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53 – Annual Tasks: Review policies and procedures
12 Plays17 days ago
The eighth task that you should complete annually is reviewing policies and procedures.
View the full report online: https://www.hstpathways.com/resources/surgery-center-industry-report/
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Transcript
Annual Review & Policy Importance
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The eighth task that you should complete annually is reviewing policies and procedures. Policies and procedures for a surgery center serve as guiding documents to ensure patient safety, adherence to legal and ethical standards, and standards of operation.
Diverse Policy Needs
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Specific policies and procedures can vary based on the type of surgeries performed, the location, and the regulatory environment. Each accrediting body also has its particular standards and requirements, but all strongly emphasize comprehensive, well-documented, and well-implemented policies and procedures. Your policies and procedures must follow suit as your surgery center evolves and
Implementing Changes
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grows. Over the year, you might implement an EHR, adjust pain management protocols, improve your fire safety and evacuation plans, update employee vaccination requirements, or change your family visitation policy. Those are just a few examples of reasons you would need to update your policies and procedures.
Steps for Policy Review
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Next, let's walk through the key process steps for this phase. Step 1. Begin by collecting all existing policies and procedures p and p's and creating an index of documents due for review. Step 2.
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Collate recent changes in regulations, industry standards, and within your surgery center that might influence documentation. Step 3. Engage with different departments and teams to gather feedback on existing P&Ps.
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Step 4. Draft necessary changes or additions. Step 5. Have all necessary parties
Updating & Training
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review. For example, legal counsel, quality committee, executive committee.
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Step 6. Distribute the updated documents to all relevant staff, ensuring old versions are archived. Step 7.
Securing & Tracking Policies
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Organize sessions to train staff on new or modified policies and procedures, ensuring everyone is aware of and understands the changes.
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Step 8. Store the updated P&Ps securely, both digitally and in physical form, ensuring proper version control. The following key performance indicators will help you track your success, the number of policies and procedures that need to be updated, and the staff policy acknowledgement rate.