Implementing Policies and Procedures

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Implementing Policies and Procedures

• Fadwa Bawazir, CPHQ
• Director, TQM Dept.
• Hera General Hospital

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• The basic purpose of establishing systems,
  processes and guiding them in policies and
  procedures is to implement them well.

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• Failing to implement, is wasting time, money,
  effort and other resources.

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Policy Implementation

• It is encouraged to have a minimum of two (2)
  weeks between the date of issue and the date of
  effect for orientation and in-service training

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Policy Implementation

• Implementation process involves a period of three
  (3) months to give time for
• distribution,
• familiarization,
• actual practice and
• monitoring

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Policy Implementation

• All the hospital staff shall sign in the
  Acknowledgement Sheet to signify that they have
  read and understood the Policies and Procedures
  (Hospital Wide, Departmental, Safety, Infection
  Control, etc.).
• Original Copy filed as page 3 in the Manual kept
  in every department

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Acknowledgement Sheet
HOSPITALWIDE POLICIES AND PROCEDURE STAFF
ACKNOWLEDGEMENT SHEET I, the undersigned, have
read and understood the contents of this
Hospital-wide Policy and Procedure Manual.
Note Original Copy in the Hospital Wide
Policies and Procedure Manual. Duplicate Copy to
be forwarded to the Total Quality Management
(TQM) Department.
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• Accrediting bodies require that policies are
• Documented
• Approved
• Communicated/educated
• Implemented

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Implementing the Various Types of Policies
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Philosophical

• Code of Ethics
• Mission
• Vision
• Organizational values
• Code of Conduct
• Dress Code
• Communication culture

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Methods

• Distribution of the policy
• Departmental meetings announcements
• Posting
• Quiz and questions for the staff
• Staff attitude
• Provision of uniforms
• Staff adherence

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Resources Deployment

• Allocation of resources
• Manpower staff distribution
• Equipment
• Space
• Financial

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Methods

• Staffing plan per unit
• Pull out process
• Leave plan
• Actual distribution of spaces amongst services
• Distribution of equipment according to priority
  criteria
• Budget and reimbursement process

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Working /Departmental/ Multidisciplinary policies

• Processes
• Guidelines
• Daily work/ services

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Methods

• Departmental meetings announcements
• In-service training
• Workshops
• Presentations and discussions
• Posting of process flowchart
• Quizzes
• Competence checks (periodically)

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Administrative

• General Rules and regulations
• Leaves, personnel processes
• Smoking policy
• Security policies
• Staff development
• TQM policies

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Methods

• Departmental meetings announcements
• Posters and signs
• Process flowchart
• Handouts
• Facility Rounds

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Memo policies

• Management notification,
• General distribution,
• Delegation of authority

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Methods

• Bulletin board
• Departmental meeting announcement

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Verbal and Telephone Order Policy

• Staff need to know when they are acceptable
• How to document them
• What is the patient safety goal related to this
  policy
• Communication with the doctors
• Nurses related responsibilities in implementing
  the policy

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Occurrence Variance Report/ Incident Report

• Posting of the flowchart
• Knowing the process flow
• Ability to identify reportable events
• Practice of using the form
• Actual use of the form
• Corrective actions-short and long term
• Trends review and recommendations
• Receipt of concerned departments and units
• Enhancement of long term measures.

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• It costs organizations a lot of time, money and
  effort to work on policies and procedures and
  establish systems and processes.

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• Not living those policies may lead to unsafe
  patient care as well as jeopardize the wellbeing
  of the staff.

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THANK YOU