POLICY AND PROCEDURE REVIEW

Chapter 7

Review and revision of policies and procedures are a critical components of effective advocacy. Establishing good policies and procedures sets the ground work for improving facility operations: good policy and procedures promote good practice.

All facilities maintain policies and procedures. They offer the advocate a great opportunity to effect institutional behavior, and they are extremely as a source of information about how things work (or how the facility thinks they should work). They are record of the facility’s official position on a number of matters.

Reviewing policies and procedures helps to determine whether a facility has addressed a particular issue and whether the policy instructions are in compliance with the law. The failure to provide a policy or procedure is not usually unlawful, so the advocate must assess whether such a failure indicates a problem that can be confirmed in other ways. But where a facility has written a policy or procedure, it must conform to legal requirements. Review the policy and procedure manual and any other documents that set forth the facility’s operating standards, including inter-office memoranda, training materials and staff directives.

A. Review Model Policy & Procedure

Where they exist, model policies and procedures serve as useful guides for revising policies and procedures. Model policy and procedures (including instructions and documentation forms) are developed to integrate state-of-the-art legal and clinical concepts. Although they may go beyond current minimum legal requirements, many of the ideas included in models are currently in use in facilities. Providing models for practice gives direction to the facility in making decisions about institutional practices.

B. Review Facility Policy & Procedure

Review facility/county policy and procedures line-by-line for compliance with statutes, regulations and case law as well as JCAHO and other clinical standards. Compare the local policy and procedures with the model policy and procedures. Draft an analysis of deficiencies in policies and procedures and make specific recommendations for changes and additions. Participate in writing the new policy and procedure. Encourage the facility to promote understanding of the policy and procedure as part of staff development and to use the policy and procedures in staff training.

C. Ensure Implementation of Revised Policies and Procedures

Promote recommendations for revised policy and procedures to staff. Explain how the proposed policy and procedures are more consistent with clinical and legal requirements and provide better/clearer guidance to staff.

D. Continue to Promote Good Policy and Procedures

Review the policy and procedures annually and recommend revisions to address continuing problems or new legal requirements. Promote continued training of staff on facility policy and procedures. Refer to and use the policy and procedures in the train, emphasizing revisions.

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