Accreditation Resource Services Newsletter
October 2020

CIHQ-ARS Article

Policies, Guidelines and Procedures

By: April McLain
Most healthcare organizations have hundreds, if not thousands of policies, guidelines and procedures to guide the activities of governance, management and the provision of care, treatment, and services provided by the organization. For those of you who have been through surveys, you know that during a survey, the organization will be asked to provide numerous policies, guidelines, and procedures. Making sure your policies are in order, easily retrievable, and current will help reduce some stress during a survey.
First a few definitions - a policy is defined as a required official action by the organization; a guideline is defined as a recommended course of action by an organization; and a procedure is defined as a sequence of steps or instructions taken to accomplish or implement a policy or guideline. For the purpose of this discussion, these will be discussed as one.
At the beginning of a survey, you will be asked to provide a number of policies, guidelines or procedures. In general, this is done to assure that your organization has developed and adopted certain required policies, guidelines or procedures; and to allow surveyors to review your policies, guidelines or procedures of select high risk processes common to most surveys, such as the use of restraints. As the survey progresses, you will be asked to provide additional policies, guidelines or procedures, potentially from multiple surveyors at the same time, to validate processes observed in the course of the survey.
Before you hand a document over to the survey team, make certain the version of the policy, guideline, or procedure provided is the most current. Having a designated team member review any policy, guideline, or procedure before it reaches the surveyor is a good idea. I remember snatching a policy from a staff member as it was being slid across the table to surveyor, as I knew the policy was not the most current version. Assure that the policies, guidelines and procedures are reviewed according to your organization’s time frame and / or any regulatory body. Your organization or accreditor may require that policies are reviewed every three (3) years, for example. There may be specific circumstances when policies are required to be reviewed more frequently than general policy review. For example, the policies included in your emergency management program which are required to be reviewed every two (2) years. While not required, make it clear on the policy, guideline, or procedure when the last review / revision was conducted. These documents may have been approved during a meeting, but it is much easier to demonstrate compliance when the last review date is noted on the document. Searching through minutes to locate the last approval date is not what you want to be doing during a survey.
The policy, guideline or procedure should clearly identify the final approver by title, committee, leader, and governing body. For organizations under the CMS Conditions of Participation for Acute Care Hospitals, the ultimate responsibility for ensuring the development and approval of organizational policies, guidelines, and procedures lies with the governing body. That is not to infer that the governing body is required to approve every policy, guideline, or procedure in the organization. Rather, the governing body can officially delegate the approval responsibility to other leaders in the organization; except for those policies that are governance related. For example, the grievance process policy is required to be approved by the governing body as it is the responsibility of the governing body, and may include the delegation of the grievance process to a grievance committee.
The following are examples of the governing board delegation of the approval of other policies, guidelines or procedures:
  • The Chief Executive Officer is responsible to approve all non-governance organization policy, guidelines or procedures such as policies related to informing patients of their rights and patient visitation.
  • The Medical Executive Committee is responsible to approve medical staff related policies and guidelines, such as policies related to the completion of a history and physical examination; performance of autopsies; and department specific policies such as required policies for anesthesia, respiratory care, laboratory oversight, and rehabilitation services.
  • The Chief Nurse Executive is responsible to approve policies and guidelines related to the practice of nursing and the delivery of nursing care in all care settings where nursing care is performed.
  • The pharmacist in charge is responsible to approve policies and guidelines related to the management of medications across the continuum such as high-alert medications, investigational medications, adherence to professional standards of practice for all compounding, packaging dispensing and drug disposal activities, and standardization of prescribing and communication practices.
  • Directors and Managers are responsible to review policies and guideline, and make recommendations for approval to the appropriate leader, as well as reviewing and approving procedures within their area / department.
Make sure your practice matches your policy, guideline, or procedure. Even the most well written policy, guideline, or procedure cause issues of non-compliance during a survey if it does not reflect the current practice. At the end of the day, you will be held to your policy, guideline, or procedure if there is a discrepancy between practice observed and policy, guideline, or procedure.
Last, and certainly not least; make sure your staff is knowledgeable about policies, guidelines or procedures, especially those that govern their day to day practice. While staff does not necessarily need to be able to recite the policy, guideline, or procedure word for word, they should have a basic understanding and be able to readily and easily access any policy, guideline, or procedure if necessary.
A special note about CMS requirements for Critical Access Hospitals
For organizations under the CMS Conditions of Participation for Critical Access Hospitals, an advisory group is required to develop and recommend for approval to the governing body or individual responsible for the critical assess hospital, policies to guide the care of patients. CMS specifically states at 485.635(a)(2) that “the final decision on the content of the written policies is made by the CAH’s governing body or individual responsible for the CAH.” The advisory group is made up of at least one MD or DO and one or more non-physician practitioner and is not only required to make policy recommendations, but is also expected to review the existing patient care policies at least every 2 years and, if it concludes that changes are needed, recommend those changes.