How to Make Your Policies Better: Tips from the Brain of an Expert Witness

Uncategorized Jul 07, 2021

Hey educators and managers! I’m in your policies a lot and some are great. Some, though, not so good. Are policies the number 1 thing that keeps your patients safe? No. But, they can be an excellent tool for the number 1 thing that is keeping your patients safe (hint: it’s the nurses). In the cases I review, there are 3 things that jump out, right off the bat, and alert me that your policies are contributing to less than optimal outcome. So read on for a few reasons your policies might be terrible and how to start making them better.


Number 1: You’ve confused policy and procedure. 

Sometimes they live in the same document, but they serve 2 distinct functions. A policy guides the actions under a certain circumstance.  A procedure tells you step by step how to do something.  For instance, an oxytocin procedure would tell the nurse. Step 1: ensure informed consent Step 2: get the bag of pit and some pump tubing step 3 turn on the pump step 4 program the pump and have it double checked step 5 hook it up to the patient.  An oxytocin policy would help the nurse in making decisions around administration with “if this, than that” language i.e. if there is tachysystole, turn off the oxytocin.  A procedure is precise and should be followed 100%.  The very best policies however are only going to cover about 80-90% of your care.  Sometimes its not going to fit your patient exactly. Don’t try to make it cover every circumstance, like a procedure might. It will be long, cumbersome, confusing….unusable.


Number 2: You had a random situation happen and now you have a policy for it. 

Just like a single policy is only going to fit 90% of circumstances perfectly, your policies can’t try to cover every eventuality. Before you even start writing that policy, determine whether you really need one or not. I consulted for a hospital once that had over 300 L & D policies! My favorite was titled “When a patient has a syncopal episode at the front door”.  So apparently, a patient passed out once at the front door and no one on shift knew what to do. If your nurses can’t figure this one out, a policy is not the answer.  Making a policy and patting yourself on the back for fixing the issue is easy.  Addressing why the staff lack judgment, critical thinking and the ability to act is hard. Also, with 300 policies, how could a nurse reasonably get through those to find what they need? Policies are a TOOL for nurses, so make sure your goal is to help nurses give good care.  Don’t fall into the trap that policies are going to cover your corporate booty.  Again you’re looking to cover the main stuff, but you can’t try to make your policies cover every single eventuality.  


Number 3: Your policy is old and your references are out of date. Or you’ve taken great liberties with your references.

When crafting a policy you should have a system in place for writing, reviewing and updating policies.  Generally, the references need to be current and the policy need to be formally reviewed every 3-5 years. Story time: I was reviewing a case and after I’d reviewed the medical record, I received the policies of the unit.  And oh jeepers did they explain a lot.  “Of course the nurses didn’t have a good grasp of fetal monitoring!” I thought.  Their fetal monitoring policy had a single reference.  It was from 1984 and it was from an organization called NACOG.  Two things here: NACOG does not exist anymore…it is what is now our beloved AWHONN.  And second, can anyone think of anything that may have happened in regards to fetal monitoring since 1984?  Oh I don’t know, maybe NICHD? Along with this, if you cite a source in your policy, make sure it’s actually what the reference source is saying. I’ve seen facilities cite AWHONN or a textbook and maybe one or two lines are taken from the source.  The rest? Pretty much made up.

These are just three things to consider if you are in charge of policies and procedures at your facility.  In fact, they are just the tip of the iceberg.  To go deeper into this territory, I’ve written another piece on policies.  It addresses what I’m calling Toxic Policy Culture (TPC) and how you can work to have policies that contribute to a healthy nursing culture. 

Let me know after read these with what your biggest frustrations are with policies.  I'm always up for helping however I can!


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