Reply To: Protocols, Policies, Procedures

  • Regina Winfrey

    April 14, 2014 at 2:26 pm

    1,2,3 We have policies and procedures. We are trialing a  protocol and made it an addedum to our policy.
    4 We have combined the protocol  to the policy.
    5. format- purpose, policy, equipment, procedure if we are able to link our policies to Mosby’s we add that link, addenum then references.
    6. The step by step process is written out in detail for ours and the ones we use in Mosby’s
    7. We have procedures that details every thing.
    Regina Wilkes
    CNL-St.Jude Children’s Research Hospital
    Memphis, TN
    United States

    Original Message:
    Sent: 04-13-2014 05:36 PM
    From: Mary Lynn Rae
    Subject: Protocols, Policies, Procedures

    This message has been cross posted to the following Discussions: Nurse Educators and Inpatient Staff Hospital Issues .
    Hello All:

    What is the structure of protocols, policies and procedures at your hospital? We used to have protocols and procedures (separate a long time ago) and our hospital decided to combine protocols and procedures several years ago so that the RN staff would not have to go to 2 places for information. 

    1. Do you have protocols?
    2. Do you have policies?
    3. Do you have procedures?
    4. Are any of the above combined?
    5.  What is the typical length of your main format above?
    6. If you have procedures is the step by step process written out in detail?
    7.  If you do not have procedures, how does the staff know the step by step process (i.e. how to change a central line dressing or change a central line cap)?
    Mary Lynn Rae, RN, MSN, CPHON
    Ann & Robert Lurie Children’s Hospital of Chicago
    Chicago, IL
    United States