Healthcare policies are critical documents that facilities use to set rules and standards for employees. Policies guide staff members' daily activities while helping facilities stay compliant and legally protected. On a deeper level, internal policies can help to shape company culture by supporting high-quality workflows and clinical practices.
In healthcare, patient outcomes have a significant impact on staff satisfaction. When a facility's policies are lacking, daily workflows can break down and patient care suffers — which can quickly lead to frustration among staff. For example, consider a facility with insufficient infection-control policies, leading to high rates of healthcare-acquired infections (HAIs). The nursing staff here may begin to feel moral distress, all due to an incomplete suite of policies.
We'll give you seven essential guiding documents that all healthcare facilities should have in place. From infection control to patient rights, these healthcare policy examples cover a range of operational areas. We'll also discuss the risks associated with missing guidance, and the steps you can take to fill in the gaps in your current manual.
The Importance of Healthcare Policies for Facilities
While there are overarching standards that many healthcare workers follow, precise rules vary among healthcare institutions. Policy documents are important because they explicitly state the rules for a particular organization. As a whole, a collection of policies guide staff actions and help workers make difficult decisions.
The Risks of Outdated, Weak, or Incomplete Policies
When a policy is missing, outdated, or too confusing to follow, healthcare employees may be forced to make individual decisions about how to move forward. Decisions may be based on previous organizations' policies that they've worked under, or their own judgment. This can create discord on teams, hazardous or unsafe conditions, and fragmented patient care.
For example, if a medical office policy related to the use of emergency codes is incomplete, a nurse could initiate an emergency response incorrectly and create a dangerous delay for the patient. In addition, as healthcare is a highly regulated industry, weak and incomplete policies introduce the risk of non-compliance and legalities.
Red Flags That a Healthcare Policy Is Needed
Facility policies must align with external regulations, such as those rooted in state and federal laws. Because external regulations are constantly shifting, maintaining alignment can be challenging. For healthcare facilities that manage hundreds of policies, technology can assist with flagging gaps and identifying healthcare policies that need to be changed.
Leadership (such as a chief compliance officer) and specialists (such as lawyers) will need to assess the situation and contribute. Here are some signs that could indicate a new policy should be created, or that an existing one needs to be updated:
- Clinicians express concern about the safety of a clinical workflow
- New technology or equipment is introduced
- New federal, state, or oversight agency regulations are introduced
- Patients voice grievances repeatedly about how a recurring situation is handled
- Audit provides poor results
- Patient outcomes are sub-par
7 Key Internal Policies For Healthcare Facilities
Whether your facility's policy and procedure manual is intended to meet basic regulatory standards, or your team works with a vast digital policy suite, it must contain key documents. Here are seven foundational healthcare institution policy documents that facilitate compliance and safe patient care.
1. Notice of Privacy Practices (NPP) Policy
This policy is important for compliance with federal law. The Health Insurance Portability and Accountability Act (HIPAA) mandates that healthcare facilities distribute a notice of privacy practices (NPP) to every patient. This lets patients know how their protected health information (PHI) will be used and shared. It's usually displayed near a reception desk and also printed for each patient before they even see a provider, meaning it's integral to a patient's first impression of care quality.
To accomplish effective management and distribution of this critical notice, facilities must have a clear, actionable NPP policy in place.
What it may cover:
- How (and when) to distribute the notice
- How to display the notice on-site and online
- How to manage signed notices
- The personnel responsible for updating the notice if federal patient privacy laws change
Key takeaways:
- An effective policy for managing NPPs is crucial for preventing HIPAA violations.
- Give staff clear guidelines regarding how to display and distribute your NPP.
2. Inquiry and Documentation of Advance Directives Policy
The Patient Self-Determination Act requires that many types of healthcare facilities (including hospitals, skilled nursing facilities, and hospice facilities) have a written policy that guides staff to ask each patient if they have an advance directive. The response must be properly documented. A primary care setting may also have a medical office policy related to advanced directives, though the requirements may be less stringent.
