Policy & Procedure is the root of all PROCESS, and process is everything in the LTPAC organization. Without process, we have inconsistency and inefficiencies. Policy & Procedure is not a manual on a shelf that collects dust. It is a “living” document that is updated to meet the needs of regulatory requirements and the organization – it has to weather changes (as these come fast and furious these days). Policy is the backbone of WHY we do WHAT we do, WHO does it, WHEN it is done and WHERE we document it. Procedure is HOW we do it. Without these components, we do not have PROCESS, and process is everything.
Process is Everything in the LTPAC Organization
WHAT - the task. Outline what needs to be done and make sure everyone knows what needs to be done. Present clear and consistent expectations to all of those people responsible for completing the task. This is the foundation for everything that follows in the process.
WHY - the reason behind the task. Answering the WHY provides the education to help ensure that staff is informed of the regulation that requires the task. A better-informed staff is a better performing staff.
WHO - the person responsible for the task. Present the responsibility and accountability for the completion of an assignment. Give staff the path to leadership in the case of obstacles. Incorporate the accountability into the job description of those who are responsible for successful and timely completion of the task.
WHEN - the deadline. Specify the timeline for completion of an assignment, and make it a part of the accountability. Not only was the job done, it was done when it needed to be done. Timelines matter.
WHERE - the place where documentation is maintained. It is an old saying – “if you didn’t document it, you didn’t do it”. Equip staff with the tools to document their work. Is it within the EHR software itself, or is it documented on a worksheet in a shared folder. Regardless of the format, the “where” has to be communicated, and the expectations consistent.
HOW - the outline of the task. The step by step outline of the task with clear and concise description of how to complete each step from beginning to end. This is the process within the policy.
Policy & Procedure has to be interwoven into job descriptions and performance evaluations. It is the foundation of the facility Corporate Compliance Plan, and the basis of Quality Assurance and Process Improvement (QAPI). If a facility fails to set forth the expectation and to provide the path for meeting them, then there is no steady foundation on which to build upon. Sooner or later, the lack of process will give out, and the walls will crumble.