Policy and ProcedureMelissa Fugate, MSN, RN, CIC

Infection Prevention and Control MangerBaptist Health Louisville

ObjectivesO Define policy and procedureO Explain importance O Give examples of common policiesO Provide resources for guidance for review

and creation of policy O Discuss “pitfalls” that can arise with policy

What is a policy?According to Webster’s Dictionary…O a definite course or method of action

selected from among alternatives and in light of given conditions to guide and determine present and future decisions

What is a procedure?According to Webster’s Dictionary…O A series of steps followed in a regular

definite orderO A traditional or established way of doing

things

Why do we need policy and procedure?

O To give guidance to staff regarding practices and behaviors

O Standardization and consistent practiceO To meet regulatory requirements

Infection Prevention Program

O GoalsO Scope of Program

O SurveillanceO Outbreak investigationO Policy and Procedure Review and RevisionO Staff EducationO Performance ImprovementO Consultation

Infection Prevention Program

O Division of responsibilitiesO Infection PreventionistO Infection Prevention Committee

O Reporting MechanismsO Who should receive the information

Common Policies O Hand HygieneO Isolation PrecautionsO Dress codeO Animals O Cleaning , Disinfection and SterilizationO Monitoring sterilizersO Endoscopes

Common PoliciesO Creutzfeldt-Jakob Disease/Prion DiseaseO Influx of Patients with Infectious DiseaseO IV TherapyO Urinary CathetersO Central Venous CathetersO Visitors

Department Specific Policies

O Sterile Processing Department

O DietaryO LaboratoryO PharmacyO Physical TherapyO Respiratory TherapyO Surgical Services

O EngineeringO Environmental

ServicesO Employee HealthO Labor and DeliveryO Radiology

Common Department Specific Policies

O Sterile Processing DepartmentO Processing, packaging O Sterilizers (loading, cycles, monitoring)O Sterilization processesO Dress/Attire for employees

O Surgical servicesO AttireO Surgical ScrubO Skin prepO Restricted areasO SterilizersO Immediate Use Steam Sterilization

Common Department Specific Policies

O PharmacyO Equipment (hood)O Clean roomsO Hand hygieneO Compounding standardsO Cleaning/Environmental Standards

Common Department Specific Policies

O RadiologyO EquipmentO Aseptic Technique for Invasive ProceduresO Cleaning

O Environmental ServicesO Waste ManagementO AttireO Bed BugsO Cleaning/Disinfection

Where to get guidance for policies?

O CDCO USP 797O Regulatory Agencies

O OSHA/NIOSHO Professional organizations

O APICO SHEAO AORNO AAMIO INS

Pitfalls of PoliciesO Not easily understoodO Not usedO InaccurateO Not updated with evidence-based practicesO Doesn’t match current practiceO Unrealistic standards

Questions?