EXECUTIVE SUMMARY

Creating new policies or revising existing procedures should be a priority to meet the challenges of managing the ongoing COVID-19 pandemic and administering the vaccine.

  • Define policies about staff vaccine mandates and offering a center as a public vaccination site. Include explanations about COVID-19 testing.
  • Once centers identify needs, focus on creating a draft that can be presented to governing boards.
  • Implementation of approved new or revised policies should begin with education and communication among teammates.

The COVID-19 pandemic uncovered gaps in knowledge and planning at surgery centers. Leaders were forced to make hard choices. Often, existing policies and procedures were insufficient to meet the moment. It is for this reason why surgery centers should consider revising operations now, even as the pandemic shows no signs of abating.

“During the time of the pandemic, we know from experience that our policies have been changing sometimes daily, definitely weekly, as we get new information,” says Mary K. Ryan, RN, BSN, MBA, CASC, CAIP, senior consultant for Amblitel in Louisville, CO. “We want to deliver best practices with the best current information. It’s really important to follow the development of a policy and take each of the steps necessary in a policy cycle.” Most sites probably need to create policies about how to manage the COVID-19 vaccine rollout.

“How do we implement the vaccine rollout at an ambulatory surgery center? What does that mean to staff, individually?” Ryan asks. “Is it a policy that everyone is required to get the vaccine? There are a lot of variations you need to take into consideration.”

Other policy changes could include revisions in COVID-19 testing policies. “Once we roll out of the flu season, does it make sense to look at pre-op testing policies differently, especially as people get the vaccine?” Ryan offers. “You need to be thoughtful and mindful on starting up your policies and processes. For those centers that closed down the during pandemic surge, what kinds of things do they need to have in their policy to be ready for a new start?”

To simplify the policy creation process, surgery centers can follow six steps:

Identify the need. “When you identify a need, it can be related to an incident or process that didn’t function appropriately,” Ryan offers. “It might be a change in regulations or standards that you update policy on or create a new policy on.”

The need might show up in benchmarking. Maybe a center’s outcomes do not match the benchmarks. “Take steps backward and see if that could relate to policies you change to increase the incidence of having best outcomes or having best practices,” Ryan says.

Research and review the process. “Dig into what the industry is saying. Dig into some benchmarking, and look at best practices from other surgery centers,” Ryan suggests. “You can look to state associations or the Ambulatory Surgery Center Association for any policies or thoughts on a topic to make sure you are indeed putting a process in place. Review listservs and see what other people are doing out there.”

Other techniques for researching the prospective change include making phone calls, conducting online research (using accurate and verifiable sources), contacting other surgery centers within the group or in the state, and asking people how they reached their highest levels of care.

“Talk to peers,” Ryan says. “I am a big people person, and I believe you can forge and massage your relationship when you call someone to ask, ‘How do you do this?’”

Asking for help by phone is better than sending an email or text message. However, an administrator could send an introductory email to a contact to set up a phone call. “In text messages, you’re reducing words, and it may not be taken into the context you need it delivered,” Ryan adds. “The delivery of the ask is huge.”

Create a policy draft. There should be a format that makes it more efficient to write new policies.

“Put into your policy format the things you found out and how you want to create that action going forward,” Ryan says. “Be sure it’s clear, concise, and be sure you have the resources and information to back up why you want to do what you’re doing.”

This requires looking seriously at available resources and ensuring they are valid. “Make sure you’re doing the change for the right reason,” Ryan says. “Make sure you use data, regulations, or standards by various organizations that are experts in the field.”

Obtain approval from governing body. Typically, the policy will go through the quality committee first. Then, it can be seen by a working group, medical executive committee, or clinical review committee (a group of physicians with representation from each specialty).

“They’re the working group that looks at policy development and makes sure it makes sense from their side,” Ryan explains. “They recommend it to the board of managers, the final group of individuals that approve policy.”

The faster review process uses technology. “Many of us have processes in place to do an electronic approval,” Ryan says. “Send the policy electronically to the working group of physicians, and ask for them to recommend approval. Then, you can forward it to the board of managers for final approval.”

Be sure to include the electronic approval information in the next board packet, which verifies the appropriate steps had been taken to approve the new policy or revision. Someone also could call an emergency meeting if a policy needs to be reviewed and implemented under a tight deadline.

Implement the policy. “Once the policy is approved, you roll it out to teammates to make sure everybody has a good understanding and grasp of the policy,” Ryan says. “You can do this through a team meeting or through a self-learning packet and have them sign-off on it. At the end of the day, you want to be sure that the teammates understand they’re accountable to that policy, and they need to be sure to read it.”

If the policy change is controversial, then it is important to engage in a conversation with teammates about the change and why it is needed. “Nurses want to know why they’re doing things,” Ryan observes. “It’s huge for us to understand why the policy is being put into place and about all of the discussion, research, and important points that go into it.” Ryan adds that it is more likely for everyone to follow the policy if they understand why it exists.

Another implementation tactic is to release a summary sheet on the policy change, or post the policy and tell people that it will be discussed at a meeting. This gives staff time to think about the change and look it over. “There are many ways to communicate these things,” Ryan notes. “It’s tough to over-communicate.”

Evaluate the policy’s effectiveness. Evaluation of the new/revised policy should occur at least annually to ensure the policy remains applicable, necessary, and effective.

“As we’re going through the pandemic, make sure it stays current with [the latest] knowledge and the literature out there,” Ryan says. “This includes everything we know about the vaccine, how long we’ll have immunity, and how that impacts what we do next fall and what we do tomorrow.”

The quality improvement committee can re-evaluate the policy and how changes were implemented. They can review benchmarking results and outcomes and report these to the governing committee.

“If you’re doing really great on your outcomes, I recommend you celebrate because we don’t do that enough,” Ryan says. “If there are opportunities for improvements, then I recommend that you put those changes ... in place.”

A celebration can be as simple as letting employees know the center met a benchmark it had not met before. “Or, you could say we’ve made some incremental improvements, and any step in the right direction is a positive thing,” Ryan adds. “We need to take steps forward to reach our goal.”