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Too many details can be trouble
As hospitals continue their efforts to comply with the National Patient Safety Goals issued by the Joint Commission on Accreditation of Healthcare Organizations, some risk management and quality assurance experts are issuing a strong warning: Don’t go overboard with your efforts to write new policies and procedures because they can create unnecessary liability risks.
The problem occurs when well-meaning hospital leaders develop overly detailed and prescriptive policies and procedures to ensure compliance with the safety goals, says Geri Amori, PhD, ARM, FASHRM, president of Communicating HealthCare, a risk management consulting firm in Shelby, VT, and past president of the American Society for Healthcare Risk Management (ASHRM).
Some health care organizations are painting themselves into a corner with these new policies and procedures, she says. "You create a policy and procedure that nobody can keep up with," she says. "Then you go to court and the attorney says, You have a policy and procedure. Why didn’t you follow it?’ Either you have to make an excuse for not following it or you have to say you didn’t know about it. Neither one sounds good in court."
That’s not to say that policies and procedures won’t be necessary in your efforts to meet the patient safety goals. It might even be appropriate to develop entirely new policies and procedures. But Amori says you must be careful not to make them so strict that they don’t apply to all situations and your staff can’t follow them. Policies and procedures should be based on reality, not an ideal, she says. "I think what’s happening is we’re getting these new goals but we don’t know how to deal with them, so we create more policies and procedures because that’s what we know how to do," she says. "All we’re really doing is creating more liability."
System analysis necessary for safety goals
The Joint Commission announced the first set of National Patient Safety Goals a year ago and they are in effect through the calendar year. In January 2004, the next set of goals take effect. The goals are intended to help accredited organizations address specific areas of concern regarding patient safety.
Each goal includes no more than two evidence- or expert-based recommendations. To ensure a greater focus on priority safe practices, no more than six goals are established for any given year. Each year, the goals and associated recommendations are reevaluated; some may continue while others will be replaced because of emerging new priorities. New goals and recommendations are announced in July and become effective Jan. 1 of the following year. (For the 2003 and 2004 goals, see the JCAHO web site at www.jcaho.org.)
All JCAHO-accredited health care organizations will be surveyed for implementation of the recommendations, or acceptable alternatives, as appropriate to the services the organization provides. Alternatives must be at least as effective as the published recommendations in achieving the goals. Hospitals have a strong motivation to comply — failure by an organization to implement any of the applicable recommendations (or an acceptable alternative) will result in a special Type I recommendation — and that is spurring some of the policy and procedure overkill Amori says will create new liability.
Developing a proper response to the patient safety goals should involve far more than just writing or revising a policy, Amori says. First, she says you should look at the processes that the goal assesses in your own institution. Then you need to look at the broad reasons why your system works the way it does regarding that goal.
"You’re really doing a failure-mode analysis and sort of a root-cause analysis to determine why it’s working that way in your system," she says. "Is there something in your policies and your system that is creating a system where you are not monitoring high-risk medications or that allows you to misidentify patients, or whatever the goal is? Once you have the data showing what’s going on in your organization, only then do you go about developing policies and procedures to improve the situation."
If you put too much focus on writing the policy and procedures, you may not be paying enough attention to the actual process improvement, she says. When you have created a better process, then you might want to document that through a new policy and procedure. "We’ve said that for a million years in risk management," Amori says. "Policies and procedures don’t change behavior. They should memorialize the type of behavior we think is important. Change the behavior first, and write a policy and procedure that reflects that change."
Meeting JCAHO goals may not be enough
That advice is seconded by Marie Pears, RHIA, CPHQ, quality coordinator at Meadville (PA) Medical Center. She says her hospitals has struggled with its efforts to comply with the patient safety goals, at first developing some policies and procedures that went overboard.
For the 2003 goal regarding identification of patients, for instance, Meadville at first started developing a policy that required proper identification for any kind of encounter with a patient, but then Pears and others realized that wasn’t what JCAHO intended. But they still had to figure out how to meet that goal. "We did have policies and procedures for patient identification in place already, but we didn’t have two patient identifiers, so we went to work on that," she says.
"In this case, we almost went overboard because we said that whatever you do with the patient you have to use those two patient identifiers," Pears explains. "But in some cases, that’s not necessary. We wrote the policy saying that at first, then we went back and rewrote it. That’s an example of how you can go overboard with your policies and procedures," she adds.
Do thorough investigations
That experience with patient identification confirmed the value of the team approach Meadville uses for meeting the patient safety goals. Pears put together an overall team made up of key department leaders to address the goals, then that group broke up into smaller teams to look at individual goals. After allowing some time for the smaller teams to work, everyone regrouped to discuss their findings and recommendations. Some teams determined that the hospital was already meeting that goal and no further action was needed. (In that case, Pears says, she still was careful to document the team’s analysis and recommendations.)
To keep up with all the teams’ work and ensure that the goals would be met on time, Pears used a matrix that listed each goal, who was working on it, the team’s recommendations, and when any actions should completed.
Each team investigated what Meadville should do to comply with the goal, mainly by asking these questions: What is the patient safety goal? What problems have we had that pertains to this patient safety goal? Do we have data available on this topic? Do the data show we’ve had a problem in this area? Do we already have a policy and procedure in place? Are we already in compliance with what the goal says? Is that enough or do we want to do better? How far beyond compliance do we want to go?
The goals give you areas to focus on that might not otherwise capture your attention, she says.
Even if it seems you are already meeting the safety goal, according to Pears, you should still study each one carefully. Use the patient safety goals as a reason to carefully assess your own policies and procedures for loopholes and weaknesses. You won’t have to develop a new policy and procedure for every goal, she says, but you will want to take a look at each policy and procedure addressing the goals. Some might be fine; some might need improvement; and some goals may need completely new policies and procedures.
Err on the side of generalizations
Whether you’re refining or developing them from scratch, Pears offers this advice: "You certainly can go overboard with policies and procedures. You need to keep them simple. The more complicated a policy and procedure gets, the harder it is for people to comply and that gives you more chance for error. You could be creating a problem just by the way you’re writing the policy and procedure."
Amori says that, in general, you should avoid writing a highly detailed policy and procedure. When in doubt, err on the side of being too general, she says. "It can be extremely detailed if there is a complex process that only can happen one way, but my guess is 99.9% of our processes aren’t that way," Amori says.
"In most cases, you’re probably better off not spelling out the step-by-step details of what a nurse should do in a certain situation, unless it’s absolutely a situation where you know that’s the best way and the nurse knows where the policy and procedure is, and it happens with enough frequency that people are going to know to look there," Pears explains. "Otherwise, you’re giving a plaintiff’s attorney lots of ammunition, and you’re going to have lots of frustrated staff," she adds.