By Ifetayo Freeman, EdM

Dynamic healthcare professionals are redesigning and upgrading systems, identifying ways to improve the patient experience. However, quality services to patients should begin with every staff member embracing the reason why they exist at a healthcare organization.  Make sure that all messaging vehicles—from web pages to people—are informed by current vision and mission statements in policies and procedures that are aligned with federal and state laws as well as accrediting entities’ standards.

Six must-haves for a viable framework of accountability are:

1.    Integrality

A good reason to take another look at policies and procedures now is to determine whether the mission and vision in the policy manual allow all staff to see where they fit in the organization’s innovative approaches. Multidisciplinary teams serving people in outpatient settings day in and day out need their focus refreshed individually and as a group, particularly if they are partnered on the “big picture” with a larger institution. Few people use the words “policies and procedures” and motivation in the same sentence. Is the mission statement simple enough that every healthcare professional in the organization can remember it?

2.    Accreditation

Adherence to policies and procedures is necessary to maintain accreditation and comply with federal and state laws. Continuity of care, preparation for emergencies, risk management programs, expiring licenses, adverse actions, and restrictions on who can perform pain management are just a few topics addressed in the Institute for Medical Quality (IMQ) standards manual for ambulatory care; IMQ is just one accreditation entity that issues standards to protect a clinic’s license and save patients’ lives. Imaging services departments in particular need to consider safety. IMQ has new and amended standards concerning facilities with radiology and imaging equipment preventive maintenance.

3.    Federal Law

The endoscopy outpatient clinic that allowed an unauthorized physician to perform a procedure on comedian Joan Rivers had a privacy policy statement on their website: “This notice takes effect April 14, 2003 and will remain in effect until we replace it.”[i] The Health Insurance Portability and Accountability Act (HIPAA) Omnibus Final Rule requires HIPAA-covered entities to revise the Notice of Privacy Practices and use a revision date on or after September 2013. Patient safety provisions for personal health information are an important part of a policy and procedure review and absolutely necessary to prevent costly civil and criminal penalties.

Other federal regulatory agencies such as the US Food and Drug Administration (FDA) periodically issue guidance on topics such as cautions on off-label use that are important to know.

4. State Law

X-ray practices and dose safety are under careful scrutiny with new laws impacting radiology department technologists. Women’s breast care has become a national discussion due to the emergence of digital tomosynthesis as an alternative to mammography.  California has passed new laws concerning women’s health that should be reflected in policies and procedures. California Senate bills 1538[ii] and 1237[iii] are just two examples that affect practices in outpatient settings. California Labor Code Hospital Patient and Health Care Worker Injury Protection Act regulation became effective October 1, 2014, granting technologists and staff the right to refuse to lift and handle patients believed to expose staff to unacceptable risk of injury. Clinic administrators should appoint members to a safety committee to ensure compliance, analysis of risk, education, and appropriate reporting.

5.    Best Practices

Enhance outpatient radiology clinics’ policies and procedures with the American College of Radiology 2014 Practice Parameter on Performing Diagnostic Mammography and the 2013 Manual on Contrast Media concerning steps to prevent adverse reactions as well as the Centers for Disease Control and Prevention 2014 Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care concerning Standard Precautions.

6.    Training by a Neutral Third Party

Utilizing consulting services for training provides staff with a safe space to share concerns on poor policies and procedures implementation without fear of retribution. The appointment of radiation safety officer(s) and directors of quality management programs and risk management programs is important to assist with the periodic review and amendment to an outpatient clinic’s policies and procedures. Nonetheless, thorough assessment generally requires time and a depth of work that outpatient clinics are hard pressed to staff.

These six areas are a good start for accountability. Organizing the policies and procedures to match the framework is tedious work. Technology is here to stay and administrators need to build manuals that support the innovative change underway. Patients, especially women, are choosing facilities based on ability to optimize technology to produce better results for their personal health. Reviewing the latest version of a manual and signing a form acknowledging receipt of policies and procedures does not have to be the default for policies and procedures accountability efforts.

####

Ifetayo Freeman, EdM, is an analyst at Ascendian Healthcare Consulting. Ascendian Healthcare Consulting is a vendor educated leader in HIT solutions, helping a number of healthcare organizations that have been nationally recognized for their advances in medical education, research, and patient care. 



[i] Accessed on October 16, 2014: http://www.yorkville-endoscopy.com/privacy.html.

[ii] California Health and Safety Code Section 123222.3 impacts Mammography Reports, Results and Medical Outcomes Audit and should be updated to reflect SB 1538 notification to patients with dense breast tissue and BI-RADS categories.

[iii] California Health and Safety Code Section 115113 changes previous protocols concerning repeat images for computed tomography (CT).