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POLICY AND PROCEDURE DELAYS

55% of the applications received in 2008 were delayed for issues related to miscellaneous policies.

Developing, implementing and maintaining clearly written policies and procedures is one of the key elements in ensuring the successful outcome of a process and improved patient care. The ICACTL requires that applicant laboratories have a comprehensive quality assurance program in place that assures quality patient care, as well as written policies and procedures to facilitate the program. As evident by the data, many applicant laboratories applying for ICACTL accreditation find that writing policies and procedures proves to be a challenging part of the process.

POLICIES AND PROCEDURES GUIDANCE

What are the characteristics of good policies and procedures? The overall goal for any policy or procedure document calls for the design to be simple, consistent and easy to use. A consistent format between policies and procedures is recommended as this facilitates changes and allows for recognition of the documents.

Characteristics Of Good Policies:
• Policies are written in clear, concise, simple language.
• Policy statements address the rule itself, rather than how to implement the rule.
• Collectively, policies represent a consistent, logical framework for laboratory function.

Characteristics Of Good Procedures:
• Procedures are tied to policies.
• The relationship should be explicit with regards to how the procedure helps the laboratory achieve its goal.
• Procedures are developed with the customer/user in mind. Well developed and thought out procedures provide benefits to the procedure user. Ideally, there is a sense of ownership among procedure users. Therefore, it is beneficial to involve the ultimate users when developing procedures.
• The procedures are understandable. Procedures should be written in a format allowing the steps to be easily followed by all users.

Suggested Writing Style For Policies And Procedures:
• Concise, minimal use of verbiage
• Factual
• Avoidance of including information that may quickly become outdated (e.g., names)
• Spelling out of acronyms the first time they are used
• Inclusion of step-by-step instructions
• Written in a tone to be understood by all employees, regardless of their amount of tenure with the laboratory

The Quality Assurance committee should act as the policy and procedure “owners”, and as such is accountable for the timely review, updating and dissemination of the documents to those in the laboratory. Assignment of responsibility for policies or procedures may be accomplished through a series of delegations of authority to specified laboratory staff members.

Recommended Components For Policies And Procedures:

1. The policy should be laboratory specific.
   
2. The policy should appear on the laboratory, clinic, office, hospital or medical center’s letterhead. (Copying policies from manuals or web pages can be used as guidance, but should be modified to reflect your specific facility practices.)
   
3. The policies should be numbered (e.g.: CT policy 01).
   
4. The policy should have a title (e.g.: Acute Medical Emergency Policy).
   
5. The policy should be stated at the beginning of the document, inclusive of a statement outlining the goal and purpose (e.g.: It is the policy of ABC Imaging Center to inform and educate all personnel on the proper procedures to be taken in the event of a medical emergency in the CT room.)
   
6. The procedure document should detail the step-by-step process that outlines how the goal stated in the policy will be achieved. For example:
   In the event of an adverse event or emergency while performing a CT procedure:
   - stop the scan
   - assess patient’s condition
   - call for appropriate assistance (code team, physician, nurse, etc.)
   - assemble emergency equipment if needed (crash cart, oxygen, AED, etc.)
   - start CPR, if needed
   - assist emergency personnel, as requested
   
7. The procedure document should include the effective date, revised date and review date.
   
8. The procedure document should include the approval signature(s) from member(s) of the QA Committee.
   
9. The procedure document should be detailed and inclusive of precise functional instructions. The exact action to be taken and when, should be specified. In contrast, it is best not to include what not to do as this will only add confusion.

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