the policy.

If you test your policies properly, before they are brought to a committee, there will be little discussion at your committee. Ever hear the statement, "Why are we discussing these details in the committee meeting?" The more time you spend in the "testing phase", the less discussion there will be in committee. I can't say enough about the importance of investing in testing, before a policy is brought to a committee for approval.

3. The way you approve your policies is important.

Depending on how you organize your policy manual, you will need a committee, or a group of committees, to approve your policies. A well-designed committee is small, efficient, and has a well-designed voting structure, run by a committee chairperson who understands basic rules of parliament and chairperson responsibilities. (For this, I recommend Robert's Rules of Order : Newly Revised - In Brief.)

If your committee has a well-designed charter (and voting structure), and is run by a chairperson who understands their responsibilities, the approval process will be efficient and the committee will make good decisions - ultimately they need to decide whether to approve, deny, or modify a policy.

And if you organize your committee structure properly, then subcommittees that struggle to approve a policy, or end up in a tie vote, should usually have a top-level committee that can discuss all of the policies that cause extensive discussion.

4. The way you publish your policies is important.

It's not enough to have well-written, approved policies in a binder in someone's desk or laptop. The policy manual has to be organized, comprehensive, and put in a place where everyone can access it. 

Every employee should know where it is, and should be introduced to it when they are hired.

5. The way you enforce and monitor your policies is important.

It's not enough to have well-written, approved policies in an organized, common policy manual. Managers need to enforce policies. Sure, during emergencies, there may be exceptions/emergencies where your front-line staff violate a policy, but when that happens, the employee should document the reason and managers/directors should ask "Why?". If someone is repeatedly violating a policy, it either means the policy is not appropriate/realistic, not properly designed, or the employee may need educating. (In my opinion, violating a policy should never be an automatic black mark against the employee - It should make the manager pause to reflect on the reason for the violation.)

It's also not enough to just schedule a re-review of policies every 2-3 years. Enforcement and monitoring is a continuous, ongoing job, which hopefully your managers are doing continuously. Those managers should be well-connected to your policy mechanism, so they can respond appropriately.

Finally, I will leave you with this Top-10 list of overheard comments which suggest your policy/governance mechanism may not be working the way you want it to :

1. "Why aren't our committees (or physicians) more engaged?"
2. "I don't know how to make a change around here" or "We can't change anything."
3. "Why didn't they tell us they were doing that?" (or "They have no idea what we're doing.")
4. "Who the heck passed that policy?" (or "That policy makes no sense.")
5. "Where is the policy manual?"
6. "I didn't know I was supposed to do that."
7. "Why do we have so many order sets?" (or policies, or protocols, or forms...)
8. "Our committee just decided against that, why are people still doing it?"
9. "Why aren't the owners updating their policies?" (or, "These policies are so old.")
10. "What can we do to standardize care?"

The good news is that organizing a policy manual and mechanism, and fixing your governance, can be a great experience that draws your entire staff together and rallies the troops. Feel free to leave your own stories about policy mechanism and governance!