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Policies and procedures

In any well-governed organisation, everyone needs to know not only what they are supposed to be doing but also how they are supposed to be doing it. Standardising guidelines, policies and protocols across all sites is considered essential if care, surgery and outcomes are to be consistent.

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  • Some variation is necessary in order to enable individual sites to respond promptly to local conditions: how much is acceptable needs to be established.
  • There needs to be a robust clinical governance framework to manage policies and procedures and ensure that the documents are available and clear.
  • Shortened, more visual formats such as infographics can be used to provide summaries which are accessible and quick to read.
  • Major new policies should be actively promoted for example via mandatory training sessions or via remote educational resources.
  • Ensure you have the right policies in the right place, for instance standard operating procedures, procedures for the deteriorating patient, resuscitation in high risk areas.

“The pathways are based on protocols, some supported by pharmacists working in the community with GPs, and we think they will get patients to the right place more quickly.”

“It gets messy because of course each trust is its own legal entity with its own clinical governance. But, what we’ve said is that if you’re doing this in our network, you adhere to these clinical guidelines.’

“You can write protocols till you’re blue in the face but it’s still very important to know someone – know that they’ll follow them and that you can trust them.”

Policies and procedures

Tools, documents, resources