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Assessment 5
Creation of Policy or Procedure
Create
a new policy for the medical center based on evidence using the attached
Hospital Policy template.
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Introduction
Quality
improvement begins with the end in mind. Up until now, you have researched the
practice problem and developed a focused, evidence-based intervention to address
a patient safety problem. The next step would be to implement the practice
change and evaluate the change to determine the effect it had on the
population. Now, developing a policy will help sustain the change.
Along
the way, you will learn that as a leader in a health care organization, you
will not only facilitate the steps of evidence-based practice, but you will
apply evidence-based leadership strategies to serve as a role model for
decision making in your organization. Your skills and ability to promote and
encourage evidence-based behavior and decision making among staff, providers,
and other leaders will be invaluable to creating and sustaining an
evidence-based organization and a culture of evidence. Your own leadership
style will influence how you support and model evidence-based processes at your
organization.
The
purpose of this assessment is to complete the stages in the EBP process,
translating the research into practice. You will be developing a policy or
procedure to address a patient safety issue in a healthcare setting.
Incorporate information from prior assessment where appropriate.
Scenario
As the
Director of Clinical Operations and Nursing Excellence, it is your
responsibility to ensure that the best practices and protocols are implemented
and sustained at the medical center. The next step is to translate the evidence
into practice. Policy development is an important final step. Without a formal
policy or guideline, it is likely the change will not become permanent.
Policies and procedures standardize care which in turn, improves patient
safety.
Instructions
Create a new policy for the medical center based on
evidence, using the Hospital Policy Template
[DOCX] Download Hospital Policy Template [DOCX].
1.     
Review the template
before you begin filling in each section, and gather any materials or
documentation you will need.
2.     
In the Subject/Title of
Policy section of the Hospital Policy Template
[DOCX] Download Hospital Policy Template [DOCX], type the name of the policy.
3.     
In the Purpose section,
explain the purpose of the policy in 1-2 short paragraphs. Include the
following:
o   
Summarize the patient
safety issue.
§  Explain the gap or a problem in a health care or public
health situation that caused the issue.
o   
Use supporting evidence
from the literature to show how it determined the need.
§  Explain how the evidence was gathered.
o   
Include your revised
PICO(T) question.
o   
Explain why it was
necessary to take action with the development of this policy.
4.     
In the Population
Affected by the Policy section, identify and describe the populations affected
by the change and how the scope of the problem was determined.
o   
Scope is the extent of
the problem, or how wide-sweeping the issue is for the target population and
the community.
o   
Describe the target
population to be addressed by an intervention in enough detail that it is clear
what population is included or excluded.
5.     
In the Definitions
section, create definitions that explain the industry specific terms used
throughout the document needed for the understanding of the policy.
o   
Explain the terms in a
manner that is descriptive to non-industry personnel.
6.     
In the Policy Statement
section, create a policy statement in a 3-5 sentence paragraph that includes
the following:
o   
State the organization’s
declaration of the plans giving a timeframe and scope of the policy
implementation.
o   
Explain the
organization’s intentions or goal regarding the patient safety issue.
o   
Clearly describe the
policy plans, explaining that this is a quality improvement project based on
evidence-based practices to address a specific patient safety issue.
7.     
In the Procedure
section, elaborate on the step-by-step procedure that was outlined in the
policy statement above in enough detail that one could replicate the process
based on your description alone.
o   
Information needs to be
clear and easy to read. Avoid using wordy paragraphs.
o   
Describe all the
processes involved. This section could be in a numbered list or a detailed
flowchart. Include the following:
§  All participants with their specific responsibilities
listed.
§  Step-by-step description of the logistical flow of how the
policy is to be implemented.
§  Instructions for completing each step.
§  Any supplies that may be needed.
o   
If a protocol or
guideline already exists for your patient safety issue, use additional
guidelines and literature to revise and create a procedure using your own
words.
8.     
In the Resources
section, include a complete reference list of all sources used in the
development of the protocol as part of the policy template. Use APA format for
the citations.
Additional Resources
·        
Use the Hospital Policy Template
[DOCX] Download Hospital Policy Template [DOCX]provided.
·        
No smaller than 11 point
font, Times New Roman.
·        
Single spaced format
within the template.
·        
Minimum of 12 resources.
·        
APA formatting for
citations and reference list.