Policy Gap Analysis–the past current and future status of the where we are -Policy Question–A survey was given to the staff on what policies they felt were needed -Polic

Previous state

· Policies were purged and Lippincott was implemented

· This caused a huge dissatisfier for the staff and mostly new hires.

· This left staff confused and feeling lost with basic standard of practices

· Policies, Guidelines, SOPs and Lippincott are all located in different areas making it difficult for the staff to locate

· Staff and management not understanding the difference between Policies, guideline, and SOP’s.

Current state

Below is where the hospital is currently at with policies, SOP, and guidelines.

· Steps taken to get here

· Standardization of education across the hospital and ownership of policies

· Education to the education team and leaders on the difference of Policy vs SOP vs Guideline

· Education to the education tem on how to initiate and follow up on policies via compliance 360

This was completed by the Holtz Women’s and children’s education team

· Current Policy revisions

· Pediatrics

· Brain Death Determination Pedi—JHS 400.087.1

· Parental or Guard Notification for Pts under 18 for Pregnancy—JHS 4000.013.1

· Organ Donation After Cardiac Death Pedi—JHS 400.018.1

· Disclosure of HIV Status to Minors—JHS 400.050

· Exchange transfusion

· Closed medication administration system

· Women’s

· Fetal Reeducation—JHS 400.013.2

· Termination of Pregnancy—JHS 400.013

· Certificate of Fetal Death; Stillbirth Reg—JHS 400.011

· Sterilization—JHS 400.010

· Low Risk Delivery Newborn Resuscitation

· Baby Friendly breast feeding

· High risk delivery newborn resuscitation

· Newly Established Policies

· VAD policy

· Oxytocin concentration

· PCN desensitization

· CRRT/ECHMO

· OB

· OB patient disposition

· OB patient care

· Pediatric Code Blue

· Neonatal Code Blue

· Guidelines

· Unit Admission Guidelines

· Unit specific Documentation Guidelines

· Required task per shift (eg: IPOC)

· Pathways

· Early onset sepsis

· Hypoglycemia

· Hyperbilirubinemia

· Code Pink

· SOP’s

· Protocol for management of Placentas

· OB Alert Emergency Standard of Care

· MFTI

· Prioritization of the OB patient in triage

· Quick tips

· IV site documentation

· Admission, Discharge, transfer criteria (referencing policy 401)

· Care and Maintenance of Vascular Access Devices

· Medication Administration (referencing policy 400.025)

· Berlin Heart

Resource Binders

The Education team has also been a part of the following system wide policies

· Suicide Prevention policy non-behavioral Health (there are now 2)

Top 6 policies requested from the survey (see attached)

Vascular access Device/Management/Dressing change

Unit Admission Guidelines—-Making a guideline

Documentation Guidelines—Making a Guideline

Thermoregulation (neonatal standard of practice)

Nursing standard of practice—-Addressed in the Unit admission and documentation guideline

Tracheostomy Care

Future

1. things that we are working on to ensure that resources are available for staff in a central location

· Resource Binders

· front part of each binder will be standardized hospital wide (see below)

· Second half of each binder will have valid information and tools for each unit to assist with the following:

· Documentation standards per unit

· Quick tips

· Ect.

· We are working with IT to have the binders be electronic with links for easy access.

to be on the following units within Holtz and Women’s

· Pedi Clinics

· Antepartum

· GYN/GYO

· BMT

· PRU

· Pedi Hem/Onc

· Pedi Transplant

· PICU

· CICU

· PSPU

· L&D

· OB Triage

· OB OR

· OB Recovery

· OB Transition nursing

· NICU

· NICU-D

· Mother Baby

· Pedi ED

· Dialysis

· Pedi Transport

· PPEC

Each binder to consist of the following

· Holtz and Women’s

· Emergency number

· Security

· Color codes

· Web link for badge buddy

· Hospital Department numbers

· TJC handouts (race/pass/ hand hygiene)

· Map of campus

· Nursing assessment policy (health record documentation guideline)

· Quick tips

· Restraints

· Zolls

· BBraun quick tip

· POCT reference

· Unit Specific (per unit above)

· Unit phone list

· Unit chain of command ( w/ contact info & title)

· Pathways

· Map of the Unit

· Tools (humpty dumpty)

· Unit specific documentation

· FREQUENCY (Q1, Q4, etc.)

· Pre Op/ Post op/ during procedure

· Stroke/ DKA/ STEMI/ Pitocin/ Mg drip etc.

· Resource binders to be made electronic with the help of IT

KEY

In progress

Recently completed

Requested, not initiated

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