What it may cover:
- Standards for asking patients about the presence or absence of an advanced directive
- Rules for documenting responses
- Directions to staff on providing education to the patient about their rights in this area
- Rules for communicating documented responses to other members of the care team
Key takeaways:
- Many facilities are required to have a policy for inquiry into, and documentation of, advanced directives.
- This policy shapes the workflow that staff use to gather this important information from patients.
3. Informed Consent Policy
For medical treatment to be compliant with the law, patients must provide informed consent stating that they understand the risks, benefits, and alternatives involved. Patients with decision-making capacity have the legal right to either accept or refuse the treatment. Informed consent healthcare policies guide this critical step.
What it may cover:
- Which patient groups must be provided with the opportunity to give informed consent
- Standards for situations in which a patient doesn't have decision-making capacity
- Whether there are exceptions for emergency situations
Key takeaway:
- This policy is critical for upholding patient rights and maintaining compliance with federal law.
4. Hand Hygiene Policy
HAIs are linked to tens of thousands of deaths per year and employees' hands are the most common vector of transmission. Hand hygiene is so crucial to positive patient outcomes that enacting strong, detailed guidelines is helpful, even if staff see it as redundant.
What it may cover:
- Rules for when and how to wash hands
- A list of situations that should be followed by handwashing, such as handling soiled laundry
- Standards for the use of alcohol-based hand sanitizer
- When hand washing must be performed instead of only using hand sanitizer, such as after interacting with a patient with known Clostridium difficile (C. diff)
Key takeaway:
- Communicating granular standards of hand hygiene can help to prevent the spread of infection among patients.
5. Personal Protective Equipment (PPE) Policy
This policy will help your staff follow standard precautions when providing patient care. A robust policy in this area can pre-emptively answer employees' questions about what gear to choose when they engage with a patient. It will also address exactly how to don and doff gear, a key aspect of PPE use.
Healthcare institution policy documents that deal with infection control should be easy to follow and be committed to memory. Posting signage in care areas may also help staff follow this policy.
What it may include:
- What PPE should be worn and when
- Rules for proper donning and doffing of gear, such as the sequence for removing gloves and gown
- Appropriate zones of donning and doffing
Key takeaways:
- PPE policies are integral to daily clinician routines.
- This policy should be actionable and clear.
6. Bloodborne Pathogens Post-Exposure Policy
The Occupational Safety and Health Administration (OSHA) mandates that the healthcare facilities under their oversight enact measures to assist staff in the event of a needlestick or body fluid exposure. This policy is important for helping staff to identify potentially infectious body fluids and decide whether they've truly been exposed. Even those with healthcare training may need help making this decision given the heightened emotions and urgency that can be experienced during an event.
What it may include:
- Definition of hazardous body fluids with bloodborne pathogen risk, such as vomit that contains blood
- Definition of an exposure event
- Explanation of how pathogens can enter clinician bodies, such as through open cuts or through mucous membranes in the eyes, nose or mouth
- Post-exposure action steps or guidance to the correct protocol or procedure
Key takeaways:
- This policy, or one similar to it, is mandated by federal workplace safety standards.
- Define terms and provide explanations to help employees determine if they've been exposed to a bloodborne pathogen.
7. Emergency Codes Policy
This policy can efficiently inform staff of how to use codes in the case of an emergency, such as an active shooter or natural disaster. This policy is typically part of a broader emergency operations plan (EOP). Enacting a formal EOP is required for compliance with the Centers for Medicare and Medicaid Services (CMS) and other oversight agencies. As part of the plan, facilities provide guidance on how to communicate the emergency to others.
What it may include:
- Whether specific codes are used, and what they are
- Whether plain-language emergency communication is advised
- Directions for initiating an emergency response
Key takeaways:
- This policy is commonly a sub-policy of a comprehensive EOP.
Encourage High-Quality Care and Patient Safety
Your facility's healthcare policies do more than help your team meet basic regulatory standards. They can also set the bar high so that you create the best outcomes for patients. Get more expert-backed healthcare guides and resources designed to support high-quality care.