Domain #6: Policy & Governance
Policies are designed to govern the minute-by-minute & hour-by-hour activities of hospital staff in a manner that (hopefully) incents and encourages behavior that aligns their activities to the best interest of patients and the larger organization they serve. When policies fail to keep up with changes in culture, behavior and environment they can actually provide negative incentives that undermine what is in the best interest of institutions and their customers. Furthermore, policies for whom measurement of compliance and governance are not pursued become nothing more than "guidelines" open to local interpretations.
This section allows an organization to assess the level of performance it has achieved in ensuring that its policies are crafted with an intentionality of purpose that accomplishes several things:
- Aligns staff behavior to organizational needs
- Measures compliance
- Provides education and corrective action escalations
Components of the Policy & Governance Self Assessment are listed below.
Optimized/created a "Flexing" policy that clarifies flexing guidelines for each department as volumes change
The organization's flexing policy is broad enough to allow a department who misses a productivity target during a single shift or day to make it up during the pay period.
Optimized/created a "Time & Attendance" policy that reduces waste associated with issues such as "punch & park"
The organization has reviewed its time & attendance policy to ensure that abusive behaviors and practices (such as: punching in a time clocks far distant from the department, failing to swipe to cover late arrivals, etc . . .) are measured, discouraged and punished accordingly.
Optimized/created an "Agency use" policy that limits agency renewal when additional staff are hired
The organization has created a policy that denies departments the ability to fill vacancies with new hires until agency staff have been replaced with core staff (new hires MUST be applied to agency reduction efforts BEFORE going to fill vacancies).
Optimized/created a "Scheduling policy" that ensures that; call & cancel, time-off & responding to call-outs & volume changes are optimized by "cost of each staff type" (IE agency, PD, registry, OT, etc . . .) rather than "ease of scheduling"
The organization has created/reviewed a house-wide (not just within nursing) policy that governs the behavior of department leaders responsible for staff scheduling. The policy includes rules of escalation when unexpected scheduling holes occur and the rules for "who to call/cancel in what order" to ensure that most costly staff are called last and canceled first.
Optimized/created a "Budget Variance" policy that clearly defines "variance" and the procedures for remediation including seeking the assistance of senior leaders
The organization has developed tools for bringing ever escalating assistance to the aid of managers who struggle to maintain budgetary compliance. It does not assume that managers know "how" to create budgetary compliance and does not punish their lack of knowledge of options & alternatives.
- Sr Leadership has reviewed each policy to ensure it is designed in a manner that supports organizational goals and creates appropriate behavior incentives.
- Each policy includes an "escalation strategy" that defines a minimum of 3 steps of progressive response to non-compliance.
- Each policy includes compliance requirements for both managers and staff.
- Each policy's escalation strategy ends in termination within a fixed period of time should remediation not occur.
- Communications and training plan has been created for every policy change.
Measurement & Reporting
- Methods of measuring compliance to each policy have been created.
- Weekly reports of compliance are distributed.
Labor Competency Domains
- #1) Staffing / Recruiting
- #2) Scheduling
- #3) Avoidable Days
- #4) Productivity
- #5) Process
- #6) Policy & Governance