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SNF: Simplify Policies and Procedures Cheat Sheet (DRAFT) by [deleted]

Nursing Home Simplify Policies and Procedures

This is a draft cheat sheet. It is a work in progress and is not finished yet.


Policies and procedures (P&Ps) can be user-f­riendly and also support compliance on a daily basis. Policies that lead to better outcomes are those that are accurate, clear, concise and flexible enough that your team can adjust workflows to best meet the care needs of residents.

When performing your policy review, consider these:

1. A policy identifies issues and scope

You and your staff will be held accoun­table for adhering to your P&Ps, as written, in day-to-day operat­ions, during both survey and litigation processes.

2. It's not necessary to include workflows

You don't need a P&P for every action in the facility, and certainly not for all workflows. In fact, many workflows can be taken out of policies and included in protocol documents.
Examples include ordering labs and completing a requis­ition form for medical equipment

3. A policy should not be too exclusive

Sometimes policies stipulate that only an RN can perform certain tasks, when, in fact, under the state's nurse practice act, a trained LPN also would be approp­riate

4. Procedural manuals are helpful resources

Instead of writing out each P&P to exhaus­tion, it is sometimes approp­riate to refer to a current, eviden­ce-­based resource, such as Lippincott procedures for LTC.

5. Short & Simple is better than all-en­com­passing

Policies should be one to two pages long. If a policy has more than two pages, it likely needs to be divided into separate policies, or a workflow needs to be removed


Help Tips

1. Use a template for consis­tency. Capture your procedure using a templae can help keep them structured and consis­tent.
2. Go through each task or process step by step.
As you create your procedure, think about each step you take to complete it. Write the steps down much like you would an outline. Then go back and fill in the details or background inform­ation where approp­riate.
3. Think commands, not sentences. You want to be specific without being excess­ively wordy. People are more likely to read simple commands than complete sentences, especially if they are in a hurry.
4. Use bullets or numbers as much as possible.
5. Number the steps that need to be completed in a specific order. Use bulleted lists for non-order specific instru­ctions.
6. Provide screen shots for comput­er-­related tasks.
7. To make your procedures even more effective, create a graphic or visual, such as a screen­shot, of comput­er-­related tasks to accompany the printed or written instru­ctions.
8. Ask another person to test your proced­ures. The best way to know if your procedures will work is to have someone else test them out. Ask them to identify items that don’t make sense, and list any questions they have about the proced­ures. This will help you identify gaps and fix them.