Healthcare Policy and Procedures PDF

Healthcare policy and procedures By Dr/Doaa Saeed Lecturer of Physical therapy for women’s health department at BUC university Academic year 2023-2024 Definition of policy ◦ They are the expected quality statements that define the procedures to be followed in the health institution ◦ Or general pr...

Healthcare policy and procedures By Dr/Doaa Saeed Lecturer of Physical therapy for women’s health department at BUC university Academic year 2023-2024 Definition of policy ◦ They are the expected quality statements that define the procedures to be followed in the health institution ◦ Or general principles and expectations governing action to ensure service and system quality. Example The health institution expects that all employees wash their hands before and after interacting with a patient The main purpose of developing policies and procedures ◦ Is to establish a high degree of understanding, cooperation, efficiency, and unity among employees in the health institution and to provide uniform policies for all employees so that there are no discrepancies. Priorities for developing policies and procedures in health care Magnitude of the problem: If this policy covers a frequently held job Severity of the problem Cost control Whether the issue is a root cause of other problems Trending health concerns in the community Stages of policy development 1.Work procedures analysis 2. Identify the quality characteristics for each step of the work procedure 3. Identify who will take lead responsibility 4. Approvals and accreditation 5. Disseminate policies and train staff 6. Monitor Implementation 1.Work procedures analysis The flow chart can be used in this stage to determine the process and procedure that held in the health institution and identify the appropriate steps to follow in policy development 2. Identify the quality characteristics for each step of the work procedure The characteristics of quality based on the scientific references or the opinions of experts Quality characteristics of hand washing 3. Identify who will take lead responsibility Delegate responsibility to working group or staff members, according to the experience required for developing and writing the policy draft. 4. Approvals and accreditation The policy must be approved according to the administrative hierarchy 5. Disseminate policies and train staff The policy should be delivered to the employees concerned with it through education and training 6. Monitor Implementation After monitoring implementation, the policy is developed or modified according to the implementation mechanism Components of policies and procedures 1.The policies: 2.The purpose of the policy: 3.Definitions of terms: 4.Setting forms and tools: 5.Procedures: 6.References Institution logo – Policy name Policy and procedure: Establishing entity: Policy code or number: Page: Date of release: The date of last review Approved by: Signature: 1.The policies: Quality statements that define the procedures to be followed in the health institution. Example : The health institution expects that all employees wash their hands before and after interacting with a patient. 2.The purpose of the policy: Generally, the purpose of the policy concern one of the quality dimensions Example : What is the purpose of the hand washing policy? Ensuring the safety of patients and avoid transmitting infection to them from health service providers. 3.Definitions of terms: The unclear terms or expressions should be defined. 4.Setting forms and tools: Used in policies implementation e.g. Checklist for hand washing compliance 5.Procedures: The detailed instructions of policies practice 6.References The quality management office in the health institution is responsible for policy development and review including: o The policy is written and developed in the right way o Encoding policy o Ensure that the policy passed the approval and accreditation procedures o Disseminating and delivering the policy to the employees concerned with it Quality Improvement Plan (QIP) Quality improvement plan is a basic guidance document that describes how a health department will manage, deploy, and review quality. It also serves to inform staff and stakeholders of the direction, timeline, activities, and importance of quality and quality improvement. Components of Quality improvement plan: 1. Plan goals: The main goal is to ensure the quality of health services and to ensure the safety of patients from medical errors that can be avoided 2. mission and Vision : A Mission Statement defines the institution’s objectives and its approach to reach those objectives. A Vision Statement describes the desired future position of the institution. Elements of Mission and Vision Statements are often combined to provide a statement of the institution’s purposes, goals, and values. 3. Definition of Quality: from health institution management point of view “Providing the best health services at the lowest possible costs” 4. Goals and objectives: The goals and objectives that the institution seeks to achieve e.g. (1)Improving the quality of the care provided (2)Improving patient outcomes (3)Reducing the cost of care There should be a general and specific goals and mentioning the goals that will be achieved in the first and second year of the plan. The plan is usually set for two years and is reviewed every year 5. Mechanism for developing quality management A. Identify the people involved in the plan: External and internal recipients of service and their relationship to the quality improvement plan. B. Determine the main services provided by the institution: Whether it is related to patient care or administrative jobs this helps to understand the scope of this plan and the services that will cover. C. Dimensions of quality adopted by institution: ◦The institution chooses the dimensions based on its goals and priorities. D. Priorities for improving quality performance: ◦ The institution chooses projects to work on to improve performance 6. Organizational structure for quality management: 7. Determine the mechanism of improvement: The institution chooses the appropriate mechanism used for quality improvement Such as: FOCUS-PDCA 4 steps of quality improvement methods 8. Identify priorities for quality measurement indicators Finally, this plan is summarized into an annual work plan in which we convert the goals and objectives into an action plan and identifying the resources required to implement it and who are the employees responsible for implementation. 9. Appendix A list of quality measurement indicators.