How to write patient care policies in healthcare

Policies and procedures are essential to keep patient treatment consistent and to be ready for any emergency.

August 11, 2021

Article highlights

Healthcare is one of the most complex industries there is, with patients with unique needs, potential emergency situations, a variety of specialties, and strict compliance requirements. 

As management guru Peter Drucker put it:

“Large healthcare institutions may be the most complex in human history, and even small healthcare organizations are barely manageable.”

Whether you’re a health system serving a large city or region, or if you’re a specialty clinic, you have a community of patients with different treatment needs. Giving those patients consistent treatment and promising them the best possible outcome requires not just diligent work from your doctors and staff. It requires you to have a strong foundation.

That foundation includes your patient care policies and procedures. These documents serve as the roadmap and instructions on how patients should be treated, how situations should be handled, and what to do when emergencies arise.

Creating these policies also sets you up to be compliant with state and federal regulations, as well as making the accreditation process simpler and faster.

In this article, we’ll look at the importance of these policies and go through some examples of them. Then we’ll guide you through the process of creating your own policies and procedures. It’s a big task, but well worth the effort.

Why patient care policies are important

According to Patient Safety & Quality Healthcare, these patient care policies and procedures are important for a variety of reasons, but chief among these is risk management.

“Given increasing financial pressures and the top-priority status that must be given to direct patient care, managers may find it difficult to find time to review or update policies and procedures. Deferring policy and procedure development, however, may result in negative consequences. 

“Policies and procedures may become outdated, and those who adhere to outdated policies may carry out actions that are no longer consistent with industry-recognized practices. Alternatively, they may simply elect to disregard the policy. Either choice may result in patient harm and a malpractice claim. Evidence that caregivers followed outdated policies may hinder defense of an otherwise defensible claim.”

By having good policies in place and adhering to them, your healthcare practice limits its legal liability in the event of a lawsuit.

There are many more benefits. These patient care policies and procedures serve several essential purposes. They:

  • Strengthen adherence with professional practices and standards
  • Increase compliance with regulations, statues, and accreditation requirements
  • Improve consistency across the practice
  • Create standardization of practices in all entities within a larger health system
  • Act as a resource for staff on best practices
  • Codify rules and practices, rather than relying on memory

Every time a patient comes in, rather than staff having to figure out a treatment plan from scratch, a consistent set of policies and procedures gives your staff the guidelines to know what to do, and how to do it.

These patient care policies also help administrators navigate the increasingly complicated world of compliance. Regulations can be overwhelming, pulling you away from other critical responsibilities. While it takes time to initially develop policies, once you have them, they create a roadmap to navigate that work.

Now you see how essential these policies are to all of the work you do. Let’s look at some specific types of policies.

Examples of patient care policies

Patient care policies and procedures come in a variety of forms, covering all the many ways in which patients interact with your health care system. There are no one-size-fits-all policies, because every facility is unique in its structure and the care it offers.

Your policies will cover the procedures your facility performs, the types of illnesses and injuries that you treat, instances in which you refer patients to other facilities, and how to transfer them. Policies also need to delve into how to handle specific medical situations and emergencies.

Some of these include:

Administrative Policies

These policies cover things including visitation and access, among other things related to running the facility.

Care Policies

These policies will be the most complex ones in your manual as they cover all the many ways in which you provide care to patients. These need to touch on each medical treatment offered, providing guidance to care givers. It’s important to also include responses to potential emergencies. You want your care providers to be as prepared as possible to do their essential work.

Communication Policies

These policies dictate the ways in which you communicate with your patients, including when you send them information and what methods you use, as well as communicating with emergency contacts or with other caregivers. For example, what’s your policy on transferring patient medical records to other facilities? Are all patient communications sent via mail, or do you offer digital options? Communication policies ensure a consistent response to these topics and much more.

Pharmaceutical Policies

Pharmacies have a critical role within a healthcare provider. These policies cover the rules and guidelines in how medications are prepared and distributed, assuring that this is done efficiently and without error.

Privacy Policies

These policies are critically important given the many regulations surrounding patient privacy, including HIPAA. Your policies should start with those regulations, but you should also adapt them to the specific needs of your organization.

How to develop patient care policies

As you begin the process of creating or refining your patient care policies and procedures, the first step is to think broadly about the work that you do and the way that your facility treats patients and interacts with them. Try to capture as much of that as possible. It’s better to be proactive and include even unlikely scenarios, rather than to have those situations occur and be unprepared.

To do this, conduct case studies to follow hypothetical patients through their journey, from the beginning to end of their treatment. Do this for each of your areas of practice.

As you go, ask questions. What happens in this situation? How does this relate to HIPAA rules? What needs to be communicated to the patient or their guardian?

Guidance created by OSHA for safe patient handling offers examples of these kinds of detailed policies that include things like:

  • Repositioning patients in bed
  • Transitioning patients between bed and wheelchair
  • Between bed and gurney
  • Gurney to treatment table and back

The goal is to create a roadmap of the best way for your staff to interact with patients in all possible scenarios, and to capture that on paper so that you can then use it to educate your departments.

Look to the experts

You’ll also want to make sure you have subject matter experts involved in the process. While one person might be especially skilled in questions of compliance, that doesn’t mean they’re also proficient in privacy matters, or the intricacies of a pharmacy. 

The policies that cover a specific area should be developed with experts from that area. Consider what those specialties are, and look for those who can offer critical feedback.

In addition to human experts, you can also bring in resources from the professional associations for each specialty area. For example, the American Registry of Radiologic Technologists has published standards related to radiology and patient care. Or for emergency guidance, look to those published by the American College of Emergency Physicians and the Emergency Nurses Association.

In the event of a malpractice case, these vetted standards are often presented as evidence. By matching your practice standards to them, you are limiting your organization’s liability.

Federal and state guidelines

A key part of having patient care policies is to maintain compliance, and so you’ll want to look at the federal and state rules and laws relevant to the care you provide.

Have these guidelines on hand so that your policies meet those standards. And remember to check for new regulations from HIPAA, the Affordable Care Act, and the Center for Medicaid and Medicare’s Meaningful Use.

While these provide a starting point, remember that they are broad. Every healthcare facility and system is unique, and so your patient care policies and procedures must reflect your operation.

Getting started

While healthcare will always be complex, it doesn’t have to be unmanageable. Creating effective and comprehensive patient care policies and procedures will create a foundation that leads to greater consistency, clearer communication, and improved compliance.

As you undertake this work, keep in mind the different types of policies that fall under this umbrella, and then be sure to capture all the work that is done in your facility. And don’t forget to look for the many resources available to help you in this effort.

More information about healthcare policies can be found in this article, 10 policies your healthcare organization needs.

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