Policies and Procedures in Healthcare
Published: 21 October 2019
Published: 21 October 2019
‘Policies and procedures’ is the first component of Patient Safety and Quality Systems, as outlined by the Australian Government’s National Safety and Quality Health Service Standards (NSQHSS).
Purpose: Patient safety and quality systems are in place within governance processes to allow organisations to advance the safety and the quality of patients’ care (Australian Commission on Safety and Quality in Health Care 2017).
Policies and procedures are the first things an organisation should establish in order to operate effectively. Policies are rules, guidelines and principles that communicate an organisation’s culture, values and philosophies (Kenyon 2018; Business Dictionary n.d.).
Procedures provide step-by-step instructions for routine tasks. They should also allocate people to be responsible for certain tasks. Procedures should make it clear which steps should be taken in common scenarios and who should be reported to. A checklist may be involved (Kenyon 2018).
Procedures may include:
Policies and procedures are fundamental for consistency across an organisation, for both staff and consumers. They guide the organisation, influencing and determining all major decisions and actions, and reduce liability risks (Kenyon 2018).
Policies and procedures should be widely accessible and cover all activities carried out by the organisation. All policies should be laid out in the same format and should be written in common language that all staff members can comprehend (Gasior 2017).
(Gasior 2017; NHMRC n.d.)
Policies and procedures are an incredibly important part of making sure staff know how to care for patients and how to carry out tasks with confidence. Policies and procedures provide standardisation in everyday operational activities, which helps to foster consistency in practices, decrease mistakes, and keep both patients and staff safe (Gasior 2017; Leahy n.d.).
The NSQHS Standards outline that a health service should manage risk in the following ways:
(Australian Commission on Safety and Quality in Health Care 2017)
Policies and procedures are particularly crucial in healthcare as it is an industry that is very familiar with crisis; healthcare organisations endure a high rate of liability risks. When appropriate policies and procedures are in place, an incident is easier to navigate (Kenyon 2018).
This is because procedures outline the actions that an employee and manager should take when an incident occurs. Additionally, reviewing policies, procedures and incident reports may help those in leadership positions to identify what went wrong and prevent them from reoccurring (Kenyon 2018).
It cannot be overstated that policies and procedures must be constantly reviewed and updated. Healthcare standards and regulations are constantly fluctuating. At a minimum, these documents should be refreshed annually and each time a new law or regulation is put in place or updated (Gasior 2017; Leahy n.d.).
In recent years the notion of patient involvement in reviewing policies and procedures has gained traction. Both clinical and non-clinical committees should regularly review all policies and procedures, according to recommendations by The United States-based Institute of Medicine 2011 Standards for trustworthy clinical practice guideline development (Armstrong et al. 2017).
Patient involvement is a relatively new concept and is yet to be embraced completely. This could be viewed as an opportunity wasted. Patient and public contributions to policy and procedure development can include:
(Armstrong et al. 2017)
Together, policies and procedures help to ensure that the ethos and vision of a health service organisation are communicated into tangible steps that lead to the outcome of safe, high-quality healthcare.
Ausmed’s Editorial team is committed to providing high-quality and thoroughly researched content to our readers, free of any commercial bias or conflict of interest. All articles are developed in consultation with healthcare professionals and peer reviewed where necessary, undergoing a yearly review to ensure all healthcare information is kept up to date. See Educator Profile