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Using Nursing Policy Management to Ensure Quality Care

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Using Nursing Policy Management to Ensure Quality Care

Nursing policy management is essential to ensuring quality patient care, yet creating and maintaining health policy presents a significant challenge for most healthcare facilities. 


Nursing policy protects the patient who receives care and the nurse who gives it. Nursing policy management establishes guidelines for procedures, stipulates the standards of care given, and provides a safe healthcare environment. It merges disparities in nursing programs to present a united organizational front. Nursing policy management is an expectation of stakeholders and is critical to delivering quality patient care.


No one questions the need for health policy creation and management. However, organizations are simply unable to keep up with the demands of nursing policy management.


Covid-19 provided the perfect backdrop to accentuate the challenges of nursing policy management. With daily and sometimes hourly releases by the Centers for Disease Control and Prevention (CDC), healthcare organizations scrambled to manage the development and implementation of health policy for the safety of all communities. 


Nursing policy management requires a team of dedicated and knowledgeable nurses (subject matter experts) with leadership qualities to create, review and update policies and procedures using current evidence-based practice, as well as cross-checking the content against federal and state regulations as well as accrediting organization standards.. These tasks are in addition to adhering to the organizational templates and standards. Let’s look at the construction of a nursing policy.



The Steps in Policy Management

Policy management is the corporate foundation that ensures the delivery of quality care to all patients. The creation and management of nursing policy commences with a policy agenda, followed by policy formulation, program implementation, and policy evaluation.


Policy Agenda


All policies begin with a problem that requires a solution. It is the responsibility of nurses to bring the agenda to the policy and procedure committee. During the recent pandemic, hospital organizations were concerned for the safety of their staff working in emergency departments. Since a patient arriving by ambulance in cardiac arrest could not be tested for Covid-19 before care, some medical facilities implemented a robotic chest compression device called LUCAS to give chest compressions. 


Policy Formulation


Groups of highly trained and knowledgeable nurses with solid decision-making skill sets wrote new policies on using LUCAS. Since frontline nurses are the largest group of employees that utilize nursing health policy, they are uniquely positioned to understand the needs of patient populations. They are critical to decision-making for evidence-based policy formulation.


Program Implementation


Policies are only helpful if they are available and utilized by staff—communication by email alerts staff of new policies and updates. Health policies may be posted to the organization’s internal computer network for easy access or in their policy management software, yet many still find their way into binders on nursing units. Sometimes key words chosen by policymakers need to be more intuitive for nursing staff when searching for specific policies. It is the responsibility of nurses who experience difficulties in accessing healthcare policies to report this problem to the policy and procedure committee.


Policy Evaluation


The four steps to nursing policy management are just the beginning. It is one thing to write health policies but another to keep them updated, organized, and accessible for all employees. There are yearly reviews and updates needed, changes in federal regulations, amendments to nursing guidelines, and the added urgent policy demands triggered by a pandemic. Most organizations cannot keep up with the intense workload, which becomes a quality and safety issue. MCN Healthcare (MCN) offers a proactive choice for policy management.


How a Policy Management System Helps


MCN Policy Management Software Solutions takes the pain point out of policy creation and management in five specific areas: policy creation, review, approval, and implementation and attestation. Nursing policy management is expensive for healthcare organizations when considering the total cost in time and salaries. A policy management system offers healthcare organizations a viable and empowering option. 


Policy Creation


MCN Healthcare has a Policy Library with policies and procedures that can be customized for individual healthcare organizations and smaller companies. MCN Healthcare’s Policy Manager aids healthcare organizations in the creation, review, updating and approval of policies ensuring staff have access to the most current policies and procedures for your organization.  An alert system, StayAlert!, sends your company an email detailing any changes in healthcare regulations..


Policy Review


Registered Nurses create, review and update the policies and procedures in MCN’s Policy Library. In 2019, MCN Healthcare partnered with EBSCO Information Services, whose evidenced-based resource, Dynamic Heath, provides a solid support base for policy creation and management.


Policy Approval 


How often have you created a policy only to have it sit on the desk of the clinical director awaiting a signature? Once a company chooses a policy management system, there is no longer shuffling of papers from one desk to the next.  The automated approval process sends out reminder emails for policy review and approval.


Policy Implementation and Attestation


MCN Healthcare supports initiatives for employee learning through the competency module in the policy management software.  Attestations and quizzes can be assigned to staff to ensure a new or updated policy or procedure has been reviewed.  


MCN also offers a learning management system with educational courses that assist organizations with annual education requirements.


Nursing Policy Management for Quality Care


Policy management is a demanding task requiring multiple employee hours.  MCN Healthcare’s Policy Manager streamlines healthcare policy management. MCN’s Policy Manager solves the ongoing issue of policy updates and ensures continued training and support for employees. Click on the Policy Manager demo at MCN Healthcare to further explore how your organization can improve policy management. 


For additional information, please read more of MCN Healthcare’s blog posts:



Kelly, Ursula; Edwards, Geneva; Shapiro, Susan E. (2021). Nursing Policies and Protocols: Do Nurses Really Use Them? Journal of Nursing Care Quality 36(3):p 217-222.


Salvage, Jane; White, Jill. (2019). Nursing leadership and health policy: everybody’s business. International Nursing Review, 66 (2).


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