Standards of Practice, Policies and Procedures
Before starting clinical practice, it is important for the clinical and administrative
staff to come to consensus about the program's standards of practice, and policies and
procedures related to the issues within the "Square of Care and Operations."
The best time to delineate processes, clarify the roles of interdisciplinary team members,
and establish responsibilities and accountability is before patients are seen by the program.
Specific tasks to be allocated indlue:
- Who takes telephone calls?
- Who will carry a pager?
- What is the expected time that will elapse before a patient is seen?
For many consultation services, patients are seen the same day or within 24 hours at the outside.
- Who does the initial assessment?
- Who provides symptom control?
- Who provides psychosocial support?
- Who provides spiritual support?
- How will after hours coverage be handled?
- Who does documentation? What's the standard for medical and administrative records?
- Who calls the requesting/managing attending or service with information?
- Who does billing, statistics, and other data collection?
Policies and procedures will be also be needed to define patient eligibility for clinical
services, on-call procedures, use of certain medications and treatments, and staff
education and support.
A more extensive discussion related to the development of policies and procedures
can be found under Elements.
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CAPCManual Attribution:
von Gunten CF,
Ferris FD,
Portenoy RK,
Glajchen M, eds.
CAPCManual: How to Establish A Palliative Care Program.
New York, NY: Center to Advance Palliative Care, 2001.
©
Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, CA
and
The Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, 2001
Permission to reproduce for non-commercial educational purposes with display of
attribution and
copyright is granted.
Last updated: February 20, 2002
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Development
Select section:
Change, Groups, Phase 1,
2, 3, 4
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Change
In Individuals
In Organizations
Stages of Change
Awareness
Adoption
Implementation
Institutionalization
•
Small Group Structure / Function
Leadership
Group Formation
Group Function
•
Phase 1: Prepare to Plan
Potential of Planning Process
How Much is Enough?
Ensuring Impact
Form Initial Workgroup
Elaborate Initial Idea
Stakeholders, Customers
Need, Purpose of Program
Planning Questions
Planning Steps, Timeline
Resources Needed to Plan
Use of Consultants
Use of Retreats
Write Planning Proposal
Selling, Getting Approval
•
Phase 2: Plan the Program
Form Planning Workgroup
Review, Revise Process
Strategic Planning
What is Strategic Planning?
Models
Steps
How Much is Enough?
Resources
Review Stakeholders, Customers
Conduct Needs Assessment
Company
Competition
Customers
Conduct SWOT Analysis
Case Study - United Hospital Fund
Define the Program
Purpose, Values
Mission, Vision
Mission
Vision
Service Delivery Model
Goals, Objectives
Strategies, Tactics
Strategic Decision Points
Business Planning
Case Examples:
Cleveland Clinic
University of Virginia
Organizational Structure, Leadership
Financial Plan
Implementation Plan
Human Resources
Physical Resources
Informational Resources
Community Resources
Operations
Evaluation
Marketing Plan
Targets, Timing
Write Proposal
Suggested Proposal Outline
Sell Plan
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Phase 3: Implement the Program
Staff Recruitment
Staff Training
High Functioning Team
Standards of Practice, Policies, Procedures
Clinical Evaluation
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Phase 4: Review Program, Revise Plan
Form Review Workgroup
Program Evaluation
Plan Evaluation
Continuous Quality Improvement
Utilization Review
Appropriateness of Hospitalization
Documentation
Pearls
Respond to Denials
Revise Plan, Further Development
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