One of the first questions a specialist asks an administrator who wants to set up a policy and procedures management system for a nursing department is, “What is your policies and procedures process?”

It is not uncommon for them to receive a less-than-straight answer, which is quite possibly why so many nursing departments seem to struggle to manage their policies and procedures. In order to do that successfully, it is necessary to be able to articulate the process.

In some cases, process basics can be mandated by a regulatory agency, if not several agencies. Sometimes, it’s all three. In some cases, there are requirements that policies and procedures be reviewed annually and that all personnel have access to these policies at all times. Of course, nursing departments are very busy places, which means those requirements are not always easy to meet.

When drafting a nursing department’s policies and procedures management strategy, you should keep a few important questions in mind:

  • What requirements or standards are we required to meet?In most cases, this will be driven by regulations and agency requirements, but it can also be driven by organizational standards and the company administration’s desire to be among the best, as well as the financial staff’s desire to maximize efficiency and profits.
  • What is the review date for each policy document and who will participate? It is always necessary to review each policy on a regular basis, and it will be up to you to decide when that happens. In some cases, you may want them to come up for review all at once, but in others, it might make more sense to stagger them in a way that makes reviews and revisions easier to deal with. Every policy document will need an author, and it will have to be approved by someone, which is the minimum. That said, consider setting up a policy and procedures committee to conduct the reviews. It is often a good idea to have several levels of approval.
  • What is the most effective way to communicate policy changes to all personnel?With regular reviews, there will be a great many policy updates.  Since the efficiency and the effectiveness of the organization is dependent on following these policies, it is not possible for them to keep up with them if they are not aware of the changes. A strategy for making sure all policy changes are aware of all changes made is a necessity.
  • How do we publish our policy documents, and how do relevant personnel gain access to policies? When you decide whether to put documents up online or put them in a binder, make sure you standardize that format to endure that all personnel have ready access to them at all times. This includes using the same templates, naming conventions and even fonts on every document. In some more traditional organizations, distribution of policies and procedures is via binders and shared drives, but a more technological approach is becoming far more common, in which documents are published on a web-based document management system or a company intranet.

How do we publish our documents? If you are able to answer these questions completely, then you are on track for setting up a policy management system that works for your nursing department. Not only that, but you are well on your way to setting up standards and developing something of a “policy on policies.” Doing so will allow you to clearly articulate and communicate the expectation to everyone responsible for department policies to know the process for managing, reviewing and approving policies and procedures. This is the key to evaluating and implementing policy management automation tools.