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

This article documents the successful development of a computer-assisted process for systematic review of nursing policies and procedures at The Queen Elizabeth Hospital, Toronto, Ontario. Through broad staff input, policies and procedures are research-based yet grounded in the reality of the facility's nursing practice. Client-related standards are written as measurable, realistic statements of desired client outcomes, and as such are standards for client care. Policies and procedures have been rated according to the Canadian Council on Health Facilities Accreditation criteria (client centered, high risk, high volume, problem prone, interservice, outcome-related), so that important policies are easily identified to provide focus for quality assurance activities. The review process is structured so that over the course of a year, all policies are circulated for review by all levels of nursing staff.