Procedures should promote patient safety

First, discover why compliance is lacking

By Patrice Spath, RHIT
Brown-Spath & Associaties
Forest Grove, OR

Without procedures and standardized ways of doing things, the complex process of caring for hospitalized patients would be difficult. Procedures have a central role to play in quality and patient safety. They are the codification of work practices that are seen as the best way to get things done. Without defined work practices, it would be impossible to achieve adherence to performance standards. Procedures are used to teach staff members how to perform tasks. They also serve as reminders of how tasks are to be done. These reminders are especially important for non-routine tasks.

Quality and patient safety can be compromised when procedures are not well-written or periodically updated. At times, staff members may ignore established procedures and use their own special way of doing things. Non-standard practices have their place in unusual or unique situations which cannot be anticipated or when rapid action is necessary. However, creativity can quickly become the norm even for everyday situations.

People will not follow procedures if they feel they are impractical, and they will not routinely use written procedures if they believe they already have sufficient skills and experience to get the job done. Yet, non-compliance with established procedures is probably one of the most commonly cited causes of quality problems and adverse events. Before embarking on a campaign to improve compliance with procedures, first discover why compliance is lacking. Conduct employee surveys to determine their attitudes about procedures and the extent to which written procedures are actually used during day-to-day tasks. If employees are allowed to respond anonymously, they are more likely to respond truthfully.

If procedures are not routinely used, ask why not. This question can be open ended, allowing for narrative responses, or the respondent can be asked to select from a list of common reasons for procedure noncompliance. The reasons for not using procedures may fall into several categories:

  • accuracy (out of date, inaccurate);
  • practicality (unworkable in practice, too time-consuming, too restrictive);
  • optimization (people have found a better way of doing the job);
  • presentation (too complex and difficult to use, hard-to-find information in procedure);
  • accessibility (difficult to locate the right procedure, not aware procedure exists);
  • policy (no clear policy when to use, don't understand why they are necessary);
  • usage (experienced people don't need them, people assume they know what is in the procedure).

Knowing why people don't follow procedures is an important first step toward improving compliance. For example, if staff members indicate that they've found better or quicker ways of doing the job, then it's time to investigate what actually is occurring. Some of these methods may be safe; others may not. It is essential to determine and document the best procedures and establish a situation whereby the best, quickest, and safest way of caring for patients is to follow the established procedures. Don't continue to "allow" people to work around procedures in order to get the job done; this practice can quickly become the usual (and unacceptable) practice.

If the surveys indicate that people don't understand the value of procedures or don't feel they are needed, it is quite likely you'll find significant variation in how tasks are being performed. In the absence of agreed-upon work practices, people make errors without any idea that they have done anything wrong. People may be taught to do a job incorrectly and to do it consistently wrong for a long time. Only management can change this situation by setting an expectation of procedure-based safe practices and holding people accountable for compliance. Management also must provide the resources necessary for writing and maintaining up-to-date procedures that reflect best practices.

Design procedures with users in mind

It is important to consider the patient safety implications when developing new procedures or revising existing ones. Often people make procedures too long or use complex word or phrases. Remember that the staff members who will be using the procedure may be under stress or may not have the same amount of training as the person writing the procedure. When faced with poorly written procedures, staff members may take short cuts or develop alternative methods that can lead to error. In general, the more complex an action, the more likely an error will be made while carrying it out. Sometimes procedures aren't appropriate for the given situation, resulting in staff confusion and errors. Procedures that are too simple or misleading also can lead to mistakes. A list of 10 "best practices" for procedures is found in Figure 1.

The objective in writing a safe procedure is to give the reader crisp and clear information.

Here are some ground rules for creating safer procedures:

  • Make procedures short and to the point. Don't combine different tasks into one procedure. Instead develop a procedure for each specific topic, e.g. How to use a piece of equipment, how to administer a treatment, how to run a test.
  • Keep the customer in mind. Write procedures for the people who will use them (the customers). Don't assume the reader knows something; cover all relevant tasks in the procedure. Don't write them for the experts.
  • Use flow charts to organize information prior to writing procedures. Ideally, the flow chart is sketched out while observing people actually performing the task so that every step is included in the correct order. The finalized flow chart should be incorporated into the procedure to give staff members a quick visual overview of the procedure.
  • Design procedures that can be used in stressful situations. Use short sentences in active voice (e.g. "label the container" instead of "the container should be labeled"). Use short words (e.g., "assist" instead of "facilitate"). Don't use abbreviations or acronyms. Be consistent with terminology.
  • Lay out action steps and notes in separate columns so that the reader can move quickly through the action steps and be able to refer to notes on an as-needed basis.
  • Clearly mark any warnings or cautions and put these before an action step, not after. It is a good idea to use bold print for these or put them in a highlighted area.
  • Put steps in the right sequence, and use headings to help organize the information. Don't put multiple steps into a paragraph — separate steps so they are visible. This helps people find what they need quickly and understand the flow of the procedure.
  • Use a simple numbering and identification system (e.g., use 1, 2, 3 not one, two, three).
  • Place procedures where the users can easily access them. If it is difficult to get to procedures, people won't use them. It may be helpful to post the procedures on the hospital's Intranet or group paper versions in a central location.

Procedure review process

Hospitals should have established teams to conduct periodic reviews of procedures on at least a three-year cycle. Each team should involve frontline personnel and staff educators to ensure that procedures remain current and reflect what have become best practices in hospital care.

To supplement scheduled reviews, there should be a mechanism whereby staff can report inaccuracies or ambiguities in procedures or suggest better ways of doing particular tasks. This helps to ensure that procedures are updated and improved more frequently, if necessary. The reporting mechanism must result in fairly prompt actions and improvements to the procedures; otherwise, it will not be used by the staff members.

The patient care environment of today relies heavily on advanced technology, making policies and procedures more important than ever before. The time invested in maintaining up-to-date, well-written procedures and holding people accountable for compliance is returned many times over in the reduction of mistakes, improved quality, and reduced patient complaints.