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DefinitionIf you are looking to make a change at your hospital to define or revise the way you do or should be doing things, be sure you understand whether the change should be made in policy, procedure, or guideline, or to what extent in each.

Policies are broad expressions of the intent or desired outcome of a process, typically multi-disciplinary in nature. For example, a hospital would have a Restraint and Seclusion Policy to ensure a process is in place for the appropriate management of behavioral health patients, with the compliance obligations being that patients are restrained only when clinically justified to prevent them from causing injury to themselves or others, or to enhance medical healing in accordance with applicable regulations. A good rule of thumb: If you can’t do it 100% of the time for 100% of applicable patients, it absolutely should not be a policy. Policies are not the place for idealism or wishful thinking.

Understanding the working definitions of these terms is critical. Absent this understanding, hospitals can fall prey to overly complex policies that exceed the requirements of regulators, accreditors, and payers.

Procedures are required steps that must be taken to complete a process when there can be no exception from the expectation. A common procedure at hospital might be for disinfection of endoscopes; the expectation is that an endoscope would be disinfected using the correct substance in the correct concentration, following the correct steps in the correct order. If operational considerations make one or more of the required steps impossible (e.g. ran out of disinfectant), then the scope is taken out of service until the procedure can be followed in its entirety.

Guidelines are steps that are normally taken to complete a process. Many hospitals will have a guideline for how to manage range orders with the goal being to assure the safety of the patient and the effectiveness of the intervention. Deviations from guidelines do not constitute a violation of the associated policy when justified by valid clinical or operational considerations. Hint: Any document addressing the details of a clinical process should be considered a guideline.

Understanding the working definitions of these terms is critical. Be sure all the members of your executive team, medical executive committee, physician leadership, policy steering committee, and governing body have a common understanding of these terms. Absent this understanding, hospitals can fall prey to overly complex policies that exceed the requirements of federal and state regulators, accreditors, and payers. All over the country, in facilities large and small, this “over-compliance” is leading to noncompliance, physician and nurse burnout, and decreased care quality, patient safety, and satisfaction.

If your policies are overly complex, let’s start the conversation about a simplification initiative in your organization.



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