According to The Leapfrog Group Report, diagnostic errors contribute to 40,000 to 80,000 deaths annually. This and other patient safety issues are resulting in an epidemic of preventable medical errors, exacerbated by unprecedented nurse staffing shortages and healthcare inflation. Stemming the tide of high error rates is a challenging area that nurses can address by aligning resources around evidence-based medicine.
Nurse leaders possess a key role in ensuring the nursing staff understands and acts on the same hospital-wide policies and procedures. Incorporating the latest evidence goes a long way toward minimizing disruption and promoting standardization and compliance across the organization, ultimately protecting patients from unnecessary harm.
Because healthcare workers are caught in the middle, the importance of team alignment to champion building a patient safety-centric policy and procedure program cannot be overemphasized. Every nurse and their associated team members must be on the same page with access to current evidence-based content. If policies and procedures are left to lag behind evidence, not only can this impact patient safety, it can put organizations at risk of regulatory nonconformity, threaten Magnet Recognition Program® certification, and impact workforce retention.
What is the difference between a policy and a procedure?
Establishing a clear delineation between policies and procedures is a large part of reducing confusion and creating organizational alignment. Although many institutions tend to combine the two, they should be treated as separate with different intents and objectives.
- A policy outlines organizational 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. All procedures should be linked to a policy. A hospital's clinical policy should change infrequently as opposed to clinical procedures requiring frequent revisions based on emerging evidence, updated clinical guidelines, and other industry standards.
Implications of misaligned policies and procedures
Whether adjusting to a merger and acquisition, operating as a single-location hospital or as part of a health network, or just trying to keep pace with the latest, quickly changing evidence, nurses must rely on hospital policies and procedures to ensure safe care. If the organization lacks the latest evidence from which to make care decisions, the situation can lead to dire outcomes.
Nurses don't feel supported in their desire to provide safe, effective patient care, increasing the risk that they leave
Consistent policy management and compliance are only possible when a nurse's beliefs and behaviors reflect the desired safety culture. To comply with policies, nurses need to feel confident of the workflow accessibility, integrity, and relevancy of evidence-based clinical content 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.
Inconsistency can create confusion
Many organizations fail to update their policies and procedures regularly, inadvertently putting their employees and patients at risk. Organizations foregoing investment in a content provider increase their maintenance burden by having to write their own procedures and stay current with evidence; moreover, their internal resources potentially fall behind when incorporating the latest knowledge, especially in times of staffing challenges. To resolve this issue, nurse leaders can subscribe to an evidence-based procedures solution providing ongoing updates to evidence as well as integrating with their technology platform when available. Failure to modify these procedures on a regular basis may result in organizational disconnects, causing nurses to ask: “Do I follow hospital procedures or the latest clinical evidence?”
What can nurse leaders do?
Following are three actions that leaders can undertake immediately to positively influence organizational alignment and proactive engagement of properly maintained policies and procedures.
1. Adopt a mindset of safety first, not checking boxes
Being “patient ready” promotes a culture of safety and confidence, and is integral to organization-wide compliance. To comply with hospital mandates and 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. By doing so, they and other clinical team members will come to have a sense of urgency when discovering outdated practices.
2. Link procedures to policies for easy frontline staff and leadership access and reference
Hospital policies and procedures can be either combined or separate documents. There are pros and cons to either process: combined documents are convenient and provide an easy reference, reduce confusion, and eliminate duplication; separate documents also provide easy reference and a reduction in confusion but have the added benefits of minimized regulatory risk, improved efficiency for governance review, streamlined policy approvals, and more concise policy documents. Regardless, ALL procedures should be linked to a policy. Policies rarely change, but procedures may change frequently based on new evidence.
3. Promote shared governance
Promoting shared decision-making at the staff nurse level creates an environment that fosters empowerment, and, in turn, supports retention efforts. According to the literature, transformational strategies for sustaining cultural change include the activation of a shared sense of urgency and fostering flexible levels of engagement. Managers who seek and value contributions from empowered staff at all levels promote a climate where relevant information is shared effectively.
Additionally, with experienced baby boomer nurses retiring in droves and creating a loss of institutional wisdom, clinical staff retention, together with the preservation of institutional processes to sustain evidence-based policies and procedures, should be a primary focus of nurse leaders.
One solution is to institute a knowledge-sharing and transfer system with the nursing team before the experienced nurses leave. This system can include an evaluation of organization-specific policies and procedures to help boost the provider's evidence-based culture.
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 standardization across the hospital/health system
- Provide a governance structure for policy and documentation management and repository (e.g., OCEG's Policy Management Capability Model)
- Ensure that your organization is both patient and survey ready.
Case study: Hackensack Meridian Health tackles standardization and streamlining
Not-for-profit Hackensack Meridian Health (HMH) is the largest, most comprehensive healthcare network in New Jersey. The HMH network employs more than 8,000 nurses across 17 academic centers, acute-care facilities, and research hospitals. To address the dual issues of standardizing and onboarding education and training for nurses during the pandemic, HMH turned to Lippincott® Solutions to optimize nurse competence.
- HMH integrated evidence-based clinical information into its learning management system, 63,356 assignments within the LMS
- During the initial COVID-19 surge, HMN treated 13,000 patients
- Using a virtual training approach, HMH onboarded 650-plus nurses
Download the Hackensack Meridian Health case study and learn more about how Lippincott helped.
