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Policies, Protocols, and Guidelines

Policies, Protocols, and Guidelines



By Tina Nelson


For obvious reasons, organizational policies, practice guidelines, and protocols have required continuous changes over the last two years.  With the constant evolution of health policy during the COVID crisis, leaders are trying to keep pace and make certain the regulatory mandates are reflected in their policies and guidelines, literally, on a daily basis.  


Document control functions performed by an organization are a collective effort to reduce operational risk and promote positive patient outcomes.  In order to continue to remain compliant, documents such as organizational policies, guidelines, and protocols have to be reviewed and approved through an internal document control management program and often through an expedited review process when clinical practice workflows need to change right away.  Document control requires an efficient operational strategy that is sustainable by organizational leaders to ensure the appropriate reference documents are kept up-to-date and that the turnaround time of the document’s approval is consistent with operational needs and regulatory mandates.  


Document control operational functions are rarely seen as a key component of inhibiting adverse events, but with the assurance that practice mandates are executed in a timely manner, leadership is validating that the guiding principles of the organization are well written, evidence-based, and approved for use by the appropriate subject matter experts.  This requires operational workflows that include a timely review of the evidence including the implementation of clinical practice recommendations communicated by the state, federal, and national leaders. 


Join me in my review of a healthcare organization’s reference document requirements put forward by regulatory agencies. We will discuss when to utilize a policy versus a guideline or protocol, how to determine who should be performing a review of the organization’s reference documents, and how incorrect practices can be a precursor to a citation by regulatory agencies if reference documents are not reviewed appropriately. Register Here



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