HealthSeptember 27, 2023

Standardised policies and procedures boost patient safety

It is estimated that 140,000 cases of diagnostic errors occur each year in Australia, and that most are preventable. Medical mishaps range from diagnostic and surgical mistakes to administering the wrong medication or dose, and are blamed for up to 18,000 deaths and 50,000 permanent injuries. It is, therefore, crucial that healthcare workers can access current evidence-based guidelines to improve patient safety. 

Hospitals can reduce the incidence of medical errors by empowering staff to know how to make evidence-based decisions and improving communication throughout the organisation. This is best achieved through standardised policies and procedures that enable nurses to provide consistent, patient-centric, quality care; make informed, evidence-based clinical decisions; and collaborate more effectively with colleagues.

There has been momentum toward standardising some processes for healthcare workers and organisations. National guidelines have been drawn up around infection prevention and control and medication management, a digital health record system has been created, and protocols should comply with National Safety and Quality Health Service Standards.

However, policies and procedures still vary across States and Territories, and from hospital to hospital.

What is the difference between a policy and a procedure?

Hospital policies and procedures guide day-to-day operations, standardise practices and streamline processes across the organisation, and communicate expectations to staff, ensuring that every patient receives the same level of care.

Establishing a clear delineation between policies and procedures will reduce confusion and create organisational alignment.

  • A policy outlines organisational principles and expectations and sets boundaries for decision-making regarding practice.
  • A procedure is a series of steps to be followed as a consistent and repetitive approach to accomplish a result.

In simple terms, you observe a policy, and you perform a procedure. A hospital’s clinical policy will change infrequently, while clinical procedures require regular revisions based on emerging evidence, updated clinical guidelines, and other industry standards.

Helping nurses deal with information overload

Often, however, it can be challenging to keep policies and procedures current and to ensure that staff refer to policies and procedures regularly as the source of truth for safe and effective patient care, particularly in organisations which still rely on printed documents.

Australian nurse perspectives

From technology and communication issues to time constraints and clinical care variance, nurses throughout the nation expressed numerous challenges that make it difficult to get the necessary information needed in the moment, while acquiring new skills to deliver the level of care quality they know their patients require and deserve.

Adopting a cloud-based procedures solution can significantly reduce the organizational burden of creating and updating procedures while ensuring that nursing staff have access to the latest evidence in their workflow.

Clinical care variance is another challenge that nurses face when delivering quality care. Standardised policies and procedures can reduce this variability of care, prompt more consistent care with fewer errors, and enhance the nurses’ confidence and competence. Standardisation also allows for smoother transitions as staff move around within the healthcare system.

Implications of misaligned policies and procedures

Nurses must rely on hospital policies and procedures to ensure safe care. If the organisation lacks the latest evidence on which to base this care, this can lead to two dire outcomes.

1. Nurses don’t feel supported in their desire to provide safe, effective patient care, increasing the risk that they leave

Nurses need to feel confident about the workflow accessibility, integrity, and relevancy of evidence-based clinical information incorporated into policies and procedures. Studies report that the more nurses feel supported and competent in their work, the more satisfied and more likely they are to remain with their employers. Nurse leaders set the tone for improving care and promoting safety beyond the technical requirements of compliance. Being able to access available, reliable, and up-to-date policies and procedures makes that job much easier.

2. Inconsistency can create confusion

Many organisations fail to update their policies and procedures regularly, which puts their employees and patients at risk. They can remove the burden of having to maintain their own resources by investing in an evidence-based procedures system that is frequently updated. Failure to modify procedures on a regular basis may result in organisational disconnects, causing nurses to ask: “Do I follow hospital procedures or the latest clinical evidence?”

What can nurse leaders do?

Leaders can undertake three actions to positively influence organisational alignment and proactive engagement of properly maintained policies and procedures.

1. Adopt a mindset of safety first, not checking boxes

To provide exceptional evidence-based care, nurses need to feel confident about the accuracy of the clinical content integrated into a hospital’s policies and procedures. This will also help them point out any outdated practices that may compromise patient safety.

2. Link procedures to policies for easy access and reference

All procedures should be linked to a policy. Policies rarely change, but procedures may change frequently based on new evidence. Hospital policies and procedures can be either combined or separate documents.

3. Promote shared governance

Promoting shared decision-making at the nurse level creates an environment that fosters empowerment and, in turn, supports retention efforts. Managers who seek and value contributions from staff promote a climate where relevant information is shared effectively. One solution to the exodus of experienced nurses is to institute a knowledge-sharing and transfer system to help retain their institutional wisdom.

Implementing a well-managed policy and clinical procedures program can help:

  • Establish a single source of evidence-based truth for clinical policy and procedures
  • Support current, consistent, and reliable clinical care by providing access to the latest evidence-based clinical information
  • Promote standardisation across the hospital/health system
  • Provide a governance structure for policy and documentation management and repository

Learn about the benefits of Lippincott® Procedures.

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