POLICY AND PROCEDURE

1
POLICY AND PROCEDURE

• Policy a simple clear statement of what you
  should do (what)
• Procedure a simple clear statement of who
  should do what (when, where and how)

2
AUTHORITY

• This policy is promulgated under the authority of
  the COO and the Director of Infection Control.
  The Director of Infection Control is responsible
  for administering the policy.

3
POLICY

• All medical, nursing and laboratory personnel who
  identify or suspect a case of a reportable
  disease will report such case promptly to the
  Louisiana Department of Health in accordance with
  the Sanitary Code of the State of Louisiana.

4
LAW IS NOT POLICY

• There is a term for disobeying the law as a
  matter of policy.
• Who are the two most famous proponents of this
  policy?

5
VIOLATION OF POLICY

• As with all formal policies of this hospital,
  violation of this policy is grounds for
  progressive discipline.

6
MALAPROPISM

• Mrs Malaprop in The Rivals by Sheridan written in
  1775
• infectious control nurse (infection)
• assess concerns (address)
• hold this nation hostile (hostage)

7
NONSENSE

• due to the feasibility of the department
• in the prevention of unlawful duty of care
  continues to exist for individuals
• attend to our community in the utmost fashion

8
TAKE A STAND

• You should think about considering whether you
  perhaps should look into being in the class room
  near or at the approximate time that the
  professor or other instructor may or may not
  present some information that could possibly be
  of use to some or all of you now or in certain
  circumstances in the future. COME TO CLASS!

9
MODIFIERS

• Sentences require a noun and a verb.
• Think carefully before adding an adjective or an
  adverb.
• Do not modify an absolute. I am unique, not more
  unique.
• Do not split infinitives.

10
PRONOUNS

• He and I want the books.
• Give the books to him and me.
• To whom did you give the books? To him?

11
PROBLEM SOLVING

• STRATEGIC MANAGEMENT IN HEALTHCARE
• 3 March 2008

12
GOALS AND OBJECTIVES

• GOALS
• ENDS - OUTCOMES
• VALUABLE IN THEMSELVES
• OBJECTIVES
• INTERMEDIATE STEPS - MEANS
• VALUABLE MEASURE OF PROGRESS

13
REASONING

• INDUCTIVE REASONING FROM PARTICULAR FACTS OR
  CASES TO A GENERAL CONCLUSION
• DEDUCTIVE REASONING FROM THE GENERAL TO THE
  SPECIFIC

14
CONTINUOUS QUALITY IMPROVEMENT

• PROACTIVE APPROACH THAT ASSUMES ALL PROCESSES CAN
  BE IMPROVED
• ASSUMES A REASONABLE LEVEL OF QUALITY TO BEGIN
  WITH
• ASSUMES YOU ARE DOING THE RIGHT THINGS ALREADY

15
PROBLEM SOLVING

• IDENTIFY THE PROBLEM
• ANALYZE THE SITUATION
• DEVELOP ALTERNATIVES
• CHOOSE A SOLUTION
• IMPLEMENT THE SOLUTION
• EVALUATE THE RESULTS

16
PROBLEM RECOGNITION

• IT IS EASY TO BECOME SO FOCUSED ON THIS THAT IT
  BECOMES THE PROBLEM
• LEAD, FOLLOW OR GET OUT OF THE WAY

17
PROBLEM STATEMENT

• STEM - OWNER - ACTION - GOAL
• A QUESTION WELL PUT IS HALF ANSWERED - DO YOU
  AGREE?
• OWNERSHIP/LEADERSHIP

18
ACTION ORIENTATION

• THE PSYCHOLOGICAL STIMULUS PROVIDED BY AN
  ACTION ORIENTATION SHOULD NOT BE UNDERESTIMATED
• THE VALUE OF A HOLD BOX SHOULD NOT BE
  UNDERESTIMATED EITHER

19
MILITARY MANAGEMENT

• STRATEGY PLANNING AND DIRECTING LARGE-SCALE
  OPERATIONS
• TACTICS MANEUVERING FORCES, METHODS USED TO GAIN
  AN END
• LOGISTICS PROCURING, MAINTAINING, TRANSPORTING
  MATERIAL AND PERSONNEL MANAGING THE DETAILS

20
DECISION CRITERIA

• EFFECTIVENESS
• FEASIBILITY
• LEGALITY/ETHICS
• ACCEPTABILITY
• COSTS
• SECONDARY GAINS
• UNINTENDED CONSEQUENCES

21
INFLUENCING FACTORS

• SITUATION
• ENVIRONMENT
• PROBLEM SOLVERS

22
SITUATION

• URGENCY
• MAGNITUDE/IMPORTANCE
• RISK/UNCERTAINTY
• COST/BENEFIT

23
ENVIRONMENT

• EXTERNAL
• INTERNAL

24
PROBLEM-SOLVERS

• EXPERIENCE, KNOWLEDGE, JUDGEMENT
• PERSPECTIVE, PERSONALITY, BIASES
• VALUES, PHILOSOPHY

25
GROUP PROBLEM SOLVING

• GROUP PROBLEM SOLVING PRODUCES BETTER QUALITY
  DECISIONS
• GROUPTHINK IS A PRIMARY CAUSE OF POLICY DEBACLES
• CONFLICT IS IMPORTANT TO REACHING A GOOD DECISION
• NONE OF US IS AS STUPID AS ALL OF US

26
EMPLOYEE PARTICIPATION

• QUALITY CIRCLES FAILED - PARALLEL AND IRRELEVANT
• HEARINGS DO NOT EQUAL PARTICIPATION - PATRONIZING
• SUGGESTION BOX - IMPERSONAL AND GENERALLY IGNORED

27
CASE STUDY 4

• VOLUNTEER COORDINATOR IS WORKING ONLY 6 HOURS A
  DAY
• FILLS OUT TIME CARD FOR 8 HOURS
• DOING A GOOD JOB
• GOES HOME WHEN HER WORK IS DONE
• WHAT IS THE PROBLEM?

28
CASE STUDY 1

• WORK LOAD IN A NURSING UNIT IS VERY HEAVY THIS
  MONTH
• FAMILY MEMBERS DOING PATIENT CARE AT SUGGESTION
  OF MS JOHNSON
• YOU HAVE SEEN JOHNSON SITTING IN THE UTILITY ROOM
  FOR LONG PERIODS OF TIME