Use the power of Why?’ to improve patient care

Simplify, clarify policies and procedures

The question "Why are we doing this?" could be your best tool for weeding out useless policies and procedures (P&Ps). The possibilities are exciting as long as you dig beneath the rationale "We’ve always done it that way!" Here, two self-described "why-sayers" explain how they use the question "Why?"

For Ann Bertoch, RN, MS, it started with an impending survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations. Bertoch, vice president of patient care at the 87-bed Mercy Medical Center in Williston, ND, says she was concerned about her hospital’s policy and procedure (P&P) manuals. "There were forms and even photocopied excerpts from books attached to pages in the manuals. We realized they were a mess."

Conflicting policies were not unusual. Some policies, for example, crossed department lines, unbeknownst to all the involved departments. However, when it came time to clean up, Bertoch says, "there was a lot of reluctance, and we had to kill some sacred cows."

The process started in 1995 and took more than a year to complete, using these steps:

• Intradepartmental brain-storming to agree on P&Ps.

• Interdepartmental agreement on P&Ps crossing departmental lines.

• Review of departmental manuals by P&P team.

Bertoch says the team reviewed the material, recommended revisions, and sent them back to the departments. Redundancies were eliminated — for example, job qualification lists reiterating competencies earned through professional training programs. Following the second round of revisions, the P&P team met with each department for finalization. "We kept asking, Why do you need this?’" she explains.

• Disassembly and re-creation of key P&P manuals. Global concerns such as patient confidentiality were removed from departmental books and incorporated into the housewide policies.

Vowing never to go through such an ordeal again, Mercy Medical Center converted the P&P team into a standing committee of the same stature as those for infection control or safety. To become official, each new or revised policy must be typed into a template and pass review by the P&P committee as well as other standing committees. "We keep asking Why?’ and What is this for?’ and Of what use is this?’ over and over. It breeds thought and rationality," observes Bertoch. "There isn’t enough of that in health care these days."

Each time a proposed policy crosses her desk, Louise Baldwin, MBA, RN, CAN, asks herself and her staff, "Why are we doing this, and what do we want to get out of it?" She also insists that the outcome be clear before she signs off on a policy. As director of patient care services at Harris Continued Care Hospital (HCCH) in Bedford, TX, she oversees an acute, long-term care service of 36 beds dispersed among three hospitals.

Baldwin subjects her leadership decisions to similar standards. One time, that attitude led to a dramatic change in visiting policies. The social worker asked whether a two-year-old could stay overnight in the intensive care unit with his father. At first, Baldwin stuck by hospital policy and refused. "But as the social worker was leaving, I asked myself whether the policy was for us or for the patient." The patient was from another town. The family had no relatives in the area and no money for baby sitters. The young woman was critically ill; her husband was living in the ICU waiting room. "So I called the social worker back. We discussed it and agreed that the child could stay."

Today, visitors may come to HCCH at any hour. Children are welcome, provided they are accompanied and supervised by adults. Pets are welcome under the same conditions. "We get some flak from the other hospitals about this, but we’ve never had anyone die from pet infections. The nurses probably pass more infections than the animals," she says. Reflecting on the use of policies and procedures, Baldwin adds, "I realized a long time ago that my role in an organization is to be the person who says, Excuse me, but isn’t he naked?’" (For tips on exchanging ideas such as Baldwin and Bertoch share in this article, see "Use on-line listservs to gather improvement ideas," at right.)

Need More Information?

For more on the power of asking "Why?" to rationalize services and procedures, contact:

- Ann Bertoch, RN, MS, Mercy Medical Center, Williston, ND. E-mail:

- Louise Baldwin, MBA, RN, CNA, Harris Continued Care Hospital, Bedford, TX. E-mail: