Preventing those High Noon Standoffs-making sure our policies work

Preventing those High Noon Standoffs-making sure our policies work

 

We know that a facility’s policies are considered the “laws” of the center. Not completely unlike the days of the Wild West, they provide a framework for the orderly operations of the facility, instead of what can feel like a battle at sundown with a situation or process that physicians and staff feel passionate about.
I’m sure that we can all recall a situation without a policy to support decision making. But writing, maintaining and updating policies can feel like a job in itself. Those manuals, often used as bookends, are daunting as they stare at us from their shelf homes. How often do we glance at them and remind ourselves that they need review and revision?

Part of the ever growing spare time list, right? How do we make those policies, that save our backsides when we need them easier to manage? Having helped some centers recently do just that, here is how I approached it:

• Start by creating a list of core policies needed to meet all the required regulations. CMS, AAAHC, Joint Commission or AAAASF, based on your facility accreditation, and OSHA. This becomes your new table of contents.
• Find the current policy/policies you have that match the table of contents. Review, update, and bring to your Governing Board for approval. Once approved, provide a copy to your staff for review and get a signature attestation.
• Put the updated policy in the binder, as well as in an organized e-format. I love Dropbox. I can access it anywhere, and share individual folders as needed.
• For the rest, add a tab for those policies that address the center activities. Group these policies based on type (sterilization, pre-op, PACU, etc.,) and have the staff that live these process review and offer edits.
• Any “leftover” policies may be those sacred cows we need to retire. If so, take them to your Governing Board to see if they agree, then let them go.

Once you have a new policy manual that works, review part of it each quarter, and delegate reviews to staff. Recognize the need for a new policy when those stand-offs occur at high noon and implement in a timely manner. This process will also reinforce the policy is law culture, and make your job as Sheriff much easier.