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Policies and Procedures, How Many People Actually Read Them?

Rxpert Solutions > Blogs > Policies and Procedures, How Many People Actually Read Them?

Recently someone in the healthcare profession told me they were at a nail salon and a couple women had a stack of policies in their hand from a nearby hospital. They were going through the policies line by line, with a central theme to their comments – “She didn’t do that”. My med safety background had me wondering if there had been an error which was prompting co-workers to find a place to lay blame. Hopefully not, and we can also hope that whatever prompted this policy review did not result in patient harm. It did get me thinking, how many front-line healthcare workers actually read the policies?

Prior to working in a pharmacy management capacity, I did not understand how important policies actually are. Upon hire we are trained, and hopefully in the natural course we are trained to meet policy. The emphasis and adherence to the policy may vary with who is doing the training and what their understanding is of the policies. But I wonder how often the words “per policy” are actually mentioned. Pharmacists would be more likely to emphasize protocols during training because this is part of our everyday workflow.

Pharmacist Policies

Sitting in meetings I’ve often heard leadership refer to policies as the solution to all problems; “Let’s update the policies to address this” or “It’s already in policy so we’re good”. There was no talk of training staff to the policies or educating the staff on why it is imperative they follow policy. It was more, “identify what should be in policy, put it in and then we’re all good”.

CMS regulations specify the need for policies and they survey for adherence to those policies. Boards of Pharmacy do the same. There are two key points here. Facilities must first have solid policies that address the various topics. Second, staff must be able to speak to the policies and confirm they were followed in the event of an incident. Leadership takes ownership of confirming the policies are solid and address all the areas required per the regulations. Leadership must also take responsibility for educating the front-line staff of the importance of policies. They must be proactive in confirming staff have a complete knowledge of where to find the policies, what the policies state, and understanding that they will be held accountable to those policies during a routine survey or one prompted by an event.

Our References

Terri is absolutely phenomenal. She is an incredibly knowledgeable pharmacy resource. As the medication safety officer, the quality initiatives she implemented not only impacted the patients at our medical center but also reached into the community. Terri is a genuine professional who upholds accountability while creating community among her team members. She is a great listener to identify friction points and has actionable ideas to implement improvements.

T. Eagle. MBA, MLS(ASCP), CLS Lab Operations Manager

Terri is an expert at prospective risk identification -Failure, Mode and Effects Analysis (FMEA). Terri participated in CHPSO Patient Safety Safe Tables and was part of the Hospital Quality Institute’s Regional Quality and Patient Safety Leader Network.
She is an excellent public speaker and communicates well with public and professional audiences. I look forward to her continued work in medication safety.

Regional Quality Network at HQI

Terri has done a tremendous job with the controlled substance diversion program. She has had such a positive impact and has really made the hospital a safer place.

Tri-City Medical Center
Nurse Manager

We would not be where we are with the improvements we have made with opioid prescribing if it were not for Terri driving the process.

Tri-City Emergency Medical Group
Chief Physician

In addition to understanding the ins and outs of the [controlled substance use] process completely, she is very proactive in coming to me with provider issues that she detects. She truly balances the administrative duties and the regulatory components demand with a keen sense of what my practitioners do and what their needs are on the ground. Terri is instrumental in working with my department, balancing patient care, cooperation, ability, and integrity to get the job done.

UCSD Medical Center
Chief Anesthesiologist

Terri is knowledgeable and effective in pharmacy leadership. She has the ability to be able to anticipate and prepare for the future. Her ability to utilize resources effectively in this changing environment is a strong asset. She can adapt, evolve, mentor and still never say “no” when asked to assist. She exhibits great abilities to be flexible and is a “self starter”. She has a pleasant yet effective demeanor that commands results.

Candace Fong, Pharm D
System Director of Pharmacy and Medication Safety Common Spirit Health

Terri has always impressed me as being very smart. resourceful, creative, and easy to work with. Terri’s commitment to medication safety permeated our organization, raising the awareness of this important issue throughout all levels of the institution. Terri has always been engaged, cooperative, and generous with her time.

Cary Mells, MD
Chairman of the Department of Emergency Medicine Tri-City Medical Center

Terri has done more for the Pharmacy in her few months as Interim Pharmacy Director than any other Director has done during my 12 years here.

Anita Kennedy, MBA
VP of Ancillary Services Methodist Hospital

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Address: 950 Boardwalk Suite 305, San Marcos, CA 92078

  • 760.705.4078
  • tvidals@rxpert.solutions