According to Mosby's Medical Dictionary (2009), a policy is "a principle or guideline that governs activities in a facility that employees...are expected to follow".
If you are a healthcare leader, ask yourself whether the policies in your organization are written in a way that your employees can easily follow. Do the authors use simple language that is easy to understand? Can the frontline efficiently locate them? Is it clear which policies different employees are accountable to?
It is not unusual for healthcare systems today to have thousands of policies. Add to that number the procedures, standard work, and protocols that your frontline team is expected to know, and it is no wonder we have difficulty sustaining clinical improvement in hospitals.
As the healthcare industry has embraced Lean Management as a foundation for continuous improvement, organizations often end up with even more documents and resources that are intended to provide guidance to the frontline upon completion of a project. These could be located in a policy manual (paper or electronic), in an email, on a huddle board, or frequently, inside the bathroom door (because then people are a captive audience, so they will surely read it there). Additionally, the frontline team that are now involved in improving the work may not be aware of applicable practice guidelines or other departmental policies that may conflict with the work they are doing.
Lean has provided us with an excellent foundation for eliminating waste in our clinical processes, but if you are struggling to sustain compliance in your organization, then I suggest that you apply lean thinking to the lean improvement process itself. I believe this can be quite simple if you consider what I call "The Six Ps of Practice" during every PDSA improvement project. These include Practice Guidelines, Policies & Procedures, Protocols & Order Sets, Patient Education Material, Patient Care Documentation, and Professional Development.
The Six Ps of Clinical Practice
Practice Guidelines: Healthcare is a heavily regulated industry. Be sure the improvement team begins with a thorough understanding of the regulatory, legal, quality, clinical, and professional standards of practice related to the improvement work. Document and reference all of these guidelines so that when future adjustments are made, the new team understands what the initial decisions were based upon. This also prevents rework, as the new team will not be required to spend as much time researching the same standards.
Policies and Procedures: Scour the organization for any and all policies and procedures related to this subject. This includes previous Standard Work documents created by other improvement teams (which are often stored in a different location than policies and procedures). Consider departmental as well as organizational documents. It is not uncommon for Nursing policies to reference expectations for physicians, or Laboratory and Pharmacy policies to outline nursing tasks. Often, the disciplines outside of these departments are not even aware that such policies exist. It is also typical to find that every department has their own version of organizational policies, such as infection control or hand washing. This duplicity can result in confusion and inconsistency in practice. Have the improvement team identify waste (excess verbiage, steps, pictures, etc.) in these documents and include streamlining them as part of the improvement plan.
Protocols and Order Sets: The development of the EHR has resulted in many clinical protocols (which were once embedded in policies) being built into order sets that are presented to clinicians as part of their daily routine. This is definitely a leaner practice, but it is often applied inconsistently. In such cases the frontline may find some protocols in the EHR, some on paper, and some still in the body of a policy. Have the team assess all of the applicable protocols and order sets (for all disciplines, not just physicians). Determine whether they are in line with the Practice Guidelines previously identified and if any protocols that are incorporated in policies can more effectively be built into the EHR.
Patient Education Material: In many organizations, the educational content provided to patients is determined individually by each clinician. It is not uncommon to find a file cabinet in the nurses' station with outdated material, or clinicians searching WebMD for educational content they can print on demand. This inconsistency in practice places the patient, the clinician, and the organization at risk. The improvement team should clearly identify which patient education material should be utilized and ensure it is easily accessible (preferably via a quick link in the EHR).
Patient Care Documentation: It is no secret that the complexity of EHR documentation is contributing significantly to clinician burnout. Most disciplines are documenting far more information than they ever did in the paper environment, and although some of this contributed to improved patient safety, much of it is redundant and unnecessary. Have the team examine what is being recorded and when, by every discipline, and determine whether there is an opportunity to optimize the documentation. If a hybrid paper/EHR process exists, create a plan to automate all of it as soon as possible. Living in both worlds is a huge source of waste and inefficiency in healthcare.
Professional Development: Many project teams feel the need to "educate" prior to rolling out a new process, which often takes the form of a PowerPoint presentation in an online module outlining the new expectations. The problem is, most clinicians are inundated by such "education", and rarely take the time to truly understand the content. Have the team ask themselves: does the change they are proposing require education or communication? Often, communication is all that is required, which involves much less time and effort on everyone's part than true education does. If however, the team determines that education is necessary, then ensure the content is incorporated into the overall professional development process, including competency validation and orientation. Creating an additional layer is burdensome to the frontline, and generally ineffective.
Incorporating these "Six Ps of Clinical Practice" as part of the PDSA cycle for every project will set the foundation for sustaining improvement in the long run. Although this can be a daunting task for organizations with tens of thousands of such documents, the impact on the frontline's ability to know what is expected of them is worth the time and effort. Adopting a more formalized approach to managing the documents that guide clinical practice will improve patient safety, help to reduce clinician burnout, and mitigate financial risk to the organization.