The policy & procedure manual: development of a computer-assisted process for review

Area of Science:

• Nursing Quality Improvement
• Healthcare Policy Development
• Health Informatics

Background:

• Systematic review of nursing policies and procedures is crucial for evidence-based practice.
• Existing review processes may lack efficiency or comprehensive staff input.
• The Queen Elizabeth Hospital sought to enhance its policy and procedure review system.

Purpose of the Study:

• To document the development of a computer-assisted process for systematic review of nursing policies and procedures.
• To ensure policies are research-based and aligned with clinical nursing practice.
• To establish measurable client outcome standards for quality assurance.

Main Methods:

• Development of a computer-assisted systematic review process.
• Incorporation of broad nursing staff input for policy development.
• Rating policies using Canadian Council on Health Facilities Accreditation criteria.
• Structured annual review circulation to all nursing staff levels.

Main Results:

• Successful implementation of a computer-assisted policy review system.
• Policies developed as research-based, practice-grounded, and client-centered.
• Client-related standards defined as measurable outcome statements.
• Prioritization of key policies for quality assurance through accreditation criteria rating.

Conclusions:

• The computer-assisted systematic review process enhances the development of effective nursing policies and procedures.
• Broad staff input and accreditation criteria integration lead to research-based, practical, and measurable client care standards.
• This structured approach facilitates focused quality assurance activities within nursing practice.